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1.
Biomed Opt Express ; 7(3): 943-8, 2016 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-27231599

RESUMO

We report an optical trapping method that may enable assessment of the differentiation status of cancerous cells by determining the minimum time required for cell-cell adhesion to occur. A single, live cell is trapped and brought into close proximity of another; the minimum contact time required for cell-cell adhesion to occur is measured using transformed cells from neural tumor cell lines: the human neuroblastoma SK-N-SH and rat C6 glioma cells. Earlier work on live adult rat hippocampal neural progenitors/stem cells had shown that a contact minimum of ~5 s was required for cells to adhere to each other. We now find the average minimum time for adhesion of cells from both tumor cell lines to substantially increase to ~20-25 s, in some cases up to 45 s. Upon in vitro differentiation of these cells with all-trans retinoic acid the average minimum time reverts to ~5-7 s. This proof-of-concept study indicates that optical trapping may be a quick, sensitive, and specific method for determining differentiation status and, thereby, the prognosis of cancer cells.

2.
Neurology ; 46(2): 385-7, 1996 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-8614499

RESUMO

The prevalence of MS in India is low, and it is unclear whether the manifestations of the disease in India are similar to the United States. We carried out a case-control study to compare the disease in the two populations and used clinical, evoked potential, and MRI criteria to assess similarities and differences. Our results indicate that the rate of disease progression and frequency of involvement of the cerebral hemispheres, cerebellum, spinal cord, and brainstem were similar in the two populations. The visual system was more frequently involved in Indian patients. No Indian patient had a family history of MS; this suggests an environmental disease-triggering agent.


Assuntos
Encéfalo/fisiopatologia , Esclerose Múltipla/fisiopatologia , Medula Espinal/fisiopatologia , Adulto , Idade de Início , Encéfalo/patologia , Estudos de Casos e Controles , Cerebelo/patologia , Cerebelo/fisiopatologia , Potenciais Somatossensoriais Evocados , Potenciais Evocados Visuais , Feminino , Humanos , Índia/epidemiologia , Imageamento por Ressonância Magnética , Masculino , Esclerose Múltipla/epidemiologia , Esclerose Múltipla/patologia , Nervo Óptico/patologia , Nervo Óptico/fisiopatologia , Prevalência , Valores de Referência , Medula Espinal/patologia , Estados Unidos/epidemiologia
3.
Pain ; 85(1-2): 231-8, 2000 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-10692623

RESUMO

While sensory loss in leprosy skin is the consequence of invasion by M. leprae of Schwann cells related to unmyelinated fibres, early loss of cutaneous pain sensation, even in the presence of nerve fibres and inflammation, is a hallmark of leprosy, and requires explanation. In normal skin, nerve growth factor (NGF) is produced by basal keratinocytes, and acts via its high affinity receptor (trk A) on nociceptor nerve fibres to increase their sensitivity, particularly in inflammation. We have therefore studied NGF- and trk A-like immunoreactivity in affected skin and mirror-site clinically-unaffected skin from patients with leprosy, and compared these with non-leprosy, control skin, following quantitative sensory testing at each site. Sensory tests were within normal limits in clinically-unaffected leprosy skin, but markedly abnormal in affected skin. Sub-epidermal PGP 9.5- and trk A- positive nerve fibres were reduced only in affected leprosy skin, with fewer fibres contacting keratinocytes. However, NGF-immunoreactivity in basal keratinocytes, and intra-epidermal PGP 9.5-positive nerve fibres, were reduced in both sites compared to non-leprosy controls, as were nerve fibres positive for the sensory neurone specific sodium channel SNS/PN3, which is regulated by NGF, and may mediate inflammation-induced hypersensitivity. Keratinocyte trk A expression (which mediates an autocrine role for NGF) was increased in clinically affected and unaffected skin, suggesting a compensatory mechanism secondary to reduced NGF secretion at both sites. We conclude that decreased NGF- and SNS/PN3-immunoreactivity, and loss of intra-epidermal innervation, may be found without sensory loss on quantitative testing in clinically-unaffected skin in leprosy; this appears to be a sub-clinical change, and may explain the lack of cutaneous pain with inflammation. Sensory loss occurred with reduced sub-epidermal nerve fibres in affected skin, but these still showed trk A-staining, suggesting NGF treatment may restore pain sensation.


Assuntos
Hanseníase/psicologia , Fatores de Crescimento Neural/fisiologia , Nociceptores/fisiologia , Dor/psicologia , Pele/inervação , Adulto , Idoso , Axônios/fisiologia , Feminino , Temperatura Alta , Humanos , Imuno-Histoquímica , Hibridização In Situ , Queratinócitos/fisiologia , Hanseníase/complicações , Hanseníase/patologia , Masculino , Pessoa de Meia-Idade , Fatores de Crescimento Neural/metabolismo , Dor/etiologia , Dor/patologia , Limiar da Dor/fisiologia , Estimulação Física , Receptores Proteína Tirosina Quinases/biossíntese , Reflexo/fisiologia , Pele/patologia , Canais de Sódio , Tioléster Hidrolases/metabolismo , Ubiquitina Tiolesterase , Vasodilatação/fisiologia
4.
J Neuroimmunol ; 87(1-2): 49-61, 1998 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-9670845

RESUMO

Gammadelta T cells may contribute to the pathogenesis of Multiple Sclerosis (MS) via cytotoxicity directed at the myelin-oligodendrocyte unit. We have previously demonstrated that peripheral blood-derived gammadelta T cells lyse fresh human oligodendrocytes in vitro. The present work extends these observations to gammadelta T cells derived from both peripheral blood (PBL) and cerebrospinal fluid (CSF) of MS and non-MS neurological disease controls and addresses the mechanism of cellular cytotoxicity. We found that MS patients contained increased proportions of Vdelta1+ gammadelta T cells in both CSF and PBL samples compared to other neurological disease (OND) controls. Although gammadelta T cells from all patients were cytotoxic towards Daudi, RPMI 8226, U937, Jurkat, oligodendroglioma and fresh human oligodendrocyte targets, OND-derived, Vdelta2+ rich, populations derived from the CSF exhibited greater cytotoxicity towards cell lines (Daudi, RPMI 8226) known to express high levels of heat shock proteins (hsp). To clarify the mechanism(s) of cytotoxicity used by gammadelta T cells, we first showed that cell-target contact was necessary by the use of physical barriers (transwells), which reduced target cell lysis by at least 75%. The use of Ca2+-free media reduced lysis by up to 50%, but fully blocking gammadelta T cell Perforin release and function by either Ca2+ chelation (Mg2EGTA) or the H+-ATPase inhibitor Concanamycin-A (CMA), completely abrogated the lysis of Fas-/hsp60high expressing targets (Daudi, U937). However, additional treatment with Brefeldin A was required for the complete inhibition of gammadelta T cell mediated killing of Fas+ expressing Jurkat targets and fresh human brain-derived oligodendrocytes. Inhibition of granzyme activity by an isocoumarin compound reduced cytolysis only slightly. The use of either Brefeldin A or an anti-Fas antibody alone did not significantly affect lysis. These findings suggest that in MS, gammadelta T cells may utilize either the Fas-mediated or Perforin-based cell cytotoxicity pathways in exerting oligodendrocyte damage, though the Perforin pathway is predominant.


Assuntos
Esclerose Múltipla/patologia , Oligodendroglia/fisiologia , Receptores de Antígenos de Linfócitos T gama-delta/metabolismo , Linfócitos T Citotóxicos/metabolismo , Linfócitos T Citotóxicos/fisiologia , Encéfalo/citologia , Cálcio/fisiologia , Comunicação Celular/fisiologia , Sobrevivência Celular/fisiologia , Enzimas/metabolismo , Exocitose/fisiologia , Humanos , Glicoproteínas de Membrana/fisiologia , Esclerose Múltipla/metabolismo , Perforina , Proteínas Citotóxicas Formadoras de Poros , Células Tumorais Cultivadas , Receptor fas/fisiologia
5.
J Neuroimmunol ; 102(2): 131-6, 2000 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-10636481

RESUMO

We found that human fetal astrocytes (HFA) are able to support superantigen (SAG) staphylococcal enterotoxin B (SEB) and toxic shock syndrome toxin-1 (TSST-1)-induced activation of immediately ex vivo allogenic human CD4 T cells. Using radiolabelled toxins, we demonstrate that both SEB and TSST-1 bind with high affinity to MHC class II antigen expressing astrocytes; binding is displaceable with excess cold toxin. Competition experiments further indicate that TSST-1 and SEB at least partially compete with each other for binding to astrocytes suggesting they bind to the same HLA-DR region on these cells. Our study supports the hypothesis that SAG would be capable of stimulating immune responses within the human CNS and contribute to persistence or recurrence of inflammatory responses within this compartment.


Assuntos
Células Apresentadoras de Antígenos/imunologia , Astrócitos/imunologia , Toxinas Bacterianas , Superantígenos/imunologia , Astrócitos/metabolismo , Ligação Competitiva , Linfócitos T CD4-Positivos/fisiologia , Células Cultivadas , Enterotoxinas/metabolismo , Enterotoxinas/fisiologia , Humanos , Ativação Linfocitária , Superantígenos/metabolismo , Linfócitos T/imunologia
6.
J Neural Transm Suppl ; (58): 193-203, 2000.
Artigo em Inglês | MEDLINE | ID: mdl-11128609

RESUMO

Development of neuroprotective therapies for multiple sclerosis is dependent on defining the precise mechanisms whereby immune effector cells and molecules are able to induce relatively selective injury of oligodendrocytes (OLs) and their myelin membranes. The selectivity of this injury could be conferred either by the properties of the effectors or the targets. The former would involve antigen specific recognition by either antibody or T cell receptor of the adaptive immune system. OLs are also susceptible to non antigen restricted injury mediated by components of the innate immune system including macrophages/microglia and NK cells. Target related selectivity could reflect the expression of death inducing surface receptors (such as Fas or TNFR-1) required for interaction with effector mediators and subsequent intracellular signaling pathways, including the caspase cascade. Development of therapeutic delivery systems, which would reach the site of disease activity within the CNS, will permit the administration of inhibitors either of the cell death pathway or of effector target interaction and opens new avenues to neuroprotection approach.


Assuntos
Esclerose Múltipla/tratamento farmacológico , Esclerose Múltipla/fisiopatologia , Fármacos Neuroprotetores/uso terapêutico , Doenças Autoimunes/patologia , Doenças do Sistema Nervoso Central/patologia , Humanos , Esclerose Múltipla/etiologia , Esclerose Múltipla/imunologia , Oligodendroglia/patologia , Oligodendroglia/fisiologia , Linfócitos T Reguladores/fisiologia
9.
J Neurochem ; 73(2): 605-11, 1999 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-10428056

RESUMO

Oligodendrocytes (OLs) and their myelin membranes are the primary targets in the autoimmune disease multiple sclerosis (MS). The inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) has been implicated as a mediator of OL cell injury. TNF-alpha is detectable within MS lesions and induces apoptosis of mature human OLs in vitro. One possible mechanism by which TNF-alpha mediates cell death is through the activation of c-jun N-terminal kinase (JNK). We have previously shown that treatment of human OLs with TNF-alpha leads to activation of JNK. Here we provide evidence that p53, a regulator of the cell cycle and apoptosis, is a mediator of TNF-alpha-induced apoptosis of OLs. Although p53 was undetectable by western blot analysis in adult human OLs, its levels increased within 24 h after TNF-alpha treatment (100 ng/ml). The induced p53 was immunolocalized to the nucleus prior to the appearance of significant numbers of apoptotic cells. Overexpression of p53 by adenovirus-mediated gene transfer into human OLs in vitro resulted in marked apoptosis as revealed by in situ cleavage of DNA (TUNEL positive), decreased mitochondrial function, and release of lactate dehydrogenase into the culture medium. These in vitro studies demonstrate that increased p53 levels are associated with apoptosis of human OLs. The findings further implicate p53 as a target for the JNK pathway activated during TNF-alpha-mediated cell death of human adult OLs.


Assuntos
Apoptose/fisiologia , Oligodendroglia/citologia , Oligodendroglia/metabolismo , Fator de Necrose Tumoral alfa/farmacologia , Proteína Supressora de Tumor p53/genética , Adenoviridae , Infecções por Adenoviridae , Adulto , Apoptose/efeitos dos fármacos , Encéfalo/citologia , Células Cultivadas , Feto/citologia , Regulação Viral da Expressão Gênica , Técnicas de Transferência de Genes , Humanos , Marcação In Situ das Extremidades Cortadas , Óperon Lac , Oligodendroglia/virologia , Proteínas Recombinantes/genética
10.
Br J Exp Pathol ; 68(5): 733-41, 1987 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-3318906

RESUMO

Although leprosy, a chronic disease caused by M. leprae, primarily affects skin and peripheral nerves, pathological changes and granulomas have been observed in lymph nodes which are: (a) present in tuberculoid lymph nodes in the absence of acid-fact bacilli and (b) persistent in lepromatous patients even after prolonged treatment. We detected substantial amounts of mycobacterial antigen in 16 leprous lymph nodes using anti-BCG by the peroxidase anti-peroxidase method. The load and distribution of antigen varied along the spectrum and with the duration of treatment. Tuberculoid and long-term treated lepromatous lymph nodes had a similar distribution of antigen in clusters of cells giving a 'speckled' appearance. The untreated lepromatous had a 'diffuse' staining of antigen in foamy histiocytes whereas lepromatous lesions with a lower bacillary load had a mixed pattern of 'diffuse' and 'speckled'. Antigen was also detected in a number of plasma cells along the spectrum but predominantly in lepromatous lymph nodes. Our observations indicate that: (a) antigen exists in lymph nodes despite prolonged chemotherapy which may be responsible for the persistent granuloma and (b) antigen is not confined to any particular anatomical compartment of the lymph node.


Assuntos
Antígenos de Bactérias/análise , Hanseníase/imunologia , Linfonodos/imunologia , Mycobacterium leprae/imunologia , Adolescente , Adulto , Criança , Feminino , Humanos , Técnicas Imunoenzimáticas , Hanseníase/tratamento farmacológico , Masculino , Pessoa de Meia-Idade
11.
J Immunol ; 160(4): 1606-11, 1998 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-9469416

RESUMO

Oligodendrocytes and their myelin membranes are the apparent target of the autoimmune response that characterizes the human adult central nervous system-demyelinating disease multiple sclerosis. Human oligodendrocytes do not express MHC class II molecules, a requirement for MHC-restricted injury mediated by myelin-reactive CD4+ T cells, the cell type implicated in initiating the disease process. In this study we observed that human adult central nervous system-derived oligodendrocytes can be susceptible to non-MHC-restricted lysis mediated by myelin basic protein-reactive CD4+ T cell lines. Cytotoxicity was significantly greater (37 +/- 4 vs 7 +/- 3%) with cell lines in which a high proportion of cells (mean, 28 +/- 6%) expressed CD56 compared with cytotoxicity mediated by low CD56 cell lines (8 +/- 2%). High CD56 cell lines, when rested in IL-2, lost cytotoxic activity and had reduced expression of CD56 (mean, 5 +/- 2%). CD4+ T cells isolated from short term (3-day) anti-CD3/IL-2-activated mononuclear cell cultures did not express CD56 and were not cytotoxic to oligodendrocytes unless lectin was added. In contrast, an enriched population of non-T cells extracted from the same activated MNC cultures expressed CD56 as well as other NK cell-associated surface molecules and was cytotoxic. These results indicate the potential susceptibility of human oligodendrocytes to non-MHC-restricted injury mediated by both Ag-reactive and nonspecific cellular immune effector cells, with CD56 expression being a common feature of the effector cells.


Assuntos
Antígeno CD56/biossíntese , Citotoxicidade Imunológica , Oligodendroglia/imunologia , Adulto , Células Cultivadas , Testes Imunológicos de Citotoxicidade , Humanos , Imunidade Celular , Leucócitos Mononucleares/imunologia , Complexo Principal de Histocompatibilidade/imunologia , Proteína Básica da Mielina/imunologia , Subpopulações de Linfócitos T/imunologia , Linfócitos T Citotóxicos/imunologia , Lobo Temporal
12.
Brain ; 121 ( Pt 12): 2239-47, 1998 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-9874477

RESUMO

Loss of nociception and hypohidrosis in skin are hallmarks of leprosy, attributed to early invasion by Mycobacterium leprae of Schwann cells related to unmyelinated nerve fibres. We have studied skin lesions and contralateral clinically unaffected skin in 28 patients across the leprosy spectrum with a range of selective quantitative sensory and autonomic tests, prior to biopsy of both sites. Unaffected sites showed normal skin innervation, when antibodies to the pan-neuronal marker PGP (protein gene product) 9.5 were used, with the exception of intraepidermal fibres which were not detected in the majority of cases. Elevation of thermal thresholds and reduced sensory axon-reflex flare responses in affected skin correlated with decreased nerve fibres in the subepidermis, e.g. axon-reflex flux units (means+/-SEM) for no detectable innervation; decreased innervation; and clinically unaffected skin, were 23+/-3.1; 41.2+/-7.3; and 84.5+/-4.0, respectively. Reduced nicotine-induced axon-reflex sweating was correlated with decreased innervation of sweat glands. Where methacholine-induced direct activation of sweat glands was affected, there was inflammatory infiltrate and loss of sweat gland structure. This study demonstrates a correlation between selective nerve dysfunction on clinical tests and morphological changes in skin, irrespective of the type of leprosy, and is the first to show that loss of sweating in leprosy may result either from decreased innervation and/or involvement of the sweat glands. The findings have implications for the selection and monitoring of patients with leprosy in clinical trials which aim to restore cutaneous function.


Assuntos
Hanseníase/patologia , Hanseníase/fisiopatologia , Sistema Nervoso/fisiopatologia , Pele/metabolismo , Pele/patologia , Glândulas Sudoríparas/fisiopatologia , Sistema Nervoso Autônomo/fisiopatologia , Biópsia , Temperatura Alta , Humanos , Imuno-Histoquímica , Hanseníase/metabolismo , Fibras Nervosas/metabolismo , Fibras Nervosas/patologia , Sensação/fisiologia , Limiar Sensorial/fisiologia , Pele/inervação , Pele/fisiopatologia , Tioléster Hidrolases/metabolismo , Ubiquitina Tiolesterase
13.
Glia ; 36(3): 281-94, 2001 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11746766

RESUMO

Oligodendrocyte (OL) death occurs in many disorders of the CNS, including multiple sclerosis and brain trauma. Factors reported to induce OL death include deprivation of growth factors, elevation of cytokines, oxidative stress, and glutamate excitotoxicity. Because astrocytes produce a large amount of growth factors and antioxidants and are a major source of glutamate uptake, we tested the hypothesis that astrocytes may have a protective role for OL survival. We report that when OLs from the adult mouse brain were initiated into tissue culture, DNA fragmentation and chromatin condensation resulted, indicative of apoptosis. OL death was significantly reduced in coculture with astrocytes, but not with fibroblasts, which provided a similar monolayer of cells as astrocytes. The protection of OL demise by astrocytes was not reproduced by its conditioned medium and was not accounted for by several neurotrophic factors. In contrast, interference with the alpha(6) integrin subunit, but not the alpha(1), alpha(2), alpha(3), alpha(4), alpha(5), or alpha(v) integrin chains, negated astrocyte protection of OLs. Furthermore, a function-blocking antibody to alpha(6)beta(1) integrin reduced the ability of astrocytes to promote OL survival. The extracellular matrix ligand for alpha(6)beta(1) is laminin, which is expressed by astrocytes. Significantly, neutralizing antibodies to laminin-2 and laminin-5 inhibited the astrocyte mediation of OL survival. These results implicate astrocytes in promoting OL survival through a mechanism involving the interaction of alpha(6)beta(1) integrin on OLs with laminin on astrocytes. Enhancing this interaction may provide for OL survival in neurological injury.


Assuntos
Antígenos CD/metabolismo , Astrócitos/metabolismo , Comunicação Celular/fisiologia , Morte Celular/fisiologia , Doenças do Sistema Nervoso Central/metabolismo , Laminina/metabolismo , Oligodendroglia/metabolismo , Animais , Antígenos CD/imunologia , Sobrevivência Celular/fisiologia , Células Cultivadas/citologia , Células Cultivadas/metabolismo , Doenças do Sistema Nervoso Central/patologia , Doenças do Sistema Nervoso Central/fisiopatologia , Técnicas de Cocultura , Fragmentação do DNA/fisiologia , Inibidores Enzimáticos/farmacologia , Marcação In Situ das Extremidades Cortadas , Integrina alfa6 , Camundongos , Camundongos Endogâmicos , Oligodendroglia/patologia , Fosfotransferases/antagonistas & inibidores , Fosfotransferases/metabolismo , Transdução de Sinais/fisiologia
14.
J Neurosci ; 18(4): 1297-304, 1998 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-9454839

RESUMO

Oligodendrocytes (OLs) are the primary targets in the autoimmune disease multiple sclerosis (MS). Cell receptors belonging to the tumor necrosis factor receptor (TNF-R) superfamily, such as TNF receptors and fas, are implicated in signaling the injury response of OLs. The p75 neurotrophin receptor (p75(NTR)), another member of the TNF-R superfamily, has been reported to mediate nerve growth factor (NGF)-induced apoptosis in some neural systems. To address the potential relationship between p75(NTR) signaling and OL injury, we assayed adult human OLs cultured under several different conditions for p75(NTR) and tyrosine kinase receptor trkA expression, for NGF-mediated apoptosis, and for NGF-mediated jun kinase (JNK) or nuclear factor (NF) kappaB activation. In the current study, we have found expression of p75(NTR) on cultured adult CNS-derived human OLs but not on other glial cells. TrkA was not detected on these OLs in any of the culture conditions tested. Treatment of the OLs with varying concentrations of NGF over a range of time periods resulted in no significant increase in numbers of terminal transferase (TdT)-mediated d-uridine triphosphate (UTP)-biotin nick-end labeling positive OLs, whereas significant cell death was observed using TNF-alpha. Furthermore, unlike TNF-alpha treatment, NGF treatment did not significantly activate JNK, although both TNF-alpha and NGF induced nuclear translocation of NF-kappaB. These findings contrast with the recent report of NGF-mediated apoptosis in the OLs of neonatal rats matured in vitro, which express p75(NTR) but not trkA (), and suggest that, at least in humans, p75(NTR) signaling may mediate responses other than apoptosis of OLs.


Assuntos
Fatores de Crescimento Neural/farmacologia , Oligodendroglia/efeitos dos fármacos , Oligodendroglia/metabolismo , Receptores de Fator de Crescimento Neural/metabolismo , Transdução de Sinais/fisiologia , Adulto , Apoptose , Transporte Biológico/efeitos dos fármacos , Núcleo Celular/metabolismo , Sobrevivência Celular/efeitos dos fármacos , Humanos , NF-kappa B/metabolismo , Receptor de Fator de Crescimento Neural , Receptor trkA/metabolismo
15.
Acta Neurol Scand ; 95(2): 90-5, 1997 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-9059727

RESUMO

OBJECTIVES: To compare the rate of prior environmental exposures between Indian multiple sclerosis (MS) patients and controls in order to identify potential disease triggering factors. MATERIAL AND METHODS: A standard self-administered questionnaire regarding prior exposures was presented to 56 Indian MS patients and 147 other neural disease and healthy controls at two large medical centers in India. RESULTS: The rate of prior foreign travel, surgeries, blood transfusions, clinical chicken pox and mumps infections and exposure to cats and farm animals was not significantly different between MS patients and controls. However, clinical measles infection and dog exposure occurred significantly more often in the MS patients. CONCLUSION: These findings are consistent with but do not prove an association between prior measles infection, dog exposure and MS.


Assuntos
Exposição Ambiental/efeitos adversos , Esclerose Múltipla/etiologia , Adulto , Animais , Animais Domésticos , Gatos , Distribuição de Qui-Quadrado , Cães , Exposição Ambiental/estatística & dados numéricos , Feminino , Humanos , Índia/epidemiologia , Masculino , Sarampo/complicações , Esclerose Múltipla/epidemiologia , Razão de Chances , Estudos Retrospectivos
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