451
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Zieliński M. Definitions and standard indications of minimally-invasive techniques in thymic surgery. J Vis Surg 2017; 3:99. [PMID: 29078661 DOI: 10.21037/jovs.2017.06.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND The minimally invasive thoracic procedures are those performed through the intercostal, subxiphoid, subcostal or transcervical incisions. In most of these procedures (with exception of some transcervical procedures) the video-assisted thoracic surgery (VATS) technique is used for performance of an operation under guidance of a video monitor. METHODS According to the definition the minimally invasive procedures do not include the sternal manubriotomy (upper sternal split), transverse sternotomy and subcutaneous longitudinal sternotomy. Currently, a minimally invasive extended thymectomy became a widespread procedure advised for nonthymomatous myasthenia gravis (MG) and early-stage thymomas. The definition of an extended thymectomy is a removal of the whole thymus with the surrounding adipose tissue. Instead of the term "extended thymectomy" some authors recommended a term "complete thymectomy", which means total removal of the whole thymus, without the adjacent fatty tissue. RESULTS There are a lot of doubts about the definition of extended thymectomy. There have been no prospective randomized trials comparing the transsternal and minimally invasive approaches for MG or thymomas. Possible scenarios for such trials are analyzed in this paper. CONCLUSIONS There are several issues of a minimally invasive thymectomy for MG and thymomas necessitating further clarifications.
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Affiliation(s)
- Marcin Zieliński
- Department of the Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
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452
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Dragin N, Nancy P, Villegas J, Roussin R, Le Panse R, Berrih-Aknin S. Balance between Estrogens and Proinflammatory Cytokines Regulates Chemokine Production Involved in Thymic Germinal Center Formation. Sci Rep 2017; 7:7970. [PMID: 28801669 PMCID: PMC5554297 DOI: 10.1038/s41598-017-08631-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/12/2017] [Indexed: 12/11/2022] Open
Abstract
The early-onset form of Myasthenia Gravis (MG) is prevalent in women and associates with ectopic germinal centers (GCs) development and inflammation in the thymus. we aimed to investigate the contribution of estrogens in the molecular processes involved in thymic GCs formation. We examined expression of genes involved in anti-acetylcholine receptor (AChR) response in MG, MHC class II and α-AChR subunit as well as chemokines involved in GC development (CXCL13, CCL21and CXCL12). In resting conditions, estrogens have strong regulatory effects on thymic epithelial cells (TECs), inducing a decreased protein expression of the above molecules. In knockout mouse models for estrogen receptor or aromatase, we observed that perturbation in estrogen transduction pathway altered MHC Class II, α-AChR, and CXCL13 expression. However, in inflammatory conditions, estrogen effects were partially overwhelmed by pro-inflammatory cytokines. Interestingly, estrogens were able to control production of type I interferon and therefore play dual roles during inflammatory events. In conclusion, we showed that estrogens inhibited expression of α-AChR and HLA-DR in TECs, suggesting that estrogens may alter the tolerization process and favor environment for an autoimmune response. By contrast, under inflammatory conditions, estrogen effects depend upon strength of the partner molecules with which it is confronted to.
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Affiliation(s)
- Nadine Dragin
- Inovarion, Paris, France. .,Sorbonne Universités, UPMC Univ Paris 06, Paris, France. .,INSERM U974, Paris, France.
| | - Patrice Nancy
- Department of Pathology, New York University, School of Medicine, New York, USA
| | - José Villegas
- Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,INSERM U974, Paris, France.,AIM, institute of myology, Paris, France
| | | | - Rozen Le Panse
- Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,INSERM U974, Paris, France.,AIM, institute of myology, Paris, France
| | - Sonia Berrih-Aknin
- Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,INSERM U974, Paris, France.,AIM, institute of myology, Paris, France
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453
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Huang J. "Minimalist" resection for thymoma: Is less really more? J Thorac Cardiovasc Surg 2017; 154:1466-1467. [PMID: 28784241 DOI: 10.1016/j.jtcvs.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 07/06/2017] [Indexed: 11/30/2022]
Affiliation(s)
- James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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454
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Validity, reliability, and sensitivity to change of the myasthenia gravis activities of daily living profile in a sample of Italian myasthenic patients. Neurol Sci 2017; 38:1927-1931. [PMID: 28780706 DOI: 10.1007/s10072-017-3083-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/29/2017] [Indexed: 10/19/2022]
Abstract
The purpose of this study is to report on the validity, reliability, and sensitivity of the myasthenia gravis activities of daily living profile (MG-ADL) in a sample of Italian patients. Patients with myasthenia gravis (MG) completed a protocol that included the MG-ADL, the WHO Disability Assessment Schedule (WHODAS 2.0), the Besta Neurological Institute rating scale for myasthenia gravis, and the MG-composite. Cronbach's alpha was used to test reliability, Spearman's correlation and intra-class correlation coefficient (ICC) to test short-term test-retest, Kruskal-Wallis test to assess differences in MG-ADL between patients with different disease severity, and Wilcoxon signed-rank test to assess sensitivity to change. In total, 58 patients were enrolled: 44 were females, mean MG duration 10.5 ± 10.4 years, mean MG-ADL 3.98 ± 3.07. The MG-ADL showed good internal consistency (alpha = .774), stability (test-retest correlation = .98, ICC = .97). It was superior to the WHODAS 2.0 in differentiating patients with different MG type and severity (P < .001), it showed higher sensitivity to change (P = .001 for improved and P = .007 for worsened patients) and higher correlation with the MG-composite (RHO = .625). Our analysis shows that the Italian version of the MG-ADL is valid, reliable, stable, and sensitive to change.
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455
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Guerrera F, Renaud S, Tabbò F, Filosso PL. How to design a randomized clinical trial: tips and tricks for conduct a successful study in thoracic disease domain. J Thorac Dis 2017; 9:2692-2696. [PMID: 28932577 DOI: 10.21037/jtd.2017.06.147] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Randomized controlled trials (RCTs) are considered one of the highest level of evidence in clinical practice, due to their strong confidence and robustness in producing data. The "randomization" (e.g., allocating patients randomly in each group of the study) allows eliminating many pre-analytical differences that might bias the entire study. Nevertheless, RCTs aren't free of internal pitfalls that might make them not easy to be developed or utilized. Our objective is to explain RCT management difficulties and suggest certain tips useful for the design of a RCT in thoracic disease domain. In particular have a realistic timeline, define a clear objective and precise endpoints, balance the study with a correct randomization and focus on the right equilibrium between strict selection criteria and more heterogeneous parameters are key elements that help researchers assuring a strong scientific validity.
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Affiliation(s)
| | - Stéphane Renaud
- Department of Thoracic Surgery, Nancy University Hospital, Nancy, France
| | - Fabrizio Tabbò
- Department of Oncology, University of Torino, Torino, Italy
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456
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Xue L, Wang L, Dong J, Yuan Y, Fan H, Zhang Y, Wang Q, Ding J. Risk factors of myasthenic crisis after thymectomy for thymoma patients with myasthenia gravis†. Eur J Cardiothorac Surg 2017; 52:692-697. [DOI: 10.1093/ejcts/ezx163] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 04/25/2017] [Indexed: 11/14/2022] Open
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457
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Mazzoli M, Ariatti A, Valzania F, Kaleci S, Tondelli M, Nichelli PF, Galassi G. Factors affecting outcome in ocular myasthenia gravis. Int J Neurosci 2017. [PMID: 28625092 DOI: 10.1080/00207454.2017.1344237] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIM OF THE STUDY 50%-60% of patients with ocular myasthenia gravis (OMG) progress to generalized myasthenia gravis (GMG) within two years. The aim of our study was to explore factors affecting prognosis of OMG and to test the predictive role of several independent clinical variables. MATERIALS AND METHODS We reviewed a cohort of 168 Caucasian patients followed from September 2000 to January 2016. Several independent variables were considered as prognostic factors: gender, age of onset, results on electrophysiological tests, presence and level of antibodies against acetylcholine receptors (AChR Abs), treatments, thymic abnormalities. The primary outcome was the progression to GMG and/or the presence of bulbar symptoms. Secondary outcomes were either achievement of sustained minimal manifestation status or worsening in ocular quantitative MG subscore (O-QMGS) or worsening in total QMG score (T-QMGS), assessed by Myasthenia Gravis Foundation of America (MGFA) quantitative scores. Changes in mental and physical subscores of health-related quality of life (HRQoL) were assessed with SF-36 questionnaire. Variance analysis was used to interpret the differences between AChR Ab titers at different times of follow up among the generalized and non-generalized patients. RESULTS Conversion to GMG occurred in 18.4% of patients; it was significantly associated with sex, later onset of disease and anti-AChR Ab positivity. Antibody titer above the mean value of 25.8 pmol/mL showed no significant effect on generalization. Sex and late onset of disease significantly affected T-QMGS worsening. None of the other independent variables significantly affected O-QMGS and HRQoL. CONCLUSIONS Sex, later onset and anti-AChR Ab positivity were significantly associated with clinical worsening.
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Affiliation(s)
- Marco Mazzoli
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Alessandra Ariatti
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Franco Valzania
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Shaniko Kaleci
- b Department of Diagnostic Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Manuela Tondelli
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Paolo F Nichelli
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Giuliana Galassi
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
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458
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Bakan S. Author Reply. Diagn Interv Radiol 2017; 23:331-332. [PMID: 28703107 DOI: 10.5152/dir.2017.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Selim Bakan
- Department of Radiology, İstanbul University Cerrahpaşa School of Medicine, Istanbul, Turkey.
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459
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Thymectomy is a beneficial therapy for patients with non-thymomatous ocular myasthenia gravis: a systematic review and meta-analysis. Neurol Sci 2017; 38:1753-1760. [PMID: 28707128 DOI: 10.1007/s10072-017-3058-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 07/01/2017] [Indexed: 01/26/2023]
Abstract
Ocular myasthenia gravis, an autoimmune disease, is characterized by extraocular muscle weakness. Myasthenia gravis is closely associated with the functional status of the thymus gland. The efficacy of thymectomy for non-thymomatous ocular myasthenia gravis remains controversial. Here, we present the first systematic review and meta-analysis of studies assessing the outcome of thymectomy in patients with non-thymomatous ocular myasthenia gravis and found that the pooled rate of complete stable remission was 0.5074 with considerable heterogeneity. Furthermore, subgroup analysis showed that the efficacy of thymectomy differed according to geographical location. Furthermore, thymectomy outcomes are better in children than they are in adults. Thymectomy clearly represents an effective treatment for patients with non-thymomatous ocular myasthenia gravis. However, more multicenter, randomized, controlled clinical trials are now required to confirm these conclusions.
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460
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Kawaguchi K, Fukui T, Nakamura S, Taniguchi T, Yokoi K. A bilateral approach to extended thymectomy using the da Vinci Surgical System for patients with myasthenia gravis. Surg Today 2017; 48:195-199. [PMID: 28699002 DOI: 10.1007/s00595-017-1567-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/02/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE We adopted a bilateral approach to complete robotic extended thymectomy with the excision of the pericardial fat tissue from both sides and analyzed the initial outcomes. METHODS The patient cart was docked first from the left shoulder side. After dissection of the thymus and right pericardial fat tissue, the cart was temporarily rolled out, and the bed was rotated approximately 90° clockwise. The cart was then re-docked from the right-side shoulder, and extended thymectomy was performed via the left-side approach. The outcomes were compared with four cases of unilateral approach performed for mediastinal tumor in the same term. RESULTS Four patients with myasthenia gravis (two of whom had stage I thymoma) underwent extended thymectomy by the bilateral approach. The mean operative time was 288 min, and the console time was 146 min in the right side and 67 min in the left side. The resected thymus and surrounding adipose tissue were almost symmetrical, in contrast with those obtained via the unilateral approach. No remarkable events were noted. CONCLUSION Bilateral extended thymectomy for myasthenia gravis patients was safe and reasonable based on the initial outcomes.
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Affiliation(s)
- Koji Kawaguchi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takayuki Fukui
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shota Nakamura
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tetsuo Taniguchi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.,Division of Thoracic Surgery, Komaki City Hospital, Komaki, Japan
| | - Kohei Yokoi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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461
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Priola AM, Veltri A, Priola SM. CT perfusion in characterizing anterior mediastinal solid tumors. Diagn Interv Radiol 2017; 23:331. [PMID: 28703106 PMCID: PMC5508959 DOI: 10.5152/dir.2017.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/27/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Adriano Massimiliano Priola
- From the Department of Diagnostic Imaging (A.M.P. ), San Luigi Gonzaga Hospital, University of Torino, Torino, Italy
| | - Andrea Veltri
- From the Department of Diagnostic Imaging (A.M.P. ), San Luigi Gonzaga Hospital, University of Torino, Torino, Italy
| | - Sandro Massimo Priola
- From the Department of Diagnostic Imaging (A.M.P. ), San Luigi Gonzaga Hospital, University of Torino, Torino, Italy
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462
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Ogawa Y, Nakagawa M, Yoshida T, Yazaki M, Sekijima Y, Hashimoto T, Ikeda S. Survey of epidemiology, clinical picture and current treatments for elderly‐onset (≥ 65 years) patients with myasthenia gravis in Nagano Prefecture, Japan. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/ncn3.12129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yuka Ogawa
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Michitaka Nakagawa
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Takuhiro Yoshida
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Masahide Yazaki
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | | | - Shu‐ichi Ikeda
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
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463
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Danikowski KM, Jayaraman S, Prabhakar BS. Regulatory T cells in multiple sclerosis and myasthenia gravis. J Neuroinflammation 2017; 14:117. [PMID: 28599652 PMCID: PMC5466736 DOI: 10.1186/s12974-017-0892-8] [Citation(s) in RCA: 206] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/29/2017] [Indexed: 01/09/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic debilitating disease of the central nervous system primarily mediated by T lymphocytes with specificity to neuronal antigens in genetically susceptible individuals. On the other hand, myasthenia gravis (MG) primarily involves destruction of the neuromuscular junction by antibodies specific to the acetylcholine receptor. Both autoimmune diseases are thought to result from loss of self-tolerance, which allows for the development and function of autoreactive lymphocytes. Although the mechanisms underlying compromised self-tolerance in these and other autoimmune diseases have not been fully elucidated, one possibility is numerical, functional, and/or migratory deficits in T regulatory cells (Tregs). Tregs are thought to play a critical role in the maintenance of peripheral immune tolerance. It is believed that Tregs function by suppressing the effector CD4+ T cell subsets that mediate autoimmune responses. Dysregulation of suppressive and migratory markers on Tregs have been linked to the pathogenesis of both MS and MG. For example, genetic abnormalities have been found in Treg suppressive markers CTLA-4 and CD25, while others have shown a decreased expression of FoxP3 and IL-10. Furthermore, elevated levels of pro-inflammatory cytokines such as IL-6, IL-17, and IFN-γ secreted by T effectors have been noted in MS and MG patients. This review provides several strategies of treatment which have been shown to be effective or are proposed as potential therapies to restore the function of various Treg subsets including Tr1, iTr35, nTregs, and iTregs. Strategies focusing on enhancing the Treg function find importance in cytokines TGF-β, IDO, interleukins 10, 27, and 35, and ligands Jagged-1 and OX40L. Likewise, strategies which affect Treg migration involve chemokines CCL17 and CXCL11. In pre-clinical animal models of experimental autoimmune encephalomyelitis (EAE) and experimental autoimmune myasthenia gravis (EAMG), several strategies have been shown to ameliorate the disease and thus appear promising for treating patients with MS or MG.
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Affiliation(s)
- K M Danikowski
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - S Jayaraman
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - B S Prabhakar
- Department of Microbiology and Immunology, University of Illinois at Chicago, Chicago, IL, 60612, USA.
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464
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Brenna G, Antozzi C, Montomoli C, Baggi F, Mantegazza R. A propensity score analysis for comparison of T-3b and VATET in myasthenia gravis. Neurology 2017; 89:189-195. [DOI: 10.1212/wnl.0000000000004082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 03/15/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:We performed propensity score (PS) models to compare the outcome of patients with myasthenia gravis (MG) submitted to 2 different surgical approaches: extended transsternal (T-3b) or thoracoscopic extended thymectomy (VATET).Methods:Patients' clinical data were retrieved from the MG database of the C. Besta Neurologic Institute Foundation. In the PS analysis, a matching ratio of 1:1 of the main clinical variables was obtained for the 2 groups of patients and treatment effect was estimated by comparing their outcome.Results:A total of 210 patients met the inclusion criteria, by having a complete set of clinical data, and were included in the PS model; a matched dataset of 122 participants (61 per group) showed an adequate balance of all the covariates. Our analysis demonstrated that 68.9% of patients who had thymectomy by the VATET technique reached the pharmacologic remission/remission status at 2 years from thymectomy compared to 34.4% of those operated on by the T-3b technique (p < 0.001), had a lower INCB-MG score (p < 0.001), and had less muscle fatigability (p = 0.004). Similar results were found considering only nonthymomatous patients with MG. Results were also confirmed by paired statistical tests.Conclusions:Our PS matching analysis showed that VATET is a reliable and effective surgical approach alternative to T-3b in patients with MG who are candidates for thymectomy.Classification of evidence:This study provides Class IV evidence that for patients with MG, VATET is more effective than T-3b thymectomy.
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465
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Fukuhara M, Higuchi M, Owada Y, Inoue T, Watanabe Y, Yamaura T, Muto S, Hasegawa T, Suzuki H. Clinical and pathological aspects of microscopic thymoma with myasthenia gravis and review of published reports. J Thorac Dis 2017; 9:1592-1597. [PMID: 28740673 DOI: 10.21037/jtd.2017.05.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Microscopic thymomas, defined as epithelial proliferations smaller than 1 mm in diameter, characteristically occur in patients with myasthenia gravis without macroscopic thymic epithelial tumors. However, some clinical and pathological aspects of this entity are still unclear. METHODS This retrospective study includes five consecutive patients who had undergone extended thymectomy for myasthenia gravis at our institution from April 2007 to March 2016 and in whom microscopic thymomas were diagnosed by histopathological examination of the resected specimens. During the same period, we performed 32 extended transsternal thymothymectomies/thymectomies in patients with myasthenia gravis, including the above five cases. We here review 18 cases of microscopic thymoma, including our five cases and 13 previously reported cases. RESULTS The incidence of previously undiagnosed microscopic thymoma in patients undergoing thymectomy for myasthenia gravis in our institution is 15.2%. Serum preoperative anti-acetylcholine receptor antibody (anti-AchR Ab) titers were abnormally high in all of our five cases h (74.4±53.3 nmol/L) and decreased significantly after surgery (11.7±13.5 nmol/L, P=0.037). We divided our cases into the following three groups: microscopic thymoma group (Group M), thymoma group (Group T) and non-thymic tumor group (Group N). The mean preoperative anti-AchR Ab titers of these groups were 74.4, 26.5, and 368 nmol/L, respectively. All these values decreased postoperatively. The mean anti-AchR Ab titer was significantly higher in Group M than in Group T (P=0.034). All five cases in Group M were found by post-operative pathological examination to have multifocal type A thymomas. CONCLUSIONS Microscopic thymomas tend to be multifocal type A thymomas. Anti-AchR Ab titers decreased significantly in all groups. It is very important to both perform complete extended thymectomies in patients with myasthenia gravis and pathological examination of thin slices of thymic tissue to maximize detection of microscopic thymomas.
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Affiliation(s)
- Mitsuro Fukuhara
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mitsunori Higuchi
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuki Owada
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takuya Inoue
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuzuru Watanabe
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takumi Yamaura
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Satoshi Muto
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takeo Hasegawa
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroyuki Suzuki
- Department of Chest Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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466
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The role of thymectomy in the treatment of juvenile myasthenia gravis: a systematic review. Pediatr Surg Int 2017; 33:683-694. [PMID: 28401300 DOI: 10.1007/s00383-017-4086-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The role of thymectomy in the treatment of juvenile myasthenia gravis (JMG) is poorly defined. The objective of this systematic review was to evaluate the effect of thymectomy on survival, disease severity, and peri-operative complications for patients with JMG. METHODS A search of MEDLINE, EMBASE, and the Cochrane Library (1/1/2000-3/1/2016) identified all English language, human studies of thymectomy for JMG. The population was patients with JMG age ≤18 years who underwent thymectomy (comparator group was unexposed to thymectomy). Outcomes included survival, disease severity, and post-operative complications. Data extraction was performed by independent reviewers. RESULTS Sixteen retrospective studies included 1131 participants with JMG and 488 (43%) underwent thymectomy. Post-operative improvement in JMG severity occurred for 77% (n = 376/488). Comparisons of thymectomy to non-operative management were mixed. Post-operative complications were poorly recorded. Power to compare surgical approaches was limited. Outcomes specific to antibodies, surgical pathology findings, severity of JMG, and timing of thymectomy were sparse. CONCLUSIONS Existing data regarding thymectomy for JMG are limited and entirely retrospective. The majority of patients who underwent thymectomy had improvement in disease severity and post-operative complications were rare. Prospective, multicenter study of thymectomy for JMG is warranted.
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467
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Kohler S, Keil TOP, Hoffmann S, Swierzy M, Ismail M, Rückert JC, Alexander T, Meisel A. CD4 + FoxP3 + T regulatory cell subsets in myasthenia gravis patients. Clin Immunol 2017; 179:40-46. [DOI: 10.1016/j.clim.2017.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/10/2017] [Accepted: 03/08/2017] [Indexed: 12/20/2022]
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468
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Myasthenia Gravis, Mediastinal Goiter, and Crohn's Disease. Ann Thorac Surg 2017; 103:2022. [PMID: 28528037 DOI: 10.1016/j.athoracsur.2016.09.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/22/2016] [Indexed: 11/22/2022]
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469
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Abstract
Thymectomy is the most frequent surgical operation involving the mediastinum, both for the treatment of thymic tumors and for the multidisciplinary management of myasthenia gravis (MG). Different surgical approaches have been described, either traditional open approaches or minimally invasive ones. Robotic thymectomy represents a further step in the evolution of minimally invasive surgery. Available data show that robotic thymectomy may be considered a safe and feasible operation, with encouraging long-term results in myasthenic patients and promising results in patients with early stage thymoma, both in terms of surgical and oncological outcomes. We present the surgical technique of robotic thymectomy that we apply for patients affected by myasthenia gravis and early stage thymoma.
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Affiliation(s)
- Giuseppe Marulli
- Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy
| | - Giovanni Maria Comacchio
- Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital, Padova, Italy
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470
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Sonett JR, Magee MJ, Gorenstein L. Thymectomy and myasthenia gravis: A history of surgical passion and scientific excellence. J Thorac Cardiovasc Surg 2017; 154:306-309. [PMID: 28479053 DOI: 10.1016/j.jtcvs.2016.12.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/05/2016] [Accepted: 12/17/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Joshua R Sonett
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New-York Presbyterian Hospital, New York, NY; Columbia University Medical Center, New-York Presbyterian Hospital, New York, NY.
| | | | - Lyall Gorenstein
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New-York Presbyterian Hospital, New York, NY; Columbia University Medical Center, New-York Presbyterian Hospital, New York, NY
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471
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Expression of receptor for advanced glycation end-products (RAGE) in thymus from myasthenia patients. Rev Neurol (Paris) 2017; 173:388-395. [PMID: 28461027 DOI: 10.1016/j.neurol.2017.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 12/30/2016] [Accepted: 03/31/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The receptor for advanced glycation end-products (RAGE) is a membranous immunoglobulin involved in the pathogenesis of numerous autoimmune diseases and tumors. The aim of this study was to investigate the possible involvement of RAGE in the pathogenesis of myasthenia gravis. MATERIAL AND METHODS This prospective study included 41 cases of myasthenia gravis treated at our institution between 2010 and 2015. There were 18 men and 23 women, with an average age of 36.44±14.47 years. The majority of patients (24.4%) were classified as IIb, according to MGFA scoring, and 21 of them required corticosteroid and/or immunosuppressive treatment. Assessment of RAGE in thymus specimens was done by immunohistochemistry using RAGE antibody (C-term). RAGE expression was assessed according to various clinical, paraclinical and pathological parameters. RESULTS Histopathological studies found 18 thymomas, 17 hyperplasias and six other types of pathology. Expression of RAGE was negative/weak in 19 cases and moderate/strong in 22 cases. It was more important in thymoma type B2 (P<0.001) and when the duration of myasthenia was short (P=0.04), and was not significantly related to either myasthenia clinical severity or preoperative treatment. CONCLUSION Our results suggest that the RAGE pathway is involved in myasthenia gravis pathophysiology, especially at disease onset, and in forms with thymomas. Further studies would be indispensable to explore other aspects of this signaling pathway, especially the potential role of different ligands and soluble forms of RAGE.
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472
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Abstract
Myasthenia gravis is a disorder of neuromuscular transmission that leads to fatigue of skeletal muscles and fluctuating weakness. Myasthenia that affects children can be classified into the following 3 forms: transient neonatal myasthenia, congenital myasthenic syndromes, and juvenile myasthenia gravis (JMG). JMG is an autoimmune disorder that has a tendency to affect the extraocular muscles, but can also affect all skeletal muscles leading to generalized weakness and fatigability. Respiratory muscles may be involved leading to respiratory failure requiring ventilator support. Diagnosis should be suspected clinically, and confirmatory diagnostic testing be performed, including serum acetylcholine receptor antibodies, repetitive nerve stimulation, and electromyography. Treatment for JMG includes acetylcholinesterase inhibitors, immunosuppressive medications, plasma exchange, intravenous immunoglobulins, and thymectomy. Children with myasthenia gravis require monitoring by a pediatric ophthalmologist for the development of amblyopia from ptosis or strabismus.
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473
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Hsin MK. It's been a long time coming, but it finally came. J Thorac Cardiovasc Surg 2017; 154:310-311. [PMID: 28434619 DOI: 10.1016/j.jtcvs.2017.03.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/16/2017] [Accepted: 03/23/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Michael K Hsin
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong.
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474
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Weis CA, Märkl B, Schuster T, Vollert K, Ströbel P, Marx A. [True thymic hyperplasia : Differential diagnosis of thymic mass lesions in neonates and children]. DER PATHOLOGE 2017; 38:286-293. [PMID: 28429039 DOI: 10.1007/s00292-017-0283-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Reactive and neoplastic thymic pathologies are the main considerations in the case of masses in the anterior and middle part of the mediastinum, while neurogenic tumors are predominant in the posterior mediastinum (which are not dealt with here). In neonates and infants, the commonest pathologies in the anterior mediastinum comprise germ cell tumors (mainly teratomas), congenital thymic cysts and true thymic hyperplasia (TTH). In toddlers, teratomas, yolk sac tumors and cysts predominate. In children over 5 years of age, lymphomas are the commonest mass lesions whereas thymomas and thymic carcinomas are rare. In addition, inflammation-linked hyperplasia in myasthenia gravis and rebound thymic hyperplasia after chemotherapy must be considered. Although rare at all ages, sarcomas must be considered in the differential diagnosis from birth onwards and throughout adolescence. Based on the report of a rare case of recurrent TTH, the differential diagnosis of this benign but potentially life-threatening condition is discussed.
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Affiliation(s)
- C-A Weis
- Pathologisches Institut, Universitätsmedizin Mannheim, Universität Heidelberg, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - B Märkl
- Institut für Pathologie, Klinikum Augsburg, Augsburg, Deutschland
| | - T Schuster
- Kinderchirurgische Klinik, Klinikum Augsburg, Augsburg, Deutschland
| | - K Vollert
- Klinik für Diagnostische Radiologie und Neuroradiologie, Klinikum Augsburg, Augsburg, Deutschland
| | - P Ströbel
- Institut für Pathologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - A Marx
- Pathologisches Institut, Universitätsmedizin Mannheim, Universität Heidelberg, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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475
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Omorodion JO, Pines JM, Kaminski HJ. Inpatient cost analysis for treatment of myasthenia gravis. Muscle Nerve 2017; 56:1114-1118. [PMID: 28239867 DOI: 10.1002/mus.25624] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 02/14/2017] [Accepted: 02/16/2017] [Indexed: 11/06/2022]
Abstract
INTRODUCTION We explore trends in U.S. inpatient costs of care over a 10-year period. METHODS We compare myasthenia gravis (MG) with multiple sclerosis (MS) and overall U.S. hospital admissions using the Agency for Healthcare Research and Quality Nationwide Inpatient Sample database for 2003-2013. RESULTS Total costs of MG inpatient care rose 13-fold from 2003 to 2013. This was accounted for by a greater than sixfold increase in discharges and a greater than twofold increase in cost per discharge. The < 17 and >85 years age groups experienced the greatest increases in discharges. Medicare and Medicaid use increased. Regional variations in cost were apparent. There were greater rises in the Midwestern and Southern United States, which is dissimilar to MS and all hospital admissions. DISCUSSION There was a dramatic and disproportionate rise in the number of MG discharges, most likely because of changes in practice patterns. Muscle Nerve 56: 1114-1118, 2017.
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Affiliation(s)
- Jacklyn O Omorodion
- Department of Neurology, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA
| | - Jesse M Pines
- Center for Healthcare Innovation and Policy Research, The George Washington University, Washington, DC, USA
| | - Henry J Kaminski
- Department of Neurology, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC, 20037, USA
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476
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Thymectomy for myasthenia gravis: The elephant and the blind men. J Thorac Cardiovasc Surg 2017; 154:312-313. [PMID: 28365015 DOI: 10.1016/j.jtcvs.2017.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/16/2017] [Indexed: 11/21/2022]
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477
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Abstract
In recent years, thymectomy has become a widespread procedure in the treatment of myasthenia gravis (MG). Likelihood of remission was highest in preoperative mild disease classification (Osserman classification 1, 2A). In absence of thymoma or hyperplasia, there was no relationship between age and gender in remission with thymectomy. In MG treatment, randomized trials that compare conservative treatment with thymectomy have started, recently. As with non-randomized trials, remission with thymectomy in MG treatment was better than conservative treatment with only medication. There are four major methods for the surgical approach: transcervical, minimally invasive, transsternal, and combined transcervical transsternal thymectomy. Transsternal approach with thymectomy is the accepted standard surgical approach for many years. In recent years, the incidence of thymectomy has been increasing with minimally invasive techniques using thoracoscopic and robotic methods. There are not any randomized, controlled studies which are comparing surgical techniques. However, when comparing non-randomized trials, it is seen that minimally invasive thymectomy approaches give similar results to more aggressive approaches.
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Affiliation(s)
- Yener Aydin
- Department of Thoracic Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Ali Bilal Ulas
- Department of Thoracic Surgery, Kırklareli State Hospital, Kırklareli, Turkey
| | - Vahit Mutlu
- Department of Otorhinolaryngology, Atatürk University School of Medicine, Erzurum, Turkey
| | - Abdurrahim Colak
- Department of Cardiovascular Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | - Atilla Eroglu
- Department of Thoracic Surgery, Atatürk University School of Medicine, Erzurum, Turkey
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478
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Abstract
The association between thymoma and autoimmunity is well known. Besides myasthenia gravis, which is found in 15 to 20% of patients with thymoma, other autoimmune diseases have been reported: erythroblastopenia, systemic lupus erythematosus, inflammatory myopathies, thyroid disorders, Isaac's syndrome or Good's syndrome. More anecdotally, Morvan's syndrome, limbic encephalitis, other autoimmune cytopenias, autoimmune hepatitis, and bullous skin diseases (pemphigus, lichen) have been reported. Autoimmune diseases occur most often before thymectomy, but they can be discovered at the time of surgery or later. Two situations require the systematic investigation of a thymoma: the occurrence of myasthenia gravis or autoimmune erythroblastopenia. Nevertheless, the late onset of systemic lupus erythematosus or the association of several autoimmune manifestations should lead to look for a thymoma. Neither the characteristics of the patients nor the pathological data can predict the occurrence of an autoimmune disease after thymectomy. Thus, thymectomy usefulness in the course of the autoimmune disease, except myasthenia gravis, has not been demonstrated. This seems to indicate the preponderant role of self-reactive T lymphocytes distributed in the peripheral immune system prior to surgery. Given the high infectious morbidity in patients with thymoma, immunoglobulin replacement therapy should be considered in patients with hypogammaglobulinemia who receive immunosuppressive therapy, even in the absence of prior infection.
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479
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Abstract
Imminent neuromuscular respiratory failure is recognized by shortness of breath, restlessness, and tachycardia and is often followed by tachypnea, constantly interrupting speech, asynchronous breathing and sometimes paradoxical breathing and use of scalene and sternocleidomastoid muscles. Once a patient presents with such a constellation of signs, there are some difficult decisions to be made and include assessment of the severity of respiratory failure and in particular when to intubate. Failure of the patient to manage secretions as a result of oropharyngeal weakness rather than neuromuscular respiratory weakness may be another reason for acute intubation. Any patient with rapidly worsening weakness on presentation will need admission and observation in an intensive care unit. This chapter summarizes the pathophysiology of acute neuromuscular respiratory failure, its clinical recognition and respiratory management and outcome expectations.
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Affiliation(s)
- E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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480
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Tandan R, Hehir MK, Waheed W, Howard DB. Rituximab treatment of myasthenia gravis: A systematic review. Muscle Nerve 2017; 56:185-196. [DOI: 10.1002/mus.25597] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Rup Tandan
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Michael K. Hehir
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Waqar Waheed
- Department of Neurological Sciences; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Room 426, Health Sciences Research Facility, 149 Beaumont Avenue Burlington Vermont 05405 USA
| | - Diantha B. Howard
- Center for Clinical and Translational Science; University of Vermont, Robert Larner College of Medicine and University of Vermont Medical Center; Burlington Vermont USA
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481
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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482
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Adamczyk-Sowa M, Bieszczad-Bedrejczuk E, Galiniak S, Rozmiłowska I, Czyżewski D, Bartosz G, Sadowska-Bartosz I. Oxidative modifications of blood serum proteins in myasthenia gravis. J Neuroimmunol 2017; 305:145-153. [PMID: 28284335 DOI: 10.1016/j.jneuroim.2017.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/27/2017] [Accepted: 01/28/2017] [Indexed: 01/19/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by production of antibodies against acetylcholine receptors of the neuromuscular junction (Ab). The aim of this study was to ascertain if oxidative stress accompanies MG by estimation of the several independent parameters of oxidative damage, mainly the levels of oxidative modifications of blood serum proteins. The group studied consisted of 50 MG patients (28 females and 22 males), 24 with ocular MG (OMG) and 26 with generalized MG (GMG), of mean age of 66.7 (30-81)years (y), mean disease duration of 9.5 (0.5-34)y, mean level of Ab of 8.9 (0.1-85)nmol/ml, and 25 age-matched healthy controls. MG patients were stratified into groups according to disease duration (<5y or >5y), Ab level (low, <3 or high, >3nmol/l) as well as symptoms (GMG or OMG). Glycophore fluorescence was increased in OMGa. Dityrosine was increased in both types of MGc, in patients ill <5b and >5cy, with lowc and highc levels of Ab. N-formylkynurenine was increased in OMGa and GMGb, in both disease duration groupsa, in the group of low Aba. Kynurenine was increased in the group with high Aba. Tryptophan fluorescence was decreased in OMGb and GMGc, in patients ill for <5b and >5ay, with lowa and highc Ab. Serum thiol group concentration were decreased in GMGc, in patients ill for >5yb. AOPP level was elevated in OMGa, in patients ill for >5ya with high Aba. Protein carbonyls were increased in both OMGc and GMGc, in patients ill for >5ay, with lowb and highb Ab. FRAP and ABTS• scavenging by fast antioxidants were unchanged, but ABTS• scavenging by slow antioxidants was lower in OMGb and GMGc, in patients ill for >5cy, in patients with lowc and highb Ab (ap<0.05, bp<0.01, cp<0.001). These results demonstrate systemic oxidative stress in MG, suggesting therapeutic use of antioxidants.
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Affiliation(s)
- Monika Adamczyk-Sowa
- Department of Neurology in Zabrze, Medical University of Silesia, 3-go Maja St. 13-15, Zabrze 41-800, Poland
| | - Edyta Bieszczad-Bedrejczuk
- Department of Biochemistry and Cell Biology, Faculty of Biology and Agriculture, University of Rzeszów, Zelwerowicza St. 4, 35-601 Rzeszów, Poland
| | - Sabina Galiniak
- Department of Biochemistry and Cell Biology, Faculty of Biology and Agriculture, University of Rzeszów, Zelwerowicza St. 4, 35-601 Rzeszów, Poland
| | - Izabela Rozmiłowska
- Department of Neurology in Zabrze, Medical University of Silesia, 3-go Maja St. 13-15, Zabrze 41-800, Poland
| | - Damian Czyżewski
- Department of Thoracic Surgery, SMDZ in Zabrze, Medical University of Silesia, 3-go Maja St. 13-15, Zabrze 41-800, Poland
| | - Grzegorz Bartosz
- Department of Thoracic Surgery, SMDZ in Zabrze, Medical University of Silesia, 3-go Maja St. 13-15, Zabrze 41-800, Poland; Department of Molecular Biophysics, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska St. 141/143, 90-236 Lodz, Poland
| | - Izabela Sadowska-Bartosz
- Department of Biochemistry and Cell Biology, Faculty of Biology and Agriculture, University of Rzeszów, Zelwerowicza St. 4, 35-601 Rzeszów, Poland.
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483
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Brown LM, Louie BE. Robot-Assisted Total Thymectomy: How I Teach It. Ann Thorac Surg 2017; 103:369-372. [DOI: 10.1016/j.athoracsur.2016.11.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
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484
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Jurado JE, Stiles B. Noteworthy Literature Published in 2016 for Thoracic Surgery. Semin Cardiothorac Vasc Anesth 2017; 21:36-44. [PMID: 28134011 DOI: 10.1177/1089253216688689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The past year has produced several important articles in the field of thoracic surgery, spanning many different diseases. Thoracic surgeons continue to investigate methods to perform complex operations and procedures less invasively, with the least possible morbidity to our patients. We also continue to critically evaluate new technology and procedures to ensure that they meet our rigorous standards for oncologic efficacy and for management of benign disease. Importantly, as we continue to evolve, thoracic surgeons have remained focused on optimizing processes of care, both inside and outside the operating room. The purpose of this review is to highlight the major advances in thoracic surgical disease in the year 2016.
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485
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Vander Heiden JA, Stathopoulos P, Zhou JQ, Chen L, Gilbert TJ, Bolen CR, Barohn RJ, Dimachkie MM, Ciafaloni E, Broering TJ, Vigneault F, Nowak RJ, Kleinstein SH, O'Connor KC. Dysregulation of B Cell Repertoire Formation in Myasthenia Gravis Patients Revealed through Deep Sequencing. THE JOURNAL OF IMMUNOLOGY 2017; 198:1460-1473. [PMID: 28087666 DOI: 10.4049/jimmunol.1601415] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/13/2016] [Indexed: 01/14/2023]
Abstract
Myasthenia gravis (MG) is a prototypical B cell-mediated autoimmune disease affecting 20-50 people per 100,000. The majority of patients fall into two clinically distinguishable types based on whether they produce autoantibodies targeting the acetylcholine receptor (AChR-MG) or muscle specific kinase (MuSK-MG). The autoantibodies are pathogenic, but whether their generation is associated with broader defects in the B cell repertoire is unknown. To address this question, we performed deep sequencing of the BCR repertoire of AChR-MG, MuSK-MG, and healthy subjects to generate ∼518,000 unique VH and VL sequences from sorted naive and memory B cell populations. AChR-MG and MuSK-MG subjects displayed distinct gene segment usage biases in both VH and VL sequences within the naive and memory compartments. The memory compartment of AChR-MG was further characterized by reduced positive selection of somatic mutations in the VH CDR and altered VH CDR3 physicochemical properties. The VL repertoire of MuSK-MG was specifically characterized by reduced V-J segment distance in recombined sequences, suggesting diminished VL receptor editing during B cell development. Our results identify large-scale abnormalities in both the naive and memory B cell repertoires. Particular abnormalities were unique to either AChR-MG or MuSK-MG, indicating that the repertoires reflect the distinct properties of the subtypes. These repertoire abnormalities are consistent with previously observed defects in B cell tolerance checkpoints in MG, thereby offering additional insight regarding the impact of tolerance defects on peripheral autoimmune repertoires. These collective findings point toward a deformed B cell repertoire as a fundamental component of MG.
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Affiliation(s)
- Jason A Vander Heiden
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT 06511
| | | | - Julian Q Zhou
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT 06511
| | - Luan Chen
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT 06511
| | | | - Christopher R Bolen
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS 66160
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS 66160
| | - Emma Ciafaloni
- Department of Neurology, University of Rochester School of Medicine, Rochester, NY 14642
| | | | | | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511
| | - Steven H Kleinstein
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT 06511; .,Department of Immunobiology, Yale School of Medicine, New Haven, CT 06511; and.,Department of Pathology, Yale School of Medicine, New Haven, CT 06511
| | - Kevin C O'Connor
- Department of Neurology, Yale School of Medicine, New Haven, CT 06511;
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486
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Nakahara K, Nakane S, Nakajima M, Yamashita S, Mori T, Ando Y. Effect of thymectomy for thymic atrophy in myasthenia gravis: A retrospective study on 93 patients. J Neuroimmunol 2017; 305:182-185. [PMID: 28100409 DOI: 10.1016/j.jneuroim.2017.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/22/2016] [Accepted: 01/11/2017] [Indexed: 12/28/2022]
Abstract
To clarify the efficacy of thymectomy among myasthenia gravis (MG) patients with and without thymoma. We classified MG patients who underwent thymectomy into 3 groups, such as thymic atrophy group, thymic follicular hyperplasia (TFH) group and thymoma group. We compared the data of clinical features and postoperative prognosis at very short-term, short-term, and medium-term. The clinical course of MG patients with atrophic thymus after thymectomy was even better than those of TFH or thymoma, in this retrospective study. However, we found no significant differences in the comparison of mean dose of prednisolone between the 3 groups at each time point.
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Affiliation(s)
- Keiichi Nakahara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan.
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Satoshi Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Takeshi Mori
- Department of Thoracic Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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487
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Bravo-Iñiguez CE, Jaklitsch MT. Thymectomy for myasthenia gravis: what we know and what we don't. J Thorac Dis 2017; 8:3003-3005. [PMID: 28066568 DOI: 10.21037/jtd.2016.11.88] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Carlos E Bravo-Iñiguez
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Michael T Jaklitsch
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, USA
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488
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Lopomo A, Berrih-Aknin S. Autoimmune Thyroiditis and Myasthenia Gravis. Front Endocrinol (Lausanne) 2017; 8:169. [PMID: 28751878 PMCID: PMC5508005 DOI: 10.3389/fendo.2017.00169] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/30/2017] [Indexed: 12/18/2022] Open
Abstract
Autoimmune diseases (AIDs) are the result of specific immune responses directed against structures of the self. In normal conditions, the molecules recognized as "self" are tolerated by immune system, but when the self-tolerance is lost, the immune system could react against molecules from the body, causing the loss of self-tolerance, and subsequently the onset of AID that differs for organ target and etiology. Autoimmune thyroid disease (ATD) is caused by the development of autoimmunity against thyroid antigens and comprises Hashimoto's thyroiditis and Graves disease. They are frequently associated with other organ or non-organ specific AIDs, such as myasthenia gravis (MG). In fact, ATD seems to be the most associated pathology to MG. The etiology of both diseases is multifactorial and it is due to genetic and environmental factors, and each of them has specific characteristics. The two pathologies show many commonalities, such as the organ-specificity with a clear pathogenic effect of antibodies, the pathological mechanisms, such as deregulation of the immune system and the implication of the genetic predisposition. They also show some differences, such as the mode of action of the antibodies and therapies. In this review that focuses on ATD and MG, the common features and the differences between the two diseases are discussed.
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Affiliation(s)
- Angela Lopomo
- Department of Translational Research and New Technologies in Medicine and Surgery, Division of Medical Genetics, University of Pisa, Pisa, Italy
| | - Sonia Berrih-Aknin
- Sorbonne Universités, UPMC Univ Paris 06, Paris, France
- INSERM U974, Paris, France
- AIM, Institute of Myology, Paris, France
- *Correspondence: Sonia Berrih-Aknin,
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489
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Iijima T, Hoshino J, Takaichi K, Kohno T, Fujii T, Ohashi K, Ubara Y. Lupus Nephritis with Thymoma Managed by Thoracoscopic Surgery and Prednisolone. Intern Med 2017; 56:3311-3316. [PMID: 29249764 PMCID: PMC5790719 DOI: 10.2169/internalmedicine.8966-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 48-year-old woman was admitted to our hospital to undergo evaluation for fatigue, severe weight loss, and nephrotic range proteinuria. Light microscopy of a renal biopsy specimen revealed class III (A) lupus nephritis, while immunofluorescence and electron microscopy only showed sparse immune deposits with findings that were not typical of lupus nephritis. Computed tomography revealed a mass in the anterior mediastinum, which was resected. The examination of the surgical specimen revealed type A noninvasive thymoma. In combination with thymomectomy, postoperative steroid therapy achieved the prompt remission of lupus nephritis. In this patient, thymoma-related autoimmunity may have contributed to the exacerbation of lupus nephritis.
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Affiliation(s)
| | | | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tadashi Kohno
- Department of Chest Surgery, Toranomon Hospital, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Pathology, Yokohama City University, Graduate School of Medicine, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
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490
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Valko Y, Weber KP. [Not Available]. PRAXIS 2017; 106:1107-1114. [PMID: 28976252 DOI: 10.1024/1661-8157/a002796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Die Kombination von fluktuierender und belastungsabhängiger Diplopie, Ptose und paretischem Lidschluss – unter Aussparung der Pupillomotorik – ist pathognomonisch für die okuläre Myasthenie. In den ersten zwei Jahren kommt es bei 80 % der Patienten zu einer Generalisierung, mit Entwicklung bulbärer Beschwerden und Schwäche in der Extremitätenmuskulatur. Die Diagnose der okulären Myasthenie gelingt wegen des oft schleichenden Auftretens, der schwierigen Abgrenzung zu anderen neuroophthalmologischen und neurologischen Krankheitsbildern und der niedrigen Sensitivität der apparativen Untersuchungen oft nur mit Verspätung. Eine rasche Diagnose ist wichtig, da effiziente Therapieoptionen eine gute Symptomkontrolle erlauben und weil eine frühe Immunsuppression die Häufigkeit der Konversion zu einer generalisierten Form reduzieren kann.
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Affiliation(s)
- Yulia Valko
- 1 Klinik für Neurologie, Universitätsspital Zürich
| | - Konrad P Weber
- 1 Klinik für Neurologie, Universitätsspital Zürich
- 2 Klinik für Ophthalmologie, Universitätsspital Zürich
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491
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Affiliation(s)
- Nils E Gilhus
- From the Department of Clinical Medicine, University of Bergen, and the Department of Neurology, Haukeland University Hospital - both in Bergen, Norway
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492
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Okusanya OT, Hess N, Christie N, Luketich JD, Sarkaria IS. Improved outcomes with surgery vs. medical therapy in non-thymomatous myesthenia gravis: a perspective on the results of a randomized trial. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:526. [PMID: 28149887 PMCID: PMC5233486 DOI: 10.21037/atm.2016.12.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 11/06/2022]
Abstract
Myasthenia gravis can be a debilitating neurological disorder that affects thousands worldwide. Thymectomy has historically been considered in patients refractory to medical therapy or with concurrent thymoma. While retrospective data and propensity matched trials have favored thymectomy in order to decrease disease severity and disease associated morbidity, no randomized data existed to clearly delineate the benefit of this practice. The reviewed paper by Wolfe et al. represents the first high-level randomized prospective study investigating the role of thymectomy in patients with non-thymomatous myasthenia gravis. In a subset of antibody positive patients undergoing thymectomy within 5 years of disease onset, the study demonstrated a decrease in steroid use, hospitalization and overall disease severity compared to patients receiving best medical therapy alone. This work provides a sound evidence-based foundation to strongly consider thymectomy early in the disease process, and possibly for expanded indications. Additionally, the onus lies on surgeons to identify the most efficacious and least morbid approaches to these operations, whether they be open, minimally invasive, robotic, or otherwise.
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Affiliation(s)
- Olugbenga T Okusanya
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nick Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Neil Christie
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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493
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Wolfe GI, Kaminski HJ, Sonnett JR, Aban IB, Kuo HC, Cutter GR. Randomized trial of thymectomy in myasthenia gravis. J Thorac Dis 2016; 8:E1782-E1783. [PMID: 28149641 PMCID: PMC5227194 DOI: 10.21037/jtd.2016.12.80] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gil I Wolfe
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences/SUNY, Buffalo, NY, USA
| | - Henry J Kaminski
- Department of Neurology, George Washington University Medical Center, Washington DC, USA
| | - Joshua R Sonnett
- Section of General Thoracic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Inmaculada B Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hui-Chien Kuo
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
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494
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Comparison of Conservative Treatment and Thymectomy on Myasthenia Gravis Outcome. Ann Thorac Surg 2016; 102:1805-1813. [DOI: 10.1016/j.athoracsur.2016.08.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/13/2016] [Accepted: 08/09/2016] [Indexed: 11/19/2022]
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495
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Yang J, Liu C, Li T, Li C. Prognosis of thymectomy in myasthenia gravis patients with thymus hyperplasia. Int J Neurosci 2016; 127:785-789. [PMID: 27819773 DOI: 10.1080/00207454.2016.1257993] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the post-thymectomy prognosis in different conditions of myasthenia gravis (MG) patients with thymus hyperplasia. MATERIALS AND METHODS Collecting medical record and carrying out the follow-up study of 123 myasthenia gravis patients with thymus hyperplasia who have underwent thymectomy during the period between 2003 and 2013. Dividing into different groups based on gender, age of onset, duration of disease and Myasthenia Gravis Association of America (MGFA) clinical classification to analyze different prognosis in different groups. RESULTS Complete stable remission (CSR) was achieved in 71 of 123 patients (59.5%). There is no gender-related difference in achieving CSR. Patients with early onset of MG (≤40 years old) or disease duration less than 12 months had significantly higher CSR rates than those with late onset of MG (>40 years old) or disease duration more than 12 months respectively, while no difference was found in remission rate between MGFA clinical classification I and MGFA II. CONCLUSION Myasthenia gravis patients with thymus hyperplasia who had thymectomy are proved to possess greater chance of achieving CSR. The onset age of disease and duration are the prognostic factors.
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Affiliation(s)
- Jing Yang
- a Department of Neurology , Renmin Hospital of Wuhan University , Wuhan , China
| | - Chanchan Liu
- b Department of Neurology , Tongji Hospital , Wuhan , China
| | - Tao Li
- a Department of Neurology , Renmin Hospital of Wuhan University , Wuhan , China
| | - Chengyan Li
- a Department of Neurology , Renmin Hospital of Wuhan University , Wuhan , China
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496
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Tzankov A. Commentary on "Randomized trial of thymectomy in myasthenia gravis". J Thorac Dis 2016; 8:E1420-E1422. [PMID: 27867646 DOI: 10.21037/jtd.2016.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alexandar Tzankov
- Institute of Pathology, Department of Histopathology and Autopsy, University Hospital Basel, Schoenbeinstrasse 40, CH-4031 Basel, Switzerland
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497
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Bourque PR, Warman Chardon J. A crucial first randomized controlled trial of thymectomy in non-thymomatous myasthenia gravis. J Thorac Dis 2016; 8:E1375-E1378. [PMID: 27867633 DOI: 10.21037/jtd.2016.10.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Pierre R Bourque
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada;; Faculty of Medicine, University of Ottawa, Ottawa, Canada;; The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jodi Warman Chardon
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada;; Faculty of Medicine, University of Ottawa, Ottawa, Canada;; The Ottawa Hospital Research Institute, Ottawa, Canada;; Division of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Canada
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498
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Affiliation(s)
- Gil I Wolfe
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
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499
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Sussman J. Thymectomy: the more you know, the more you know you don’t know. Pract Neurol 2016; 16:426-427. [DOI: 10.1136/practneurol-2016-001543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2016] [Indexed: 11/04/2022]
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500
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Siwachat S, Tantraworasin A, Lapisatepun W, Ruengorn C, Taioli E, Saeteng S. Comparative clinical outcomes after thymectomy for myasthenia gravis: Thoracoscopic versus trans-sternal approach. Asian J Surg 2016; 41:77-85. [PMID: 27810167 DOI: 10.1016/j.asjsur.2016.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/08/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Thymectomy is an effective treatment option for long-term remission of myasthenia gravis. The superiority of the trans-sternal and thoracoscopic surgical approaches is still being debated. The aims of this study are to compare postoperative outcomes and neurologic outcomes between the two approaches and to identify prognostic factors for complete stable remission (CSR). METHODS Myasthenia gravis patients who underwent thymectomy with trans-sternal or thoracoscopic approach in MahaRaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand between January1, 2006 and December 31, 2013 were retrospectively reviewed. The endpoints were postoperative outcomes and cumulative incidence function for CSR. The analysis was performed using multilevel model, Cox's proportional hazard model, and propensity score. RESULTS Ninety-eight patients were enrolled in this study: 53 in the thoracoscopic group and 45 in the trans-sternal group. There were no significant differences between groups in composite postoperative complications, surgical time, ventilator support days, and length of intensive care unit stay. Intraoperative blood loss and length of hospital stay were significant less in the thoracoscopic group. The CSR and median time to remission were not significantly different between the two approaches. Prognostic factors for CSR were nonthymoma (hazard ratio: 3.5, 95% confidence interval: 1.01-12.22) and presence of pharmacological remission (hazard ratio: 24.3, 95% confidence interval: 3.27-180.41). CONCLUSION Thoracoscopic thymectomy is safe and provides good neurologic outcomes in comparison to the trans-sternal approach. Two predictive factors should be considered for CSR. Further prospective studies with a larger sample size and longer follow-up period are warranted to confirm these results.
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Affiliation(s)
- Sophon Siwachat
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Worakitti Lapisatepun
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Emanuela Taioli
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn Medical School at Mount Sinai, New York, NY, USA
| | - Somcharoen Saeteng
- Thoracic Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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