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Krupp LB, Waubant E, Waltz M, Casper TC, Belman A, Wheeler Y, Ness J, Graves J, Gorman M, Benson L, Mar S, Goyal M, Schreiner T, Weinstock-Guttman B, Rodriguez M, Tillema JM, Lotze T, Aaen G, Rensel M, Rose J, Chitinis T, George A, Charvet LE. A new look at cognitive functioning in pediatric MS. Mult Scler 2023; 29:140-149. [PMID: 36189711 DOI: 10.1177/13524585221123978] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Cognitive involvement in pediatric multiple sclerosis (MS) relative to adult MS is less defined. This study advances our understanding by measuring cognitive performances in pediatric MS, adult MS, and pediatric healthy controls. METHODS Consecutive relapsing pediatric MS participants from the United States Network of Pediatric MS Centers were compared with pediatric healthy controls and adults with relapsing MS. Participants were compared on two screening batteries: the Brief International Cognitive Assessment for MS and the Cogstate Brief Battery. Results were transformed to age-normative z scores. RESULTS The pediatric groups (MS vs. Healthy Controls) did not differ on either battery's composite mean score or individual test scores (ps > 0.32), nor in the proportions impaired on either battery, Brief International Cognitive Assessment for MS (26% vs. 24%, p = 0.83); Cogstate Brief Battery (26% vs. 32%, p = 0.41). The pediatric versus adult MS group even after controlling for differences in disease duration performed better on the Brief International Cognition Assessment for MS composite (p = 0.03), Symbol Digit Modalities Test (p = 0.02), Rey Auditory Verbal Learning Test (p = 0.01), and Cogstate choice reaction time (p < 0.001). CONCLUSION Pediatric MS patients do not differ from healthy pediatric controls on cognitive screens but perform better than adults with MS.
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Affiliation(s)
- Lauren B Krupp
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Emmanuelle Waubant
- Pediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA
| | - Michael Waltz
- Data Coordinating and Analysis Center, The University of Utah, Salt Lake City, UT, USA
| | - T Charles Casper
- Data Coordinating and Analysis Center, The University of Utah, Salt Lake City, UT, USA
| | - Anita Belman
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Yolanda Wheeler
- Center for Pediatric-Onset Demyelinating Disease, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer Graves
- Pediatric Multiple Sclerosis Center, University of California San Diego, San Diego, CA, USA
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital, Boston, MA, USA
| | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital, Boston, MA, USA
| | - Soe Mar
- Washington University in St. Louis, St. Louis, MO, USA
| | - Manu Goyal
- Washington University in St. Louis, St. Louis, MO, USA
| | - Teri Schreiner
- Rocky Mountain Multiple Sclerosis Center, Children's Hospital Colorado, University of Colorado Denver, Aurora, CO, USA
| | - Bianca Weinstock-Guttman
- Jacobs Pediatric Multiple Sclerosis Center, State University of New York at Buffalo, Buffalo, NY, USA
| | - Moses Rodriguez
- Mayo Clinic Pediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - Jan-Mendelt Tillema
- Mayo Clinic Pediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Greg Aaen
- Pediatric Multiple Sclerosis Center, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Mary Rensel
- Cleveland Clinic Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - John Rose
- Data Coordinating and Analysis Center, The University of Utah, Salt Lake City, UT, USA
| | - Tanuja Chitinis
- Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Allan George
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Leigh E Charvet
- Multiple Sclerosis Comprehensive Care Center, Department of Neurology, NYU Langone Health, New York, NY, USA
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Horton MK, McCauley K, Fadrosh D, Fujimura K, Graves J, Ness J, Wheeler Y, Gorman MP, Benson LA, Weinstock‐Guttman B, Waldman A, Rodriguez M, Tillema J, Krupp L, Belman A, Mar S, Rensel M, Chitnis T, Casper TC, Rose J, Hart J, Shao X, Tremlett H, Lynch SV, Barcellos LF, Waubant E. Gut microbiome is associated with multiple sclerosis activity in children. Ann Clin Transl Neurol 2021; 8:1867-1883. [PMID: 34409759 PMCID: PMC8419410 DOI: 10.1002/acn3.51441] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify features of the gut microbiome associated with multiple sclerosis activity over time. METHODS We used 16S ribosomal RNA sequencing from stool of 55 recently diagnosed pediatric-onset multiple sclerosis patients. Microbiome features included the abundance of individual microbes and networks identified from weighted genetic correlation network analyses. Prentice-Williams-Peterson Cox proportional hazards models estimated the associations between features and three disease activity outcomes: clinical relapses and both new/enlarging T2 lesions and new gadolinium-enhancing lesions on brain MRI. Analyses were adjusted for age, sex, and disease-modifying therapies. RESULTS Participants were followed, on average, 2.1 years. Five microbes were nominally associated with all three disease activity outcomes after multiple testing correction. These included butyrate producers Odoribacter (relapse hazard ratio = 0.46, 95% confidence interval: 0.24, 0.88) and Butyricicoccus (relapse hazard ratio = 0.49, 95% confidence interval: 0.28, 0.88). Two networks of co-occurring gut microbes were significantly associated with a higher hazard of both MRI outcomes (gadolinium-enhancing lesion hazard ratios (95% confidence intervals) for Modules 32 and 33 were 1.29 (1.08, 1.54) and 1.42 (1.18, 1.71), respectively; T2 lesion hazard ratios (95% confidence intervals) for Modules 32 and 33 were 1.34 (1.15, 1.56) and 1.41 (1.21, 1.64), respectively). Metagenomic predictions of these networks demonstrated enrichment for amino acid biosynthesis pathways. INTERPRETATION Both individual and networks of gut microbes were associated with longitudinal multiple sclerosis activity. Known functions and metagenomic predictions of these microbes suggest the important role of butyrate and amino acid biosynthesis pathways. This provides strong support for future development of personalized microbiome interventions to modify multiple sclerosis disease activity.
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Affiliation(s)
- Mary K. Horton
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Kathryn McCauley
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Douglas Fadrosh
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Kei Fujimura
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Jennifer Graves
- Department of NeurosciencesUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Jayne Ness
- Division of Pediatric NeurologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Yolanda Wheeler
- Division of Pediatric NeurologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Mark P. Gorman
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
| | - Leslie A. Benson
- Department of NeurologyBoston Children’s HospitalBostonMassachusettsUSA
| | | | - Amy Waldman
- Department of NeurologyChildren’s Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | | | | | - Lauren Krupp
- Pediatric Multiple Sclerosis CenterNew York University Langone Medical CenterNew YorkNew YorkUSA
| | - Anita Belman
- Pediatric Multiple Sclerosis CenterNew York University Langone Medical CenterNew YorkNew YorkUSA
| | - Soe Mar
- Department of NeurologyWashington University in St. LouisSt. LouisMissouriUSA
| | - Mary Rensel
- Department of NeurologyCleveland ClinicClevelandOhioUSA
| | - Tanuja Chitnis
- Division of Child NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | | | - John Rose
- School of MedicineUniversity of Utah SchoolSalt Lake CityUtahUSA
| | - Janace Hart
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Xiaorong Shao
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Helen Tremlett
- Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Susan V. Lynch
- Department of Medicine‐ GastroenterologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Lisa F. Barcellos
- Division of EpidemiologyUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Emmanuelle Waubant
- Department of NeurologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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Greenberg BM, Casper TC, Mar SS, Ness JM, Plumb P, Liang S, Goyal M, Weinstock-Guttman B, Rodriguez M, Aaen GS, Belman A, Barcellos LF, Rose JW, Gorman MP, Benson LA, Candee M, Chitnis T, Harris YC, Kahn IL, Roalstad S, Hart J, Lotze TE, Rensel M, Rubin JP, Schreiner TL, Tillema JM, Waldman AT, Krupp L, Graves J, Drake K, Waubant E. Familial History of Autoimmune Disorders Among Patients With Pediatric Multiple Sclerosis. Neurol Neuroimmunol Neuroinflamm 2021; 8:e1049. [PMID: 34353894 PMCID: PMC8362349 DOI: 10.1212/nxi.0000000000001049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/17/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of this study was to determine whether family members of patients with pediatric multiple sclerosis (MS) have an increased prevalence of autoimmune conditions compared with controls. METHODS Data collected during a pediatric MS case-control study of risk factors included information about various autoimmune diseases in family members. The frequency of these disorders was compared between cases and controls. RESULTS There was an increased rate of autoimmune diseases among family members of pediatric MS cases compared with controls with first-degree history of MS excluded (OR = 2.27, 95% CI 1.71-3.01, p < 0.001). There was an increased rate of MS among second-degree relatives of pediatric MS cases compared with controls (OR = 3.47, 95% CI 1.36-8.86, p = 0.009). The OR for MS was 2.64 when restricted to maternal relatives and 6.37 when restricted to paternal relatives. DISCUSSION The increased rates of autoimmune disorders, including thyroid disorders and MS among families of patients with pediatric MS, suggest shared genetic factors among families with children diagnosed with pediatric MS.
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Affiliation(s)
- Benjamin M. Greenberg
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Theron Charles Casper
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Soe S. Mar
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jayne M. Ness
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Patricia Plumb
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Shannon Liang
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Manu Goyal
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Bianca Weinstock-Guttman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Moses Rodriguez
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Gregory S. Aaen
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Anita Belman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Lisa F. Barcellos
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - John W. Rose
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Mark P. Gorman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Leslie A. Benson
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Meghan Candee
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Tanuja Chitnis
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Yolanda C. Harris
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Ilana L. Kahn
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Shelly Roalstad
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Janace Hart
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Timothy E. Lotze
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Mary Rensel
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jennifer P. Rubin
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Teri L. Schreiner
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jan-Mendelt Tillema
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Amy Tara Waldman
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Lauren Krupp
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Jennifer Graves
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Kaylea Drake
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
| | - Emmanuelle Waubant
- From the University of Texas Southwestern (B.M.G.), Department of Neurology, Department of Pediatrics, Dallas; Data Coordinating and Analysis Center (T.C.C., S.S.R., K.D.), University of Utah, Salt Lake City; Washington University (S.S.M.), St. Louis, MO; University of Alabama Birmingham (J.M.N.); The University of Texas Southwestern (P.P.), Department of Neurology, Dallas; Department of Radiology (S.L., M.G.), Washington University in St. Louis, MO; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo, NY; Mayo Clinic Pediatric Multiple Sclerosis Center (M.R., J.-M.T.), Mayo Clinic, Rochester, MN; Pediatric Multiple Sclerosis Center (G.S.A.), Loma Linda University Children's Hospital, CA; Lourie Center for Pediatric Multiple Sclerosis (A.B.), Stony Brook University Hospital, NY; Epidemiology (L.F.B.), University of California, Berkeley; Department of Neurology (J.W.R.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis and Related Disorders Program (M.P.G., L.A.B.), Boston Children's Hospital, MA; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital, Boston; Center for Pediatric-Onset Demyelinating Disease (Y.C.H.), Children's Hospital of Alabama, University of Alabama, Birmingham; Children's National Medical Center (I.L.K.), Washington, DC; Pediatric Multiple Sclerosis Center (J.H.), University of California San Francisco; The Blue Bird Circle Clinic for Multiple Sclerosis (T.E.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.R.), Cleveland Clinic, OH; Lurie Children's Hospital of Chicago (J.P.R.), IL; Rocky Mountain Multiple Sclerosis Center (T.L.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Children's Hospital of Philadelphia (A.T.W.), PA; Pediatric Multiple Sclerosis Center (L.K.), New York University; Pediatric Multiple Sclerosis Center (J.G.), University of California San Diego; and Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco
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4
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Chitnis T, Aaen G, Belman A, Benson L, Gorman M, Goyal MS, Graves JS, Harris Y, Krupp L, Lotze T, Mar S, Ness J, Rensel M, Schreiner T, Tillema JM, Waubant E, Weinstock-Guttman B, Roalstad S, Rose J, Weiner HL, Casper TC, Rodriguez M. Improved relapse recovery in paediatric compared to adult multiple sclerosis. Brain 2021; 143:2733-2741. [PMID: 32810215 DOI: 10.1093/brain/awaa199] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/01/2020] [Accepted: 04/29/2020] [Indexed: 11/14/2022] Open
Abstract
Incomplete relapse recovery contributes to disability accrual and earlier onset of secondary progressive multiple sclerosis. We sought to investigate the effect of age on relapse recovery. We identified patients with multiple sclerosis from two longitudinal prospective studies, with an Expanded Disability Status Scale (EDSS) score within 30 days after onset of an attack, and follow-up EDSS 6 months after attack. Adult patients with multiple sclerosis (n = 632) were identified from the Comprehensive Longitudinal Investigations in Multiple Sclerosis at Brigham study (CLIMB), and paediatric patients (n = 132) from the US Network of Paediatric Multiple Sclerosis Centers (NPMSC) registry. Change in EDSS was defined as the difference in EDSS between attack and follow-up. Change in EDSS at follow-up compared to baseline was significantly lower in children compared to adults (P = 0.001), as were several functional system scores. Stratification by decade at onset for change in EDSS versus age found for every 10 years of age, EDSS recovery is reduced by 0.15 points (P < 0.0001). A larger proportion of children versus adults demonstrated improvement in EDSS following an attack (P = 0.006). For every 10 years of age, odds of EDSS not improving increase by 1.33 times (P < 0.0001). Younger age is associated with improved recovery from relapses. Age-related mechanisms may provide novel therapeutic targets for disability accrual in multiple sclerosis.
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Affiliation(s)
- Tanuja Chitnis
- Partners Paediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Greg Aaen
- Paediatric Multiple Sclerosis Center, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anita Belman
- Paediatric MS Center at NYU Langone Health, New York, NY, USA
| | - Leslie Benson
- Paediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital, MA, USA
| | - Mark Gorman
- Paediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital, MA, USA
| | | | - Jennifer S Graves
- Paediatric Multiple Sclerosis Center, University of California San Diego, San Diego, CA, USA
| | - Yolanda Harris
- UAB Center for Paediatric-Onset Demyelinating Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lauren Krupp
- Paediatric MS Center at NYU Langone Health, New York, NY, USA
| | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Soe Mar
- Washington University, St. Louis, MO, USA
| | - Jayne Ness
- UAB Center for Paediatric-Onset Demyelinating Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Teri Schreiner
- Rocky Mountain Multiple Sclerosis Center, Children's Hospital Colorado, University of Colorado at Denver, Aurora, CO, USA
| | - Jan-Mendelt Tillema
- Mayo Clinic Paediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - Emmanuelle Waubant
- Paediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA
| | - Bianca Weinstock-Guttman
- Jacobs Paediatric Multiple Sclerosis Center, State University of New York at Buffalo, Buffalo, NY, USA
| | - Shelly Roalstad
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - John Rose
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - Howard L Weiner
- Harvard Medical School, Boston, MA, USA.,Partners MS Center, Brigham and Women's Hospital, Boston, MA, USA
| | - T Charles Casper
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - Moses Rodriguez
- Mayo Clinic Paediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
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5
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Santoro JD, Waltz M, Aaen G, Belman A, Benson L, Gorman M, Goyal MS, Graves JS, Harris Y, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Rensel M, Rodriguez M, Schreiner T, Tillema JM, Waubant E, Weinstock-Guttman B, Hurtubise BF, Roalstad S, Rose J, Casper TC, Chitnis T. Pediatric Multiple Sclerosis Severity Score in a large US cohort. Neurology 2020; 95:e1844-e1853. [PMID: 32690790 DOI: 10.1212/wnl.0000000000010414] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/10/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize disease severity and distribution of disability in pediatric-onset multiple sclerosis (POMS) and to develop an optimized modeling scale for measuring disability, we performed a multicenter retrospective analysis of disability scores in 873 persons with POMS over time and compared this to previously published data in adults with multiple sclerosis (MS). METHODS This was a retrospective analysis of prospectively collected data collected from 12 centers of the US Network of Pediatric MS Centers. Patients were stratified by the number of years from first symptoms of MS to Expanded Disability Status Scale (EDSS) assessment and an MS severity score (Pediatric Multiple Sclerosis Severity Score [Ped-MSSS]) was calculated per criteria developed by Roxburgh et al. in 2005. RESULTS In total, 873 patients were evaluated. In our cohort, 52%, 19.4%, and 1.5% of all patients at any time point reached an EDSS of 2.0, 3.0, and 6.0. Comparison of our Ped-MSSS scores and previously published adult Multiple Sclerosis Severity Scores (MSSS) showed slower progression of Ped-MSSS with increasing gaps between higher EDSS score and years after diagnosis. Decile scores in our POMS cohort for EDSS of 2.0, 3.0, and 6.0 were 8.00/9.46/9.94, 7.86/9.39/9.91, and 7.32/9.01/9.86 at 2, 5, and 10 years, respectively. Notable predictors of disease progression in both EDSS and Ped-MSSS models were ever having a motor relapse and EDSS at year 1. Symbol Digit Modalities Test (SDMT) scores were inversely correlated with duration of disease activity and cerebral functional score. CONCLUSIONS Persons with POMS exhibit lower EDSS scores compared to persons with adult-onset MS. Use of a Ped-MSSS model may provide an alternative to EDSS scoring in clinical assessment of disease severity and disability accrual.
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Affiliation(s)
- Jonathan D Santoro
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA.
| | - Michael Waltz
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Greg Aaen
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Anita Belman
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Leslie Benson
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Mark Gorman
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Manu S Goyal
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Jennifer S Graves
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Yolanda Harris
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Lauren Krupp
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Timothy Lotze
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Soe Mar
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Manikum Moodley
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Jayne Ness
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Mary Rensel
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Moses Rodriguez
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Teri Schreiner
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Jan-Mendelt Tillema
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Emmanuelle Waubant
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Bianca Weinstock-Guttman
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Brigitte F Hurtubise
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Shelly Roalstad
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - John Rose
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - T Charles Casper
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA
| | - Tanuja Chitnis
- From Partners Pediatric Multiple Sclerosis Center (J.D.S., T.C.), Massachusetts General Hospital; Harvard Medical School (J.D.S.), Boston, MA; Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital (J.D.S., L.B., M.G.), MA; Children's Hospital Los Angeles (J.D.S.); Keck School of Medicine at the University of Southern California (J.D.S.), Los Angeles; Data Coordinating and Analysis Center (M.W., S.R., J.R., T.C.C.), University of Utah, Salt Lake City; Pediatric Multiple Sclerosis Center (G.A.), Loma Linda University Children's Hospital, CA; Pediatric MS Center at NYU Langone Health (A.B., L.K.), New York, NY; Washington University (M.S.G., S.M.), St. Louis, MO; Pediatric Multiple Sclerosis Center (J.S.G.), University of California San Diego; UAB Center for Pediatric-Onset Demyelinating Disease (Y.H., J.N.), University of Alabama at Birmingham; The Blue Bird Circle Clinic for Multiple Sclerosis (T.L.), Texas Children's Hospital, Baylor College of Medicine, Houston; Mellen Center for Multiple Sclerosis (M.M., M. Rensel), Cleveland Clinic, OH; Mayo Clinic Pediatric Multiple Sclerosis Center (M. Rodriguez, J.-M.T.), Mayo Clinic, Rochester, MN; Rocky Mountain Multiple Sclerosis Center (T.S.), Children's Hospital Colorado, University of Colorado at Denver, Aurora; Pediatric Multiple Sclerosis Center (E.W.), University of California San Francisco; Jacobs Pediatric Multiple Sclerosis Center (B.W.-G.), State University of New York at Buffalo; and Department of Neurology (B.F.H.), Stanford University School of Medicine, Palo Alto, CA.
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6
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Graves JS, Barcellos LF, Krupp L, Belman A, Shao X, Quach H, Hart J, Chitnis T, Weinstock-Guttman B, Aaen G, Benson L, Gorman M, Greenberg B, Lotze T, Soe M, Ness J, Rodriguez M, Rose J, Schreiner T, Tillema JM, Waldman A, Casper TC, Waubant E. Vitamin D genes influence MS relapses in children. Mult Scler 2020; 26:894-901. [PMID: 31081484 PMCID: PMC6851448 DOI: 10.1177/1352458519845842] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether a vitamin D genetic risk score (vitDGRS) is associated with 25-hydroxyvitamin D (25(OH)D) level and multiple sclerosis (MS) relapses in children. METHODS DNA samples were typed for single nucleotide polymorphisms (SNPs) from four genes previously identified to be associated with 25(OH)D levels. SNPs with strong associations with 25(OH)D after multiple comparison correction were used to create a genetic risk score (vitDGRS). Cox regression models tested associations of vitDGRS with relapse hazard. RESULTS Two independent SNPs within or near GC and NADSYN1/DHCR7 genes were strongly associated with 25(OH)D levels in the discovery cohort (n = 182) after Bonferroni correction. The vitDGRS of these SNPs explained 4.5% of the variance of 25(OH)D level after adjustment for genetic ancestry. Having the highest versus lowest vitDGRS was associated with 11 ng/mL lower 25(OH)D level (95% confidence interval (CI) = -17.5, -4.5, p = 0.001) in the discovery cohort. Adjusting for ancestry, sex, disease-modifying therapy (DMT), and HLA-DRB1*15 carrier status, the highest versus lowest vitDGRS was associated with 2.6-fold (95% CI = 1.37, 5.03, p = 0.004) and 2.0-fold (95% CI = 0.75, 5.20, p = 0.16) higher relapse hazard in the discovery and replication cohorts, respectively. CONCLUSION The vitDGRS identifies children at greater risk of relapse. These findings support a causal role for vitamin D in MS course.
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Affiliation(s)
- Jennifer S Graves
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Lisa F Barcellos
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Lauren Krupp
- Pediatric Multiple Sclerosis Center, New York University Langone Medical Center, New York, NY, USA
| | | | - Xiaorong Shao
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Hong Quach
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Janace Hart
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital for Children, Boston, MA, USA
| | | | - Gregory Aaen
- Pediatric Multiple Sclerosis Center, Loma Linda University Children's Hospital, San Bernardino, CA, USA
| | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program, Boston Children's Hospital, Boston, MA, USA
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program, Boston Children's Hospital, Boston, MA, USA
| | | | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children's Hospital, Houston, TX, USA
| | - Mar Soe
- Pediatric MS & Demyelinating Disease Center, Washington University, St. Louis, MI, USA
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease, Children's of Alabama, Birmingham, AL, USA
| | - Moses Rodriguez
- Pediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MA, USA
| | - John Rose
- Department of Neurology, The University of Utah, Salt Lake City, UT, USA
| | - Teri Schreiner
- Rocky Mountain MS Center, University of Colorado, Denver, Denver, CO, USA
| | | | - Amy Waldman
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - T Charles Casper
- Department of Pediatrics, The University of Utah, Salt Lake City, UT, USA
| | - Emmanuelle Waubant
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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7
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Krysko KM, Graves JS, Rensel M, Weinstock-Guttman B, Rutatangwa A, Aaen G, Belman A, Benson L, Chitnis T, Gorman M, Goyal MS, Harris Y, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Rodriguez M, Rose J, Schreiner T, Tillema JM, Waltz M, Casper TC, Waubant E. Real-World Effectiveness of Initial Disease-Modifying Therapies in Pediatric Multiple Sclerosis. Ann Neurol 2020; 88:42-55. [PMID: 32267005 DOI: 10.1002/ana.25737] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess real-world effectiveness of initial treatment with newer compared to injectable disease-modifying therapies (DMTs) on disease activity in pediatric multiple sclerosis (MS) and clinically isolated syndrome (CIS). METHODS This is a cohort study of children with MS/CIS followed at 12 clinics in the US Network of Pediatric MS Centers, who received initial therapy with newer (fingolimod, dimethyl fumarate, teriflunomide, natalizumab, rituximab, ocrelizumab) or injectable (interferon-β, glatiramer acetate) DMTs. Propensity scores (PSs) were computed, including preidentified confounders. Relapse rate while on initial DMT was modeled with negative binomial regression, adjusted for PS-quintile. Time to new/enlarging T2-hyperintense and gadolinium-enhancing lesions on brain magnetic resonance imaging were modeled with midpoint survival analyses, adjusted for PS-quintile. RESULTS A total of 741 children began therapy before 18 years, 197 with newer and 544 with injectable DMTs. Those started on newer DMTs were older (15.2 vs injectable 14.4 years, p = 0.001) and less likely to have a monofocal presentation. In PS-quintile-adjusted analysis, those on newer DMTs had a lower relapse rate than those on injectables (rate ratio = 0.45, 95% confidence interval (CI) = 0.29-0.70, p < 0.001; rate difference = 0.27, 95% CI = 0.14-0.40, p = 0.004). One would need to treat with newer rather than injectable DMTs for 3.7 person-years to prevent 1 relapse. Those started on newer DMTs had a lower rate of new/enlarging T2 (hazard ratio [HR] = 0.51, 95% CI = 0.36-0.72, p < 0.001) and gadolinium-enhancing lesions (HR = 0.38, 95% CI = 0.23-0.63, p < 0.001) than those on injectables. INTERPRETATION Initial treatment of pediatric MS/CIS with newer DMTs led to better disease activity control compared to injectables, supporting greater effectiveness of newer therapies. Long-term safety data for newer DMTs are required. ANN NEUROL 2020 ANN NEUROL 2020;88:42-55.
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Affiliation(s)
- Kristen M Krysko
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Jennifer S Graves
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA.,Department of Neurology, University of California, San Diego, La Jolla, CA
| | - Mary Rensel
- Department of Neurology, Cleveland Clinic, Cleveland, OH
| | | | - Alice Rutatangwa
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Gregory Aaen
- Department of Pediatrics, Loma Linda University, San Bernardino, CA
| | - Anita Belman
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Tanuja Chitnis
- Department of Pediatric Neurology, Massachusetts General Hospital, Boston, MA
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Manu S Goyal
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis, St Louis, MO
| | - Yolanda Harris
- Department of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Lauren Krupp
- Department of Neurology, New York University Langone Medical Center, New York, NY
| | - Timothy Lotze
- Department of Neurology, Texas Children's Hospital, Houston, TX
| | - Soe Mar
- Department of Neurology, Washington University in Saint Louis, St Louis, MO
| | - Manikum Moodley
- Department of Pediatrics and Neurology, Dell Children's Hospital, University of Texas, Austin, TX
| | - Jayne Ness
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - Teri Schreiner
- Departments of Neurology and Pediatrics, University of Colorado, Aurora, CO
| | | | - Michael Waltz
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Emmanuelle Waubant
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco, CA
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8
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Wallach AI, Waltz M, Casper TC, Aaen G, Belman A, Benson L, Chitnis T, Gorman M, Graves J, Harris Y, Lotze TE, Mar S, Moodley M, Ness JM, Rensel M, Rodriguez M, Rose JW, Schreiner T, Tillema JM, Waubant E, Weinstock-Guttman B, Charvet LE, Krupp LB. Cognitive processing speed in pediatric-onset multiple sclerosis: Baseline characteristics of impairment and prediction of decline. Mult Scler 2019; 26:1938-1947. [PMID: 31775571 DOI: 10.1177/1352458519891984] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cognitive impairment occurs in approximately one-third of pediatric-onset multiple sclerosis (POMS) patients. The Symbol Digit Modalities Test (SDMT), a widely used cognitive screen in adults, has yet to be incorporated early into the standard care of POMS. OBJECTIVE To screen for cognitive impairment early in the course of POMS and analyze predictive factors. METHODS Of the 955 POMS or clinically isolated syndrome (CIS) patients prospectively assessed from March 2014 to July 2018, 500 POMS and 116 CIS patients met inclusion criteria (disease onset before the age of 18, one or more SDMTs, and 8 years or older at the time of testing). Those with relapse were analyzed separately from those who were relapse-free. RESULTS At initial assessment, the mean (interquartile range (IQR)) age at symptom onset was 13.5 years (12.0, 15.9) and the mean (±SD) disease duration was 3.0 ± 2.9 years. Impaired processing speed occurred in 23.4% of POMS and in 16.4% of CIS. On serial testing (n = 383, mean follow-up: 1.8 years), 14.1% had clinically meaningful decline predicted by older age of multiple sclerosis (MS) onset and male gender. Disease relapse or steroid use led to transient worsening on the SDMT. CONCLUSION Early in the disease, some POMS and CIS patients are at risk for cognitive impairment and subsequent decline.
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Affiliation(s)
- Asya I Wallach
- Pediatric Multiple Sclerosis Center, Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Michael Waltz
- Pediatrics, The University of Utah, Salt Lake City, UT, USA
| | | | - Gregory Aaen
- Pediatric Multiple Sclerosis Center, Loma Linda University, Loma Linda, CA, USA
| | - Anita Belman
- Pediatric Multiple Sclerosis Center, Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Leslie Benson
- Partners Multiple Sclerosis Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Partners Multiple Sclerosis Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jennifer Graves
- Pediatric MS Center, Neurology, University of California, San Diego, San Diego, CA, USA
| | - Yolanda Harris
- Center for Pediatric-Onset Demyelinating Disease, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timothy E Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Soe Mar
- Pediatric MS and other Demyelinating Disease Center, Washington University in St Louis, St. Louis, MO, USA
| | - Manikum Moodley
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Jayne M Ness
- Center for Pediatric-Onset Demyelinating Disease, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Moses Rodriguez
- Pediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - John W Rose
- Pediatrics, The University of Utah, Salt Lake City, UT, USA
| | - Teri Schreiner
- Department of Neurology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | | | - Emmanuelle Waubant
- Regional Pediatric MS Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Bianca Weinstock-Guttman
- The Pediatric MS Center, Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - Leigh E Charvet
- Pediatric Multiple Sclerosis Center, Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Lauren B Krupp
- Pediatric Multiple Sclerosis Center, Department of Neurology, NYU Langone Medical Center, New York, NY, USA
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9
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Rhead B, Shao X, Graves JS, Chitnis T, Waldman AT, Lotze T, Schreiner T, Belman A, Krupp L, Greenberg BM, Weinstock–Guttman B, Aaen G, Tillema JM, Rodriguez M, Hart J, Caillier S, Ness J, Harris Y, Rubin J, Candee MS, Gorman M, Benson L, Mar S, Kahn I, Rose J, Casper TC, Quach H, Quach D, Schaefer C, Waubant E, Barcellos LF. miRNA contributions to pediatric-onset multiple sclerosis inferred from GWAS. Ann Clin Transl Neurol 2019; 6:1053-1061. [PMID: 31211169 PMCID: PMC6562070 DOI: 10.1002/acn3.786] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Onset of multiple sclerosis (MS) occurs in childhood for approximately 5% of cases (pediatric MS, or ped-MS). Epigenetic influences are strongly implicated in MS pathogenesis in adults, including the contribution from microRNAs (miRNAs), small noncoding RNAs that affect gene expression by binding target gene mRNAs. Few studies have specifically examined miRNAs in ped-MS, but individuals developing MS at an early age may carry a relatively high burden of genetic risk factors, and miRNA dysregulation may therefore play a larger role in the development of ped-MS than in adult-onset MS. This study aimed to look for evidence of miRNA involvement in ped-MS pathogenesis. METHODS GWAS results from 486 ped-MS cases and 1362 controls from the U.S. Pediatric MS Network and Kaiser Permanente Northern California membership were investigated for miRNA-specific signals. First, enrichment of miRNA-target gene network signals was evaluated using MIGWAS software. Second, SNPs in miRNA genes and in target gene binding sites (miR-SNPs) were tested for association with ped-MS, and pathway analysis was performed on associated target genes. RESULTS MIGWAS analysis showed that miRNA-target gene signals were enriched in GWAS (P = 0.038) and identified 39 candidate biomarker miRNA-target gene pairs, including immune and neuronal signaling genes. The miR-SNP analysis implicated dysregulation of miRNA binding to target genes in five pathways, mainly involved in immune signaling. INTERPRETATION Evidence from GWAS suggests that miRNAs play a role in ped-MS pathogenesis by affecting immune signaling and other pathways. Candidate biomarker miRNA-target gene pairs should be further studied for diagnostic, prognostic, and/or therapeutic utility.
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Affiliation(s)
- Brooke Rhead
- Division of EpidemiologySchool of Public HealthUniversity of CaliforniaBerkeleyCalifornia
- Computational Biology Graduate GroupUniversity of CaliforniaBerkeleyCalifornia
| | - Xiaorong Shao
- Division of EpidemiologySchool of Public HealthUniversity of CaliforniaBerkeleyCalifornia
| | - Jennifer S. Graves
- Department of NeurologyUniversity of CaliforniaSan FranciscoCalifornia
- Department of NeurosciencesUniversity of CaliforniaSan DiegoCalifornia
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis CenterMassachusetts General Hospital for ChildrenBostonMassachusetts
| | - Amy T. Waldman
- Division of NeurologyChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvania
| | - Timothy Lotze
- Blue Bird Circle Multiple Sclerosis CenterBaylor College of MedicineHoustonTexas
| | - Teri Schreiner
- Children's Hospital ColoradoUniversity of ColoradoDenverColorado
| | - Anita Belman
- Lourie Center for Pediatric MSStony Brook Children's HospitalStony BrookNew York
| | - Lauren Krupp
- Lourie Center for Pediatric MSStony Brook Children's HospitalStony BrookNew York
| | - Benjamin M. Greenberg
- Department of Neurology and NeurotherapeuticsUniversity of Texas SouthwesternDallasTexas
| | | | - Gregory Aaen
- Pediatric MS Center at Loma Linda University Children's HospitalLoma LindaCalifornia
| | | | | | - Janace Hart
- University of California, San FranciscoRegional Pediatric MS Center NeurologySan FranciscoCalifornia
| | - Stacy Caillier
- University of California, San FranciscoRegional Pediatric MS Center NeurologySan FranciscoCalifornia
| | - Jayne Ness
- University of Alabama Center for Pediatric–onset Demyelinating DiseaseChildren's Hospital of AlabamaBirminghamAlabama
| | - Yolanda Harris
- University of Alabama Center for Pediatric–onset Demyelinating DiseaseChildren's Hospital of AlabamaBirminghamAlabama
| | - Jennifer Rubin
- Department of Pediatric NeurologyNorthwestern Feinberg School of MedicineChicagoIllinois
| | - Meghan S. Candee
- Division of Pediatric NeurologyUniversity of UtahPrimary Children's HospitalSalt Lake CityUtah
| | - Mark Gorman
- Boston Children's HospitalBostonMassachusetts
| | | | - Soe Mar
- Pediatric–onset Demyelinating Diseases and Autoimmune Encephalitis CenterSt. Louis Children's HospitalWashington University School of MedicineSt. LouisMissouri
| | - Ilana Kahn
- Children's National Medical CenterWashingtonDistrict of Columbia
| | - John Rose
- Department of NeurologyUniversity of Utah School of MedicineSalt Lake CityUtah
| | - T. Charles Casper
- Department of PediatricsUniversity of Utah School of MedicineSalt Lake CityUtah
| | - Hong Quach
- Division of EpidemiologySchool of Public HealthUniversity of CaliforniaBerkeleyCalifornia
| | - Diana Quach
- Division of EpidemiologySchool of Public HealthUniversity of CaliforniaBerkeleyCalifornia
| | - Catherine Schaefer
- Kaiser Permanente Division of ResearchOaklandCalifornia
- Research Program on Genes, Environment and HealthKaiser PermanenteOaklandCalifornia
| | | | - Lisa F. Barcellos
- Division of EpidemiologySchool of Public HealthUniversity of CaliforniaBerkeleyCalifornia
- Computational Biology Graduate GroupUniversity of CaliforniaBerkeleyCalifornia
- Kaiser Permanente Division of ResearchOaklandCalifornia
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10
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Aaen G, Waltz M, Vargas W, Makhani N, Ness J, Harris Y, Casper TC, Benson L, Candee M, Chitnis T, Gorman M, Graves J, Greenberg B, MD TL, Mar S, Tillema JM, Rensel M, Rodriguez M, Rose J, Rubin J, Schreiner T, Waldman A, Weinstock-Guttman B, Belman A, Waubant E, Krupp L. Acquisition of Early Developmental Milestones and Need for Special Education Services in Pediatric Multiple Sclerosis. J Child Neurol 2019; 34:148-152. [PMID: 30556452 PMCID: PMC6579723 DOI: 10.1177/0883073818815041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children with pediatric-onset multiple sclerosis and pediatric controls were enrolled across 16 pediatric multiple sclerosis centers in the United States and completed questionnaires that addressed time of first unaided walking and acquisition of 2-word phrases. A total of 467 (308 female) cases and 428 (209 female) controls were enrolled. Pediatric multiple sclerosis (n = 467) were not delayed in walking or using 2-word phrases compared to healthy controls (n = 428) (2.2% vs 5.7%, respectively). Children with disease onset before age 11 versus onset at 11 years or after were more likely to need an individualized education plan (P = .002), reading assistance (P = .0003), and math assistance (P = .001). Children with multiple sclerosis onset prior to age 18 are not delayed in meeting the 2 major early developmental milestones but do have a significantly increased use of special services or learning assistance at school. Further research will need to address whether other measures of development (eg, rate of language acquisition or fine motor skills) differ between pediatric multiple sclerosis and controls.
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Affiliation(s)
- Gregory Aaen
- Pediatric Multiple Sclerosis Center at Loma Linda University Children’s Hospital
| | | | - Wendy Vargas
- Pediatric Multiple Sclerosis Program, Columbia University Medical Center
| | - Naila Makhani
- Pediatric Multiple Sclerosis Program, Yale MS and Neuroimmunology Center
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease at the Children’s Hospital of Alabama
| | - Yolanda Harris
- Center for Pediatric-Onset Demyelinating Disease at the Children’s Hospital of Alabama
| | | | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children’s Hospital
| | | | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Center at the Massachusetts General Hospital for Children
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children’s Hospital
| | | | | | - Timothy Lotze MD
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children’s Hospital
| | - Soe Mar
- Washington University Pediatric Multiple Sclerosis and other Demyelinating Disease Center, St. Louis
| | | | | | | | - John Rose
- Department of Pediatrics, University of Utah
| | | | - Teri Schreiner
- Rocky Mountain Multiple Sclerosis Center, University of Colorado at Denver
| | | | | | | | | | - Lauren Krupp
- Pediatric Multiple Sclerosis Center at New York University Langone Medical Center
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11
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Chi C, Shao X, Rhead B, Gonzales E, Smith JB, Xiang AH, Graves J, Waldman A, Lotze T, Schreiner T, Weinstock-Guttman B, Aaen G, Tillema JM, Ness J, Candee M, Krupp L, Gorman M, Benson L, Chitnis T, Mar S, Belman A, Casper TC, Rose J, Moodley M, Rensel M, Rodriguez M, Greenberg B, Kahn L, Rubin J, Schaefer C, Waubant E, Langer-Gould A, Barcellos LF. Admixture mapping reveals evidence of differential multiple sclerosis risk by genetic ancestry. PLoS Genet 2019; 15:e1007808. [PMID: 30653506 PMCID: PMC6353231 DOI: 10.1371/journal.pgen.1007808] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 01/30/2019] [Accepted: 11/02/2018] [Indexed: 01/22/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease with high prevalence among populations of northern European ancestry. Past studies have shown that exposure to ultraviolet radiation could explain the difference in MS prevalence across the globe. In this study, we investigate whether the difference in MS prevalence could be explained by European genetic risk factors. We characterized the ancestry of MS-associated alleles using RFMix, a conditional random field parameterized by random forests, to estimate their local ancestry in the largest assembled admixed population to date, with 3,692 African Americans, 4,915 Asian Americans, and 3,777 Hispanics. The majority of MS-associated human leukocyte antigen (HLA) alleles, including the prominent HLA-DRB1*15:01 risk allele, exhibited cosmopolitan ancestry. Ancestry-specific MS-associated HLA alleles were also identified. Analysis of the HLA-DRB1*15:01 risk allele in African Americans revealed that alleles on the European haplotype conferred three times the disease risk compared to those on the African haplotype. Furthermore, we found evidence that the European and African HLA-DRB1*15:01 alleles exhibit single nucleotide polymorphism (SNP) differences in regions encoding the HLA-DRB1 antigen-binding heterodimer. Additional evidence for increased risk of MS conferred by the European haplotype were found for HLA-B*07:02 and HLA-A*03:01 in African Americans. Most of the 200 non-HLA MS SNPs previously established in European populations were not significantly associated with MS in admixed populations, nor were they ancestrally more European in cases compared to controls. Lastly, a genome-wide search of association between European ancestry and MS revealed a region of interest close to the ZNF596 gene on chromosome 8 in Hispanics; cases had a significantly higher proportion of European ancestry compared to controls. In conclusion, our study established that the genetic ancestry of MS-associated alleles is complex and implicated that difference in MS prevalence could be explained by the ancestry of MS-associated alleles.
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Affiliation(s)
- Calvin Chi
- Genetic Epidemiology and Genomics Laboratory, University of California, Berkeley, Berkeley, California, United States of America
- Computational Biology Graduate Group, University of California, Berkeley, Berkeley, California, United States of America
- * E-mail: (CC); (LB)
| | - Xiaorong Shao
- Genetic Epidemiology and Genomics Laboratory, University of California, Berkeley, Berkeley, California, United States of America
| | - Brooke Rhead
- Genetic Epidemiology and Genomics Laboratory, University of California, Berkeley, Berkeley, California, United States of America
- Computational Biology Graduate Group, University of California, Berkeley, Berkeley, California, United States of America
| | - Edlin Gonzales
- Department of Research & Evaluation, Kaiser Permanente Southern California, Los Angeles, California, United States of America
| | - Jessica B. Smith
- Department of Research & Evaluation, Kaiser Permanente Southern California, Los Angeles, California, United States of America
| | - Anny H. Xiang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Los Angeles, California, United States of America
| | - Jennifer Graves
- Department of Neurology, University of California, San Francisco, San Francisco, California, United States of America
| | - Amy Waldman
- Leukodystrophy Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Timothy Lotze
- Neurology and Developmental Neuroscience Department, Texas Children’s Hospital, Houston, Texas, United States of America
| | - Teri Schreiner
- University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Bianca Weinstock-Guttman
- Department of Neurology, State University of New York, Buffalo, Buffalo, New York, United States of America
| | - Gregory Aaen
- Loma Linda University, Loma Linda, California, United States of America
| | - Jan-Mendelt Tillema
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jayne Ness
- Children’s of Alabama, Birmingham, Alabama, United States of America
| | - Meghan Candee
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Lauren Krupp
- Department of Neurology, NYU Langone Health, New York, New York, United States of America
| | - Mark Gorman
- Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Leslie Benson
- Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Tanuja Chitnis
- MassGeneral Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Soe Mar
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Anita Belman
- Department of Neurology, NYU Langone Health, New York, New York, United States of America
| | - Theron Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, Utah, United States of America
| | - Manikum Moodley
- Center for Pediatric Neurosciences, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Mary Rensel
- Mellen Center, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Moses Rodriguez
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Benjamin Greenberg
- Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, Texas, United States of America
| | - Llana Kahn
- Children’s National Medical Center, Northwest Washington, D.C., United States of America
| | - Jennifer Rubin
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
| | - Catherine Schaefer
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Emmanuelle Waubant
- Department of Neurology, University of California, San Francisco, San Francisco, California, United States of America
| | - Annette Langer-Gould
- Kaiser Permanente, Southern California Permanente Medical Group, Pasadena, California, United States of America
- Los Angeles Medical Center, Neurology Department, Los Angeles, California, United States of America
| | - Lisa F. Barcellos
- Genetic Epidemiology and Genomics Laboratory, University of California, Berkeley, Berkeley, California, United States of America
- * E-mail: (CC); (LB)
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12
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Mar S, Liang S, Waltz M, Casper TC, Goyal M, Greenberg B, Weinstock-Guttman B, Rodriguez M, Aaen G, Belman A, Barcellos LF, Rose J, Gorman M, Benson L, Candee M, Chitnis T, Harris Y, Kahn I, Roalsted S, Hart J, Lotze T, Moodley M, Ness J, Rensel M, Rubin J, Schreiner T, Tillema JM, Waldman A, Krupp L, Graves JS, Waubant E. Several household chemical exposures are associated with pediatric-onset multiple sclerosis. Ann Clin Transl Neurol 2018; 5:1513-1521. [PMID: 30564618 PMCID: PMC6292189 DOI: 10.1002/acn3.663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/05/2018] [Indexed: 12/12/2022] Open
Abstract
Background There is limited information about the potential associations of multiple sclerosis (MS) and commonly used household chemicals. Methods We performed a case‐control study of exposures to common household chemicals during childhood in children with MS and healthy pediatric controls. Exposures to household products were collected from a comprehensive questionnaire (http://www.usnpmsc.org/Documents/EnvironmentalAssessment.pdf) completed by parents at the time of enrollment in the study. Cases included children diagnosed with MS or clinically isolated syndrome with at least two silent T2 bright lesions on MRI, recruited within 4 years of disease onset from 16 pediatric MS clinics in the USA. Multivariate analyses using logistic regression were adjusted for possible confounders including age, sex, race, ethnicity, mother's highest level of education, and urban versus rural living. Results Questionnaire responses to household chemicals were available for 312 eligible cases (median age 15.7 years, 63% girls) and 490 healthy controls (median age 15.0, 57% girls). Exposure to rodenticides (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.35–3.26, P ≤ 0.001), weed control agents (OR 1.99, 95% CI 1.36–2.92, P ≤ 0.001) and products for plant/tree disease control (OR 2.72, 95% CI 1.54–4.82, P ≤ 0.001) anytime during childhood were associated with an increased risk for pediatric‐onset MS in adjusted and multiple comparisons analyses. Conclusions Our findings suggest that exposure to specific household chemicals during early childhood is associated with the risk of developing pediatric‐onset MS. Future studies are needed to elucidate a causal relationship and the exact agents involved.
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Affiliation(s)
- Soe Mar
- Pediatric Multiple Sclerosis and other Demyelinating Disease Center Washington University in St. Louis St. Louis Missouri
| | - Shannon Liang
- Department of Neurology UC Davis Children's Hospital Sacramento California
| | - Michael Waltz
- Data Coordinating and Analysis Center University of Utah Salt Lake City Utah
| | - T Charles Casper
- Data Coordinating and Analysis Center University of Utah Salt Lake City Utah
| | - Manu Goyal
- Department of Radiology Washington University in St. Louis St. Louis Missouri
| | | | - Bianca Weinstock-Guttman
- Jacobs Pediatric Multiple Sclerosis Center State University of New York at Buffalo Buffalo New York
| | - Moses Rodriguez
- Mayo Clinic Pediatric Multiple Sclerosis Center Mayo Clinic Rochester Minnesota
| | - Gregory Aaen
- Pediatric Multiple Sclerosis Center Loma Linda University Children's Hospital Loma Linda California
| | - Anita Belman
- Lourie Center for Pediatric Multiple Sclerosis Stony Brook University Hospital New York New York
| | - Lisa F Barcellos
- Depatment of Epidemiology University of California Berkeley Northern California
| | - John Rose
- Department of Neurology University of Utah Salt Lake City Utah
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program Boston Children's Hospital Boston Massachusetts
| | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program Boston Children's Hospital Boston Massachusetts
| | - Meghan Candee
- Primary Children's Hospital University of Utah Salt Lake City Utah
| | - Tanjua Chitnis
- Partners Pediatric Multiple Sclerosis Center Massachusetts General Hospital Boston Massachusetts
| | - Yolanda Harris
- Center for Pediatric-Onset Demyelinating Disease Children's Hospital of Alabama University of Alabama Birmingham Alabama
| | - Ilana Kahn
- Children's National Medical Center Washington DC
| | - Shelly Roalsted
- Data Coordinating and Analysis Center University of Utah Salt Lake City Utah
| | - Janace Hart
- Pediatric Multiple Sclerosis Center University of California San Francisco San Francisco California
| | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis Texas Children's Hospital Baylor College of Medicine Houston Texas
| | - Manikum Moodley
- Mellen Center for Multiple Sclerosis Cleveland Clinic Cleveland Ohio
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease Children's Hospital of Alabama University of Alabama Birmingham Alabama
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis Cleveland Clinic Cleveland Ohio
| | | | - Teri Schreiner
- Rocky Mountain Multiple Sclerosis Center Children's Hospital Colorado University of Colorado at Denver Aurora Colorado
| | - Jan-Mendelt Tillema
- Mayo Clinic Pediatric Multiple Sclerosis Center Mayo Clinic Rochester Minnesota
| | - Amy Waldman
- Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Lauren Krupp
- Pediatric Multiple Sclerosis Center New York University New York New York
| | - Jennifer S Graves
- Pediatric Multiple Sclerosis Center University of California San Francisco San Francisco California
| | - Emmanuelle Waubant
- Pediatric Multiple Sclerosis Center University of California San Francisco San Francisco California
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13
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Lavery AM, Waubant E, Casper TC, Roalstad S, Candee M, Rose J, Belman A, Weinstock-Guttman B, Aaen G, Tillema JM, Rodriguez M, Ness J, Harris Y, Graves J, Krupp L, Charvet L, Benson L, Gorman M, Moodley M, Rensel M, Goyal M, Mar S, Chitnis T, Schreiner T, Lotze T, Greenberg B, Kahn I, Rubin J, Waldman AT. Urban air quality and associations with pediatric multiple sclerosis. Ann Clin Transl Neurol 2018; 5:1146-1153. [PMID: 30349849 PMCID: PMC6186930 DOI: 10.1002/acn3.616] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/12/2018] [Accepted: 06/01/2018] [Indexed: 01/26/2023] Open
Abstract
Background We previously identified air quality as a risk factor of interest for pediatric multiple sclerosis. The purpose of this study is to more closely examine the association between the six criteria air pollutants and pediatric MS as well as identify specific areas of toxic release using data from the Toxic Release Inventory. Methods Pediatric MS cases (N = 290) and healthy controls (N = 442) were included as part of an ongoing case-control study. We used the National Emissions Inventory system to estimate particulate exposure by county of residence for each participant. Proximity to Toxic Release Inventory (TRI) sites was also assessed using ArcGIS mapping tools. Risk-Screening Environmental Indicators (RSEI) classified counties at risk to exposure of environmental toxic releases. Results Fine particulate matter (PM 2.5), carbon monoxide (CO), sulfur dioxide (SO 2), and lead air emissions were associated with increased odds for pediatric MS (P < 0.01) for those residing within 20 miles of an MS center. Most study participants (75%) resided within 5 miles of at least one TRI site; however, the mean total pounds of stack air releases was higher for sites near MS cases (81,000 tons) compared to those near healthy controls (35,000 tons, P = 0.002). Average RSEI scores did not differ significantly between cases and controls. Conclusion Out of several air pollutants examined, we show that fine particulate matter and three other criteria pollutants (SO 2, CO, and lead) were statistically associated with higher odds for pediatric MS.
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Affiliation(s)
- Amy M Lavery
- Division of Child Neurology Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | | | | | | | | | - John Rose
- University of Utah Salt Lake City Utah
| | | | | | - Greg Aaen
- Loma Linda University Children's Hospital Loma Linda California
| | | | | | - Jayne Ness
- University of Alabama Tuscaloosa Alabama
| | | | - Jennifer Graves
- University of California San Francisco San Francisco California
| | - Lauren Krupp
- New York University Medical Center New York New York
| | - Leigh Charvet
- New York University Medical Center New York New York
| | - Leslie Benson
- Boston Children's Pediatric MS Center Boston Massachusetts
| | - Mark Gorman
- Boston Children's Pediatric MS Center Boston Massachusetts
| | | | | | - Manu Goyal
- Washington University in St. Louis St. Louis Missouri
| | - Soe Mar
- Washington University in St. Louis St. Louis Missouri
| | - Tanuja Chitnis
- Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
| | | | - Tim Lotze
- Texas Children's Hospital Houston Texas
| | | | - Ilana Kahn
- Children's National Medical Center Washington District of Columbia
| | | | - Amy T Waldman
- Division of Child Neurology Children's Hospital of Philadelphia Philadelphia Pennsylvania
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14
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Nourbakhsh B, Rutatangwa A, Waltz M, Rensel M, Moodley M, Graves J, Casper TC, Waldman A, Belman A, Greenberg B, Goyal M, Harris Y, Kahn I, Lotze T, Mar S, Schreiner T, Aaen G, Hart J, Ness J, Rubin J, Tillema JM, Krupp L, Gorman M, Benson L, Rodriguez M, Chitnis T, Rose J, Candee M, Weinstock-Guttman B, Shao X, Barcellos L, James J, Waubant E. Heterogeneity in association of remote herpesvirus infections and pediatric MS. Ann Clin Transl Neurol 2018; 5:1222-1228. [PMID: 30349857 PMCID: PMC6186938 DOI: 10.1002/acn3.636] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/21/2022] Open
Abstract
Objective While prior Epstein–Barr virus (EBV) infection has been consistently associated with subsequent risk of developing multiple sclerosis (MS), the association with other common herpesviruses has been more controversial. Our objectives were to determine whether remote infection with EBV and other common herpesviruses affect the susceptibility to pediatric MS and if there are interactions between genetic and demographic factors and viral infections. Methods Cases with pediatric‐onset MS or clinically isolated syndrome within 4 years of disease onset, and controls were recruited from 16 American pediatric MS centers. Logistic regression models adjusted for potential confounders assessed the association between case status and serological evidence for past infection with EBV, cytomegalovirus (CMV), Herpes Simplex viruses‐1 (HSV‐1) and ‐2. We determined the heterogeneity of the effect of viral infection on the risk of having MS according to race, ethnicity and HLA‐DRB1:1501 status. Results A total of 356 pediatric cases and 493 controls were recruited. In multivariable models, EBV‐viral capsid antigen (VCA) seropositivity was associated with increased odds of having MS by 7.4 times (95% CI: 4.5–12.0, P < 0.001). Seropositivity for HSV‐1 was also associated with increased odds of having MS (OR 1.54, 95% CI: 1.06–2.25, P = 0.025) but this increase was seen only in Whites (OR = 2.18, 95% CI 1.35–3.52, P < 0.001) and those negative for HLA‐DRB1*1501 (OR = 1.89, 95% CI 1.17–3.03, P = 0.009). The effect of remote EBV infection on the risk of pediatric MS depended on race and HLA‐DRB1*15:01 status. Interpretation EBV seropositivity is strongly associated with pediatric MS, as is HSV‐1 seropositivity in subjects negative for HLA‐DRB1*15:01. Our report of interactions between select viral exposures, and age, race and DRB1 status suggests a complex effect of environmental and genetic risk factors on MS development.
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Affiliation(s)
| | - Alice Rutatangwa
- Department of Neurology Stony Brook University Hospital Stony Brook New York
| | - Michael Waltz
- Department of Pediatrics University of Utah Salt Lake City Utah
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis Cleveland Clinic Cleveland Ohio
| | - Manikum Moodley
- Mellen Center for Multiple Sclerosis Cleveland Clinic Cleveland Ohio
| | | | | | - Amy Waldman
- Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Anita Belman
- Lourie Center for Pediatric MS at Stony Brook University Hospital Stony Brook New York
| | | | - Manu Goyal
- Washington University Pediatric MS and other Demyelinating Disease Center Washington University in St. Louis St. Louis Missouri
| | - Yolanda Harris
- Center for Pediatric-Onset Demyelinating Disease at the Children's of Alabama University of Alabama Birmingham Alabama
| | - Ilana Kahn
- Children's National Medical Center Washington District of Columbia
| | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis Texas Children's Hospital Baylor College of Medicine Houston Texas
| | - Soe Mar
- Washington University Pediatric MS and other Demyelinating Disease Center Washington University in St. Louis St. Louis Missouri
| | - Teri Schreiner
- Rocky Mountain MS Center Children's Hospital Colorado University of Colorado at Denver Aurora Colorado
| | - Gregory Aaen
- Pediatric Multiple Sclerosis Center at Loma Linda University Children's Hospital Loma Linda University Loma Linda California
| | - Janace Hart
- UCSF Regional Pediatric MS Center San Francisco California
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease at the Children's of Alabama University of Alabama Birmingham Alabama
| | | | | | - Lauren Krupp
- Pediatric MS Center New York University New York New York
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital Harvard Medical School Boston Massachusetts
| | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program at Boston Children's Hospital Harvard Medical School Boston Massachusetts
| | - Moses Rodriguez
- Mayo Clinic Pediatric MS Center Mayo Clinic Rochester Minnesota
| | - Tanuja Chitnis
- Partners Pediatric MS Center Massachusetts General Hospital Boston Massachusetts
| | - John Rose
- Department of Neurology University of Utah Salt Lake City Utah
| | - Meghan Candee
- Primary Children's Hospital University of Utah Salt Lake City Utah
| | - Bianca Weinstock-Guttman
- The Pediatric MS Center at the Jacobs Neurological Institute State University of New York at Buffalo Buffalo New York
| | - Xiaorong Shao
- School of Public Health University of California, Berkeley Berkeley California
| | - Lisa Barcellos
- School of Public Health University of California, Berkeley Berkeley California
| | - Judith James
- University of Oklahoma Health Sciences Center Oklahoma City Oklahoma
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15
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Pakpoor J, Seminatore B, Graves J, Schreiner T, Waldman A, Lotze T, Belman A, Greenberg B, Weinstock-Guttman B, Aaen G, Tillema J, McDonald J, Hart J, Ness J, Harris Y, Rubin J, Candee M, Krupp L, Gorman M, Benson L, Rodriguez M, Chitnis T, Mar S, Kahn I, Rose J, Carmichael S, Roalstad S, Waltz M, Casper T, Waubant E. Dietary factors and pediatric multiple sclerosis: A case-control study. Mult Scler 2018; 24:1067-1076. [PMID: 28608728 PMCID: PMC5711616 DOI: 10.1177/1352458517713343] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of diet in multiple sclerosis (MS) is largely uncharacterized, particularly as it pertains to pediatric-onset disease. OBJECTIVE To determine the association between dietary factors and MS in children. METHODS Pediatric MS patients and controls were recruited from 16 US centers (MS or clinically isolated syndrome onset before age 18, <4 years from symptom onset and at least 2 silent lesions on magnetic resonance imaging). The validated Block Kids Food Screener questionnaire was administered 2011-2016. Chi-squared test compared categorical variables, Kruskal-Wallis test compared continuous variables, and multivariable logistic regression analysis was performed. RESULTS In total, 312 cases and 456 controls were included (mean ages 15.1 and 14.4 years). In unadjusted analyses, there was no difference in intake of fats, proteins, carbohydrates, sugars, fruits, or vegetables. Dietary iron was lower in cases ( p = 0.04), and cases were more likely to consume below recommended guidelines of iron (77.2% of cases vs 62.9% of controls, p < 0.001). In multivariable analysis, iron consumption below recommended guidelines was associated with MS (odds ratio = 1.80, p < 0.01). CONCLUSION Pediatric MS cases may be less likely to consume sufficient iron compared to controls, and this warrants broader study to characterize a temporal relationship. No other significant difference in intake of most dietary factors was found.
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Affiliation(s)
- J. Pakpoor
- Unit of Health-Care Epidemiology, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - B. Seminatore
- Multiple Sclerosis Center, University of California, San Francisco, CA
| | - J. Graves
- Multiple Sclerosis Center, University of California, San Francisco, CA
| | - T. Schreiner
- University of Colorado School of Medicine, Neurology
| | - A. Waldman
- Children’s Hospital of Philadelphia, Neurology
| | - T. Lotze
- Texas Children’s Hospital, Child Neurology
| | - A. Belman
- Stony Brook University Medical Center, Department of Neurology, Neurology
| | | | | | - G. Aaen
- Loma Linda University, Neurology
| | | | - J. McDonald
- Multiple Sclerosis Center, University of California, San Francisco, CA
| | - J. Hart
- University of California, San Francisco, Regional Pediatric MS Center, Neurology
| | - J. Ness
- University of Alabama at Birmingham, Pediatrics
| | - Y. Harris
- University of Alabama at Birmingham, Pediatrics
| | - J. Rubin
- Ann & Robert Lurie Children's Hospital of Chicago, Neurology
| | | | - L. Krupp
- Stony Brook University Medical Center, Department of Neurology, Neurology
| | - M. Gorman
- Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center
| | - L. Benson
- Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center
| | | | | | - S. Mar
- Washington University St. Louis, Neurology
| | - I. Kahn
- Children’s National Medical Center, Washington, D.C
| | - J. Rose
- University of Utah, Neurology
| | - S.L. Carmichael
- Department of Pediatrics Division of Neonatal and Developmental Medicine, Stanford University, California, USA
| | | | | | | | - E. Waubant
- Multiple Sclerosis Center, University of California, San Francisco, CA
- University of California, San Francisco, Regional Pediatric MS Center, Neurology
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16
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Suleiman L, Waubant E, Aaen G, Belman A, Benson L, Candee M, Chitnis T, Gorman M, Goyal M, Greenberg B, Harris Y, Hart J, Kahn I, Krupp L, Lotze T, Mar S, Moodley M, Ness J, Nourbakhsh B, Rensel M, Rodriguez M, Rose J, Rubin J, Schreiner T, Tillema JM, Waldman A, Weinstock-Guttman B, Casper TC, Waltz M, Graves JS. Early infectious exposures are not associated with increased risk of pediatric-onset multiple sclerosis. Mult Scler Relat Disord 2018; 22:103-107. [PMID: 29653437 DOI: 10.1016/j.msard.2018.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/16/2018] [Accepted: 03/20/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We sought to determine if early infectious exposures such as daycare, early use of antibiotics, vaccinations and other germ exposures including pacifier use and playing on grass are associated with multiple sclerosis (MS) risk in children. METHODS This was a case-control study of children with MS or clinically isolated syndrome (CIS) and healthy controls enrolled at sixteen clinics participating in the US Network of Pediatric MS Centers. Parents completed a comprehensive environmental questionnaire that captured early infectious exposures, habits, and illnesses in the first five years of life. A panel of at least two pediatric MS specialists confirmed diagnosis of participants. Association of early infectious variables with diagnosis was assessed via multivariable logistic regression analyses, adjusting for age, sex, race, ethnicity, US birth region, and socioeconomic status (SES). RESULTS Questionnaire responses for 326 eligible cases (mean age 14.9, 63.5% girls) and 506 healthy pediatric subjects (mean age 14.4, 56.9% girls) were included in analyses. History of flu with high fever before age five (p = 0.01), playing outside in grass and use of special products to treat head lice or scabies (p = 0.04) were associated with increased risk of MS in unadjusted analyses. In the multivariable model adjusted for age, sex, race, ethnicity, and mother's highest educational attainment, these results were not statistically significant. Notably, antibiotic use (p = 0.22) and regular daycare attendance before age 6 (p = 0.09) were not associated with odds of developing MS. CONCLUSION Early infectious factors investigated in this study were not associated with MS risk.
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Affiliation(s)
- Leena Suleiman
- Pediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA.
| | - Emmanuelle Waubant
- Pediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA
| | - Gregory Aaen
- Pediatric Multiple Sclerosis Center, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anita Belman
- Lourie Center for Pediatric Multiple Sclerosis, Stony Brook University Hospital, Stony Brook, New York, NY, USA
| | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Disorders Program, Boston Children's Hospital, Boston, MA, USA
| | - Meghan Candee
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Disorders Program, Boston Children's Hospital, Boston, MA, USA
| | - Manu Goyal
- University Pediatric Multiple Sclerosis and other Demyelinating Disease Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | | | - Yolanda Harris
- Center for Pediatric-Onset Demyelinating Disease, Children's Hospital of Alabama, University of Alabama, Birmingham, AL, USA
| | - Janace Hart
- Pediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA
| | - Ilana Kahn
- Children's National Medical Center, Washington, DC, USA
| | - Lauren Krupp
- Pediatric Multiple Sclerosis Center, New York University, New York, NY, USA
| | - Timothy Lotze
- The Blue Bird Circle Clinic for Multiple Sclerosis, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Soe Mar
- University Pediatric Multiple Sclerosis and other Demyelinating Disease Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Manikum Moodley
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Jayne Ness
- Center for Pediatric-Onset Demyelinating Disease, Children's Hospital of Alabama, University of Alabama, Birmingham, AL, USA
| | - Bardia Nourbakhsh
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Moses Rodriguez
- Mayo Clinic Pediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | | | - Teri Schreiner
- Rocky Mountain Multiple Sclerosis Center, Children's Hospital Colorado, University of Colorado at Denver, Aurora, CO, USA
| | - Jan-Mendelt Tillema
- Mayo Clinic Pediatric Multiple Sclerosis Center, Mayo Clinic, Rochester, MN, USA
| | - Amy Waldman
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bianca Weinstock-Guttman
- Pediatric Multiple Sclerosis Center, Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - T Charles Casper
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael Waltz
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, Utah, USA
| | - Jennifer S Graves
- Pediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA, USA
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17
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Azary S, Schreiner T, Graves J, Waldman A, Belman A, Guttman BW, Aaen G, Tillema JM, Mar S, Hart J, Ness J, Harris Y, Krupp L, Gorman M, Benson L, Rodriguez M, Chitnis T, Rose J, Barcellos LF, Lotze T, Carmichael SL, Roalstad S, Casper CT, Waubant E. Contribution of dietary intake to relapse rate in early paediatric multiple sclerosis. J Neurol Neurosurg Psychiatry 2018; 89:28-33. [PMID: 28993476 PMCID: PMC5732893 DOI: 10.1136/jnnp-2017-315936] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 08/09/2017] [Accepted: 08/09/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The role of diet in multiple sclerosis (MS) course remains largely unknown. Children with MS have a higher relapse rate compared with MS in adults. Thus, studying the effect of diet on relapse rate in this age group is likely to provide more robust answers. METHODS This is a multicentre study done at 11 paediatric MS centres in the USA. Patients with relapsing-remitting MS (RRMS) or clinically isolated syndrome (CIS) with disease onset before 18 years of age and duration of less than 4 years were included in this study. Dietary intake during the week before enrolment was assessed with the validated Block Kids Food Screener. The outcome of the study was time from enrolment to the next relapse. 219 patients with paediatric RRMS or CIS were enrolled. Each 10% increase in energy intake from fat increased the hazard of relapse by 56% (adjusted HR 1.56, 95% CI 1.05 to 2.31, p=0.027), and in particular each 10% increase in saturated fat tripled this hazard (adjusted HR: 3.37, 95% CI 1.34 to 8.43, p=0.009). In contrast, each additional one cup equivalent of vegetable decreased the hazard of relapse by 50% (adjusted HR: 0.50, 95% CI 0.27 to 0.91, p=0.024). These associations remained with mutual adjustment and persisted when adjusting for baseline 25(OH) vitamin D serum level. Other studied nutrients were not associated with relapse. CONCLUSIONS This study suggests that in children with MS, high energy intake from fat, especially saturated fat, may increase the hazard to relapse, while vegetable intake may be independently protective.
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Affiliation(s)
- Saeedeh Azary
- Department of Neurology, UCSF Regional Pediatric MS Center, San Francisco, California, USA
| | - Teri Schreiner
- Department of Neurology, University of Colorado, Aurora, Colorado, USA
| | - Jennifer Graves
- Department of Neurology, UCSF Regional Pediatric MS Center, San Francisco, California, USA
| | - Amy Waldman
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Belman
- Department of Neurology, SUNY Stony Brook, Stony Brook, New York, USA
| | - Bianca Weinstock Guttman
- Department of Neurology, The Pediatric MS Center at the Jacobs Neurological Institute, SUNY, Buffalo, New York, USA
| | - Gregory Aaen
- Department of Child Neurology, Loma Linda University, Loma Linda, California, USA
| | | | - Soe Mar
- Division of Pediatric Neurology, Washington University, St. Louis, Missouri, USA
| | - Janace Hart
- Department of Neurology, UCSF Regional Pediatric MS Center, San Francisco, California, USA
| | - Jayne Ness
- Department of Neurology, Alabama Pediatric MS Center, Birmingham, Alabama, USA
| | - Yolanda Harris
- Department of Neurology, Alabama Pediatric MS Center, Birmingham, Alabama, USA
| | - Lauren Krupp
- Department of Neurology, New York University, New York City, New York, USA
| | - Mark Gorman
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Leslie Benson
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Moses Rodriguez
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tanuja Chitnis
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Lisa F Barcellos
- Division of Epidemiology, UC Berkeley, Berkeley, California, USA
| | - Tim Lotze
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Shelly Roalstad
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Charles T Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Emmanuelle Waubant
- Department of Neurology, UCSF Regional Pediatric MS Center, San Francisco, California, USA
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18
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Graves JS, Barcellos LF, Simpson S, Belman A, Lin R, Taylor BV, Ponsonby AL, Dwyer T, Krupp L, Waubant E, van der Mei IAF. The multiple sclerosis risk allele within the AHI1 gene is associated with relapses in children and adults. Mult Scler Relat Disord 2017; 19:161-165. [PMID: 29409597 DOI: 10.1016/j.msard.2017.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/12/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND While common variant non-HLA (human leukocyte antigen) alleles have been associated with MS risk, their role in disease course is less clear. We sought to determine whether established multiple sclerosis (MS) genetic susceptibility factors are associated with relapse rate in children and an independent cohort of adults with MS. METHODS Genotyping was performed for 182 children with MS or clinically isolated syndrome with high risk for MS from two Pediatric MS Centers. They were prospectively followed for relapses. Fifty-two non-HLA MS susceptibility single nucleotide polymorphisms (SNPs) were evaluated for association with relapse rate. Cox regression models were adjusted for sex, genetic ancestry, disease-modifying therapy (DMT), 25-OH vitamin D level and HLA-DRB1*15:01/03 status. Investigation of pediatric subject SNP results was performed using a second cohort of 141 adult MS subjects of Northern European ancestry from the Southern Tasmanian Multiple Sclerosis Longitudinal Study. RESULTS For pediatric subjects, 408 relapses were captured over 622 patient-years of follow-up. Four non-HLA risk SNPs (rs11154801, rs650258, rs12212193, rs2303759) were associated with relapses (p < 0.01) in the pediatric subjects. After adjustment for genetic ancestry, sex, age, vitamin D level, DMT use and HLA-DRB1*15 status, having two copies of the MS risk allele within AHI1 (rs11154801) was associated with increased relapses among children (HR = 1.75,95%CI = 1.18-2.48, p = 0.006) and this result was also observed among adults (HR = 1.81,95%CI = 1.05-3.03, p = 0.026). CONCLUSIONS Our results suggest that the MS genetic risk variant within the gene AHI1 may contribute to disease course in addition to disease susceptibility.
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Affiliation(s)
- Jennifer S Graves
- UCSF Pediatric MS Center, San Francisco, CA, USA; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Lisa F Barcellos
- Genetic Epidemiology and Genomics Lab, School of Public Health, and California Institute of Quantitative Biosciences, UC Berkeley, Berkeley, CA, USA; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Steve Simpson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Anita Belman
- National Pediatric MS Center, Stonybrook, NY, USA; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Rui Lin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Guangxi Center for Disease Prevention and Control, Nanning, China; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Anne-Louise Ponsonby
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Terence Dwyer
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Lauren Krupp
- National Pediatric MS Center, Stonybrook, NY, USA; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Emmanuelle Waubant
- UCSF Pediatric MS Center, San Francisco, CA, USA; School of Medicine, University of Tasmania, Hobart, Australia.
| | - Ingrid A F van der Mei
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; School of Medicine, University of Tasmania, Hobart, Australia.
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19
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Gianfrancesco MA, Stridh P, Shao X, Rhead B, Graves JS, Chitnis T, Waldman A, Lotze T, Schreiner T, Belman A, Greenberg B, Weinstock-Guttman B, Aaen G, Tillema JM, Hart J, Caillier S, Ness J, Harris Y, Rubin J, Candee M, Krupp L, Gorman M, Benson L, Rodriguez M, Mar S, Kahn I, Rose J, Roalstad S, Casper TC, Shen L, Quach H, Quach D, Hillert J, Hedstrom A, Olsson T, Kockum I, Alfredsson L, Schaefer C, Barcellos LF, Waubant E. Genetic risk factors for pediatric-onset multiple sclerosis. Mult Scler 2017; 24:1825-1834. [PMID: 28980494 DOI: 10.1177/1352458517733551] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Strong evidence supports the role of both genetic and environmental factors in pediatric-onset multiple sclerosis (POMS) etiology. OBJECTIVE We comprehensively investigated the association between established major histocompatibility complex (MHC) and non-MHC adult multiple sclerosis (MS)-associated variants and susceptibility to POMS. METHODS Cases with onset <18 years (n = 569) and controls (n = 16,251) were included from the United States and Sweden. Adjusted logistic regression and meta-analyses were performed for individual risk variants and a weighted genetic risk score (wGRS) for non-MHC variants. Results were compared to adult MS cases (n = 7588). RESULTS HLA-DRB1*15:01 was strongly associated with POMS (odds ratio (OR)meta = 2.95, p < 2.0 × 10-16). Furthermore, 28 of 104 non-MHC variants studied (23%) were associated (p < 0.05); POMS cases carried, on average, a higher burden of these 28 variants compared to adults (ORavg = 1.24 vs 1.13, respectively), though the difference was not significant. The wGRS was strongly associated with POMS (ORmeta = 2.77, 95% confidence interval: 2.33, 3.32, p < 2.0 × 10-16) and higher, on average, when compared to adult cases. Additional class III risk variants in the MHC region associated with POMS were revealed after accounting for HLA-DRB1*15:01 and HLA-A*02. CONCLUSION Pediatric and adult MS share many genetic variants suggesting similar biological processes are present. MHC variants beyond HLA-DRB1*15:01 and HLA-A*02 are also associated with POMS.
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Affiliation(s)
- Milena A Gianfrancesco
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Pernilla Stridh
- Department of Clinical Neuroscience and Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Xiaorong Shao
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Brooke Rhead
- Computational Biology Graduate Group, University of California, Berkeley, Berkeley, CA, USA
| | - Jennifer S Graves
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Amy Waldman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy Lotze
- Blue Bird Circle Multiple Sclerosis Center, Baylor College of Medicine, Houston, TX, USA
| | - Teri Schreiner
- Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Anita Belman
- The Lourie Center for Pediatric MS, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - Benjamin Greenberg
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
| | - Bianca Weinstock-Guttman
- Pediatric Multiple Sclerosis Center, Jacobs Neurological Institute, SUNY Buffalo, Buffalo, NY, USA
| | - Gregory Aaen
- Pediatric MS Center, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Jan M Tillema
- Pediatric MS Center, Mayo Clinic, Rochester, MN, USA
| | - Janace Hart
- Department of Neurology and Regional Pediatric MS Center, University of California, San Francisco, San Francisco, CA, USA
| | - Stacy Caillier
- Department of Neurology and Regional Pediatric MS Center, University of California, San Francisco, San Francisco, CA, USA
| | - Jayne Ness
- Center for Pediatric Onset Demyelinating Disease, University of Alabama and Children's Hospital of Alabama, Birmingham, AL, USA
| | - Yolanda Harris
- Center for Pediatric Onset Demyelinating Disease, University of Alabama and Children's Hospital of Alabama, Birmingham, AL, USA
| | - Jennifer Rubin
- Division of Neurology, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Meghan Candee
- University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Lauren Krupp
- The Lourie Center for Pediatric MS, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | | | | | | | - Soe Mar
- Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Ilana Kahn
- Children's National Medical Center, Washington, DC, USA
| | - John Rose
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shelly Roalstad
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ling Shen
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Hong Quach
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Diana Quach
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Jan Hillert
- Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden
| | - Anna Hedstrom
- Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience and Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience and Center for Molecular Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Lars Alfredsson
- Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden/Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Catherine Schaefer
- Division of Research, Kaiser Permanente, Oakland, CA, USA/Research Program on Genes, Environment and Health, Kaiser Permanente, Oakland, CA
| | - Lisa F Barcellos
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA/Computational Biology Graduate Group, University of California, Berkeley, Berkeley, CA, USA; Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Emmanuelle Waubant
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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20
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Zhou Y, Graves JS, Simpson S, Charlesworth JC, Mei IVD, Waubant E, Barcellos LF, Belman A, Krupp L, Lucas R, Ponsonby AL, Taylor BV. Genetic variation in the gene LRP2 increases relapse risk in multiple sclerosis. J Neurol Neurosurg Psychiatry 2017; 88:864-868. [PMID: 28739605 DOI: 10.1136/jnnp-2017-315971] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Due to the lack of prospective studies with longitudinal data on relapse, past genetic studies have not attempted to identify genetic factors that predict relapse risk (the primary endpoint of many pivotal clinical trials testing the efficacy of multiple sclerosis (MS) disease-modifying drugs) at a genome-wide scale. METHODS We conducted a genome-wide association analysis (GWAS) to identify genetic variants that predict MS relapse risk, using a three-stage approach. First, GWAS was conducted using the southern Tasmania MS Longitudinal Study with 141 cases followed prospectively for a mean of 2.3 years. Second, GWAS was conducted using the Ausimmune Longitudinal Study with 127 cases having a classic first demyelinating event followed for 5 years from onset. Third, the top hits with p<5.0×10-6 from the first two stages were combined with a longitudinal US paediatric MS cohort with 181 cases followed for 5 years after onset. Predictors of time to relapse were evaluated by a mixed effects Cox model. An inverse variance fixed effects model was then used to undertake a meta-analysis. RESULTS In the pooled results, using these three unique longitudinal MS cohorts, we discovered one novel locus (LRP2; most significant single nucleotide polymorphism rs12988804) that reached genome-wide significance in predicting relapse risk (HR=2.18, p=3.30×10-8). LRP2 is expressed on the surface of many central nervous system cells including neurons and oligodendrocytes and is a critical receptor in axonal guidance. CONCLUSIONS The finding of a genetic locus that has extensive effects on neuronal development and repair is of interest as a potential modulator of MS disease course.
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Affiliation(s)
- Yuan Zhou
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Jennifer S Graves
- Department of Neurology, University of California, San Francisco, USA
| | - Steve Simpson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.,Institute for Health and Ageing, Australian Catholic University, Melbourne, Australia
| | - Jac C Charlesworth
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Ingrid van der Mei
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | | | - Lisa F Barcellos
- Division of Epidemiology, School of Public Health, University of California, Berkeley, USA
| | - Anita Belman
- Stonybrook University, Stonybrook, New York, USA
| | | | - Robyn Lucas
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia
| | - Anne-Louise Ponsonby
- Murdoch Childrens Research Institute, University of Melbourne, Melbourne, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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21
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Lavery AM, Waldman AT, Charles Casper T, Roalstad S, Candee M, Rose J, Belman A, Weinstock-Guttman B, Aaen G, Tillema JM, Rodriguez M, Ness J, Harris Y, Graves J, Krupp L, Benson L, Gorman M, Moodley M, Rensel M, Goyal M, Mar S, Chitnis T, Schreiner T, Lotze T, Greenberg B, Kahn I, Rubin J, Waubant E. Examining the contributions of environmental quality to pediatric multiple sclerosis. Mult Scler Relat Disord 2017; 18:164-169. [PMID: 29141802 DOI: 10.1016/j.msard.2017.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/05/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a presumed autoimmune disease caused by genetic and environmental factors. It is hypothesized that environmental exposures (such as air and water quality) trigger the innate immune response thereby activating a pro-inflammatory cascade. OBJECTIVE To examine potential environmental factors in pediatric MS using geographic information systems (GIS). METHODS Pediatric MS cases and healthy controls were identified as part of an ongoing multicenter case-control study. Subjects' geographic locations were mapped by county centroid to compare to an Environmental Quality Index (EQI). The EQI examines 5 individual environmental components (air, land, water, social, built factors). A composite EQI score and individual scores were compared between cases and controls, stratified by median proximity to enrollment centers (residence <20 or ≥20 miles from the recruiting center), using logistic regression. RESULTS Of the 287 MS cases and 445 controls, 46% and 49% respectively live in areas where the total EQI is the highest (worst environmental quality). Total EQI was not significantly associated with the odds for MS (p = 0.90 < 20 miles from center; p = 0.43 ≥ 20 miles); however, worsening air quality significantly impacted the odds for MS in those living near a referral center (OR = 2.83; 95%CI 1.5, 5.4) and those who reside ≥ 20 miles from a referral center (OR = 1.61; 95%CI 1.2, 2.3). CONCLUSION Among environmental factors, air quality may contribute to the odds of developing MS in a pediatric population. Future studies will examine specific air constituents and other location-based air exposures and explore potential mechanisms for immune activation by these exposures.
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Affiliation(s)
- Amy M Lavery
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Amy T Waldman
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | | | - Meghan Candee
- University of Utah, Salt Lake City, UT, United States
| | - John Rose
- University of Utah, Salt Lake City, UT, United States
| | - Anita Belman
- Stony Brook University, Stony Brook, NY, United States
| | | | - Greg Aaen
- Loma Linda University Children's Hospital, Loma Linda, CA, United States
| | | | | | - Jayne Ness
- University of Alabama, Tuscaloosa, AL, United States
| | | | - Jennifer Graves
- University of California San Francisco, San Francisco, CA, United States
| | - Lauren Krupp
- New York University Medical Center, New York, NY, United States
| | - Leslie Benson
- Boston Children's Pediatric MS Center, Boston, MA, United States
| | - Mark Gorman
- Boston Children's Pediatric MS Center, Boston, MA, United States
| | | | - Mary Rensel
- Cleveland Clinic, Cleveland, OH, United States
| | - Manu Goyal
- Washington University in St. Louis, St. Louis, MO, United States
| | - Soe Mar
- Washington University in St. Louis, St. Louis, MO, United States
| | - Tanuja Chitnis
- Massachusetts General Hospital, Harvard Medical School, Boston, MS, United Staes
| | | | - Tim Lotze
- Texas Children's Hospital, Houston, TX, United States
| | - Benjamin Greenberg
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ilana Kahn
- Children's National Medical Center, Washington, DC, United States
| | | | - Emmanuelle Waubant
- University of California San Francisco, San Francisco, CA, United States
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22
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Gianfrancesco MA, Stridh P, Rhead B, Shao X, Xu E, Graves JS, Chitnis T, Waldman A, Lotze T, Schreiner T, Belman A, Greenberg B, Weinstock-Guttman B, Aaen G, Tillema JM, Hart J, Caillier S, Ness J, Harris Y, Rubin J, Candee M, Krupp L, Gorman M, Benson L, Rodriguez M, Mar S, Kahn I, Rose J, Roalstad S, Casper TC, Shen L, Quach H, Quach D, Hillert J, Bäärnhielm M, Hedstrom A, Olsson T, Kockum I, Alfredsson L, Metayer C, Schaefer C, Barcellos LF, Waubant E. Evidence for a causal relationship between low vitamin D, high BMI, and pediatric-onset MS. Neurology 2017; 88:1623-1629. [PMID: 28356466 DOI: 10.1212/wnl.0000000000003849] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/20/2017] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To utilize Mendelian randomization to estimate the causal association between low serum vitamin D concentrations, increased body mass index (BMI), and pediatric-onset multiple sclerosis (MS) using genetic risk scores (GRS). METHODS We constructed an instrumental variable for vitamin D (vitD GRS) by computing a GRS for 3 genetic variants associated with levels of 25(OH)D in serum using the estimated effect of each risk variant. A BMI GRS was also created that incorporates the cumulative effect of 97 variants associated with BMI. Participants included non-Hispanic white individuals recruited from over 15 sites across the United States (n = 394 cases, 10,875 controls) and Sweden (n = 175 cases, 5,376 controls; total n = 16,820). RESULTS Meta-analysis findings demonstrated that a vitD GRS associated with increasing levels of 25(OH)D in serum decreased the odds of pediatric-onset MS (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.55, 0.94; p = 0.02) after controlling for sex, genetic ancestry, HLA-DRB1*15:01, and over 100 non-human leukocyte antigen MS risk variants. A significant association between BMI GRS and pediatric disease onset was also demonstrated (OR 1.17, 95% CI 1.05, 1.30; p = 0.01) after adjusting for covariates. Estimates for each GRS were unchanged when considered together in a multivariable model. CONCLUSIONS We provide evidence supporting independent and causal effects of decreased vitamin D levels and increased BMI on susceptibility to pediatric-onset MS.
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Affiliation(s)
- Milena A Gianfrancesco
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Pernilla Stridh
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Brooke Rhead
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Xiaorong Shao
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Edison Xu
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Jennifer S Graves
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Tanuja Chitnis
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Amy Waldman
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Timothy Lotze
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Teri Schreiner
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Anita Belman
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Benjamin Greenberg
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Bianca Weinstock-Guttman
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Gregory Aaen
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Jan M Tillema
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Janace Hart
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Stacy Caillier
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Jayne Ness
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Yolanda Harris
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Jennifer Rubin
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Meghan Candee
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Lauren Krupp
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Mark Gorman
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Leslie Benson
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Moses Rodriguez
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Soe Mar
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Ilana Kahn
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - John Rose
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Shelly Roalstad
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - T Charles Casper
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Ling Shen
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Hong Quach
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Diana Quach
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Jan Hillert
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Maria Bäärnhielm
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Anna Hedstrom
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Tomas Olsson
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Ingrid Kockum
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Lars Alfredsson
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Catherine Metayer
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Catherine Schaefer
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Lisa F Barcellos
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA
| | - Emmanuelle Waubant
- From the Division of Epidemiology, School of Public Health (M.A.G., X.S., E.X., H.Q., D.Q., C.M., L.F.B.), and Computational Biology Graduate Group (B.R.), University of California, Berkeley; Department of Clinical Neuroscience and Center for Molecular Medicine (P.S.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Neurology (J.S.G., E.W.) and Regional Pediatric MS Center, Neurology (J.H., S.C.), University of California, San Francisco; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; Division of Neurology (A.W.), Children's Hospital of Philadelphia, PA; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Children's Hospital Colorado (T.S.), University of Colorado, Denver; Lourie Center for Pediatric Multiple Sclerosis (A.B., L.K.), Stony Brook Children's Hospital, NY; Department of Neurology (B.G.), University of Texas Southwestern, Dallas; Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, NY; Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA; Mayo Clinic's Pediatric Multiple Sclerosis Center (J.M.T., M.R.), Rochester, MN; University of Alabama Center for Pediatric-onset Demyelinating Disease (J.N., Y.H.), Children's Hospital of Alabama, Birmingham; Department of Pediatric Neurology (J.R.), Northwestern Feinberg School of Medicine, Chicago, IL; Primary Children's Hospital (M.C.), University of Utah, Salt Lake City; Boston Children's Hospital (M.G., L.B.), MA; Pediatric-onset Demyelinating Diseases and Autoimmune Encephalitis Center (S.M.), St. Louis Children's Hospital, Washington University School of Medicine, MO; Children's National Medical Center (I.K.), Washington, DC; Departments of Neurology (J.R.) and Pediatrics (S.R., T.C.C.), University of Utah School of Medicine, Salt Lake City; Kaiser Permanente Division of Research (L.S., C.S., L.F.B.), Oakland, CA; Institute of Environmental Medicine (J.H., M.B., A.H., T.O., I.K., L.A.), Karolinska Institutet; Centre for Occupational and Environmental Medicine (L.A.), Stockholm County Council, Stockholm, Sweden; and Research Program on Genes, Environment and Health (C.S.), Kaiser Permanente, Oakland, CA.
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Bourne T, Waltz M, Casper TC, Kavak K, Aaen G, Belman A, Benson L, Candee M, Chitnis T, Graves J, Greenberg B, Gorman M, Harris Y, Krupp L, Lotze T, Mar S, Ness J, Olsen C, Roalstad S, Rodriguez M, Rose J, Rubin J, Schreiner T, Tillema JM, Kahn I, Waldman A, Barcellos L, Waubant E, Weinstock-Guttman B. Evaluating the association of allergies with multiple sclerosis susceptibility risk and disease activity in a pediatric population. J Neurol Sci 2017; 375:371-375. [PMID: 28320170 DOI: 10.1016/j.jns.2017.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/16/2017] [Accepted: 02/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) and allergies are both considered to be related to imbalanced Th1 and Th2 immune responses. Previous studies evaluating the relationship between MS and allergies provide conflicting results. OBJECTIVE To assess allergies and asthma as risk factors for MS and as predictors of MS relapses in a pediatric cohort. METHODS The environment and genetic risk factors for pediatric MS study is a national case-control project with 16 participating US sites. An environmental questionnaire is used that includes history of allergies in the first five years of life. Case-control data are entered in the pediatric MS Network database and cases at 12 of the 16 sites enter relapse data prospectively. Annualized relapse rate was calculated for patients with follow-up and adjusted for age at disease onset, gender, race, ethnicity, and use of disease-modifying therapy (DMT). RESULTS We included 271 cases (mean age at disease onset of 15.7years and 62% female) and 418 controls. Relapse data were available for 193 cases. There was no difference in prevalence of allergies or asthma between cases and controls. Patients with food allergies had fewer relapses compared to patients without food allergies (0.14 vs 0.48, p=0.01). CONCLUSIONS While allergies and asthma are not associated with pediatric MS, cases with food allergies have fewer relapses compared to those without food allergies.
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Affiliation(s)
| | | | - T C Casper
- University of Utah, Pediatrics, United States
| | - K Kavak
- State University of New York, Neurology, United States
| | - G Aaen
- Loma Linda University, Neurology, United States
| | - A Belman
- SUNY Stony Brook, Neurology, United States
| | - L Benson
- Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center, United States
| | - M Candee
- University of Utah, Pediatrics, United States
| | - T Chitnis
- Brigham and Women's Hospital, Neurology, United States
| | - J Graves
- Multiple Sclerosis Center, University of California, San Francisco, CA, United States
| | - B Greenberg
- University of Texas Southwestern, Neurology, United States
| | - M Gorman
- Massachusetts General Hospital, Partners Pediatric Multiple Sclerosis Center, United States
| | - Y Harris
- University of Alabama at Birmingham, Pediatrics, United States
| | - L Krupp
- SUNY Stony Brook, Neurology, United States
| | - T Lotze
- Texas Children's Hospital, Child Neurology, United States
| | - S Mar
- Washington University St. Louis, Neurology, United States
| | - J Ness
- University of Alabama at Birmingham, Pediatrics, United States
| | - C Olsen
- University of Utah, Pediatrics, United States
| | - S Roalstad
- University of Utah, Pediatrics, United States
| | | | - J Rose
- University of Utah, Neurology, United States
| | - J Rubin
- Ann & Robert Lurie Children's Hospital of Chicago, Neurology, United States
| | - T Schreiner
- University of Colorado School of Medicine, Neurology, United States
| | | | - I Kahn
- Children's National Medical Center, Washington, United States
| | - A Waldman
- Children's Hospital of Philadelphia, Neurology, United States
| | - L Barcellos
- University of California Berkeley, United States
| | - E Waubant
- Multiple Sclerosis Center, University of California, San Francisco, CA, United States
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24
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Nourbakhsh B, Graves J, Casper TC, Lulu S, Waldman A, Belman A, Greenberg B, Weinstock-Guttman B, Aaen G, Tillema JM, Hart J, Ness J, Rubin J, Krupp L, Gorman M, Benson L, Rodriguez M, Chitnis T, Rose J, Barcellos L, Waubant E. Dietary salt intake and time to relapse in paediatric multiple sclerosis. J Neurol Neurosurg Psychiatry 2016; 87:1350-1353. [PMID: 27343226 PMCID: PMC5370574 DOI: 10.1136/jnnp-2016-313410] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/09/2016] [Accepted: 06/05/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Salt intake was reported to be associated with increased clinical and MRI activity in adult patients with relapsing-remitting multiple sclerosis (MS). OBJECTIVE To determine if salt intake is associated with time to relapse in patients with paediatric-onset MS. METHODS Paediatric-onset MS and patients with clinically isolated syndrome (CIS) within 4 years of disease onset were recruited from 15 paediatric MS centres in the USA as part of a case-control study. Patients with available prospective relapse data subsequent to enrolment were included in this project. Dietary sodium intake was assessed by self-report questionnaire using the validated Block Kids Food Screener. Cox proportional-hazards regression models were employed to determine the association of sodium density, excess sodium intake and sodium density tertiles with time to relapse following study enrolment, adjusting for several confounders. RESULTS 174 relapsing-remitting MS/CIS patients were included in this analysis (mean age of 15.0 years, and 64.9% females). Median duration of follow-up was 1.8 years. In an unadjusted analysis, density of daily sodium intake was not associated with time to relapse, and patients with excess sodium intake had no decrease in time to relapse as compared with patients with non-excess sodium intake. The multivariable analysis demonstrated that patients in the medium and high tertile of sodium density had a HR of 0.69 (95% CI 0.37 to 1.30, p=0.25) and 1.37 (95% CI 0.74 to 2.51, p=0.32) compared with patients in the lowest tertile, respectively. CONCLUSIONS Higher salt intake was not associated with decreased time to relapse in patients with paediatric-onset MS.
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Affiliation(s)
| | - Jennifer Graves
- UCSF Regional Paediatric MS Center, San Francisco, California, USA
| | - T Charles Casper
- Department of Paediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sabeen Lulu
- UCSF Regional Paediatric MS Center, San Francisco, California, USA
| | - Amy Waldman
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Belman
- Department of Neurology, SUNY Stony Brook, Stony Brook, New York, USA
| | | | | | - Gregory Aaen
- Department of Child Neurology, Loma Linda University, Loma Linda, California, USA
| | | | - Janace Hart
- UCSF Regional Paediatric MS Center, San Francisco, California, USA
| | - Jayne Ness
- Alabama Paediatric MS Center, Birmingham, Alabama, USA
| | - Jennifer Rubin
- Department of Paediatric Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Krupp
- Department of Neurology, New York University, New York, New York, USA
| | - Mark Gorman
- Partners Paediatric MS Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leslie Benson
- Partners Paediatric MS Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moses Rodriguez
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tanuja Chitnis
- Partners Paediatric MS Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Rose
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Lisa Barcellos
- Department of Epidemiology, UC Berkeley, Berkeley, California, USA
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Chitnis T, Graves J, Weinstock-Guttman B, Belman A, Olsen C, Misra M, Aaen G, Benson L, Candee M, Gorman M, Greenberg B, Krupp L, Lotze T, Mar S, Ness J, Rose J, Rubin J, Schreiner T, Tillema J, Waldman A, Rodriguez M, Casper C, Waubant E. Distinct effects of obesity and puberty on risk and age at onset of pediatric MS. Ann Clin Transl Neurol 2016; 3:897-907. [PMID: 28097202 PMCID: PMC5224818 DOI: 10.1002/acn3.365] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/13/2016] [Accepted: 09/02/2016] [Indexed: 12/15/2022] Open
Abstract
Objective The aim of this study was to examine the relative contributions of body mass index (BMI) and pubertal measures for risk and age of onset of pediatric MS. Methods Case–control study of 254 (63% female) MS cases (onset<18 years of age) and 420 (49% female) controls conducted at 14 U.S. Pediatric MS Centers. Sex‐ and age‐stratified BMI percentiles were calculated using CDC growth charts from height and weight measured at enrollment for controls, and within 1 year of onset for MS cases. Sex‐stratified associations between MS risk and age at symptom onset with both BMI and pubertal factors were estimated controlling for race and ethnicity. Results Only 11% of girls and 15% of boys were prepubertal (Tanner stage I) at MS onset. 80% of girls had onset of MS after menarche. BMI percentiles were higher in MS cases versus controls (girls: P < 0.001; boys: P = 0.018). BMI was associated with odds of MS in multivariate models in postpubertal girls (OR = 1.60, 95% confidence interval [CI]: 1.12, 2.27, P = 0.009) and boys (OR = 1.43, 95% CI: 1.08, 1.88, P = 0.011). In girls with MS onset after menarche, higher BMI was associated with younger age at first symptoms (P = 0.031). Younger menarche was associated with stronger effects of BMI through mediation and interaction analysis. In pubertal/postpubertal boys, 89% of whom were obese/overweight, earlier sexual maturity was associated with earlier onset of MS (P < 0.001). Interpretation Higher BMI in early adolescence is a risk factor for MS in girls and boys. Earlier age at sexual maturity contributes to earlier age at MS onset, particularly in association with obesity.
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Affiliation(s)
- Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Center Massachusetts General Hospital for Children Boston Massachusetts
| | - Jennifer Graves
- Department of Neurology University of California San Francisco California
| | | | - Anita Belman
- Lourie Center for Pediatric MS Stony Brook Children's Hospital Stonybrook New York
| | - Cody Olsen
- Department of Pediatrics University of Utah Salt Lake City Utah
| | - Madhusmita Misra
- Department of Pediatric Endocrinology Massachusetts General Hospital for Children Boston Massachusetts
| | - Gregory Aaen
- Pediatric MS Center at Loma Linda University Children's Hospital Loma Linda California
| | | | - Meghan Candee
- University of Utah/Primary Children's Hospital Salt Lake City Utah
| | - Mark Gorman
- Boston Children's Hospital Boston Massachusetts
| | | | - Lauren Krupp
- Lourie Center for Pediatric MS Stony Brook Children's Hospital Stonybrook New York
| | - Timothy Lotze
- Blue Bird Circle Multiple Sclerosis Center Baylor College of Medicine Houston Texas
| | - Soe Mar
- Pediatric Onset Demyelinating Diseases and Autoimmune Encephalitis Center St. Louis Children's Hospital Washington University School of Medicine St. Louis Missouri
| | - Jayne Ness
- University of Alabama Center for Pediatric Onset Demyelinating Disease Children's Hospital of Alabama Birmingham Alabama
| | - John Rose
- Department of Neurology University of Utah Salt Lake City Utah
| | - Jennifer Rubin
- Department of Pediatric Neurology Northwestern Feinberg School of Medicine Chicago Illinois
| | - Teri Schreiner
- Children's Hospital Colorado University of Colorado Denver Colorado
| | - Jan Tillema
- Mayo Clinic's Pediatric MS Center Rochester Minnesota
| | - Amy Waldman
- Department of Neurology University of Pennsylvania Philadelphia Pennsylvania
| | | | - Charlie Casper
- Department of Pediatrics University of Utah Salt Lake City Utah
| | - Emmanuelle Waubant
- Department of Neurology University of California San Francisco California; Department of Pediatrics Benioff Children's Hospital University of California San Francisco California
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Charvet L, Cersosimo B, Schwarz C, Belman A, Krupp LB. Behavioral Symptoms in Pediatric Multiple Sclerosis: Relation to Fatigue and Cognitive Impairment. J Child Neurol 2016; 31:1062-7. [PMID: 26961266 PMCID: PMC4925200 DOI: 10.1177/0883073816636227] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 02/05/2016] [Indexed: 11/16/2022]
Abstract
The emotional and behavioral problems associated with pediatric multiple sclerosis remain unclear. Participants with pediatric multiple sclerosis or clinically isolated syndrome (n = 140; ages 5-18 years) completed self- and parent ratings using the Behavioral Assessment System for Children, Second Edition, neurologic exam, the Fatigue Severity Scale, and neuropsychological assessment. Mean self- and parent-ratings on the Behavioral Assessment System for Children, Second Edition, were in the typical range across all scales. However, 33.1% indicated a clinically significant problem on a least 1 scale. Although the type of clinical problems varied across participants, attention problems, somatization, and anxiety were found to be most common. Disease features including duration, age of onset, neurologic disability, and fatigue did not distinguish those with and without clinical problems. However, cognitive functioning significantly predicted the presence of a clinical problem (P =02). Pediatric multiple sclerosis is associated with a range of nonspecific emotional and behavioral clinical problems, occurring more frequently in those patients with cognitive involvement.
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Affiliation(s)
- Leigh Charvet
- New York University MS Comprehensive Care Center, New York, NY, USA
| | - Bianca Cersosimo
- Department of Neurology, Stony Brook Medicine, Stony Brook, NY, USA
| | - Colleen Schwarz
- New York University MS Comprehensive Care Center, New York, NY, USA Department of Neurology, Stony Brook Medicine, Stony Brook, NY, USA
| | - Anita Belman
- New York University MS Comprehensive Care Center, New York, NY, USA Department of Neurology, Stony Brook Medicine, Stony Brook, NY, USA
| | - Lauren B Krupp
- New York University MS Comprehensive Care Center, New York, NY, USA Department of Neurology, Stony Brook Medicine, Stony Brook, NY, USA
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Graves JS, Barcellos LF, Shao X, Noble J, Mowry EM, Quach H, Belman A, Casper TC, Krupp LB, Waubant E. Genetic predictors of relapse rate in pediatric MS. Mult Scler 2016; 22:1528-1535. [PMID: 26769066 DOI: 10.1177/1352458515624269] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 11/25/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Genetic ancestry, sex, and individual alleles have been associated with multiple sclerosis (MS) susceptibility. OBJECTIVE To determine whether established risk factors for disease onset are associated with relapse rate in pediatric MS. METHODS Whole-genome genotyping was performed for 181 MS or high-risk clinically isolated syndrome patients from two pediatric MS centers. Relapses and disease-modifying therapies were recorded as part of continued follow-up. Participants were characterized for 25-hydroxyvitamin D serum status. Ancestral estimates (STRUCTURE v2.3.1), human leukocyte antigen (HLA)-DRB1*15 carrier status (direct sequencing), sex, and a genetic risk score (GRS) of 110 non-HLA susceptibility single-nucleotide polymorphisms (SNPs) were evaluated for association with relapse rate with Cox and negative binomial regression models. RESULTS Over 622 patient-years, 408 relapses were captured. Girls had greater relapse rate than boys (incident rate ratio (IRR) = 1.40, 95% confidence interval (CI) = 1.04-1.87, p = 0.026). Participants were genetically diverse; ~40% (N = 75) had <50% European ancestry. HLA-DRB1*15 status modified the association of vitamin D status (pixn = 0.022) with relapse rate (per 10 ng/mL, in DRB1*15+ hazard ratio (HR) = 0.72, 95% CI = 0.58-0.88, p = 0.002; in DRB1*15- HR = 0.96, 95% CI = 0.83-1.12, p = 0.64). Neither European ancestry nor GRS was associated with relapse rate. CONCLUSION We demonstrate that HLA-DRB1*15 modifies the association of vitamin D status with relapse rate. Our findings emphasize the need to pursue disease-modifying effects of MS genes in the context of environmental factors.
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Affiliation(s)
| | - Lisa F Barcellos
- Genetic Epidemiology and Genomics Lab, School of Public Health, and California Institute for Quantitative Biosciences, University of California-Berkeley, Berkeley, CA, USA
| | - Xiaorong Shao
- Genetic Epidemiology and Genomics Lab, School of Public Health, and California Institute for Quantitative Biosciences, University of California-Berkeley, Berkeley, CA, USA
| | - Janelle Noble
- Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Ellen M Mowry
- The Multiple Sclerosis Center, Johns Hopkins University, Baltimore, MD, USA
| | - Hong Quach
- Genetic Epidemiology and Genomics Lab, School of Public Health, and California Institute for Quantitative Biosciences, University of California-Berkeley, Berkeley, CA, USA
| | - Anita Belman
- National Pediatric Multiple Sclerosis Center, Stony Brook, NY, USA
| | - T Charles Casper
- Data Coordinating and Analysis Center, University of Utah, Salt Lake City, UT, USA
| | - Lauren B Krupp
- National Pediatric Multiple Sclerosis Center, Stony Brook, NY, USA
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Chitnis T, Ness J, Krupp L, Waubant E, Hunt T, Olsen CS, Rodriguez M, Lotze T, Gorman M, Benson L, Belman A, Weinstock-Guttman B, Aaen G, Graves J, Patterson M, Rose JW, Casper TC. Clinical features of neuromyelitis optica in children: US Network of Pediatric MS Centers report. Neurology 2015; 86:245-52. [PMID: 26683648 PMCID: PMC4733158 DOI: 10.1212/wnl.0000000000002283] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 09/21/2015] [Indexed: 01/03/2023] Open
Abstract
Objective: To compare clinical features of pediatric neuromyelitis optica (NMO) to other pediatric demyelinating diseases. Methods: Review of a prospective multicenter database on children with demyelinating diseases. Case summaries documenting clinical and laboratory features were reviewed by an adjudication panel. Diagnoses were assigned in the following categories: multiple sclerosis (MS), acute disseminated encephalomyelitis, NMO, and recurrent demyelinating disease not otherwise specified. Results: Thirty-eight cases of NMO were identified by review panel, 97% of which met the revised International Panel on NMO Diagnosis NMO-SD 2014 criteria, but only 49% met 2006 Wingerchuk criteria. Serum or CSF NMO immunoglobulin G (IgG) was positive in 65% of NMO cases that were tested; however, some patients became seropositive more than 3 years after onset despite serial testing. No patient had positive CSF NMO IgG and negative serum NMO IgG in contemporaneous samples. Other than race (p = 0.02) and borderline findings for sex (p = 0.07), NMO IgG seropositive patients did not differ in demographic, clinical, or laboratory features from seronegatives. Visual, motor, and constitutional symptoms (including vomiting, fever, and seizures) were the most common presenting features of NMO. Initiation of disease-modifying treatment was delayed in NMO vs MS. Two years after onset, patients with NMO had higher attack rates, greater disability accrual measured by overall Expanded Disability Status Scale score, and visual scores than did patients with MS. Conclusion: The new criteria for NMO spectrum disorders apply well to the pediatric setting, and given significant delay in treatment of NMO compared to pediatric MS and worse short-term outcomes, it is imperative to apply these to improve access to treatment.
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Affiliation(s)
- Tanuja Chitnis
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA.
| | - Jayne Ness
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Lauren Krupp
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Emmanuelle Waubant
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Tyler Hunt
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Cody S Olsen
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Moses Rodriguez
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Tim Lotze
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Mark Gorman
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Leslie Benson
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Anita Belman
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Bianca Weinstock-Guttman
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Greg Aaen
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Jennifer Graves
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - Marc Patterson
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - John W Rose
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
| | - T Charles Casper
- From Partners Multiple Sclerosis Center (T.C.), Department of Neurology, Brigham and Women's Hospital, Brookline; Partners Pediatric Multiple Sclerosis Center (T.C.), Massachusetts General Hospital for Children, Boston; University of Alabama Center for Pediatric Onset Demyelinating Disease (J.N.), Children's Hospital of Alabama, Birmingham; the Lourie Center for Pediatric MS, Stony Brook Children's Hospital (L.K., A.B.), New York, NY; the Department of Neurology (E.W., J.G.) and the Department of Pediatrics, Benioff Children's Hospital (E.W.), University of California, San Francisco; the Departments of Pediatrics (T.H., C.S.O., T.C.C.) and Neurology (J.W.R.), University of Utah, Salt Lake City; Mayo Clinic's Pediatric MS Center (M.R., M.P.), Rochester, MN; Blue Bird Circle Multiple Sclerosis Center (T.L.), Baylor College of Medicine, Houston, TX; Boston Children's Hospital (M.G., L.B.), MA; the Pediatric Multiple Sclerosis Center (B.W.-G.), Jacobs Neurological Institute, SUNY Buffalo, New York, NY; and Pediatric MS Center at Loma Linda University Children's Hospital (G.A.), CA
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Casper TC, Rose JW, Roalstad S, Waubant E, Aaen G, Belman A, Chitnis T, Gorman M, Krupp L, Lotze TE, Ness J, Patterson M, Rodriguez M, Weinstock-Guttman B, Browning B, Graves J, Tillema JM, Benson L, Harris Y. The US Network of Pediatric Multiple Sclerosis Centers: Development, Progress, and Next Steps. J Child Neurol 2015; 30:1381-7. [PMID: 25270659 PMCID: PMC4379142 DOI: 10.1177/0883073814550656] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/19/2014] [Indexed: 11/16/2022]
Abstract
Multiple sclerosis and other demyelinating diseases in the pediatric population have received an increasing level of attention by clinicians and researchers. The low incidence of these diseases in children creates a need for the involvement of multiple clinical centers in research efforts. The Network of Pediatric Multiple Sclerosis Centers was created initially in 2006 to improve the diagnosis and care of children with demyelinating diseases. In 2010, the Network shifted its focus to multicenter research while continuing to advance the care of patients. The Network has obtained support from the National Multiple Sclerosis Society, the Guthy-Jackson Charitable Foundation, and the National Institutes of Health. The Network will continue to serve as a platform for conducting impactful research in pediatric demyelinating diseases of the central nervous system. This article provides a description of the history and development, organization, mission, research priorities, current studies, and future plans of the Network.
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Affiliation(s)
- T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John W Rose
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shelly Roalstad
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Emmanuelle Waubant
- Department of Neurology, University of California, San Francisco, CA, USA Department of Pediatrics, Benioff Children's Hospitals, San Francisco, CA, USA
| | - Gregory Aaen
- Pediatric MS Center at Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anita Belman
- Lourie Center for Pediatric MS, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - Tanuja Chitnis
- Partners MS Center, Harvard Medical School, Boston, MA, USA
| | - Mark Gorman
- Pediatric Multiple Sclerosis and Related Diseases Program, Boston Children's Hospital, Boston, MA, USA
| | - Lauren Krupp
- Lourie Center for Pediatric MS, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - Timothy E Lotze
- Blue Bird Circle Multiple Sclerosis Center, Texas Children's Hospital, Houston, TX, USA
| | - Jayne Ness
- UAB Center for Pediatric Onset Demyelinating Disease, Children's Hospital of Alabama, Birmingham, AL, USA
| | | | | | - Bianca Weinstock-Guttman
- Pediatric Multiple Sclerosis Center, Jacobs Neurological Institute, SUNY Buffalo, Buffalo, NY, USA
| | - Brittan Browning
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jennifer Graves
- Department of Neurology, University of California, San Francisco, CA, USA
| | | | - Leslie Benson
- Pediatric Multiple Sclerosis and Related Diseases Program, Boston Children's Hospital, Boston, MA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Weisbrot D, Charvet L, Serafin D, Milazzo M, Preston T, Cleary R, Moadel T, Seibert M, Belman A, Krupp L. Psychiatric diagnoses and cognitive impairment in pediatric multiple sclerosis. Mult Scler 2013; 20:588-93. [DOI: 10.1177/1352458513504249] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Pediatric multiple sclerosis (MS) represents approximately 5% of the MS population; information regarding clinical features is slowly accumulating. Cognitive and psychiatric impairments frequently occur, but remain poorly understood. Objectives: To describe psychiatric diagnoses among children with MS referred for psychiatric assessment and their relation to cognitive impairment. Methods: Forty-five pediatric MS patients (aged 8 to 17 years) were referred for outpatient psychiatric evaluation including a psychiatric interview (K-SADS), a clinician-based global assessment of functioning (Children’s Global Assessment Scale, CGAS), a neurologic examination including the Expanded Disability Status Scale (EDSS), and a neuropsychological test battery. Results: The most common categories of psychiatric diagnoses were anxiety disorders ( n=15), attention deficit hyperactivity disorder (ADHD, n=12), and mood disorders ( n=11). Cognitive impairment was classified in 20/25 (80%) of patients meeting criteria for a psychiatric disorder versus 11/20 (55%) of those without psychiatric disorder ( p=0.08). Those diagnosed with anxiety or mood disorder had the highest frequency of cognitive impairment, with a significantly higher rate when compared with those with psychiatric diagnoses in other categories ( p=0.05). Conclusions: A variety of psychiatric diagnoses can occur in children with pediatric MS. Many of these children also had cognitive impairment, particularly those in the mood and anxiety groups.
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Affiliation(s)
- Deborah Weisbrot
- Department of Psychiatry and Behavioral Sciences, Stony Brook University Medical Center - Division of Child and Adolescent Psychiatry, USA
| | - Leigh Charvet
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Dana Serafin
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Maria Milazzo
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Thomas Preston
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Rebecca Cleary
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Tiffany Moadel
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Michelle Seibert
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Anita Belman
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
| | - Lauren Krupp
- Stony Brook University Medical Center Department of Neurology - Lourie Center for Pediatric Multiple Sclerosis, USA
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Julian L, Serafin D, Charvet L, Ackerson J, Benedict R, Braaten E, Brown T, O’Donnell E, Parrish J, Preston T, Zaccariello M, Belman A, Chitnis T, Gorman M, Ness J, Patterson M, Rodriguez M, Waubant E, Weinstock-Guttman B, Yeh A, Krupp LB. Cognitive impairment occurs in children and adolescents with multiple sclerosis: results from a United States network. J Child Neurol 2013; 28:102-7. [PMID: 23155206 PMCID: PMC3652651 DOI: 10.1177/0883073812464816] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the largest sample studied to date, we measured cognitive functioning in children and adolescents with pediatric multiple sclerosis (n = 187) as well as those with clinically isolated syndrome (n = 44). Participants were consecutively enrolled from six United States Pediatric Multiple Sclerosis Centers of Excellence. Participants had a mean of 14.8 ± 2.6 years of age and an average disease duration of 1.9 ± 2.2 years. A total of 65 (35%) children with multiple sclerosis and 8 (18%) with clinically isolated syndrome met criteria for cognitive impairment. The most frequent areas involved were fine motor coordination (54%), visuomotor integration (50%), and speeded information processing (35%). A diagnosis of multiple sclerosis (odds ratio = 3.60, confidence interval = 1.07, 12.36, P = .04) and overall neurologic disability (odds ratio = 1.47, confidence interval = 1.10, 2.10, P = .03) were the only independent predictors of cognitive impairment. Cognitive impairment may occur early in these patients, and prompt recognition is critical for their care.
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Affiliation(s)
- Laura Julian
- Department of Neuropsychology, University of California San Francisco, San Francisco, CA, USA
| | - Dana Serafin
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Leigh Charvet
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Joseph Ackerson
- Department of Psychiatry and behavioral Neurobiology, University of Alabama, Birmingham, AL, USA
| | - Ralph Benedict
- Department of Neurology, Jacobs Neurological Institute, State University of New York, Buffalo, NY, USA
| | - Ellen Braaten
- Department of Psychology, Massachusetts General Hospital, Boston, MA, USA
| | - Tanya Brown
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Ellen O’Donnell
- Department of Psychology, Massachusetts General Hospital, Boston, MA, USA
| | - Joy Parrish
- Department of Neuropsychology, Jacobs Neurological Institute, State University of New York, Buffalo, NY, USA
| | - Thomas Preston
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | | | - Anita Belman
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Tanuja Chitnis
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Mark Gorman
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jayne Ness
- Department of Neurology, University of Alabama, Birmingham, AL, USA
| | - Marc Patterson
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Emmanuelle Waubant
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs Neurological Institute, State University of New York, Buffalo, NY, USA
| | - Ann Yeh
- Department of Neurology, Jacobs Neurological Institute, State University of New York, Buffalo, NY, USA
| | - Lauren B. Krupp
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
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Waubant E, Mowry EM, Krupp L, Chitnis T, Yeh EA, Kuntz N, Ness J, Belman A, Milazzo M, Gorman M, Weinstock-Guttman B, Rodriguez M, James JA. Antibody response to common viruses and human leukocyte antigen-DRB1 in pediatric multiple sclerosis. Mult Scler 2012; 19:891-5. [PMID: 23232601 DOI: 10.1177/1352458512469693] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND As remote infections with common herpes viruses are associated with modulation of the risk of multiple sclerosis (MS), we hypothesized that antibody concentrations against these viruses may further modify risk. As many common viruses are first encountered during childhood, pediatric MS offer a unique opportunity to investigate more closely their influence on susceptibility. Our aim was to determine if MS patients who were positive for these viruses had higher levels of antibodies to these viruses. We also assessed whether human leukocyte antigen (HLA)-DRB1*1501 genotype influenced viral antibody levels. METHODS Antibody response levels toward Epstein Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV)-1, and HLA-DRB1*1501 status were determined in pediatric MS patients (n=189) and controls (n=38). Multivariate analyses were used, adjusted for age, gender, race, ethnicity and use of disease-modifying therapies. RESULTS The antibody concentrations against EBV (Epstein-Barr nuclear antigen 1 (EBNA-1), viral capsid antigen (VCA) and early antigen (EA)), CMV and HSV-1 were similar between pediatric MS patients and controls positive for seroconversion against the virus of interest. EBNA-1 humoral responses were higher in HLA-DRB1 positive individuals (p=0.005) whereas other viral humoral responses were similar in HLA-DRB1 positive and negative individuals. CONCLUSION Among those positive for EBNA-1, MS patients did not have higher levels of antibody response to EBNA-1: however, titers for EBNA-1 were higher in those who were HLA-DRB1 positive. This suggests that genotype might influence the humoral response to EBV. Whether other genotypes influence antibody response to other viruses remains to be determined.
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Affiliation(s)
- Emmanuelle Waubant
- Regional Pediatric Multiple Sclerosis Center, University of California San Francisco, San Francisco, CA 94158, USA.
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Weisbrot D, Charvet L, Serafin D, Belman A, Seibert M, Moadel T, Krupp L. Cognitive and Psychiatric Status in Pediatric Multiple Sclerosis (MS) (P04.106). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p04.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Graves J, Krupp L, Weinstock-Guttman B, Strober J, Belman A, Yeh EA, Ness J, Gorman M, Rodriguez M, Chitnis T, Waubant E. EBV, CMV, and HSV IgG Titers Are Not Predictive of Subsequent Relapse Risk in Pediatric Multiple Sclerosis (P02.096). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Waubant E, Mowry EM, Krupp L, Chitnis T, Yeh EA, Kuntz N, Ness J, Chabas D, Strober J, McDonald J, Belman A, Milazzo M, Gorman M, Weinstock-Guttman B, Rodriguez M, Oksenberg JR, James JA. Common viruses associated with lower pediatric multiple sclerosis risk. Neurology 2011; 76:1989-95. [PMID: 21646624 DOI: 10.1212/wnl.0b013e31821e552a] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Because common viruses are encountered during childhood, pediatric multiple sclerosis (MS) offers a unique opportunity to investigate the influence of these viruses on disease susceptibility and the interactions between seroprevalence and select HLA genotypes. We studied seroprevalence for Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV) type 1 and HLA-DRB1*1501/1503 status as predictors of pediatric MS. METHODS This was a retrospective analysis of prospectively collected demographic, clinical, and biologic data in subjects up to 18 years of age with early MS, control subjects seen at the same regional referral pediatric MS clinics, and additional healthy pediatric control subjects. RESULTS Patients with early pediatric MS (n=189) and pediatric control subjects (n=66) were tested. Epstein-Barr nuclear antigen-1 seropositivity was associated with an increased odds of MS (odds ratio [OR] 3.78, 95% confidence interval [CI] 1.52-9.38, p=0.004) in analyses adjusted for age, sex, race, ethnicity, and HLA-DRB1*1501/1503 status. In multivariate analyses including EBV status, a remote infection with CMV (OR 0.27, 95% CI 0.11-0.67, p=0.004) was associated with a lower risk of developing MS. Although a remote infection with HSV-1 was not associated with an increased odds of MS, a strong interaction was found between HSV-1 status and HLA-DRB1 in predicting MS (p<0.001). HSV-1 was associated with an increased risk of MS in those without a DRB1*15 allele (OR 4.11, 95% CI 1.17-14.37, p=0.03), whereas the effect was reversed in those who were DRB1*15-positive (OR 0.07, 95% CI 0.02-0.32, p=0.001). CONCLUSIONS These findings suggest that some infections with common viruses may in fact lower MS susceptibility. If this is confirmed, the pathways for risk modification remain to be elucidated.
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Affiliation(s)
- E Waubant
- UCSF Regional Pediatric Multiple Sclerosis Center, 350 Parnassus Ave., Suite 908, San Francisco, CA 94117, USA.
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Yeh EA, Waubant E, Krupp LB, Ness J, Chitnis T, Kuntz N, Ramanathan M, Belman A, Chabas D, Gorman MP, Rodriguez M, Rinker JR, Weinstock-Guttman B. Multiple Sclerosis Therapies in Pediatric Patients With Refractory Multiple Sclerosis. ACTA ACUST UNITED AC 2011; 68:437-44. [DOI: 10.1001/archneurol.2010.325] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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O'Connor KC, Lopez-Amaya C, Gagne D, Lovato L, Moore-Odom NH, Kennedy J, Krupp L, Tenembaum S, Ness J, Belman A, Boyko A, Bykova O, Mah JK, Stoian CA, Waubant E, Kremenchutzky M, Ruggieri M, Bardini MR, Rensel M, Hahn J, Weinstock-Guttman B, Yeh EA, Farrell K, Freedman MS, Iivanainen M, Bhan V, Dilenge M, Hancock MA, Gano D, Fattahie R, Kopel L, Fournier AE, Moscarello M, Banwell B, Bar-Or A. Anti-myelin antibodies modulate clinical expression of childhood multiple sclerosis. J Neuroimmunol 2010; 223:92-9. [PMID: 20381173 DOI: 10.1016/j.jneuroim.2010.02.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 02/02/2010] [Accepted: 02/22/2010] [Indexed: 10/19/2022]
Abstract
Anti-myelin basic protein (MBP) antibodies in pediatric-onset MS and controls were characterized. Serum samples were obtained from 94 children with MS and 106 controls. Paired CSF and serum were obtained from 25 children with MS at time of their initial episode of acute demyelinating syndrome (ADS). Complementary assays were applied across samples to evaluate the presence, and the physical binding properties, of anti-MBP antibodies. While the prevalence and titers of serum anti-MBP antibodies against both immature and mature forms of MBP were similar in children with MS and in controls, binding characteristics and formal Surface Plasmon Resonance (SPR) studies indicated surprisingly high binding affinities of all pediatric anti-MBP antibodies. Serum levels of anti-MBP antibodies correlated significantly with their CSF levels, and their presence in children with MS was associated with significantly increased risk of an acute disseminated encephalomyelitis-like initial clinical presentation. While antibodies to both immature and mature forms of MBP can be present as part of the normal pediatric humoral repertoire, these anti-myelin antibodies are of surprisingly high affinity, can access the CNS during inflammation, and have the capacity to modulate disease expression. Our findings identify an immune mechanism that could contribute to the observed heterogeneity in spectrum of clinical presentations in early-onset MS.
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Affiliation(s)
- K C O'Connor
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Chabas D, Ness J, Belman A, Yeh EA, Kuntz N, Gorman MP, Strober JB, De Kouchkovsky I, McCulloch C, Chitnis T, Rodriguez M, Weinstock-Guttman B, Krupp LB, Waubant E. Younger children with MS have a distinct CSF inflammatory profile at disease onset. Neurology 2010; 74:399-405. [PMID: 20124205 DOI: 10.1212/wnl.0b013e3181ce5db0] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The clinical and MRI presentation differs between earlier- and later-onset pediatric multiple sclerosis (MS), whereas the effect of age on the CSF inflammatory profile is unknown and may contribute to delayed diagnosis. OBJECTIVES To compare the CSF cellular and immunoglobulin G (IgG) profiles between earlier- and later-onset pediatric MS. METHODS We queried the databases of 6 pediatric MS centers for earlier-onset (onset <11 years) and later-onset (> or = 11 and <18 years) patients with MS or clinically isolated syndrome who underwent CSF analysis within the first 3 months of presentation (observational study). We compared CSF white blood cell (WBC) differential count, IgG index, and IgG oligoclonal bands between age groups. RESULTS We identified 40 earlier-onset (mean age at onset = 7.2 +/- 2.7 years, 60% females) and 67 later-onset pediatric MS patients (15.1 +/- 1.7 years, 63% females). Although WBC count tended to be higher in earlier-onset patients (median = 9/mm(3) [0-343] vs 6 [0-140], p = 0.15), they had a lower proportion of lymphocytes (70% [0-100] vs 93% [0-100] of WBCs, p = 0.0085; difference = +3% per 1-year increase of age, p = 0.0011) and higher proportion of neutrophils than later-onset patients (0.5% [0-75] vs 0% [0-50] of WBCs, p = 0.16; difference = -1% per 1-year increase of age, p = 0.033). In earlier-onset disease, fewer patients had an elevated IgG index than in the later-onset group (35% vs 68% of patients, p = 0.031). CONCLUSION Age modifies the CSF profile at pediatric multiple sclerosis (MS) onset, which may mislead the diagnosis. Our findings suggest an activation of the innate rather than the adaptive immune system in the earlier stages of MS or an immature immune response.
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Affiliation(s)
- D Chabas
- UCSF Regional Pediatric MS Center, 350 Parnassus Ave., Suite 908, San Francisco, CA 94117, USA.
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MacAllister WS, Christodoulou C, Troxell R, Milazzo M, Block P, Preston TE, Bender HA, Belman A, Krupp LB. Fatigue and quality of life in pediatric multiple sclerosis. Mult Scler 2009; 15:1502-8. [DOI: 10.1177/1352458509345902] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fatigue and quality of life are significant concerns in adult multiple sclerosis (MS) but little is known about these factors in pediatric MS. The present investigation evaluates fatigue and quality of life in 51 pediatric MS patients to determine the rate of fatigue and reduced quality of life and assesses the relations between these variables and clinical factors. Fatigue and quality of life were assessed by self- and parent-report via the PedsQL Multidimensional Fatigue Scale and the PedsQL Quality of Life Scale. One-sample t-tests determined if scores were below published data for healthy individuals. Moreover, scores falling one standard deviation from norms were considered mildly affected, with severe difficulties being defined as scores falling two or more standard deviations from norms. Associations between self- and parent-reported difficulties and clinical factors were examined via Pearson correlation analyses. In comparison with healthy samples, pediatric MS patients reported greater difficulties with respect to fatigue, sleep, cognition, physical limitations, and academics. In addition to significant difficulties on these factors, parents reported problems with respect to emotional functioning, and tended to report greater fatigue, sleep, and cognitive difficulties than were self-reported. Expanded Disability Status Scale score was the only neurologic variable significantly related to fatigue or quality of life scores. Fatigue was significantly correlated with reports of sleep difficulties, cognitive problems, and quality of life variables. These findings suggest that fatigue and poorer quality of life is a clear concern in pediatric MS, and is related to overall physical disability.
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Affiliation(s)
| | | | - Regina Troxell
- State University of New York at Stony Brook, Department of Neurology, USA
| | - Maria Milazzo
- State University of New York at Stony Brook, Department of Neurology, USA
| | - Pamela Block
- State University of New York at Stony Brook, Department of Occupational Therapy, USA
| | - Thomas E Preston
- State University of New York at Stony Brook, Department of Neurology, USA
| | - Heidi A Bender
- New York University, Department of Neurology, Comprehensive Epilepsy Center, USA
| | - Anita Belman
- State University of New York at Stony Brook, Department of Neurology, USA
| | - Lauren B Krupp
- State University of New York at Stony Brook, Department of Neurology, USA
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Banwell B, Krupp L, Kennedy J, Tellier R, Tenembaum S, Ness J, Belman A, Boiko A, Bykova O, Waubant E, Mah JK, Stoian C, Kremenchutzky M, Bardini MR, Ruggieri M, Rensel M, Hahn J, Weinstock-Guttman B, Yeh EA, Farrell K, Freedman M, Iivanainen M, Sevon M, Bhan V, Dilenge ME, Stephens D, Bar-Or A. Clinical features and viral serologies in children with multiple sclerosis: a multinational observational study. Lancet Neurol 2007; 6:773-81. [PMID: 17689148 DOI: 10.1016/s1474-4422(07)70196-5] [Citation(s) in RCA: 232] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The full spectrum of clinical manifestations and outcome, and the potential importance of regional or demographic features or viral triggers in paediatric multiple sclerosis (MS), has yet to be fully characterised. Our aim was to determine some of these characteristics in children with MS. METHODS 137 children with MS and 96 control participants matched by age and geographical region were recruited in a multinational study. They underwent structured clinical-demographic interviews, review of academic performance, physical examination, disability assessment (MS patients only), and standardised assays for IgG antibodies directed against Epstein-Barr virus, cytomegalovirus, parvovirus B19, varicella zoster virus, and herpes simplex virus. FINDINGS MS was relapsing-remitting at diagnosis in 136 (99%) children. The first MS attack resembled acute disseminated encephalomyelitis (ADEM) in 22 (16%) of the children, most under 10 years old (mean age 7.4 [SD 4.2] years). Children with ADEM-like presentations were significantly younger than were children with polyfocal (11.2 [4.5] years; p<0.0001) or monofocal (12.0 [3.8] years; p=0.0005) presentations. Permanent physical disability (EDSS>or=4.0) developed within 5 years in 15 (13%) of the 120 children for whom EDSS score was available. 23 (17%) had impaired academic performance, which was associated with increasing disease duration (p=0.02). Over 108 (86%) of the children with MS, irrespective of geographical residence, were seropositive for remote EBV infection, compared with only 61 (64%) of matched controls (p=0.025, adjusted for multiple comparisons). Children with MS did not differ from controls in seroprevalence of the other childhood viruses studied, nor with respect to month of birth, sibling number, sibling rank, or exposure to young siblings. INTERPRETATION Paediatric MS is a relapsing-remitting disease, with presenting features that vary by age at onset. MS in children might be associated with exposure to EBV, suggesting a possible role for EBV in MS pathobiology.
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Affiliation(s)
- Brenda Banwell
- Division of Neurology, The Hospital for Sick Children, University of Toronto, ON, Canada.
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Gabis L, Belman A, Huang W, Milazzo M, Nachman S. Clinical and imaging study of human immunodeficiency virus-1-infected youth receiving highly active antiretroviral therapy: pilot study using magnetic resonance spectroscopy. J Child Neurol 2006; 21:486-90. [PMID: 16948932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
In the initial assessment of children with new-onset seizures, the suggestion that electroencephalography (EEG) should be standard and that magnetic resonance imaging (MRI) should be optional has been questioned. The purposes of this children (four boys) with vertically transmitted stable HIV infection had a neurologic examination, neuropsychologic testing, and a neuroimaging study. The structural magnetic resonance imaging (MRI) and metabolic changes (magnetic resonance spectroscopy) were compared with the cognitive, clinical, and laboratory results. Our results for the eight children who completed the magnetic resonance spectroscopic study showed that a high N-acetylaspartate (NAA) to choline ratio correlated significantly with IQ subtests of arithmetic (r = .74; P < .034) and comprehension (r = .77; P = .025). Our results suggest that lower NAA and higher choline values represent neuronal dysfunction and inflammation that can be recognized before anatomic changes appear on MRI. In addition, a low NAA to Cho ratio correlated with poor performance. These data suggest that magnetic resonance spectroscopy can be used as a follow-up tool in addition to the structural MRI. Moreover, a change in a child's performance with a concomitant change in NAA and choline, as measured with magnetic resonance spectroscopy, could indicate the need for more aggressive intervention.
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Affiliation(s)
- Lidia Gabis
- Child Development Center, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel 52621.
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McAbee G, Ciminera P, Knapik M, Solitare G, Belman A, Dickson D. Rapid and fatal neurologic deterioration due to central nervous system Candida infection in an HIV-1-infected child. J Child Neurol 1995; 10:405-7. [PMID: 7499762 DOI: 10.1177/088307389501000513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- G McAbee
- Nassau County Medical Center, East Meadow, New York, USA
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Burger H, Belman A, Grimson R. HIV-positive but not symptomatic. Nurs Times 1990; 86:10. [PMID: 2381833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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