{
  "abstract": "Background Clinical guidelines for relapsing remitting multiple sclerosis (RRMS) do not recommend disease modifying therapy (DMT) escalation after a single on-treatment clinically silent MRI lesion (CSL).Methods From the MSBase international registry, we studied adults with RRMS who had MRI brain scans 6-18 months apart while clinically stable and established on a DMT. Cox models compared outcomes (relapse and 6 month confirmed disability worsening [CDW]) in those with and without CSLs, adjusted for sex, age, calendar year, MS duration, EDSS score, relapses in the prior 2 years, DMT efficacy and country health expenditure. In those with CSLs on platform or moderate-efficacy DMTs, an emulated a target trial compared DMT escalation within 6 months of a silent lesion versus unchanged DMT (unless a post-MRI clinical event occurred).Results Among 10,308 people with RRMS, 2-year hazard ratios (HR [95% confidence interval]) comparing CSL with no CSL were 1.78 [1.59–2.00] for relapse and 1.38 [1.18–1.61] for CDW. Associations were similar in people with both single and multiple CSLs, on platform and moderate-efficacy baseline DMTs, and regardless of disease duration. In 2,295 people with CSLs on platform and moderate-efficacy DMTs, DMT escalation (n=288) reduced the median 4-year relapse risk from 38.9% to 17.0% (HR 0.34 [0.23–0.48]).Conclusions People with RRMS with single or multiple on-treatment clinically silent MRI lesions have higher subsequent risks of relapse and disability worsening than those without CSLs. DMT escalation mitigates the relapse risk. Contrary to clinical guidelines, DMT escalation should be considered even after a single CSL.cyrus.daruwalla@nhs.net",
  "authors": [
    {
      "affiliations": [
        "University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK",
        "Addenbrooke’s Hospital, Cambridge, UK"
      ],
      "name": "Cyrus Daruwalla"
    },
    {
      "affiliations": [
        "University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK"
      ],
      "name": "Courtney Kremler"
    },
    {
      "affiliations": [
        "Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy",
        "Multiple Sclerosis Unit, AOU Policlinico G Rodolico-San Marco, University of Catania, Catania, Italy"
      ],
      "name": "Francesco Patti"
    },
    {
      "affiliations": [
        "Charles University and Motol University Hospital, Department of Neurology, Second Faculty of Medicine, Prague, Czech Republic"
      ],
      "name": "Jana Libertínová"
    },
    {
      "affiliations": [
        "Izmir University of Economics, Medical Point Hospital, Izmir, Türkiye"
      ],
      "name": "Serkan Ozakbas"
    },
    {
      "affiliations": [
        "Charles University and University Hospital Pilsen, Department of Neurology, Faculty of Medicine in Pilsen, Pilsen, Czech Republic",
        "Department of Neurology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital, Hradec Kralove, Czech Republic"
      ],
      "name": "Marek Peterka"
    },
    {
      "affiliations": [
        "Charles University and General University Hospital, Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Prague, Czech Republic",
        "Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czech Republic"
      ],
      "name": "Marta Vachova"
    },
    {
      "affiliations": [
        "KTU Medical Faculty Farabi Hospital, Trabzon, Türkiye"
      ],
      "name": "Cavit Boz"
    },
    {
      "affiliations": [
        "University Newcastle, Hunter Medical Research Institute, Newcastle, Australia",
        "Hunter New England Health, John Hunter Hospital, NSW, Australia"
      ],
      "name": "Jeannette Lechner Scott"
    },
    {
      "affiliations": [
        "Clinical Outcomes Research Unit (CORe), University of Melbourne, Melbourne, Australia",
        "Royal Melbourne Hospital, Melbourne, Australia, Neuroimmunology Centre, Department of Neurology, Melbourne, Australia"
      ],
      "name": "Izanne Roos"
    },
    {
      "affiliations": [
        "S. Maria delle Croci Hospital, AUSL Romagna, Department of Neuroscience, MS Center, Neurology Unit,, Ravenna, Italy",
        "Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy"
      ],
      "name": "Matteo Foschi"
    },
    {
      "affiliations": [
        "S. Maria delle Croci Hospital of Ravenna, Department of Neuroscience, MS Center, Neurology Unit, Ravenna, Italy"
      ],
      "name": "Andrea Surcinelli"
    },
    {
      "affiliations": [
        "S. Maria delle Croci Hospital of Ravenna, AUSL Romagna, Department of Diagnostic Imaging, Ravenna, Italy"
      ],
      "name": "Stefano Neri"
    },
    {
      "affiliations": [
        "American University of Beirut Medical Center, Nehme and Therese Tohme Multiple Sclerosis Center, Beirut, Lebanon"
      ],
      "name": "Samia Khoury"
    },
    {
      "affiliations": [
        "Department of Neurology, The Alfred Hospital, Melbourne, Australia",
        "Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia"
      ],
      "name": "Anneke van der Walt"
    },
    {
      "affiliations": [
        "The Alfred Hospital, Department of Neurology, Melbourne, Australia",
        "Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Australia"
      ],
      "name": "Helmut Butzkueven"
    },
    {
      "affiliations": [
        "Virgen de la Arrixaca Clinical University Hospital, Multiple Sclerosis CSUR and Clinical Neuroimmunology Unit, Neurology Department, Murcia, Spain",
        "UCAM-San Antonio Catholic University, Murcia, Spain"
      ],
      "name": "Jose E Meca-Lallana"
    },
    {
      "affiliations": [
        "Palacky University Olomouc and University Hospital Olomouc, Department of Neurology, Faculty of Medicine and Dentistry, Olomouc, Czech Republic"
      ],
      "name": "Zuzana Rous"
    },
    {
      "affiliations": [
        "University Hospital Center Zagreb, Department of Neurology, Zagreb, Croatia",
        "University of Zagreb, School of Medicine, Zagreb, Croatia"
      ],
      "name": "Mario Habek"
    },
    {
      "affiliations": [
        "Amiri Hospital, Division of Neurology, Department of Medicine, Sharq, Kuwait"
      ],
      "name": "Raed Alroughani"
    },
    {
      "affiliations": [
        "CISSS Chaudière-Appalache, Levis, Canada"
      ],
      "name": "Pierre Grammond"
    },
    {
      "affiliations": [
        "Hospital Clinic de Barcelona, Center of Neuroimmunology, Service of Neurology, Barcelona, Spain"
      ],
      "name": "Yolanda Blanco"
    },
    {
      "affiliations": [
        "Universitary Hospital Ghent, Department of Neurology, Ghent, Belgium"
      ],
      "name": "Guy Laureys"
    },
    {
      "affiliations": [
        "Department of Neurosciences, Box Hill Hospital, Box Hill, Australia",
        "Monash University, Eastern Health Clinical School, Box Hill, Australia"
      ],
      "name": "Katherine Buzzard"
    },
    {
      "affiliations": [
        "Department of Neurology, The Alfred Hospital, Melbourne, Australia",
        "Box Hill Hospital, Department of Neurology, Melbourne, Australia",
        "Department of Neurosciences, Eastern Health Clinical School, Monash University, Melbourne, Australia"
      ],
      "name": "Olga Skibina"
    },
    {
      "affiliations": [
        "South Eastern HSC Trust, Belfast, UK"
      ],
      "name": "Orla Gray"
    },
    {
      "affiliations": [
        "University of Queensland, Brisbane, Australia",
        "Royal Brisbane and Women’s Hospital, Brisbane, Australia"
      ],
      "name": "Pamela McCombe"
    },
    {
      "affiliations": [
        "Hospital Universitario Virgen Macarena, Sevilla, Spain"
      ],
      "name": "Guillermo Izquierdo Ayuso"
    },
    {
      "affiliations": [
        "Hospital Universitario Virgen Macarena, Department of Neurology, Sevilla, Spain"
      ],
      "name": "Sara Eichau"
    },
    {
      "affiliations": [
        "Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy"
      ],
      "name": "Daniele LA Spitaleri"
    },
    {
      "affiliations": [
        "ARNAS Garibaldi, Centro Sclerosi Multipla, UOC Neurologia, Catania, Italy"
      ],
      "name": "Davide Maimone"
    },
    {
      "affiliations": [
        "CHUM MS Center and Universite de Montreal, Montreal, Canada"
      ],
      "name": "Alexandre Prat"
    },
    {
      "affiliations": [
        "CHUM MS Center and Universite de Montreal, Montreal, Canada"
      ],
      "name": "Marc Girard"
    },
    {
      "affiliations": [
        "CHUM MS Center and Universite de Montreal, Montreal, Canada"
      ],
      "name": "Pierre Duquette"
    },
    {
      "affiliations": [
        "Galdakao-Usansolo University Hospital, Osakidetza-Basque Health Service, Department of Neurology, Galdakao, Spain",
        "Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain"
      ],
      "name": "Jose Luis Sanchez"
    },
    {
      "affiliations": [
        "Cliniques Universitaires Saint-Luc, Brussels, Belgium",
        "Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium"
      ],
      "name": "Vincent Van Pesch"
    },
    {
      "affiliations": [
        "St. Michael’s Hospital, Toronto, Canada"
      ],
      "name": "Jiwon Oh"
    },
    {
      "affiliations": [
        "Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Türkiye"
      ],
      "name": "Aysun Soysal"
    },
    {
      "affiliations": [
        "University of Florence, Department NEUROFARBA, Florence, Italy",
        "IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy"
      ],
      "name": "Maria Pia Amato"
    },
    {
      "affiliations": [
        "Pelt and Hasselt University, University MS Centre, Noorderhart, Rehabilitation and MS, Hasselt, Belgium"
      ],
      "name": "Bart Van Wijmeersch"
    },
    {
      "affiliations": [
        "Zuyderland Medical Center, Academic MS Center Zuyd, Department of Neurology, Sittard-Geleen, Netherlands",
        "School for Mental Health and Neuroscience, Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands"
      ],
      "name": "O Gerlach"
    },
    {
      "affiliations": [
        "Università di Bologna, Dipartimento di Scienze Biomediche e Neuromotorie, Bologna, Italy",
        "IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy"
      ],
      "name": "Alessandra Lugaresi"
    },
    {
      "affiliations": [
        "University G. d’Annunzio of Chieti-Pescara, Institute for Advanced Biomedical Technologies (ITAB), Dept Neurosciences, Imaging and Clinical Sciences, Chieti, Italy",
        "Centre for Rehabilitation, Disability and Sport Medicine (CARES), Chieti, Italy",
        "MS Centre, Clinical Neurology, SS Annunziata University Hospital, Chieti, Italy"
      ],
      "name": "Valentina Tomassini"
    },
    {
      "affiliations": [
        "UNSW, Immune tolerance laboratory Ingham Institute and Dept of Medicine, Sydney, Australia"
      ],
      "name": "Suzanne Hodgkinson"
    },
    {
      "affiliations": [
        "University Hospital Ostrava, Department of Neurology, Ostrava, Czech Republic"
      ],
      "name": "Pavel Hradilek"
    },
    {
      "affiliations": [
        "Masaryk University, St. Anne’s University Hospital, First Department of Neurology, Brno, Czech Republic"
      ],
      "name": "Michal Dufek"
    },
    {
      "affiliations": [
        "Frimley Park Hospital, Department of Neurology, Frimley, UK"
      ],
      "name": "Silvia Messina"
    },
    {
      "affiliations": [
        "Royal Hobart Hospital, Hobart, Australia"
      ],
      "name": "Bruce Taylor"
    },
    {
      "affiliations": [
        "Royal Hobart Hospital, MS research flagship, Hobart, Australia",
        "Royal Hobart Hospital, Tasmanian Health Service, Hobart, Australia",
        "School of Translational Medicine, Monash University, Melbourne, Australia"
      ],
      "name": "Yi Chao Foong"
    },
    {
      "affiliations": [
        "Hospital Universitario Nacional de Colombia Bogota, Centro de Esclerosis M˙ltiple (CEMHUN), Departamento de NeurologÌa, Bogota, Colombia",
        "Departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogota, Colombia"
      ],
      "name": "Simón Cárdenas-Robledo"
    },
    {
      "affiliations": [
        "AST Macerata, Neurology Unit, Macerata, Italy"
      ],
      "name": "Elisabetta Cartechini"
    },
    {
      "affiliations": [
        "Monash University, Department of Medicine, School of Clinical Sciences, Clayton, Australia",
        "Department of Neurology, Monash Health, Clayton, Australia"
      ],
      "name": "Nevin A John"
    },
    {
      "affiliations": [
        "Austin Health, Melbourne, Australia"
      ],
      "name": "Richard MacDonell"
    },
    {
      "affiliations": [
        "University of Foggia, Department of Medical and Surgical Sciences, Foggia, Italy"
      ],
      "name": "Emanuele D’amico"
    },
    {
      "affiliations": [
        "Department of Neurology, Antwerp University Hospital, Edegem, Belgium",
        "Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium",
        "Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium"
      ],
      "name": "Barbara Willekens"
    },
    {
      "affiliations": [
        "Westmead Hospital, Sydney, Australia"
      ],
      "name": "Justin Garber"
    },
    {
      "affiliations": [
        "Mayis University, Medical Faculty, Samsun, Türkiye"
      ],
      "name": "Murat Terzi"
    },
    {
      "affiliations": [
        "St Vincent’s Hospital, Sydney, Australia"
      ],
      "name": "Jennifer Massey"
    },
    {
      "affiliations": [
        "Hospital Ceske Budejovice, Department of Neurology, Ceske Budejovice, Czech Republic"
      ],
      "name": "Jana Houskova"
    },
    {
      "affiliations": [
        "Centre Hospitalier Universitaire de Sherbrooke,, Sherbrooke, Canada"
      ],
      "name": "Emmanuelle Lapointe"
    },
    {
      "affiliations": [
        "Charles University and Hospital Kralovske Vinohrady, Department of Neurology, Third Faculty of Medicine, Prague, Czech Republic"
      ],
      "name": "Ivana Stetkarova"
    },
    {
      "affiliations": [
        "Sultan Qaboos University, College of Medicine and Health Sciences and Sultan Qaboos University Hospital, Al-Khodh, Oman"
      ],
      "name": "Abdullah Al-Asmi"
    },
    {
      "affiliations": [
        "Brain and Mind Centre, Sydney, Australia"
      ],
      "name": "Michael Barnett"
    },
    {
      "affiliations": [
        "Flinders University, College of Medicine and Public Health, Adelaide, Australia"
      ],
      "name": "Mark Slee"
    },
    {
      "affiliations": [
        "Unidade Local de Saúde de São João, Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal"
      ],
      "name": "Joana Guimaraes"
    },
    {
      "affiliations": [
        "University of Debrecen, Department of Neurology, Faculty of Medicine, Debrecen, Hungary"
      ],
      "name": "Tünde Csépány"
    },
    {
      "affiliations": [
        "Razi University Hospita, Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health, Tunis, Tunisia",
        "Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia"
      ],
      "name": "Riadh Gouider"
    },
    {
      "affiliations": [
        "Razi University Hospita, Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health, Tunis, Tunisia",
        "Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia"
      ],
      "name": "Saloua Mrabet"
    },
    {
      "affiliations": [
        "Harley Street Medical Centre, Neurology Institute and MS Center, Abu Dhabi, United Arab Emirates"
      ],
      "name": "Bassem Yammout"
    },
    {
      "affiliations": [
        "University Hospital and University of Basel, Department of Neurology, Basel, Switzerland",
        "Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital"
      ],
      "name": "Jens Kuhle"
    },
    {
      "affiliations": [
        "TalTech, Senior Scientist, Tallinn, Estonia"
      ],
      "name": "Katrin Gross-Paju"
    },
    {
      "affiliations": [
        "Hospital Universitario Donostia and IIS Biodonostia, San Sebastián, Spain"
      ],
      "name": "Tamara Castillo-Triviño"
    },
    {
      "affiliations": [
        "Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Department of Neurology, Ipswich, UK"
      ],
      "name": "Simon Kerrigan"
    },
    {
      "affiliations": [
        "University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK"
      ],
      "name": "Aviva Tolkovsky"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol Medical School, Population Health Sciences, Bristol, UK"
      ],
      "name": "Paul Madley-Dowd"
    },
    {
      "affiliations": [
        "University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK"
      ],
      "name": "Alasdair Coles"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol Medical School, Population Health Sciences, Bristol, UK"
      ],
      "name": "Jonathan Sterne"
    },
    {
      "affiliations": [
        "Clinical Outcomes Research Unit (CORe), University of Melbourne, Melbourne, Australia",
        "Royal Melbourne Hospital, Melbourne, Australia, Neuroimmunology Centre, Department of Neurology, Melbourne, Australia"
      ],
      "name": "Tomas Kalincik"
    },
    {
      "affiliations": [
        "University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK",
        "Clinical Outcomes Research Unit (CORe), University of Melbourne, Melbourne, Australia",
        "NMR Research Unit, Queen Square Multiple Sclerosis Centre, University College London (UCL) Queen Square Institute of Neurology, London, UK"
      ],
      "name": "William Brown"
    },
    {
      "affiliations": [
        "University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK",
        "Addenbrooke’s Hospital, Cambridge, UK",
        "Department of Medical and Surgical Sciences and Advanced Technologies, GF Ingrassia, Catania, Italy",
        "Multiple Sclerosis Unit, AOU Policlinico G Rodolico-San Marco, University of Catania, Catania, Italy",
        "Charles University and Motol University Hospital, Department of Neurology, Second Faculty of Medicine, Prague, Czech Republic",
        "Izmir University of Economics, Medical Point Hospital, Izmir, Türkiye",
        "Charles University and University Hospital Pilsen, Department of Neurology, Faculty of Medicine in Pilsen, Pilsen, Czech Republic",
        "Department of Neurology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital, Hradec Kralove, Czech Republic",
        "Charles University and General University Hospital, Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Prague, Czech Republic",
        "Department of Neurology, KZ a.s., Hospital Teplice, Teplice, Czech Republic",
        "KTU Medical Faculty Farabi Hospital, Trabzon, Türkiye",
        "University Newcastle, Hunter Medical Research Institute, Newcastle, Australia",
        "Hunter New England Health, John Hunter Hospital, NSW, Australia",
        "Clinical Outcomes Research Unit (CORe), University of Melbourne, Melbourne, Australia",
        "Royal Melbourne Hospital, Melbourne, Australia, Neuroimmunology Centre, Department of Neurology, Melbourne, Australia",
        "S. Maria delle Croci Hospital, AUSL Romagna, Department of Neuroscience, MS Center, Neurology Unit,, Ravenna, Italy",
        "Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy",
        "S. Maria delle Croci Hospital of Ravenna, Department of Neuroscience, MS Center, Neurology Unit, Ravenna, Italy",
        "S. Maria delle Croci Hospital of Ravenna, AUSL Romagna, Department of Diagnostic Imaging, Ravenna, Italy",
        "American University of Beirut Medical Center, Nehme and Therese Tohme Multiple Sclerosis Center, Beirut, Lebanon",
        "Department of Neurology, The Alfred Hospital, Melbourne, Australia",
        "Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia",
        "The Alfred Hospital, Department of Neurology, Melbourne, Australia",
        "Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Australia",
        "Virgen de la Arrixaca Clinical University Hospital, Multiple Sclerosis CSUR and Clinical Neuroimmunology Unit, Neurology Department, Murcia, Spain",
        "UCAM-San Antonio Catholic University, Murcia, Spain",
        "Palacky University Olomouc and University Hospital Olomouc, Department of Neurology, Faculty of Medicine and Dentistry, Olomouc, Czech Republic",
        "University Hospital Center Zagreb, Department of Neurology, Zagreb, Croatia",
        "University of Zagreb, School of Medicine, Zagreb, Croatia",
        "Amiri Hospital, Division of Neurology, Department of Medicine, Sharq, Kuwait",
        "CISSS Chaudière-Appalache, Levis, Canada",
        "Hospital Clinic de Barcelona, Center of Neuroimmunology, Service of Neurology, Barcelona, Spain",
        "Universitary Hospital Ghent, Department of Neurology, Ghent, Belgium",
        "Department of Neurosciences, Box Hill Hospital, Box Hill, Australia",
        "Monash University, Eastern Health Clinical School, Box Hill, Australia",
        "Box Hill Hospital, Department of Neurology, Melbourne, Australia",
        "Department of Neurosciences, Eastern Health Clinical School, Monash University, Melbourne, Australia",
        "South Eastern HSC Trust, Belfast, UK",
        "University of Queensland, Brisbane, Australia",
        "Royal Brisbane and Women’s Hospital, Brisbane, Australia",
        "Hospital Universitario Virgen Macarena, Sevilla, Spain",
        "Hospital Universitario Virgen Macarena, Department of Neurology, Sevilla, Spain",
        "Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati Avellino, Avellino, Italy",
        "ARNAS Garibaldi, Centro Sclerosi Multipla, UOC Neurologia, Catania, Italy",
        "CHUM MS Center and Universite de Montreal, Montreal, Canada",
        "Galdakao-Usansolo University Hospital, Osakidetza-Basque Health Service, Department of Neurology, Galdakao, Spain",
        "Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain",
        "Cliniques Universitaires Saint-Luc, Brussels, Belgium",
        "Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium",
        "St. Michael’s Hospital, Toronto, Canada",
        "Bakirkoy Education and Research Hospital for Psychiatric and Neurological Diseases, Istanbul, Türkiye",
        "University of Florence, Department NEUROFARBA, Florence, Italy",
        "IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy",
        "Pelt and Hasselt University, University MS Centre, Noorderhart, Rehabilitation and MS, Hasselt, Belgium",
        "Zuyderland Medical Center, Academic MS Center Zuyd, Department of Neurology, Sittard-Geleen, Netherlands",
        "School for Mental Health and Neuroscience, Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands",
        "Università di Bologna, Dipartimento di Scienze Biomediche e Neuromotorie, Bologna, Italy",
        "IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy",
        "University G. d’Annunzio of Chieti-Pescara, Institute for Advanced Biomedical Technologies (ITAB), Dept Neurosciences, Imaging and Clinical Sciences, Chieti, Italy",
        "Centre for Rehabilitation, Disability and Sport Medicine (CARES), Chieti, Italy",
        "MS Centre, Clinical Neurology, SS Annunziata University Hospital, Chieti, Italy",
        "UNSW, Immune tolerance laboratory Ingham Institute and Dept of Medicine, Sydney, Australia",
        "University Hospital Ostrava, Department of Neurology, Ostrava, Czech Republic",
        "Masaryk University, St. Anne’s University Hospital, First Department of Neurology, Brno, Czech Republic",
        "Frimley Park Hospital, Department of Neurology, Frimley, UK",
        "Royal Hobart Hospital, Hobart, Australia",
        "Royal Hobart Hospital, MS research flagship, Hobart, Australia",
        "Royal Hobart Hospital, Tasmanian Health Service, Hobart, Australia",
        "School of Translational Medicine, Monash University, Melbourne, Australia",
        "Hospital Universitario Nacional de Colombia Bogota, Centro de Esclerosis M˙ltiple (CEMHUN), Departamento de NeurologÌa, Bogota, Colombia",
        "Departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogota, Colombia",
        "AST Macerata, Neurology Unit, Macerata, Italy",
        "Monash University, Department of Medicine, School of Clinical Sciences, Clayton, Australia",
        "Department of Neurology, Monash Health, Clayton, Australia",
        "Austin Health, Melbourne, Australia",
        "University of Foggia, Department of Medical and Surgical Sciences, Foggia, Italy",
        "Department of Neurology, Antwerp University Hospital, Edegem, Belgium",
        "Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium",
        "Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium",
        "Westmead Hospital, Sydney, Australia",
        "Mayis University, Medical Faculty, Samsun, Türkiye",
        "St Vincent’s Hospital, Sydney, Australia",
        "Hospital Ceske Budejovice, Department of Neurology, Ceske Budejovice, Czech Republic",
        "Centre Hospitalier Universitaire de Sherbrooke,, Sherbrooke, Canada",
        "Charles University and Hospital Kralovske Vinohrady, Department of Neurology, Third Faculty of Medicine, Prague, Czech Republic",
        "Sultan Qaboos University, College of Medicine and Health Sciences and Sultan Qaboos University Hospital, Al-Khodh, Oman",
        "Brain and Mind Centre, Sydney, Australia",
        "Flinders University, College of Medicine and Public Health, Adelaide, Australia",
        "Unidade Local de Saúde de São João, Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Porto, Portugal",
        "University of Debrecen, Department of Neurology, Faculty of Medicine, Debrecen, Hungary",
        "Razi University Hospita, Department of Neurology, Clinical Investigation Centre Neurosciences and Mental Health, Tunis, Tunisia",
        "Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia",
        "Harley Street Medical Centre, Neurology Institute and MS Center, Abu Dhabi, United Arab Emirates",
        "University Hospital and University of Basel, Department of Neurology, Basel, Switzerland",
        "Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Departments of Biomedicine and Clinical Research, University Hospital",
        "TalTech, Senior Scientist, Tallinn, Estonia",
        "Hospital Universitario Donostia and IIS Biodonostia, San Sebastián, Spain",
        "Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Department of Neurology, Ipswich, UK",
        "University of Bristol, Bristol Medical School, Population Health Sciences, Bristol, UK",
        "NMR Research Unit, Queen Square Multiple Sclerosis Centre, University College London (UCL) Queen Square Institute of Neurology, London, UK"
      ],
      "name": "on behalf of the MSBase study group"
    }
  ],
  "title": "247 Clinically silent MRI lesions in RRMS: prognostic impact and an emulated trial of disease modifying therapy escalation",
  "uid": "b48582ab-ae91-59a2-b8c9-6787b9d77a40"
}