Wednesday, March 14, 2012

10 2011 Guidelines For Treating Lyme Disease...

... from Russia are here. With love.

This past weekend I got into a lengthy discussion with "radicale" on the Embers et al Issues a Statement post, and somewhere along the line, amid over 50 comments there (I highly recommend reading them, too), radicale advised that I check out documentation and research on Lyme disease from Russia and the Balkans.

So I did, and I did in part because he's the one who told me that treatment for both acute and disseminated Lyme disease in Serbia - particularly at two hospitals in the country - is more aggressive by default than it is either in the US or in Canada. He also stated that this treatment is backed by clinical studies (two of which are mentioned in the comments on the above post) - and because it was his home country and had this scientific backing, he went there for treatment for Lyme disease rather than in Canada.

He shared what he said was the standard antibiotic treatment schedule for Lyme disease given to patients in a few hospitals in Serbia:

"It is interesting that in Serbia, where every third tick is infected, amoxicillin is the drug of choice and it is routinely given for 6 weeks for early Lyme Disease.

In addition, disseminated Lyme Disease is treated in the following manner:

1) 4 weeks of ceftriaxone 2g/day plus metronidazole 500 mg bid
or three weeks of amoxicillin 1g tid followed by three weeks doxycycline 200mg bid plus metronidazole 500 mg bid
2) in case of persisting symptoms therapy is extended using pulsed doses up to 6 months

There are open-label control studies to support this type of treatment (in Serbian)."

I found this difference in approach to treatment interesting and I wanted a confirmation with a reliable source - so I have requested more information from him in terms of a citation for official guidelines using this antibiotic treatment.

While awaiting his response, I decided to see if I could find guidelines for other countries in the region and translate them. So far, I have found the 2011 guidelines for treatment of tickborne Borreliosis (they call it SDS) for Russia and ran them through Google Translate.

They are - as you will see - pretty bare bones relative to the guidelines document written up by either the IDSA or ILADS... And oh, OPTIONS... We have OPTIONS... did I say we have options? Yes, only I don't know what all the options actually are yet - I would have to figure out what all the drugs are by name.

Far as I can tell, Azitroks = azithromycin. doksitsi-wedge is, I think, some form of liquid doxycycline that is highly absorbent. klaforan = Claforan. Instructions at the bottom "per os" means "by mouth" or "orally".

I can figure out what some of the other drugs are due to their spelling coming close to the English word - but other drugs are unknown to me by the name being used...

APPROVED
Head of the Department of Health
Tomsk Oblast
O.S. Kobyakov
2011
Lepekhin A.
MD, Professor, Head of
Infectious Diseases and Epidemiology, State Educational Institution SSMU Health Ministry of Russia

Lukashova L.
MD, Professor, Department of Infectious Diseases and Epidemiology
GOU VPO SSMU Health Ministry of Russia

Ilyinskikh EN
MD, Professor, Department of Infectious Diseases and Epidemiology
GOU VPO SSMU Health Ministry of Russia

Zhukov, N.
MD, Professor of Neurology and Neurosurgery
GOU VPO SSMU Health Ministry of Russia

Portnyagina EV
PhD, Assistant Professor of Epidemiology and Infectious Diseases
GOU VPO SSMU Health Ministry of Russia

Dobkin, MN
PhD, chief freelance specialist in infectious
Health Department of the Tomsk region

Guidelines for Physicians
(Third edition, revised and enlarged)

Tomsk - 2011

THERAPY PROGRAM SDS

Schemes of causal treatment for tickborne Lyme Borreliosis

During the acute, manifest form (mild)

(Schema therapy - individual choice of doctor)
A. Amoxicillin 0.5 g three times daily per os (0.375 g of amoxiclav three times daily
per os), 14 days.
 or
Two. Azitroks 0.5 1 g once a day per os, 6 days.
 or
Three. Doxycycline 0.1 g 2 times a day per os, 14 days.

During the acute, manifest form (medium severity)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 1.0 g 2 times a day by intravenous drip, and 7 days, then - Amoxil-
penicillin of 0.75 g 3 times daily per os (0.375 g of amoxiclav three times daily per os),
7 days.
  or
Two. Ceftriaxone 1.0 g 2 times a day by intravenous drip, and 7 days, then - doksitsi-
wedge of 0.2 g 2 times a day intravenous drip, and 7 days.
 or
Three. 0.75 g of amoxicillin three times daily per os (0.560 g of amoxiclav three times daily
per os), 7 days, then - Azitroks 0.5 g of 1 time per day per os, 6 days.
 or
4. Doxycycline 0.2 g 2 times a day intravenous drip, and 7 days, then - Azitroks
0.5 1 g once a day per os, 6 days.

During the acute, manifest form (severe severity)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 2.0 g 2 times a day intravenous drip, and 10 days later - Amoxil-
penicillin at 1.0 g three times daily per os (amoxiclav, 0.625 g 3 times daily per os),
10 days.
 or
Two. Ceftriaxone 2.0 g 2 times a day intravenous drip, and 10 days later - doksitsi-
wedge of 0.2 g 2 times a day intravenous drip, and 10 days.
 or
Three. Amoxicillin 1.0 g three times daily per os (amoxiclav, 0.625 g 3 times a day
per os), 7 days, then - Azitroks of 1.0 g of 1 time per day per os in a 1-day and 0.5 g of 1
once a day per os for the next 5 days.
 or
4. Doxycycline 0.2 g 2 times a day intravenous drip, and 7 days, then - Azitroks 1.0 g of 1 time per day per os in 1-day and 0.5 g of 1 time per day per os for at- the next 5 days.

8Podostroe for (mild)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 1.0 g of a once-daily intravenous infusion, and 10 days later - doksitsi-
wedge of 0.1 g 2 times a day intravenous drip, and 10 days.
 or
Two. Amoxicillin 0.5 g three times daily per os (amoxiclav, 0.625 g 3 times a day
per os), 10 days later - doxycycline 0.1 g 2 times daily intravenous-drip
10 days.

Subacute (medium severity)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 1.0 g of a once-daily intravenous infusion, and 10 days later - doksitsi-
wedge of 0.2 g 2 times a day intravenous drip, and 10 days.
 or
Two. Ceftriaxone 1.0 g of a once-daily intravenous infusion, and 10 days later - Amoxil-
penicillin of 0.75 g 3 times daily per os (0.375 g of amoxiclav three times daily per os),
10 days.

Subacute (severe severity)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - doksitsi-
wedge of 0.2 g 2 times a day intravenous drip, and 10 days.
 or
Two. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - Amoxil-
penicillin at 1.0 g three times daily per os (amoxiclav, 0.625 g 3 times daily per os),
10 days.

Chronic (phase compensation)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - klaforan
2.0 g 2 times a day by intravenous infusion or intramuscular injection, and 10 days, then -
amoxicillin 0.5 g three times daily per os (0.375 g of amoxiclav three times daily
per os), 7 days.
 or
Two. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - klaforan
2.0 g 2 times a day by intravenous infusion or intramuscular injection, and 10 days, then -
doxycycline 0.1 g 2 times a day by intravenous drip, and 10 days.

Chronic (Stage subcompensation)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - klaforan
2.0 g 2 times a day by intravenous infusion or intramuscular injection, and 10 days, then -
amoxicillin 0.5 g three times daily per os (0.375 g of amoxiclav three times daily
per os), 10 days.
 or
Two. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - klaforan
2.0 g 2 times a day by intravenous infusion or intramuscular injection, and 10 days, then -
doxycycline 0.2 g 2 times a day by intravenous drip, and 10 days.

9Hronicheskoe for (stage decompensation)

(Schema therapy - individual choice of doctor)
A. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - klaforan
2.0 g 2 times a day by intravenous infusion or intramuscular injection, and 10 days, then -
amoxicillin 0.5 g three times daily per os (0.375 g of amoxiclav three times daily
per os), 10 days.
 or
Two. Ceftriaxone 2.0 g of a once-daily intravenous infusion, and 10 days later - klaforan
2.0 g 2 times a day by intravenous infusion or intramuscular injection, and 10 days, then -
doxycycline 0.2 g 2 times a day by intravenous drip, and 10 days.

Scheme of pathogenetic and symptomatic therapy

Universal scheme of pathogenetic and symptomatic therapy
patients with SDS

(Drugs, marked with #, appoint, and the testimony of an individual selection, dosing regimen of drugs - depending on the severity of illness)

- Lineks 1-2 capsules three times daily per os, 30 days;
# 0.9% sodium chloride, 200 ml of intravenous-drip of 5% glucose solution
200-400 ml of intravenous-drip reopolyglukine 200-400 ml of intravenous-ka-
pelno;

# Immunomodulators (including data immunogram).

When neurological manifestations...

# Venotonicheskie tools
- 2.4% -10.0 aminophylline IV-drip, 10 days
or
- Cavinton (vinpocetine) 4-mL intravenous infusion, 10 days
# Neuroprotective drugs
- 10 ml Cerebrolysin intravenous-infusion, 10 days
or
- Actovegin 5-20 ml per day by intravenous drip, and 10 days later - on 0.2 g of 3
times a day per os, 30 days
or
- Cytoflavin 10 ml intravenous drip, in 100-200 ml of 5-10% solution of glucoside
goats, or 0.9% sodium chloride solution, 1 time per day, 10 days later - on 2
tablets 2 times daily per os, 25-30 days
or
- Nootropil 5 ml intravenous drip, and 10 days
or
- Lutset 10 ml intravenous bolus, and 10 days

# Metabolic means

- Mildronat 10% -5.0 (10.0) IV-bolus, 10 days
or
- Panangin 10-20 ml intravenous bolus, and 10 days, then - 1 tablet 3 times a
per day per os, 30 days

# Vitamin
- Milgamma 2 ml daily intramuscular injections of 10
or
1011
- Berokka plus 1 tablet daily per os, 30 days
or
- Benfolipen (combined multivitamin complex) 1 tablet 1.3
times daily after meals per os, 30 days

# Tranquilizers
- Nozepam of 0.01 g per os the night
or
- Grandaksin of 0.05 g 2 times a day per os
or
- Alprazolam 0,025 g per night per os, with a gradual increase in dose
0.025 g in 3-5 days
or
- Phenazepam of 0.005-0.01 g per night per os, 7-10 days
or
- Glycine, 0.1 g 4-6 times a day sublingually, long-term (period-rekonva
lestsentsii)
or
- Adaptol (mebikar) to 0.5 g 2-3 times a day per os, a few days to 2-3
months (the period of convalescence)

# Sedatives
- New-passive 1 tablet or 1 tsp. solution 3 times a day per os, 30 days
or
- Tincture of motherwort (peony, Valerian) or Corvalol (valokordin, valoser-
din)

otvornye tools
- Donormil to 0,015 g per night per os
or
- Radedorm to 0,005 g per night per os
or
- Ivadal of 0.010 g per os the night
or
- Imovan of 0.0075 g per night per os
or
- Sanval to 0,005 g per night per os

# antidepressants
- Amitriptyline to 0,025 g per night per os, with a gradual increase in dose
0.025 g, 30-40 days
or
- Luvox of 0.05-0.1 g per night per os, up to 3 months
or
- Agomelatine 0,025 g per night per os, up to 3 months
When arthrologic manifestations

# Non-steroidal anti-inflammatory drugs
- Diclofenac 3 ml intramuscular injections of 6 or 0.025-0.05 g 3 times
per day per os, up to 7 days
or
- Movalis 1.5 mL intramuscularly or 0.015 g of 1 time per day per os, up to 7 days
or 12
- Ksefokam of 0,008 g 1-2 times daily per os
or
- Celebrex to 0.2 g 2 times a day per os, up to 7 days
or
- Artrozan (meloxicam) to 0,015 g 1 a day per os

# Antispasmodics
- Midokalm of 0.05 g 2-3 times a day per os, with a gradual increase razo-
curve to the dose of 0.15 g (0.1 g 1-2 times a day intramuscularly or intravenously
slowly)
or
- Sirdalud 0,002 g 3 times a day

# With the express pain
- Diprospan 1 ml in 2-4 ml of 0.5% solution of novocaine or lidocaine 2%
an intramuscular injection once a week, 3-5 injections
or
- Combilipen (combined multivitamin complex in conjunction with the Do-
dokainom) 2 ml intramuscularly daily for 5-7 days, then - 2
ml 2-3 times a week for 2 weeks

# Massage, therapeutic exercise, physical therapy (in the period of convalescence)

When cardiac manifestations...

# Metabolic means
- 10% mildronat -5,0-10,0 intravenous bolus, and 10 days (myocarditis, myocardial-
odistrofiya, ECG signs of repolarization, disturbances of rate)
- Panangin 10-20 ml intravenous bolus, and 10 days, then - 1 tablet 3 times a
per day per os, 30 days (arrhythmias and conduction)

# Sedatives
- New-passive 1 tablet or 1 tsp. solution 3 times a day per os, 30 days
(Syndrome of vegetative dystonia)
or
- Tincture of motherwort (peony, Valerian) or Corvalol (valokordin, valoser-
din)

# Antihypertensives
- Atenolol to 0.05-0.1 g per day, 20-30 days (arterial hypertension syndrome-
sion, cardiac arrhythmias, the syndrome of vegetative dystonia, stenokardicheskie
syndrome)



Comments? Questions? Thoughts?

My first thought on these guidelines are that the first thing I notice is that they are broken down into certain stages and conditional stages of Lyme disease/Borreliosis that are not defined here - perhaps they are defined in another document I have yet to locate, but just at first glance, medical professionals in Russia seem to break the stages down into finer grades of distinction with treatments to match.

My second thought is it seems their approach is to vary the kind of antibiotic used, and use the most bactericidal antibiotic first, followed by progressively less bactericidal and more bacteriostatic antibiotics. I am wondering if this is done for any specific reason.

My third thought is that the IDSA would probably not like part of these guidelines because they recommend using vitamins, massage therapy, and a little alternative medicine. That tincture of motherwort would probably be troubling to them. (Personally, I found valerian root to be a useful sleep aid, but it smells like dirty socks so I don't use it.)

My fourth thought is that this is pretty thorough in terms of intensive treatment for patients with cardiac and neurological manifestations of disseminated and late stage Lyme disease/Borreliosis, and I like that it offers ideas for supportive treatment for not only pain, anxiety, and depression - but for irregular heart rhythms.

There are some things that didn't translate well and I'm wondering what they are. "8Podostroe" for one thing."9Hronicheskoe" for another... I don't know what that is, either. Readers are invited to guess.

One thing I have learned while looking at various Russian and Balkans regional web sites on Lyme disease: They take it seriously.

You are considered an early mild case only within the first few days of a bite. After that, there is concern the disease has moved to the disseminated phase and it is treated more intensively. They also believe in relapses, and will give additional antibiotics if the initial course fails. In a number of places, you are expected to visit an infectious disease doctor as an outpatient 1, 3, 6, and 12 months after treatment in order to get follow up testing, report any relapsing, ongoing, or new symptoms, and give doctors more data for them to collect to understand how Lyme disease affects people.

There's more I've learned, but I'll share it later. Right now I just wanted to put these out here for you to see what other countries are doing to treat Lyme disease.


10 comments:

  1. Harkening back to college Russian...
    8 podostroe = approach.
    9Hronicheskoe = Chronic.

    thank you for your continued work and efforts.

    ReplyDelete
  2. I neglected to commented on the translation post, that I believe that I was first exposed to Lyme in Lithuania on break from studies in Moscow. Upon returning from Lithuania where we travelled by bus and toileted in fields, I had a rash and flu sickness but chalked it up to dissentary and nettles. After struggling in the year following my studies in Russia, I was sent to ID stateside and tested but did not have enough bands and thus never treated.

    ReplyDelete
  3. Anonymous 10:18 AM-10:25AM,

    Thank you for your quick translation skills. That helps. There are a few headers beneath those words which you translated that which say "something in Russian" tools. If you could also tell me what those words mean, that would be greatly appreciated.

    I'm sorry you got sick with Lyme Borreliosis in Lithiuania. How long ago did you get the rash? How is your health today? Have you had any antibiotics since then and have they affected how you feel?

    I don't know what the position of the health authorities of Russia were at the time you were first ill - or even what the differences are between Russia's approach and that of the Ukraine, Serbia, Slovania, Croatia - basically the Balkans. But just about every public health forum online I visited this week - the equivalent of WebMD and Just Ask kind of forums here in the US - it seemed doctors took patients seriously when they talked about their symptoms and they pushed them to retest if they were still symptomatic after a tick bite.

    The other striking difference I read on various sites was that it was accepted that Borrelia burgdorferi and the other regional strains of Borrelia have a latent stage. The existence of this latent stage is one of the things which is a source of controversy here in the US.

    If there is such a thing - and you begin to have symptoms which look like Lyme disease - maybe you should consider testing to see how many bands you do get?

    Anyway, thanks for reading and commenting here.

    ReplyDelete
  4. Anonymous,

    With all seriousness, you might want to get checked out for Lyme disease. Having a negative test doesn't mean you don't have Lyme disease - let alone having a few (but not enough) bands.

    ReplyDelete
  5. Did you see the Chinese CDC's western blot criteria?
    PMID 21112481 - Jiang et al., 2010

    for IgG, at least one band of P83/100, P58, P39, P30, OspC (22kd) , P17, P66, and Osp A (31 kd)

    73% sensitive, 99% specific

    Lorima

    for IgM, at least one band of P83/100, P58, OspA, P30, P17, or P41.

    “In addition, when the positive band is p41, syphilis, leptospirosis and other related diseases should be excluded.”

    50% sensitive, 93% specific

    ReplyDelete
  6. This is interesting. Russian Lyme disease guidelines with the word 'choice' mentioned several times!
    In the beginning when I was trying to lobby UK doctors to treat my partner's neurological Lyme disease a psychiatrist friend of mine commmented, 'But Sandra we don't live in a totalitarian state!' I've tried to explain the impasse many times to other fellow psychs and they just don't get it. 'Surely he's allowed a trial of treatment?' piped one, 'What about giving him the benefit of the doubt?' suggested another. All to no avail of course. Because actually....
    So I find it enormously ironic that a more liberal and felxible approach exists in Russia.

    ReplyDelete
  7. Camp other,
    Thank you for your comments. As for the Russian, it is difficult for me to translate with little medical background in the language and no medical dictionary. The words appear to be more technical or at least not in my dictionary. I do, however, have a Russian friend with whom I will check.

    As for Lyme testing, I have been tested by both a standard lab and a specialtiy reference lab. I am CDC negative though my test is rife with bands. Of course, these would not include reference for a Russian/Balkan/European strain.

    I was tested last year after a five day hospitalization resulting in a probable MS diagnosis. We started to pursue more Lyme testing once my spouse began to have similar neurological symptoms. I was plagued with arthralgias and intermittent fatigue since my return from Russia but never put more thought to Lyme until now. Finally, all the pieces began to make sense.

    Incidently, I was first seen in 1994 near Dearborn, MI where the IDSA standards were tightened and under the old protocols, I would have tested positive. Of course, all of this is hindsight.

    I never sought treatment in Russia as I was unaware there could be a problem. Oh, how I wish I could have that recognized care now. I am currently following a Combined Antibiotic Protocol like Stratton et al. at Vanderbilt unoversity after some months of Lyme only protocol. There has been a marked improvement in my health and I feel like I have my life back since undergoing treatment.

    I long for sanity in the controversy, sound research and less politics. Your approach is good. I have seen all ends of the conversation and am afraid it only produces more suffering.

    I'll update when I have answers to the Russian questions.

    ReplyDelete
  8. Anonymous 7:03 am,

    It's been a while since I've seen that Chinese study by Jiang et al. I'm not sure what to think - other than if p41 is the only band that's positive, I'd test the other conditions to exclude them. You can always be infected by more than one organism.

    Given what I've read about immune responses to Bb in the host, one can be seronegative but still have Lyme disease. The more I read about testing, the more I realize just how difficult a subject it is when it comes to Lyme Borreliosis: Timing is important, the host immune system response is important, and so is the strain/genotype relative to antigen in the test. Having just finished a few Russian papers on serological diagnosis (as well as using PCR very early in infection), my brain is swimming in knowledge of the difficulties involved.

    LymePickle,

    I'm sorry your partner had so much trouble getting treatment. That's not good to hear. I hope he is doing better now.

    I don't know what his odds would have been in Russia - I only know that after reading several online medical forums where both doctors and the public meet that there is a huge amount of encouragement to get people with tick bites to the doctor or ER for removal and strong advisement against doing it yourself, plus strong encouragement for followup testing if you are first negative on tests but continue to have symptoms.

    Beyond that, I am still learning what is done there and how people are treated in Russia and the Balkans - guidelines and radicale's Serbian experience aside. I don't know if radicale's experience was the typical Serbian experience or not - I'd like to hear from more people who live in that area.

    ReplyDelete
  9. Anonymous 4:09 PM,

    Thank you for your impromptu Russian translation - and thank any friend you have who may be able to help translate the remaining words Google failed to translate.

    It sounds like you were infected a long time ago, and unfortunately the test results you had did not qualify based on changes out of Dearborn. I think that there has been too much emphasis on the use of serology when Lyme disease is supposed to be a clinical diagnosis. I think when in doubt, doctors could take the empric approach and see how you to respond to treatment. Better to try that than do nothing - or worse, provide you with inappropriate treatment like steroids and other drugs which may not help Lyme disease.

    What kind of improvements have you seen since you began the Combined Antibiotic Protocol like Stratton et al. at Vanderbilt University?
    Can you please share a link to this protocol for me and other readers of this blog? I am glad to hear you are getting your life back. I hope you continue to improve, however long it takes.

    You said,

    "I long for sanity in the controversy, sound research and less politics. Your approach is good. I have seen all ends of the conversation and am afraid it only produces more suffering."

    Yes. Agreed.

    I'm tired of the suffering and I have seen a lot of it over the years - mine and others. I think at this point the problem has to be approached from a different place, and this is where I've started. Let's see where things go.

    ReplyDelete
  10. Interesting: one more (probable) MS case / patient who improves on ABs.

    Gabriel Steiner in a 1922 review from Germany presented evidence that the (hypothetical) spirochetal infection causing MS was transmitted by ticks, and around 1930 documented spirochetes in the MS lesions in the CNS of deceased patients.

    Now there are new data from pilot studies that mino- or doxyycycline seem to be effective in MS, but neurologists simply ignore the overwhelming evidence that MS is a severe (demyelinating) form of NB / neuroborreliosis!

    Of course MS CANNOT be an autoimmune disease because of the FOCAL and ASYMMETRIC MS lesions. The cause has to be sought within the focal lesions, very clear more than 100 years ago: the search for (suspected) spirochetes by G.Steiner and others was successful within the first decades of the 20th century - but now ignored. (Just like the similar recent research by Judith Miklossy in Alzheimer's brains.)

    To me it's clear that G.Steiner (1883-1965) discovered B."b" / tick borreliosis about half a century earlier than W. Burgdorfer, without collecting ticks (just statistical analysis of ?85 MS patient histories, compared to control data).

    The guidelines for DD / differential diagnosis MS vs. NB are "nonsense". The difference is the undeniable genetic predisposition for MS: meanwhile dozens of "risk genes" (mutations) have been reported, without (clear) understanding.
    Since MS is known as the disease "of 1000 faces" and LD as the new great imitator (the "old" one was syphilis) it is clear that there must be much overlap.

    I wonder how long it will take until neurologists admit the "continuity" from NB to MS (at least as long the exact contribution of all those "MS risk genes / mutations" does not allow to draw a clear ?border (distinction?)).

    For therapy it should be obvious that MS has to be treated with appropriate antibiotics (which can cross the blood brain barrier)! That was clear to Prof. G. Steiner in his late years at Wayne University in Detroit MI. But unfortunately doxycycline was not available to him for his early AB clinical intervention studies (just the polar ABs penicilline and tetracycline).

    If doxy had been available a decade earlier medical history probably would have taken a different course: G.Steiner KNEW the causal infection, and it was perfectly clear to him that he had to get a suitable AB into the CNS for therapy (without bothering about a "DD" NB vs. MS at that time)!
    See his book "Die multiple Sklerose", Springer Verlag 1962, which unfortunately has not been translated into English to this day (as far as I know).
    chen-men

    ReplyDelete

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