MS Briefs

Key clinical point: Higher serum concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with a reduced risk for multiple sclerosis (MS).

Major finding: Being in the top 25(OH)D quintile was significantly associated with a reduced risk of multiple sclerosis (odds ratio, 0.68; 95% confidence interval, 0.50-0.93).

Study details: A nested case-control study using data from 6 Swedish biobanks (665 cases and an equal number of matched controls).

Disclosures: This study was supported by the Swedish Research Council and through a regional agreement between Umea University and the Vasterbotten County Council. One author received speaking fees from Merck-Serono and served on advisory boards for Merck-Serono and Biogen and another received honoraria for lectures from Genzyme and for advisory board roles from Roche and Novartis.

Citation: Biström M et al. Mult Scler J Exp Transl Clin. 2019 Dec 6. doi: 10.1177/2055217319892291.

Key clinical point: Higher serum concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with a reduced risk for multiple sclerosis (MS).

Major finding: Being in the top 25(OH)D quintile was significantly associated with a reduced risk of multiple sclerosis (odds ratio, 0.68; 95% confidence interval, 0.50-0.93).

Study details: A nested case-control study using data from 6 Swedish biobanks (665 cases and an equal number of matched controls).

Disclosures: This study was supported by the Swedish Research Council and through a regional agreement between Umea University and the Vasterbotten County Council. One author received speaking fees from Merck-Serono and served on advisory boards for Merck-Serono and Biogen and another received honoraria for lectures from Genzyme and for advisory board roles from Roche and Novartis.

Citation: Biström M et al. Mult Scler J Exp Transl Clin. 2019 Dec 6. doi: 10.1177/2055217319892291.

Key clinical point: Higher serum concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with a reduced risk for multiple sclerosis (MS).

Major finding: Being in the top 25(OH)D quintile was significantly associated with a reduced risk of multiple sclerosis (odds ratio, 0.68; 95% confidence interval, 0.50-0.93).

Study details: A nested case-control study using data from 6 Swedish biobanks (665 cases and an equal number of matched controls).

Disclosures: This study was supported by the Swedish Research Council and through a regional agreement between Umea University and the Vasterbotten County Council. One author received speaking fees from Merck-Serono and served on advisory boards for Merck-Serono and Biogen and another received honoraria for lectures from Genzyme and for advisory board roles from Roche and Novartis.

Citation: Biström M et al. Mult Scler J Exp Transl Clin. 2019 Dec 6. doi: 10.1177/2055217319892291.

Key clinical point: In patients with relapsing multiple sclerosis, fingolimod has a superior effect on clinical and magnetic resonance imaging (MRI) outcomes than placebo and presents an acceptable safety profile.

Major finding: Compared with placebo, fingolimod (0.5, 1.25, and 5 mg/day doses) had a significant reduction in annualized relapse rate. Fingolimod demonstrated beneficial effects on MRI outcomes, including the number of gadolinium-enhancing T1 lesions, and improved patient quality of life. No significant difference was found between the groups in terms of adverse events.

Study details: This was a systematic review and meta-analysis of 10 studies, including 6,547 participants.

Disclosures: The authors reported having no conflicts of interest.

Citation: Yang T et al. Br J Clin Pharmacol. 2019 Dec 23. doi: 10.1111/bcp.14198.

Key clinical point: In patients with relapsing multiple sclerosis, fingolimod has a superior effect on clinical and magnetic resonance imaging (MRI) outcomes than placebo and presents an acceptable safety profile.

Major finding: Compared with placebo, fingolimod (0.5, 1.25, and 5 mg/day doses) had a significant reduction in annualized relapse rate. Fingolimod demonstrated beneficial effects on MRI outcomes, including the number of gadolinium-enhancing T1 lesions, and improved patient quality of life. No significant difference was found between the groups in terms of adverse events.

Study details: This was a systematic review and meta-analysis of 10 studies, including 6,547 participants.

Disclosures: The authors reported having no conflicts of interest.

Citation: Yang T et al. Br J Clin Pharmacol. 2019 Dec 23. doi: 10.1111/bcp.14198.

Key clinical point: In patients with relapsing multiple sclerosis, fingolimod has a superior effect on clinical and magnetic resonance imaging (MRI) outcomes than placebo and presents an acceptable safety profile.

Major finding: Compared with placebo, fingolimod (0.5, 1.25, and 5 mg/day doses) had a significant reduction in annualized relapse rate. Fingolimod demonstrated beneficial effects on MRI outcomes, including the number of gadolinium-enhancing T1 lesions, and improved patient quality of life. No significant difference was found between the groups in terms of adverse events.

Study details: This was a systematic review and meta-analysis of 10 studies, including 6,547 participants.

Disclosures: The authors reported having no conflicts of interest.

Citation: Yang T et al. Br J Clin Pharmacol. 2019 Dec 23. doi: 10.1111/bcp.14198.

Key clinical point: The discontinuation of natalizumab (NTZ) therapy may lead to a marked reactivation of multiple sclerosis (MS); high disease activity and a high level of disability before NTZ initiation predicted multiple sclerosis reactivation.

Major finding: Clinical reactivation was reported in 20.2% of patients within 6 months after NTZ discontinuation. A higher number of relapses during the year before NTZ initiation was significantly associated with an increased risk of reactivation at 6 and 12 months. At 6 months, an Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk.

Study details: The findings are based on the results of a retrospective study of 89 patients with MS who had discontinued NTZ treatment.

Disclosures: The study was in part supported by a VTR grant from Kuopio University Hospital and personal grants from Ilkka Rauma, MD, from Orion Research Foundation and The Finnish Medical Foundation.

Citation: Mustonen T BM et al. Mult Scler Relat Disord. 2019 Nov 5. doi: 10.1016/j.msard.2019.101498.

Key clinical point: The discontinuation of natalizumab (NTZ) therapy may lead to a marked reactivation of multiple sclerosis (MS); high disease activity and a high level of disability before NTZ initiation predicted multiple sclerosis reactivation.

Major finding: Clinical reactivation was reported in 20.2% of patients within 6 months after NTZ discontinuation. A higher number of relapses during the year before NTZ initiation was significantly associated with an increased risk of reactivation at 6 and 12 months. At 6 months, an Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk.

Study details: The findings are based on the results of a retrospective study of 89 patients with MS who had discontinued NTZ treatment.

Disclosures: The study was in part supported by a VTR grant from Kuopio University Hospital and personal grants from Ilkka Rauma, MD, from Orion Research Foundation and The Finnish Medical Foundation.

Citation: Mustonen T BM et al. Mult Scler Relat Disord. 2019 Nov 5. doi: 10.1016/j.msard.2019.101498.

Key clinical point: The discontinuation of natalizumab (NTZ) therapy may lead to a marked reactivation of multiple sclerosis (MS); high disease activity and a high level of disability before NTZ initiation predicted multiple sclerosis reactivation.

Major finding: Clinical reactivation was reported in 20.2% of patients within 6 months after NTZ discontinuation. A higher number of relapses during the year before NTZ initiation was significantly associated with an increased risk of reactivation at 6 and 12 months. At 6 months, an Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk.

Study details: The findings are based on the results of a retrospective study of 89 patients with MS who had discontinued NTZ treatment.

Disclosures: The study was in part supported by a VTR grant from Kuopio University Hospital and personal grants from Ilkka Rauma, MD, from Orion Research Foundation and The Finnish Medical Foundation.

Citation: Mustonen T BM et al. Mult Scler Relat Disord. 2019 Nov 5. doi: 10.1016/j.msard.2019.101498.

Key clinical point: Older age at onset and presence of clinical or radiological disease activity was found to correlate with disability progression in patients with primary progressive multiple sclerosis (MS).

Major finding: The analysis of age at onset showed that for every 10-year increase, the risk of reaching Expanded Disability Status Scale (EDSS) scores of 4 and 6 increased by 26% and 31%, respectively. Patients with clinical exacerbations reached EDSS scores of 6, 7, and 8 faster than those without associated exacerbations; patients with gadolinium-enhancing lesions reached EDSS scores of 7 earlier.

Study details: A retrospective study conducted at 2 multiple sclerosis clinics in Argentina that included 178 patients with a median age of MS onset of 42 years.

Disclosures: This study was partially financed by an unrestricted grant from Merck Argentina (JC) and supported by internal funds from the Neuroimmunology Department of Fleni. The corresponding author is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM.

Citation: Marrodan M, et al. Mult Scler Relat Disord. 2019 Dec 14. doi: 10.1016/j.msard.2019.101892.

Key clinical point: Older age at onset and presence of clinical or radiological disease activity was found to correlate with disability progression in patients with primary progressive multiple sclerosis (MS).

Major finding: The analysis of age at onset showed that for every 10-year increase, the risk of reaching Expanded Disability Status Scale (EDSS) scores of 4 and 6 increased by 26% and 31%, respectively. Patients with clinical exacerbations reached EDSS scores of 6, 7, and 8 faster than those without associated exacerbations; patients with gadolinium-enhancing lesions reached EDSS scores of 7 earlier.

Study details: A retrospective study conducted at 2 multiple sclerosis clinics in Argentina that included 178 patients with a median age of MS onset of 42 years.

Disclosures: This study was partially financed by an unrestricted grant from Merck Argentina (JC) and supported by internal funds from the Neuroimmunology Department of Fleni. The corresponding author is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM.

Citation: Marrodan M, et al. Mult Scler Relat Disord. 2019 Dec 14. doi: 10.1016/j.msard.2019.101892.

Key clinical point: Older age at onset and presence of clinical or radiological disease activity was found to correlate with disability progression in patients with primary progressive multiple sclerosis (MS).

Major finding: The analysis of age at onset showed that for every 10-year increase, the risk of reaching Expanded Disability Status Scale (EDSS) scores of 4 and 6 increased by 26% and 31%, respectively. Patients with clinical exacerbations reached EDSS scores of 6, 7, and 8 faster than those without associated exacerbations; patients with gadolinium-enhancing lesions reached EDSS scores of 7 earlier.

Study details: A retrospective study conducted at 2 multiple sclerosis clinics in Argentina that included 178 patients with a median age of MS onset of 42 years.

Disclosures: This study was partially financed by an unrestricted grant from Merck Argentina (JC) and supported by internal funds from the Neuroimmunology Department of Fleni. The corresponding author is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM.

Citation: Marrodan M, et al. Mult Scler Relat Disord. 2019 Dec 14. doi: 10.1016/j.msard.2019.101892.

Key clinical point: Poor sleep and sleep disorders are prevalent in patients with mild to moderately severe multiple sclerosis (MS) and are associated with other comorbidities.

Main finding: Poor sleep was reported in 66% of patients with MS, sleep apnea in 31%, insomnia in 29%, and restless legs in 26%. Poor sleep and insomnia were independent predictors of fatigue (odds ratio, 2.63; P = .046) and depression (odds ratio, 5.62; P = .003), respectively.

Study details: A sleep substudy of a randomized controlled trial, including 111 adults with MS and an expanded disability status scale score between 2 and 6.

Disclosures: The study was supported by a grant from the National Health and Medical Research Council-Motor Impairment Program.

Citation: Hensen HA, et al. Sleep Med. 2019 Dec 16. doi: 10.1016/j.sleep.2019.11.415.

Key clinical point: Poor sleep and sleep disorders are prevalent in patients with mild to moderately severe multiple sclerosis (MS) and are associated with other comorbidities.

Main finding: Poor sleep was reported in 66% of patients with MS, sleep apnea in 31%, insomnia in 29%, and restless legs in 26%. Poor sleep and insomnia were independent predictors of fatigue (odds ratio, 2.63; P = .046) and depression (odds ratio, 5.62; P = .003), respectively.

Study details: A sleep substudy of a randomized controlled trial, including 111 adults with MS and an expanded disability status scale score between 2 and 6.

Disclosures: The study was supported by a grant from the National Health and Medical Research Council-Motor Impairment Program.

Citation: Hensen HA, et al. Sleep Med. 2019 Dec 16. doi: 10.1016/j.sleep.2019.11.415.

Key clinical point: Poor sleep and sleep disorders are prevalent in patients with mild to moderately severe multiple sclerosis (MS) and are associated with other comorbidities.

Main finding: Poor sleep was reported in 66% of patients with MS, sleep apnea in 31%, insomnia in 29%, and restless legs in 26%. Poor sleep and insomnia were independent predictors of fatigue (odds ratio, 2.63; P = .046) and depression (odds ratio, 5.62; P = .003), respectively.

Study details: A sleep substudy of a randomized controlled trial, including 111 adults with MS and an expanded disability status scale score between 2 and 6.

Disclosures: The study was supported by a grant from the National Health and Medical Research Council-Motor Impairment Program.

Citation: Hensen HA, et al. Sleep Med. 2019 Dec 16. doi: 10.1016/j.sleep.2019.11.415.

Key clinical point: Learning a second language may increase the grey matter volume in patients with multiple sclerosis (MS) and consequently improve mental health and health-related quality of life.

Major finding: Training in a second language was associated with a significant increase of grey matter volume in the right hippocampus, parahippocampus, and putamen region of the brain in patients with MS.

Study details: A prospective evaluation of second language training in patients with MS (n = 11) and healthy controls (n = 12).

Disclosures: The study was funded by Merck Austria, without any other external funding. None of the authors was affiliated with Merck Austria.

Citation: Ehling R, et al. PLoS One. 2019 Dec 23. doi: 10.1371/journal.pone.0226525.

Key clinical point: Learning a second language may increase the grey matter volume in patients with multiple sclerosis (MS) and consequently improve mental health and health-related quality of life.

Major finding: Training in a second language was associated with a significant increase of grey matter volume in the right hippocampus, parahippocampus, and putamen region of the brain in patients with MS.

Study details: A prospective evaluation of second language training in patients with MS (n = 11) and healthy controls (n = 12).

Disclosures: The study was funded by Merck Austria, without any other external funding. None of the authors was affiliated with Merck Austria.

Citation: Ehling R, et al. PLoS One. 2019 Dec 23. doi: 10.1371/journal.pone.0226525.

Key clinical point: Learning a second language may increase the grey matter volume in patients with multiple sclerosis (MS) and consequently improve mental health and health-related quality of life.

Major finding: Training in a second language was associated with a significant increase of grey matter volume in the right hippocampus, parahippocampus, and putamen region of the brain in patients with MS.

Study details: A prospective evaluation of second language training in patients with MS (n = 11) and healthy controls (n = 12).

Disclosures: The study was funded by Merck Austria, without any other external funding. None of the authors was affiliated with Merck Austria.

Citation: Ehling R, et al. PLoS One. 2019 Dec 23. doi: 10.1371/journal.pone.0226525.

Key clinical point: Dalfampridine may be a treatment option for balance impairment associated with multiple sclerosis (MS).

Major finding: The dalfampridine treated group demonstrated better balance in both single- (quiet standing test) and dual-task (Stroop test) conditions than the placebo group; however, the benefits of dalfampridine were not retained beyond 4 weeks after discontinuation of treatment.

Study details: A substudy of a randomized, double-blind, placebo-controlled trial in which patients received dalfampridine 10 mg (27 patients) or placebo (14 patients) twice a day for 12 weeks.

Disclosures: The original trial was funded by Biogen. The corresponding author disclosed consultancy with Almirall, Biogen, Novartis, Genzyme, Roche, and Teva and research funding from Associazione Italiana Sclerosi Multipla and Genzyme.

Citation: Prosperini L, et al. Neurotherapeutics. 2019 Dec 9. doi: 10.1007/s13311-019-00813-5.

Key clinical point: Dalfampridine may be a treatment option for balance impairment associated with multiple sclerosis (MS).

Major finding: The dalfampridine treated group demonstrated better balance in both single- (quiet standing test) and dual-task (Stroop test) conditions than the placebo group; however, the benefits of dalfampridine were not retained beyond 4 weeks after discontinuation of treatment.

Study details: A substudy of a randomized, double-blind, placebo-controlled trial in which patients received dalfampridine 10 mg (27 patients) or placebo (14 patients) twice a day for 12 weeks.

Disclosures: The original trial was funded by Biogen. The corresponding author disclosed consultancy with Almirall, Biogen, Novartis, Genzyme, Roche, and Teva and research funding from Associazione Italiana Sclerosi Multipla and Genzyme.

Citation: Prosperini L, et al. Neurotherapeutics. 2019 Dec 9. doi: 10.1007/s13311-019-00813-5.

Key clinical point: Dalfampridine may be a treatment option for balance impairment associated with multiple sclerosis (MS).

Major finding: The dalfampridine treated group demonstrated better balance in both single- (quiet standing test) and dual-task (Stroop test) conditions than the placebo group; however, the benefits of dalfampridine were not retained beyond 4 weeks after discontinuation of treatment.

Study details: A substudy of a randomized, double-blind, placebo-controlled trial in which patients received dalfampridine 10 mg (27 patients) or placebo (14 patients) twice a day for 12 weeks.

Disclosures: The original trial was funded by Biogen. The corresponding author disclosed consultancy with Almirall, Biogen, Novartis, Genzyme, Roche, and Teva and research funding from Associazione Italiana Sclerosi Multipla and Genzyme.

Citation: Prosperini L, et al. Neurotherapeutics. 2019 Dec 9. doi: 10.1007/s13311-019-00813-5.

Key clinical point: Low sun exposure increases the risk of multiple sclerosis (MS) both directly and indirectly, which impacts vitamin D levels. Low sun exposure and vitamin D deficiency may be different risk factors acting synergistically.

Major finding: Low exposure to sunlight was associated with a 26% and 10% higher risk for MS through direct and indirect effects on the vitamin D levels, respectively. About 30% of the total effect of low sun exposure-related MS risk was mediated by vitamin D deficiency.

Study details: The data were obtained from two population-based case–control studies (7,069 cases; 6,632 matched controls).

Disclosures: The research was supported by grants received from the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, the Swedish Brain Foundation, and the Swedish Society for Medical Research. Some of the investigators reported receiving grants and personal fees from multiple pharmaceutical companies.

Citation: Hedström AK, et al. J Neurol. 2019 Dec 12. doi: 10.1007/s00415-019-09677-3.

Key clinical point: Low sun exposure increases the risk of multiple sclerosis (MS) both directly and indirectly, which impacts vitamin D levels. Low sun exposure and vitamin D deficiency may be different risk factors acting synergistically.

Major finding: Low exposure to sunlight was associated with a 26% and 10% higher risk for MS through direct and indirect effects on the vitamin D levels, respectively. About 30% of the total effect of low sun exposure-related MS risk was mediated by vitamin D deficiency.

Study details: The data were obtained from two population-based case–control studies (7,069 cases; 6,632 matched controls).

Disclosures: The research was supported by grants received from the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, the Swedish Brain Foundation, and the Swedish Society for Medical Research. Some of the investigators reported receiving grants and personal fees from multiple pharmaceutical companies.

Citation: Hedström AK, et al. J Neurol. 2019 Dec 12. doi: 10.1007/s00415-019-09677-3.

Key clinical point: Low sun exposure increases the risk of multiple sclerosis (MS) both directly and indirectly, which impacts vitamin D levels. Low sun exposure and vitamin D deficiency may be different risk factors acting synergistically.

Major finding: Low exposure to sunlight was associated with a 26% and 10% higher risk for MS through direct and indirect effects on the vitamin D levels, respectively. About 30% of the total effect of low sun exposure-related MS risk was mediated by vitamin D deficiency.

Study details: The data were obtained from two population-based case–control studies (7,069 cases; 6,632 matched controls).

Disclosures: The research was supported by grants received from the Swedish Medical Research Council, the Swedish Research Council for Health, Working Life and Welfare, the Swedish Brain Foundation, and the Swedish Society for Medical Research. Some of the investigators reported receiving grants and personal fees from multiple pharmaceutical companies.

Citation: Hedström AK, et al. J Neurol. 2019 Dec 12. doi: 10.1007/s00415-019-09677-3.

Key clinical point: Breastfeeding may prevent postpartum relapses in women with multiple sclerosis (MS). Major finding: Women with MS who breastfed had a 37% lower risk of postpartum relapse, compared with those who did not breastfeed (P = .006); exclusive breastfeeding had a greater benefit than nonexclusive breastfeeding.

Study details: A systematic review and meta-analysis of 24 studies, including 2,974 women.

Disclosures: The National Multiple Sclerosis Society supported the study through a Sylvia Lawry Physician Fellowship awarded to Dr. Krysko.

Citation: Krysko KM, et al. JAMA Neurol. 2019 Dec 9. doi: 10.1001/jamaneurol.2019.4173.

Key clinical point: Breastfeeding may prevent postpartum relapses in women with multiple sclerosis (MS). Major finding: Women with MS who breastfed had a 37% lower risk of postpartum relapse, compared with those who did not breastfeed (P = .006); exclusive breastfeeding had a greater benefit than nonexclusive breastfeeding.

Study details: A systematic review and meta-analysis of 24 studies, including 2,974 women.

Disclosures: The National Multiple Sclerosis Society supported the study through a Sylvia Lawry Physician Fellowship awarded to Dr. Krysko.

Citation: Krysko KM, et al. JAMA Neurol. 2019 Dec 9. doi: 10.1001/jamaneurol.2019.4173.

Key clinical point: Breastfeeding may prevent postpartum relapses in women with multiple sclerosis (MS). Major finding: Women with MS who breastfed had a 37% lower risk of postpartum relapse, compared with those who did not breastfeed (P = .006); exclusive breastfeeding had a greater benefit than nonexclusive breastfeeding.

Study details: A systematic review and meta-analysis of 24 studies, including 2,974 women.

Disclosures: The National Multiple Sclerosis Society supported the study through a Sylvia Lawry Physician Fellowship awarded to Dr. Krysko.

Citation: Krysko KM, et al. JAMA Neurol. 2019 Dec 9. doi: 10.1001/jamaneurol.2019.4173.

Key clinical point: Little is known about what factors predict the progression of cognitive impairment (CI) and progression after a diagnosis of multiple sclerosis (MS).

Major finding: Twenty-two percent of patients had CI at baseline in newly diagnosed MS patients. At follow-up, only 14% of patients had CI. Cognitive changes within 1 year of follow-up could not be determined by baseline characteristics or initiation of treatment.

Study details: Demographic, clinical, and conventional MRI markers at baseline were investigated for CI and changes in 1,123 patients from a multicenter cohort study.

Disclosures: “The German National MS cohort and KKNMS are supported by grants from the German Federal Ministry for Education and Research.” Several study investigators reported received financial support and grants from pharmaceutical agencies.

Citation: Johnen A, et al. J Neurol. 2019 Feb;266(2):386-397. doi: 10.1007/s00415-018-9142-y.

Key clinical point: Little is known about what factors predict the progression of cognitive impairment (CI) and progression after a diagnosis of multiple sclerosis (MS).

Major finding: Twenty-two percent of patients had CI at baseline in newly diagnosed MS patients. At follow-up, only 14% of patients had CI. Cognitive changes within 1 year of follow-up could not be determined by baseline characteristics or initiation of treatment.

Study details: Demographic, clinical, and conventional MRI markers at baseline were investigated for CI and changes in 1,123 patients from a multicenter cohort study.

Disclosures: “The German National MS cohort and KKNMS are supported by grants from the German Federal Ministry for Education and Research.” Several study investigators reported received financial support and grants from pharmaceutical agencies.

Citation: Johnen A, et al. J Neurol. 2019 Feb;266(2):386-397. doi: 10.1007/s00415-018-9142-y.

Key clinical point: Little is known about what factors predict the progression of cognitive impairment (CI) and progression after a diagnosis of multiple sclerosis (MS).

Major finding: Twenty-two percent of patients had CI at baseline in newly diagnosed MS patients. At follow-up, only 14% of patients had CI. Cognitive changes within 1 year of follow-up could not be determined by baseline characteristics or initiation of treatment.

Study details: Demographic, clinical, and conventional MRI markers at baseline were investigated for CI and changes in 1,123 patients from a multicenter cohort study.

Disclosures: “The German National MS cohort and KKNMS are supported by grants from the German Federal Ministry for Education and Research.” Several study investigators reported received financial support and grants from pharmaceutical agencies.

Citation: Johnen A, et al. J Neurol. 2019 Feb;266(2):386-397. doi: 10.1007/s00415-018-9142-y.