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I've been taking Tysabri for a year and a half and have always been JCV negative. Just got back results positive .45. When do you recommend I retest blood to make sure no upward trend? How fast can index potentially rise from .4 to .6? .... Answer: Great question. Since January 2012 when the JCV index became widely available to assess risk of PML on Tysabri, only 2 patients who were anti-JCV Ab negative at baseline (like yourself) out of total of 34,379 patients negative at baseline developed PML. This data can also be converted to a PML incidence rate of 0.058 per 1000 patients or 1 case of PML per 17,000 people treated in patients who were anti-JCV Ab negative at baseline (before starting Tysabri) . This is regardless of whether patients subsequently turned JCV index positive. While this news is reassuring, it doesn't directly answer your question. Clearly, the risk of PML will go up in people who become JCV Index positivee and requires more frequent testing to assess this risk over time. For people, like yourself, with low titer positive conversion (usually, this includes index levels between 0.4 and 0.9), we often recommend switching to every 6-week infusions and repeat JCV index testing every 3 months. There is randomized clinical trial data that 6-week infusions are as beneficial as 4-week infusions in people who go on extended interval dosing after a year of Tysabri monthly treatment; there is also data derived from the TOUCH registry that extended interval dosing reduces the risk of PML. Therefore, we also usually recommend switching to every 6-week infusions of Tysabri. If your JCV index rises above 1.0 (many specialists have a different JCV index cut off levels for stopping Tysabri, but this is mine) with continued JCV index monitoring, we often recommend switching to another DMT, often an anti-CD20 therapy (i.e., Ocrevus, Briumvi, Rituximab or Kesimpta) after ensuring there is no evidence of pre-symptomatic PML by repeat MRI prior to starting the new therapy. Hope this information helps with your discussions with your doctor and your ultimate decision. As usual the ultimate recommendation by your MD may depend on additional information we are not aware of such as your prior use of immunosuppressant therapies, age, disease type or co-morbidities. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #Tysabri #multiplesclerosis #JCVindex
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Here is My Question:
I’ve recently started getting cramps in my feet. At first the weren’t bad but now it feels like someone crushing my foot. I’m on a mild muscle relaxer but it works a little. Answer: For the purpose of answering this question I will assume you have Multiple Sclerosis and no other problems associated with either cramps or spasms. There are three basic principles to follow for relieving muscle spasms in particular muscle groups.
Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #footcrampsandms #MS #multiplesclerosis #footcramp Here is My Question:
I don't have a diagnosis of MS, but am having multiple symptoms that make me worried I might have this condition. I don't have health insurance so I can't see a doctor unless I can really justify sinking thousands of dollars into testing. I was just wondering if these symptoms are concerning so I can be sure it's worth going into medical debt to get checked out. At first I thought this was probably just a pinched nerve or something but I have been in constant pain/discomfort for over three months so I'm starting to get worried that this is something else. Here is a (very long, so sorry) list of my symptoms: - pain in upper back between my shoulder blades going down left arm. The pain is burning, stabbing, or shocking (though sometimes is a persistent deep aching) and sometimes I can feel the muscles in the neck/back/shoulder contracting (feels like "locking up") and becoming hard and painful. Worst overnight and right after waking up in the morning. -Tried ice, heat, icyhot, massage, rest, Tylenol, ibuprofen, stretching, etc. But nothing has helped -I can feel a nerve pulling when I try to look down, bend down, turn my head, or move my arm. I cannot tilt my head back to look up at the ceiling. Sometimes it just hurts but other times I physically can't do it and need to tilt my head with my hands. At it's worst I also need to physically tilt my head to the side or turn my head down with my hands. -with both the pain from my muscles and the nerve pulling sensation, my body jolts forward slightly when I feel them, almost like wincing but more pronounced. It usually stops after a few seconds. -If it's not pain then it's numbness and tingling and generally uncomfortable. 24/7. It never stops. It just gets either better or worse depending on the day/week. -I can't sleep for more than a couple of hours at a time because there is no comfortable position to be in, no matter if it's standing or sitting or laying down. The pain isn't unbearable (though at times I couldn't even raise myself up to get out of bed and had to have my wife physically lift me out of bed, so the worst of it comes and goes). -even though I do have strength in my left arm it feels weaker than usual and gets fatigued almost immediately when I raise it up, or I can't lift/grip things as easily when my muscles do that contracting thing, due to pain. Example: I couldn't lift a pan out of the sink this morning with my left arm but could with my right. (this post was shortened as it is unable to fit due to word length constraint) Answer: Thank you for the in-depth observation of your symptoms. The diagnostic process in neurology is complex and depends a great deal on your age, past medical, surgical and family history and examination; but at a minimum it sounds like you have a problem involving the lower part of your cervical spine on the left side. This could be as simple as arthritis or a disc compressing a nerve root or even the spinal cord, or as complex as MS or even a tumor. Most of the common causes I've mentioned are very treatable, especially when evaluated early before the condition progresses too much. It is not too late to purchase health insurance on the exchange in your state or sign up for Medicaid if you fall under the income limit. Open enrollment through the affordable care act is underway until the middle of December, so you will need to hurry. For Medicaid you can sign up at any time during the year. Neither option will exclude you because of a pre-existing condition. Good luck Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
I was recently diagnosed with MS my MRI shows 2 lesions and my CFS OLIGOCLONAL BAND PROFILE shows 4 bands and abnormal, what stage is this? Answer: We currently stage MS by clinical criteria (see below), not by MRI or CSF results. MRI and CSF results are used for diagnosis and prognostication. Most people newly diagnosed with MS under the age of 40 have relapsing MS and those over 40 have a mix of relapsing and progressive forms of MS. Relapsing MS is characterized by acute or subacute onset of new neurological symptoms and findings consistent with MS that variably improve over weeks to months. 80 % of people with MS relapses reach their nadir (worse point) within 2 weeks and 90 % within 4 weeks. Improvement typically takes 3 to 6 months following a relapse. Progressive MS is characterized by steadily worsening neurological symptoms and findings over a year or more without remission Two lesions on an MRI of the brain would be considered a low lesion burden. Similarly, 4 oligoclonal bands in cerebrospinal fluid (CSF) would not be considered an additional risk factor for subsequent disease worsening, although this finding is certainly useful for assisting in the diagnosis of MS. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #multiplesclerosis Here is My Question:
What do you think about taking Duavee as hormone replacement therapy in MS patients? I have an early onset menopause, and have come across some research about Duavee. Thanks! Answer: We have no current information about the use of Duavee in menopausal women with MS at this time. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego I'm getting a Tattoo on Saturday and Starting Kesimpta treatment last Friday. Is this OK?12/10/2023 Here is My Question:
I started Kesimpta treatment last Friday, I’m due to inject this Friday, can I have a small tattoo done on Saturday. Answer: I see no reason to delay your Kesimpta injection because of a tattoo, but as always check with your physician. I would not inject at the tattoo site. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #tattooandmultiplesclerosis #MStattoo #tattooandMS #MS #multiplesclerosis #Kesimpta PLEASE NOTE: This information/opinions on this site should be used as an information source only. This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition. Here is My Question:
I have been on Ocrevus for 2.5 yrs now. About 8 weeks prior to each infusion, my physician has me complete a set of labs. The labs are usually things like Vitamin D, IGg, WBC, RBC, etc. They also require a urinalysis. The urinalysis is what I am curious about. What are they looking for with that? Infection? What things are typically checked prior to an infusion of Ocrevus? Answer: I would ask your physician what she or he is looking for in any test they order. If the test is not easily explainable there is no reason for the test. We usually obtain a urinalysis to check for infection although I do not do this testing prior to Ocrevus infusions unless I suspect an infection. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #multiplesclerosis #MS #Ocrevus Here is My Question:
I have MS and I got Avonex treatment. I want to know about one thing, is there an obligation to get Avonex once or twice a week? If we do it, for example, once a month, what can happen? Answer: There was an initial reason for dosing Avonex injections once a week that was established prior to the pivotal clinical trial started over 30 years ago. Pre-clinical studies showed that downstream activation of interferon sensitive genes (ISGs) after injection of Avonex 30 ug in normal controls, and subsequently people with MS, led to secretion of certain proteins (MxA and neopterin) easy to measure in a blood test that persisted for up to 5 days. This information was used to select a dosing interval of once a week. It is important to note that there is no clinical evidence that secretion of MxA or neopterin after Type 1 interferon injections (e.g. avonex, betaseron or rebif) is at all responsible for any benefits of this therapy; this was simply an easy to measure marker of activation of ISGs. The phase III clinical trial of Avonex demonstrated the known benefits of Avonex with once weekly dosing and the rest is history. Since the original approval of Type 1 interferons to treat relapsing forms of MS, there has been continued debate about the effects of different doses and dose intervals of all Type 1 interferons. If all patients with a diagnosis of MS exhibited similar dysregulation of type I interferon responsiveness, then it is likely that higher doses would benefit people with MS not responding to standard dosing. However, Richard Ransohoff and Tony Reder, two prominent experts on interferon signaling, demonstrated years ago that approximately 20 % of relapsing MS patients exhibit an overactive response to Type I interferon injections that is associated with continued disease activity or even an increase in pre-treatment MS disease activity on standard dosing. This overactive response to Type I interferon signaling is similar to what we observe in patients with lupus (SLE) and neuromyelitis optica (NMO), two conditions known to worsen when treated with Type I interferons. Therefore, it would not make sense to increase the dose or dose frequency of type 1 interferons in relapsing MS patients experiencing breakthrough disease on these therapies unless there was a validated method to predictably determine their interferon responsiveness. Of course, one could argue for increasing doses or dose intervals of interferons if there was controlled clinical trial evidence that this strategy was effective. Unfortunately, this type of study was never done and would not be considered ethical in the current environment of readily available, highly active, well tolerated disease modifying therapies with treatment effects far larger than those observed with interferons. However, this study would be ethical if you could reliably exclude those MS patients with an overactive response to Type I interferon signaling. Great question. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #Avonex #multiplesclerosis #MS Here is My Question:
I’ve had optic neuritis related to my MS since 1987, stable MS. Am I a candidate for LASIK surgery? Answer: If you have had optic neuritis due to MS you can still get LASIK surgery. You will need to see a corneal specialist who does LASIK surgery to see if it is an appropriate procedure for you to have. Benjamin Osborne, MD Director, Neuromyelitis Optica (NMO), Neuro-Ophthalmology Clinics and MS/Neuro-immunology Fellowship Director Associate Director of the NIH/Georgetown Neurology Residency Program Medstar Georgetown University Hospital #msandlasik #lasiksurgeryandms #multiplesclerosis #MS Here is My Question:
I have a question having to do with taking vitamins and/or supplements to boost the immune system while on Rituximab for MS. Would it be recommended to take vitamins/supplements and if so what should it be and at what dosage? In addition, how compromised is my immune system due to the Rituximab infusions? Answer: There is little evidence to generally support vitamin supplementation for people with MS other than supplementation with vitamin D. Any further supplementation recommendations are based on actual or potential risks of vitamin deficiency. For instance, people who have undergone partial gastrectomy's should supplement with vitamin B12 and copper and people who are vegan or vegetarian may require additional B vitamin and mineral supplementation . Similarly, people with conditions likely related to vitamin or mineral deficiencies should be thoroughly evaluated and receive supplements as appropriate Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
I have been to several doctors and also to an MS specialist who is still saying that my spots are suspicious of MS and that they are not active and old!! I have been having symptoms and the symptoms are getting worse week to week and having new symptoms that I just feel are pointless to tell her because I’m tired of her telling me that my lumbar puncture was equivocal for MS but was not within normal range either?? I still don’t understand what she means?? All my blood work is inconclusive except my C-reactive protein is elevated and my IGg index level was 0.70 in my CSF. I’m having a lot of issues with my right side and it all started with my left eye 6 years ago. I had an EMG yesterday that was normal except there was decreased activation of the right tibialis anterior muscle (not reduced recruitment). The doctor suspected this is related to pain, as I did have pain with activation of this muscle, but decreased activation can also be seen with central nervous system disorders. I never told this doctor I had a Nervous System Disorder?? Every doctor I see that reads my report and look at my scans say do I have MS? I reply “NO”, that’s what I have been told, well what are these lesions?? I have no history of strokes, heart problems, alcohol, drug abuse etc!! I’m a 46 year old mother of two that has been trying to figure this out and get the right answers!! It’s not a B12 deficiency, yes I’m an anemic and have potassium issues but take care of these issues. I have been Vitamin D deficient for a long time, but no one has test me for this not once. I would like to send a picture of my lesions to see what others think??!! This has been so stressful ! Thanks Answer: Thank you so much for telling us your story. I can feel your frustration. Let me try to explain. In medicine there are many problems that can cause frustration among both patients and their physicians. The first is disorders without a diagnostic test and highly variable presentations and courses. Top of the list are disorders like MS or Lupus. These disorders rely instead on a set of clinical criteria for a diagnosis that are never perfect and are often applied variably. For those who fail to meet the clinical requirements for a diagnosis of MS, it is imperative that their physicians explain what is going on and help them manage their symptoms. The patient must first understand that receiving a diagnosis will not necessarily lead to a treatment that alleviates their symptoms or even prevents worsening of their condition over time. In most cases failing to meet the diagnostic criteria for MS after 6 years tends to be a good thing; usually, the person either has a benign form of the disease or another problem altogether. What you need is a good neurologist who will take the time to explain why they think you do or do not have MS and is also willing to help you manage your symptoms. This can be hard but ask around I am sure you will find a doctor (perhaps not even an MS specialist) who is willing to help you. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
I'm a 70 y.o. female, diagnosed with MS in my 40's. Avonex stopped d/t side effects. Amazing response to Tysabri but became JC positive so switched to Copaxone. Anaphylaxis so started Aubagio. Dropped WBC and lymphocytes so stopped. Decided no more DMT. IgG also low so started IVIG with improvement of various issues Now on IVIG every 5 weeks and maintaining. I need to get a Shingrix shot but am concerned about interaction with IVIG. This is from the CDC site: "Patients who have quantitative B-cell deficiencies and are receiving immunoglobulin therapy should not receive either non-live or live vaccines while receiving the immunoglobulin therapy because of concerns about effectiveness of the vaccines". They also state in another place to wait between the two drugs, I think it was six months but can't find that source. I know I need the Shingrix, I just don't want to decrease its effect by dosing it incorrectly. The MD's all say it doesn't matter but that doesn't seem to be true. Does anyone on this site know ? Thank you. Answer: The issue you raise concerns the effectiveness of vaccination in the setting of therapy induced immune depletion or immune modulation. This is difficult to predict based on cell counts and impossible to measure when one is receiving immunoglobulin infusions. Let me explain. Vaccination generates both T cell and B cell immune memory, but we usually only measure the humoral immune response to the vaccine. Humoral immunity is referring to the measurement of antibodies that detect some component of the virus used in the vaccination. People who have received B cell depleting therapies (e.g., rituximab, ocrelizumab etc.) often have blunted, resting state immunoglobulin levels against the virus when tests are done to determine if they have adequate immunity post vaccination. These tests do not measure the cell mediated immunity (T cell responses) that is critical for eradicating intracellular viruses during infection, nor do they measure the prompt ability of your body to mount an antibody response following virus exposure. This later ability is achieved by long lived memory B cells and plasma cells. Immunoglobulin therapy has complicated effects, but for the purposes of this discussion, this therapy will make it difficult to detect your own antibodies (which are also immunoglobulins) produced by vaccination. Because of these difficulties we use approximations to determine when to get vaccines when receiving these therapies for MS or another condition. In the case of B cell depleting therapies, you definitely want to wait until the therapy is out of your system before getting vaccinated. In the case of Ocrelizumab and the rest of the high dose infusions that deplete B cells, this means waiting at least 3 months to get vaccinated after an infusion. Some argue to wait 6 months after an infusion to allow for some repletion of naive B cells. Clearly the longer you wait, the better the chance for an improved immune response with vaccination, but this must be balanced against the need for seasonal or yearly vaccine protection. You could see a doctor who specializes in allergy and immunology to determine your vaccination response to make sure you have protection. While it is harder to detect T cell responses to a vaccine because of the lack of commercial assays, you can determine if your body is able to mount a prompt antibody response post vaccination by simply giving a booster injection. People with good primary immunity will quickly generate a lot of detectable antibodies after a booster, whereas this response is delayed in people who have not generated immunity. I hope this helps. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
I am having peripheral neuropathy on my both feet and having pins and needles pain always on both my feet. I am taking Cymbalta 50 mg and pregablin 75 mg daily. There is not much relief. Can you suggest any good pain relief medication. Thanks Answer: You are taking low doses of pregabalin, so I would recommend asking your doctor if the dose can be increased gradually. If you require doses that make you sleepy in order to control the pain, make sure you only take these doses in the evening before bedtime. Other options are available but start with this recommendation. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
Are MS patients able to take pheromone for weight loss? Answer: I am not aware of Pheromones for weight loss. I suspect-based on its name-that this is a chemical scent advertised by its manufacturer as a means to reduce appetite and does not require FDA approval. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
What is PML? Answer: PML stands for Progressive Multifocal Leukoencephalopathy. This is viral infection of the brain caused by a mutated, "neurotropic" version of a common virus called the JC virus or Human Polyomavirus 2. Many if not most people are exposed to this virus in life, and it tends to remain dormant in your body without causing any initial or subsequent symptoms or disease. Under certain conditions of immunosuppression, a mutated version of the virus can proliferate and infect the brain causing PML. This is very difficult to treat unless the condition is detected prior to symptom onset (usually an MRI scan) and only if it is possible to reverse the immunosuppression rapidly. PML is most commonly observed in people with HIV and immunosuppression before they start highly active retroviral therapy. The emergence of PML in some individuals treated with Natalizumab (Tysabri), a therapy not considered a broad immunosuppressant, taught us a lot about PML prevention. Because of this knowledge there has been a dramatic reduction in cases of PML in the United States since 2012. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #PML #JCvirus #MS #multiplesclerosis Here is my Question:
First, thank you for your continued support and advice, I've learned so much from your Virtual MS Center. On your blog post, Is there information on the long-term impact of B cell depletion therapies (whether treating MS or otherwise)?, I wanted to ask if there is yet a way to determine whether the cells which return during the bone marrow repletion process are less autoreactive and/or better regulated? I'm hoping you will say yes, but I suspect you'll say no, not yet anyway. Another question: in general, if CD19 is still zero 6 months after Ocrevus infusion, is it safe to postpone the next infusion until B cells have started to repopulate? Answer: You are correct. At present we have no validated way to determine if the differentiated B cells which return post repletion are less autoreactive or, to reverse the question, when they can become less regulated and more autoreactive. We can look at the clonal size of certain autoreactive cells, but this still only tells us about structure and this information has not been associated with measures of actual MS disease activity. Can you postpone an Ocrevus infusion if CD19+ B cells are undetectable? You actually asked if it is "safe" to postpone infusions, but I am not sure what that means. The risks of postponing infusions in a relapsing or progressive MS patient are small. The real question is how long can you postpone infusions? We really do not know the answer to this question, but there you can ask how long is it safe to continue infusions every 6 months. This answer will depend on many factors including age, prior treatments, comorbid conditions, level of disability and how long you've been on Ocrevus or another anti-CD20 agent. Certainly, if you have an increased risk of infection or demonstrate increased infections on treatment or if your IgG level drops too much, then the risks may be considered too high. These are all individual decisions you must make with a clinician you trust who knows your condition and your goals of therapy. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego Here is My Question:
When choosing an infusion, are there any significant risks or benefits over selecting Tysabri verses Rituximab? Answer: Interesting question Tysabri is an adhesion molecule inhibitor that reversible interferes with immune trafficking in the brain, thus decreasing the potential for any new inflammatory lesion formation or relapses Rituximab and the other anti-CD20 agents are selective immune depleting agents with more sustained and in some cases long term effects on immune suppression. This theoretically has more long-term risk In practice they are both relatively safe compared to their remarkable benefits as long as you follow the rules for safe administration
Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #MS #multiplesclerosis #Tysabri #Rituxumab Here is My Question:
I was JCV negative until this month and my index is 3.49. My doctor doesn’t seem as concerned as I am. I am really scared. Isn’t this considered extremely high? Answer: A JCV index this high in a person on Tysabri increases the risk of developing PML in the future but should not be a cause for immediate concern. Specifically, this DOES NOT MEAN you have PML or will get PML. It does mean your future risk of PML may be as high as 3 % after 5 years of treatment. This is considered high for most medical or surgical treatments. There is a specific protocol we follow to mitigate the risk of PML when the JCV index increases to high levels while on treatment.
Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #MS #multiplesclerosi #JCVindex #Tysabri PLEASE NOTE: This information/opinions on this site should be used as an information source only. This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition. Here is My Question: What does this mean? "There is a nonspecific T2/FLAIR hyperintese focus within the subcortical white matter of inferior right temporal lobe (7/20)" Answer: Excellent Question What is a "non-specific T2/FLAIR hyperintense focus" on an MRI scan? Other descriptions which mean the same thing include, "non-specific white matter lesion" or "non-specific T2 hyperintensity". Some radiologists will push the appropriate limits on this description and use the term, "microvascular ischemic changes", although this is not an appropriate description since it implies a diagnosis that is often not based on the facts. Remember, a white spot on a T2/FLAIR imaging sequence does not mean demyelination. White spots essentially represent areas of altered interaction of water with the underlying tissue or replacement of tissue with essentially water. There are many causes, including primary or inflammatory demyelination. When we say non-specific T2/FLAIR hyperintense focus, we are referring to signal alterations within the tissue (basically white spots on the typical image viewed by your doctor) that carry no diagnostic specificity. The possible causes of white spots - including normal things like aging - are numerous and often depend on your age and other medical conditions, as well as their location, size, and appearance on other imaging sequences. When the "white spots" have the location, shape, size, and characteristics on other imaging sequences that are more specific for MS, it is appropriate for the radiologist to raise this possibility, but the radiologist cannot diagnose MS. Unfortunately, all too often the report says something like the following: nonspecific white matter lesions consistent with microvascular ischemic changes, migraine or demyelinating disease (MS). This is unfortunate since non-specific white matter changes require expert neurological evaluation to determine if any of these possibilities are correct. Revere P (Rip) Kinkel, MDProfessor of Neurosciences Director of the Multiple Sclerosis Program University of California San Diego #MS #multiplesclerosis #MRI |
PLEASE NOTE: This information/opinions on this site should be used as an information source only. This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment. Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.
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