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Lo YL, Najjar RP, Teo KY, Tow SL, Loo JL, Milea D. A reappraisal of diagnostic tests for myasthenia gravis in a large Asian cohort. J Neurol Sci 2017; 376:153-158. [PMID: 28431604 DOI: 10.1016/j.jns.2017.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 03/10/2017] [Accepted: 03/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by weakness of bodily skeletal muscles. Office-based diagnostic tests such as repetitive nerve stimulation (RNS), single fiber electromyography (SFEMG), and the ice test, are used to refine the differential clinical diagnosis of this disease. Evaluating the clinical sensitivity and specificity of these tests, however, may be confounded by lack of a gold standard, non-blinding, incorporation bias, use of non-representative populations and retrospective data. OBJECTIVE In this study comprising a large Asian cohort of 127 patients recruited from a Neuro-ophthalmology clinic, we minimized aforementioned confounders and tested the diagnostic value of 3 office-based tests against 2 reference standards of MG by virtue of clinical features, antibody assay and response to treatment. RESULTS Regardless of the reference standard used, the ice and SFEMG tests displayed a higher sensitivity (86.0 to 97.3%) compared to the RNS test (21.3 to 30.6%). Conversely, the specificity of the ice (31.3%) and SFEMG (21.7% and 17.2%) tests were reduced compared to the RNS test (82.6% and 84.4%). The combined use of the ice test and SFEMG, improved the specificity of MG diagnosis to 63.6% and 64.3%, without affecting the sensitivity of those tests. CONCLUSION Our findings indicate, in an Asian population, high sensitivity of the SFEMG test and suggest the ice test as a valid, affordable and less technically demanding approach to diagnose MG with ocular involvement. Both ice test and SFEMG alone, however, yielded poor specificity. We suggest that the combination of SFEMG and ice test provides a more reliable diagnosis of MG.
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Affiliation(s)
- Yew Long Lo
- Duke-NUS Graduate Medical School, Singapore; National Neuroscience Institute, Singapore General Hospital, Singapore.
| | - Raymond P Najjar
- Duke-NUS Graduate Medical School, Singapore; Singapore Eye Research Institute, Singapore
| | - Kelvin Y Teo
- Singapore Eye Research Institute, Singapore; Singapore National Eye Centre, Singapore
| | - Sharon L Tow
- Duke-NUS Graduate Medical School, Singapore; Singapore Eye Research Institute, Singapore; Singapore National Eye Centre, Singapore; National University Hospital, Singapore
| | - Jing Liang Loo
- Duke-NUS Graduate Medical School, Singapore; Singapore Eye Research Institute, Singapore; Singapore National Eye Centre, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Dan Milea
- Duke-NUS Graduate Medical School, Singapore; Singapore Eye Research Institute, Singapore; Singapore National Eye Centre, Singapore
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102
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Verschuuren J, Strijbos E, Vincent A. Neuromuscular junction disorders. HANDBOOK OF CLINICAL NEUROLOGY 2017; 133:447-66. [PMID: 27112691 DOI: 10.1016/b978-0-444-63432-0.00024-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diseases of the neuromuscular junction comprise a wide range of disorders. Antibodies, genetic mutations, specific drugs or toxins interfere with the number or function of one of the essential proteins that control signaling between the presynaptic nerve ending and the postsynaptic muscle membrane. Acquired autoimmune disorders of the neuromuscular junction are the most common and are described here. In myasthenia gravis, antibodies to acetylcholine receptors or to proteins involved in receptor clustering, particularly muscle-specific kinase, cause direct loss of acetylcholine receptors or interfere with the agrin-induced acetylcholine receptor clustering necessary for efficient neurotransmission. In the Lambert-Eaton myasthenic syndrome (LEMS), loss of the presynaptic voltage-gated calcium channels results in reduced release of the acetylcholine transmitter. The conditions are generally recognizable clinically and the diagnosis confirmed by serologic testing and electromyography. Screening for thymomas in myasthenia or small cell cancer in LEMS is important. Fortunately, a wide range of symptomatic treatments, immunosuppressive drugs, or other immunomodulating therapies is available. Future research is directed to understanding the pathogenesis, discovering new antigens, and trying to develop disease-specific treatments.
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Affiliation(s)
- Jan Verschuuren
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Ellen Strijbos
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
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Oliveira EF, Nacif SR, Urbano JJ, Silva AS, Oliveira CS, Perez EA, Polaro MN, Valerio BCO, Stirbulov R, Insalaco G, Oliveira ASB, Oliveira LVF. Sleep, lung function, and quality of life in patients with myasthenia gravis: A cross-sectional study. Neuromuscul Disord 2017; 27:120-127. [DOI: 10.1016/j.nmd.2016.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 11/17/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
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104
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Bou Ali H, Salort-Campana E, Grapperon AM, Gallard J, Franques J, Sevy A, Delmont E, Verschueren A, Pouget J, Attarian S. New strategy for improving the diagnostic sensitivity of repetitive nerve stimulation in myasthenia gravis. Muscle Nerve 2017; 55:532-538. [DOI: 10.1002/mus.25374] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Hanna Bou Ali
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
| | - Emmanuelle Salort-Campana
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Aude Marie Grapperon
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
| | - Julien Gallard
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
| | - Jerome Franques
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
| | - Amandine Sevy
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Emilien Delmont
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Annie Verschueren
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Jean Pouget
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Shahram Attarian
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
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105
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Tiwari P, Khanra D, Mukherjee A, Ray S, Samanta B. A case of ocular myasthenia: An eye-opener. APOLLO MEDICINE 2016. [DOI: 10.1016/j.apme.2016.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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106
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C.N. Machado F, A. Kouyoumdjian JOÃO, E. Marchiori P. Diagnostic accuracy of concentric needle jitter in myasthenia: Prospective study. Muscle Nerve 2016; 55:190-194. [DOI: 10.1002/mus.25229] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/03/2016] [Accepted: 06/24/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Flavia C.N. Machado
- Department of Neurology; Medical School, Universidade de São Paulo; São Paulo Brazil
- Fleury Medicina e Saúde; São Paulo Brazil
| | - JOÃO A. Kouyoumdjian
- Neuromuscular Investigation Laboratory; Faculdade Medicina São José do Rio Preto; São Paulo Brazil
| | - Paulo E. Marchiori
- Department of Neurology; Medical School, Universidade de São Paulo; São Paulo Brazil
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107
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Baruca M, Leonardis L, Podnar S, Hojs-Fabjan T, Grad A, Jerin A, Blagus R, Šega-Jazbec S. Single fiber EMG as a prognostic tool in myasthenia gravis. Muscle Nerve 2016; 54:1034-1040. [DOI: 10.1002/mus.25174] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Mateja Baruca
- University Medical Centre Ljubljana, Department of Neurology; Zaloška cesta 2,1000 Ljubljana Slovenia
| | - Lea Leonardis
- University Medical Centre Ljubljana, Institute of Clinical Neurophysiology; Ljubljana Slovenia
| | - Simon Podnar
- University Medical Centre Ljubljana, Institute of Clinical Neurophysiology; Ljubljana Slovenia
| | | | - Anton Grad
- General Hospital of Isola; Isola Slovenia
| | - Aleš Jerin
- University Medical Centre Ljubljana, Clinical institute of Clinical Chemistry and biochemistry; Ljubljana Slovenia
| | - Rok Blagus
- Institute for Biostatistics and Medical Informatics; University of Ljubljana, Faculty of Medicine; Ljubljana Slovenia
| | - Saša Šega-Jazbec
- University Medical Centre Ljubljana, Department of Neurology; Zaloška cesta 2,1000 Ljubljana Slovenia
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108
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Peeler CE, De Lott LB, Nagia L, Lemos J, Eggenberger ER, Cornblath WT. Clinical Utility of Acetylcholine Receptor Antibody Testing in Ocular Myasthenia Gravis. JAMA Neurol 2016; 72:1170-4. [PMID: 26258604 DOI: 10.1001/jamaneurol.2015.1444] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The sensitivity of acetylcholine receptor (AChR) antibody testing is thought to be lower in ocular myasthenia gravis (OMG) compared with generalized disease, although estimates in small-scale studies vary. There is little information in the literature about the implications of AChR antibody levels and progression from OMG to generalized myasthenia gravis. OBJECTIVES To test the hypothesis that serum AChR antibody testing is more sensitive in OMG than previously reported and to examine the association between AChR antibody levels and progression from OMG to generalized myasthenia gravis. DESIGN, SETTING, AND PARTICIPANTS A retrospective, observational cohort study was conducted of 223 patients (mean [SD] age, 59.2 [16.4] years; 139 [62.3%] male) diagnosed with OMG between July 1, 1986, and May 31, 2013, at 2 large, academic medical centers. MAIN OUTCOMES AND MEASURES Baseline characteristics, OMG symptoms, results of AChR antibody testing, and progression time to generalized myasthenia gravis (if this occurred) were recorded for each patient. Multiple logistic regression was used to measure the association between all clinical variables and antibody result. Kaplan-Meier survival analysis was performed to examine time to generalization. RESULTS Among the 223 participants, AChR antibody testing results were positive in 158 participants (70.9%). In an adjusted model, increased age at diagnosis (odds ratio [OR], 1.03; 95% CI, 1.01-1.04; P = .007) and progression to generalized myasthenia gravis (OR, 2.92; 95% CI, 1.18-7.26; P = .02) were significantly associated with positive antibody test results. Women were less likely to have a positive antibody test result (OR, 0.36; 95% CI, 0.19-0.68; P = .002). Patients who developed symptoms of generalized myasthenia gravis had a significantly higher mean (SD) antibody level than those who did not develop symptoms of generalized myasthenia gravis (12.7 [16.5] nmol/L vs 4.2 [7.9] nmol/L; P = .002). CONCLUSIONS AND RELEVANCE We demonstrate a higher sensitivity of AChR antibody testing than previously reported in the largest cohort of patients with OMG available to date. Older age, male sex, and progression to generalized myasthenia gravis were significantly associated with a positive antibody test result. In addition, to our knowledge, this is the first report of an association between high AChR antibody levels and progression from OMG to generalized disease.
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Affiliation(s)
- Crandall E Peeler
- Neuro-Ophthalmology Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston2Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Lindsey B De Lott
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Lina Nagia
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing
| | - Joao Lemos
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing
| | - Eric R Eggenberger
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing
| | - Wayne T Cornblath
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
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109
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Valko Y, Rosengren SM, Jung HH, Straumann D, Landau K, Weber KP. Ocular vestibular evoked myogenic potentials as a test for myasthenia gravis. Neurology 2016; 86:660-8. [DOI: 10.1212/wnl.0000000000002383] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/29/2015] [Indexed: 11/15/2022] Open
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110
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Patil SA, Bokoliya SC, Nagappa M, Taly AB. Diagnosis of myasthenia gravis: Comparison of anti-nicotinic acetyl choline receptor antibodies, repetitive nerve stimulation and Neostigmine tests at a tertiary neuro care centre in India, a ten year study. J Neuroimmunol 2016; 292:81-4. [PMID: 26943963 DOI: 10.1016/j.jneuroim.2016.01.006] [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] [Received: 05/15/2014] [Revised: 11/21/2015] [Accepted: 01/06/2016] [Indexed: 12/01/2022]
Abstract
Anti-nicotinic AChR antibodies (Anti-nAChR antibodies), Repetitive Nerve Stimulation (RNS) and Neostigmine test are used for diagnosis of myasthenia gravis (MG). We compared their diagnostic agreement in a cohort of 486 MG patients over a period of ten years. Anti-nAChR antibodies, RNS and Neostigmine test showed positivity of 57.36%, 51.78%, and 93.4% respectively in ocular myasthenia and 93.77%, 82.35%, and 97.92% respectively in generalized myasthenia group. Neostigmine test showed higher positivity than anti-nAChR antibodies and RNS test in both groups. A marginal to fair agreement was observed between these tests highlighting their significance in the diagnosis of the disease.
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Affiliation(s)
- Shripad A Patil
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India.
| | - Suresh C Bokoliya
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India
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111
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Affiliation(s)
- Sashank Prasad
- From Brigham and Women's Hospital (S.P.), Harvard Medical School, Boston, MA; and Royal Prince Alfred Hospital (G.M.H.), University of Sydney, Australia.
| | - G Michael Halmagyi
- From Brigham and Women's Hospital (S.P.), Harvard Medical School, Boston, MA; and Royal Prince Alfred Hospital (G.M.H.), University of Sydney, Australia
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112
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Hoffmann S, Siedler J, Brandt AU, Piper SK, Kohler S, Sass C, Paul F, Reilmann R, Meisel A. Quantitative motor assessment of muscular weakness in myasthenia gravis: a pilot study. BMC Neurol 2015; 15:265. [PMID: 26701600 PMCID: PMC4690227 DOI: 10.1186/s12883-015-0517-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Muscular weakness in myasthenia gravis (MG) is commonly assessed using Quantitative Myasthenia Gravis Score (QMG). More objective and quantitative measures may complement the use of clinical scales and might detect subclinical affection of muscles. We hypothesized that muscular weakness in patients with MG can be quantified with the non-invasive Quantitative Motor (Q-Motor) test for Grip Force Assessment (QGFA) and Involuntary Movement Assessment (QIMA) and that pathological findings correlate with disease severity as measured by QMG. METHODS This was a cross-sectional pilot study investigating patients with confirmed diagnosis of MG. Data was compared to healthy controls (HC). Subjects were asked to lift a device (250 and 500 g) equipped with electromagnetic sensors that measured grip force (GF) and three-dimensional changes in position and orientation. These were used to calculate the position index (PI) and orientation index (OI) as measures for involuntary movements due to muscular weakness. RESULTS Overall, 40 MG patients and 23 HC were included. PI and OI were significantly higher in MG patients for both weights in the dominant and non-dominant hand. Subgroup analysis revealed that patients with clinically ocular myasthenia gravis (OMG) also showed significantly higher values for PI and OI in both hands and for both weights. Disease severity correlates with QIMA performance in the non-dominant hand. CONCLUSION Q-Motor tests and particularly QIMA may be useful objective tools for measuring motor impairment in MG and seem to detect subclinical generalized motor signs in patients with OMG. Q-Motor parameters might serve as sensitive endpoints for clinical trials in MG.
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Affiliation(s)
- Sarah Hoffmann
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Jana Siedler
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Alexander U Brandt
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sophie K Piper
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Centrum für Schlaganfallforschung Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Christian Sass
- George-Huntington-Institute, Technology-Park, Johann-Krane Weg 27, 48149, Muenster, Germany. .,Department of Neurology, Asklepios Klinikum Harburg, Eißendorfer Pferdeweg 52, 21075, Hamburg, Germany.
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Ralf Reilmann
- George-Huntington-Institute, Technology-Park, Johann-Krane Weg 27, 48149, Muenster, Germany. .,Department of Radiology, Universitätsklinikum Münster, Albert-Schweitzer Campus 1, 48149, Muenster, Germany. .,Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research, University of Tuebingen, Hoppe-Seyler Str. 3, 72076, Tuebingen, Germany.
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Evoli A, Iorio R, Bartoccioni E. Overcoming challenges in the diagnosis and treatment of myasthenia gravis. Expert Rev Clin Immunol 2015; 12:157-68. [PMID: 26675896 DOI: 10.1586/1744666x.2016.1110487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In recent years, the discovery of new autoantigens and the use of sensitive assays have expanded the clinical spectrum of myasthenia gravis (MG). In particular, antibodies binding to clustered acetylcholine receptors and to the low-density lipoprotein receptor-related protein 4 have not only bridged a significant gap in diagnosis but also have relevant clinical implications. MG management includes different therapeutic options, from symptomatic agents as the only therapy in mildly affected cases to combined long-term immunosuppression and thymectomy in patients with severe disabling disease. MG biological diversity can influence the response to therapies and should be taken into account when planning treatment. Biologic agents are promising, though their use is currently limited to patients with refractory disease.
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Affiliation(s)
- Amelia Evoli
- a Institute of Neurology , Catholic University , Roma , Italy
| | - Raffaele Iorio
- a Institute of Neurology , Catholic University , Roma , Italy.,b Don Gnocchi ONLUS Foundation , Milan , Italy
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Zambelis T, Pappas V, Kokotis P, Zouvelou V, Karandreas N. Patients with ocular symptoms referred for electrodiagnosis: how many of them suffer from myasthenia gravis? Acta Neurol Belg 2015; 115:671-4. [PMID: 25822064 DOI: 10.1007/s13760-015-0460-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/16/2015] [Indexed: 11/28/2022]
Abstract
The aim of this study was the diagnosis of patients with isolated ocular manifestations (ptosis and/or diplopia) referred for electrophysiological evaluation to the electrodiagnostic laboratory of a University Neurological Department. Examination was performed either in inpatient status or in outpatient basis. We analyzed the clinical, electrophysiological and other laboratory data in 79 subjects. Myasthenia gravis (MG) was diagnosed in 38 %, 45.6 % in other diseases (Graves disease, blepharospasm, IIId cranial verve palsy, multiple sclerosis, stroke, etc.), while in 16.5 %, the cause remained unidentified. Symptoms fluctuation was significantly more frequent in the myasthenic patients, compared to patients with other diseases. The presence of both diplopia and ptosis are more likely due to MG rather than other pathology.
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Affiliation(s)
- Th Zambelis
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece.
| | - V Pappas
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - P Kokotis
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - V Zouvelou
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - N Karandreas
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
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Abstract
BACKGROUND Myasthenia gravis is an autoimmune disease of the neuromuscular junction, commonly affecting the ocular muscles. Cigarette smoking has been shown to influence many autoimmune diseases, including multiple sclerosis and rheumatoid arthritis, but its effect on myasthenia gravis has not been well studied. We sought to determine whether cigarette smoking influenced disease-related symptoms in ocular myasthenia gravis (OMG). METHODS We performed a prospective, clinic-based cross-sectional study in a single academic neuro-ophthalmology practice. All patients diagnosed with OMG between November 2006 and April 2014 were included. A prospective telephone survey was administered to determine smoking status and myasthenia gravis-related symptom severity. The main outcome measure was the myasthenia gravis-specific activities of daily living (MG-ADL) score, a well-validated marker of symptoms and quality of life in myasthenia gravis. RESULTS Forty-four patients were included in the analysis. Comparison of MG-ADL ocular subscores between current smokers (3.4 ± 2.6), former smokers (1.8 ± 2.1), and never smokers (1.1 ± 1.5) revealed a statistically significant relationship (P = 0.031) where current smokers had the highest MG-ADL ocular subscores and never smokers the lowest. Comparison of MG-ADL total scores revealed the same relationship (current 5.6 ± 4.5, former 2.9 ± 3.1, never 1.4 ± 2.5, P = 0.003). There were borderline significant correlations of pack years with MG-ADL ocular subscore (r = 0.27, P = 0.074) and MG-ADL total score (r = 0.30, P = 0.051). CONCLUSIONS Our findings indicate an association between cigarette smoking and symptom severity in OMG. This association suggests that smoking cessation in OMG patients may lead to improved symptom-related quality of life.
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117
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Respiratory failure as presenting symptom of necrotizing autoimmune myopathy with anti-melanoma differentiation-associated gene 5 antibodies. Neuromuscul Disord 2015; 25:457-60. [DOI: 10.1016/j.nmd.2015.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/25/2015] [Accepted: 03/25/2015] [Indexed: 02/08/2023]
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118
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Kang SY, Oh JH, Song SK, Lee JS, Choi JC, Kang JH. Both binding and blocking antibodies correlate with disease severity in myasthenia gravis. Neurol Sci 2015; 36:1167-71. [PMID: 25964166 DOI: 10.1007/s10072-015-2236-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disease associated with antibodies directed to the postsynaptic muscle components of the neuromuscular junction. The heterogeneous nature of the acetylcholine receptor (AChR) antibody response had led to the categorization of AChR antibodies into 3 types: binding, blocking, and modulating antibodies. The purpose of this study is to compare the AChR antibodies' type with the clinical severity of MG patients. The patients enrolled in the study had been tested for both binding and blocking antibodies and had disease duration exceeding 2 years since diagnosis. The patients were divided into five main classes by the Myasthenia Gravis Foundation of America clinical classification. Again, the enrolled patients were divided into ocular and generalized group. We compared the type and titer of antibodies and the thymus status between the ocular and generalized group. Thirty-five patients met the inclusion criteria. Of these, 16 patients (47 %) had both blocking and binding AChR antibodies, 11 patients (31 %) had only binding antibodies, and 8 patients (22 %) had only blocking antibodies. By defined clinical classification, the ocular and generalized groups included 10 and 25 patients, respectively. Sixteen patients in the generalized group possessed both AChR antibodies, with the remaining patients displaying only the binding antibody. All the patients with only blocking antibody were classified into ocular group. Use of binding and blocking antibodies' tests may, therefore, be more helpful in predicting the prognosis and diagnoses of MG patient.
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Affiliation(s)
- Sa-Yoon Kang
- Department of Neurology, Jeju National University School of Medicine, 1 Ara 1-dong, Jeju-si, Jeju, 690-756, Republic of Korea,
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Golden SK, Reiff CJ, Painter CJ, Repplinger MD. Myasthenia Gravis Presenting as Persistent Unilateral Ptosis with Facial Droop. J Emerg Med 2015; 49:e23-5. [PMID: 25797936 DOI: 10.1016/j.jemermed.2015.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 01/03/2015] [Accepted: 01/05/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that is classically characterized by fluctuating weakness and fatigability of the ocular, bulbar, limb, or respiratory muscles. Over half of patients with MG will initially experience isolated ocular symptoms in one or both eyes. Most patients report that ocular symptoms are mild or undetectable upon awakening, and worsen throughout the day or with tasks such as driving. We describe an unusual case of MG presenting with an acute onset of persistent unilateral ptosis and ipsilateral facial droop without diurnal variation or other fluctuation in severity. CASE REPORT A 58-year-old man presented to the Emergency Department with a 3-day history of persistent, unilateral ptosis with facial droop, concerning for stroke. However, magnetic resonance imaging of the head found no evidence of stroke or any other central etiology. Routine laboratory testing was unremarkable. Neurology was consulted and they recommended sending acetylcholine receptor antibody tests. At the patient's subsequent neurology clinic visit, these tests were found to be abnormal. Electromyography was also done at this visit, confirming the diagnosis of MG. The patient subsequently underwent thymectomy and immunosuppressive therapy, with great improvement in his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MG may present as unilateral ptosis or facial drooping without the hallmark characteristic of fluctuating muscle weakness. Early diagnosis and subsequent treatment of MG improves long-term prognosis and remission rates. Emergency physicians should consider myasthenia gravis in cases of unilateral ocular symptoms after ruling out emergent central etiologies.
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Affiliation(s)
- Sean K Golden
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris J Reiff
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Chris J Painter
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michael D Repplinger
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Plomp JJ, Morsch M, Phillips WD, Verschuuren JJGM. Electrophysiological analysis of neuromuscular synaptic function in myasthenia gravis patients and animal models. Exp Neurol 2015; 270:41-54. [PMID: 25620417 DOI: 10.1016/j.expneurol.2015.01.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/07/2015] [Accepted: 01/16/2015] [Indexed: 12/21/2022]
Abstract
Study of the electrophysiological function of the neuromuscular junction (NMJ) is instrumental in the understanding of the symptoms and pathophysiology of myasthenia gravis (MG), an autoimmune disorder characterized by fluctuating and fatigable muscle weakness. Most patients have autoantibodies to the acetylcholine receptor at the NMJ. However, in recent years autoantibodies to other crucial postsynaptic membrane proteins have been found in previously 'seronegative' MG patients. Electromyographical recording of compound and single-fibre muscle action potentials provides a crucial in vivo method to determine neuromuscular transmission failure while ex vivo (miniature) endplate potential recordings can reveal the precise synaptic impairment. Here we will review these electrophysiological methods used to assess NMJ function and discuss their application and typical results found in the diagnostic and experimental study of patients and animal models of the several forms of MG.
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Affiliation(s)
- Jaap J Plomp
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Marco Morsch
- Motor Neuron Disease Research Group, Macquarie University, Sydney, Australia
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Seo EJ, Park A, Chung SA. Two Cases with Positive Ice Tests Mimicking Ocular Myasthenia Gravis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.2.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Eoi Jong Seo
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Aram Park
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Seung Ah Chung
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
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The anti-acetylcholine receptor antibody test in suspected ocular myasthenia gravis. J Ophthalmol 2014; 2014:689792. [PMID: 25478208 PMCID: PMC4247930 DOI: 10.1155/2014/689792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/18/2014] [Accepted: 10/29/2014] [Indexed: 11/23/2022] Open
Abstract
Aim. To estimate the clinical significance of anti-acetylcholine receptor antibody (anti-AChR-Ab) levels in suspected ocular myasthenia gravis. Methods. In total, 144 patients complaining of fluctuating diplopia and ptosis were evaluated for serum levels of anti-acetylcholine receptor antibody and their medical charts were retrospectively reviewed. Subjects were classified into three groups: variable diplopia only, ptosis only, and both variable diplopia and ptosis. We investigated serum anti-AChR-Ab titer levels and performed thyroid autoantibody tests. Results. Patients' chief complaints were diplopia (N = 103), ptosis (N = 12), and their concurrence (N = 29). Abnormal anti-AChR-Ab was observed in 21 of 144 patients (14.1%). Between the three groups, mean age, number of seropositive patients, and mean anti-AChR-Ab level were not significantly different (P = 0.224, 0.073, and 0.062, resp.). Overall, 27.5% of patients had abnormal thyroid autoantibodies. Conclusion. The sensitivity of anti-AChR-Ab was 14.1% in suspected ocular myasthenia gravis and seropositivity in myasthenia gravis patients showed a high correlation with the presence of thyroid autoantibodies.
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Abstract
BACKGROUND In myasthenia gravis, antibody-mediated blockade of acetylcholine receptors at the neuromuscular junction abolishes the naturally occurring 'safety factor' of synaptic transmission. Acetylcholinesterase inhibitors provide temporary symptomatic treatment of muscle weakness but there is controversy about their long-term efficacy, dosage and side effects. This is the second update of a review published in The Cochrane Library Issue 2, 2011. OBJECTIVES To evaluate the efficacy of acetylcholinesterase inhibitors in all forms of myasthenia gravis. SEARCH METHODS On 8 July 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE for randomised controlled trials and quasi-randomised controlled trials regarding usage of acetylcholinesterase inhibitors in myasthenia gravis. Two authors scanned the articles for any study eligible for inclusion. We also contacted the authors and known experts in the field to identify additional published or unpublished data and searched clinical trials registries for ongoing trials. SELECTION CRITERIA The types of studies were randomised or quasi-randomised trials. Participants were myasthenia gravis patients diagnosed by an internationally accepted definition. The intervention was treatment with any form of acetylcholinesterase inhibitor. Types of outcome measures Primary outcome measureImprovement in the presenting symptoms within one to 14 days of the start of treatment. Secondary outcome measures(1) Improvement in the presenting symptoms more than 14 days after the start of treatment.(2) Change in impairment measured by a recognised and preferably validated scale, such as the quantitative myasthenia gravis score, within one to 14 days and more than 14 days after the start of treatment.(3) Myasthenia Gravis Association of America post-intervention status more than 14 days after start of treatment.(4) Adverse events including muscarinic side effects. DATA COLLECTION AND ANALYSIS One author (MMM) extracted the data, which were checked by a second author. We contacted study authors for extra information and collected data on adverse effects from the trials. MAIN RESULTS We did not find any large randomised or quasi-randomised trials of acetylcholinesterase inhibitors in generalised myasthenia gravis either for the first version of this review or this update. One cross-over randomised trial using intranasal neostigmine in a total of 10 participants was only available as an abstract. It included three participants with ocular myasthenia gravis and seven with generalised myasthenia gravis. Symptoms of myasthenia gravis (measured as improvement in at least one muscle function) improved in nine of the 10 participants after the two-week neostigmine treatment phase. No participant improved after the placebo phase. Lack of detail in the report meant that the risk of bias was unclear. Adverse events were minor. AUTHORS' CONCLUSIONS Except for one small and inconclusive trial of intranasal neostigmine, no other randomised controlled trials have been conducted on the use of acetylcholinesterase inhibitors in myasthenia gravis. The response to acetylcholinesterase inhibitors in observational studies is so clear that a randomised controlled trial depriving participants in a placebo arm of treatment would be difficult to justify.
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Affiliation(s)
| | - Sanjay Pandey
- G.B. Pant HospitalDepartment of Neurology#502, Academic BlockNew DelhiIndia110002
| | - Thierry Kuntzer
- CHU Vaudois and University of LausanneNerve‐Muscle Unit, Service of NeurologyLausanneSwitzerland1011
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Wu H, She S, Liu Y, Xiong W, Guo Y, Fang H, Chen H, Li J. Protective effect of Sijunzi decoction on neuromuscular junction ultrastructure in autoimmune myasthenia gravis rats. J TRADIT CHIN MED 2014; 33:669-73. [PMID: 24660594 DOI: 10.1016/s0254-6272(14)60040-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the protective role of Sijunzi decoction in neuromuscular junction (NMJ) and muscle cell mitochondria ultrastructure; as well as its effects on the amount of adenosine triphosphate (ATP) and the activities of mitochondrial respiratory chain complexes I, II, III, and IV in autoimmune myasthenia gravis rats. METHODS An experimental autoimmune myasthenia gravis (EAMG) rat model was established by inoculating rats with acetylcholine receptors extracted from Torpedo. Rats were divided into three groups: model, prednisone, and Sijunzi decoction, and were fed physiological saline, prednisone, or Sijunzi decoction, respectively. NMJ and muscle cell mitochondria ultrastructure were observed by transmission electron microscope. The amount of ATP was assessed by high performance liquid chromatography. The activities of mitochondrial respiratory chain complexes I, II, III, and IV was determined using the Clark oxygen electrode method. RESULTS In the model group, there were sparse muscle fibers, with decreased mitochondria, and sparse, diffluent, or absent NMJ folds. After intervention with Sijunzi decoction, the above pathology changes were improved: muscle fiber structure was clear and complete; the mitochondria count was higher; and the NMJ structure was close to normal. Gastrocnemius muscle mitochondria in the model group produced significantly less ATP than those in the prednisone group (P < 0.01). Conversely, the ATP of Sijunzi decoction group was significantly higher than prednisone group (P < 0.01). The activities of gastrocnemius muscle mitochondrial respiratory chain complexes I, II, III, and IV in both the prednisone and Sijunzi decoction groups was dramatically higher compared with the model group (P < 0.05). The activities of complexes I and III in the Sijunzi decoction group were significantly higher than those in the prednisone group (P < 0.05), but there was no obvious difference in complex II or IV activities between the two groups (P > 0.05). CONCLUSION Sijunzi decoction improved pathological changes in muscle mitochondria and NMJ, enhanced the amount of ATP in gastrocnemius muscle mitochondria, and improved the activities of respiratory chain complexes I, II, III, and IV (especially I and III) of the EAMG rats.
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Ariatti A, Stefani M, Miceli P, Benuzzi F, Galassi G. Prognostic factors and health-related quality of life in ocular Myasthenia Gravis (OMG). Int J Neurosci 2013; 124:427-35. [PMID: 24228829 DOI: 10.3109/00207454.2013.853664] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluate the factors predictive of prognosis in 91 Caucasian patients affected by ocular myasthenia gravis (OMG), followed at our Institution during an observational time, ranging from 12 to 240 months. The Myasthenia Gravis Foundation of America (MGFA) clinical classification was used to grade the disease severity. We considered as outcome measures the variation in two subscores, ocular (O-QMG) and nonocular (NO-QMG); the last one reflected bulbar, neck, extremity functions. None of the independent variables evaluated for association with the outcome, as age of onset, type of therapy, length of interval between first and last examinations, and presence of antibodies to acetylcholine receptors (AChR-Abs) significantly affected the evolution of O-QMG and of NO-QMG. Health-related quality of life (HRQol) was assessed in 63 patients. Variations of diplopia or ptosis did not affect significantly physical (PCS) or mental composite subscores (MCS) of the Short-Form Health Survey (SF-36). Human leukocyte antigen (HLA) genotyping was studied to explore whether HLA class I and II allelic distribution differed among MG patients and controls. None of the studied HLA alleles significantly differed between OMG patients and controls. Similarly, none of the alleles with frequencies higher than 15% either in OMG patients or in controls was significantly associated, after Bonferroni correction, with the presence or absence of anti-AChR-Abs in serum.
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Affiliation(s)
- Alessandra Ariatti
- Department of Neurosciences, and Department of Onco-Haematology, University Hospitals of Modena & Reggio Emilia , Italy
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Padua L, Caliandro P, Di Iasi G, Pazzaglia C, Ciaraffa F, Evoli A. Reliability of SFEMG in diagnosing myasthenia gravis: sensitivity and specificity calculated on 100 prospective cases. Clin Neurophysiol 2013; 125:1270-3. [PMID: 24296278 DOI: 10.1016/j.clinph.2013.11.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 10/16/2013] [Accepted: 11/02/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study aimed to determine the utility of single-fibre electromyography (SFEMG) in the diagnosis of myasthenia gravis (MG) in subjects with a clinical suspicion of the disease. METHODS We performed a prospective, single-blinded study on 100 consecutive patients. SFEMG was not considered a criterion in making the MG diagnosis. For all cases, a different physician than the one performing SFEMG made the diagnosis of MG. All subjects underwent standard SFEMG of a single muscle, the orbicularis oculi. RESULTS SFEMG was abnormal in 67 of 100 patients. A final diagnosis of definite MG was made in 54 patients (30 men/24 women). SFEMG was positive in 53 of 54 patients diagnosed with MG. The sensitivity of SFEMG in diagnosing MG was 98% (95% CI: 0.94-1.02), while the specificity was 70% (95% CI: 0.54-0.86), with a positive predictive value of 79% (95% CI: 0.74-0.79) and a negative predictive value of 97% (95% CI: 0.94-0.99). CONCLUSIONS In this cohort of patients, normal SFEMG findings were unlikely to occur in patients with MG. SIGNIFICANCE SFEMG is not a confirmatory test for the diagnosis of MG, but it has a high negative predictive value in identifying patients without MG.
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Affiliation(s)
- L Padua
- Institute of Neurology, Catholic University, Rome, Italy; Don Carlo Gnocchi Onlus Foundation, Milan, Italy.
| | - P Caliandro
- Institute of Neurology, Catholic University, Rome, Italy
| | - G Di Iasi
- 1st Division of Neurology, Department of Neuroscience, Seconda Università, Napoli, Italy
| | - C Pazzaglia
- Don Carlo Gnocchi Onlus Foundation, Milan, Italy
| | - F Ciaraffa
- Institute of Neurology, Catholic University, Rome, Italy
| | - A Evoli
- Institute of Neurology, Catholic University, Rome, Italy
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Alkhawajah NM, Oger J. Late-onset myasthenia gravis: A review when incidence in older adults keeps increasing. Muscle Nerve 2013; 48:705-10. [DOI: 10.1002/mus.23964] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2013] [Indexed: 01/26/2023]
Affiliation(s)
- Nuha M. Alkhawajah
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
| | - Joel Oger
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
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Fakiri MO, Tavy DL, Hama-Amin AD, Wirtz PW. Accuracy of the ice test in the diagnosis of myasthenia gravis in patients with ptosis. Muscle Nerve 2013; 48:902-4. [DOI: 10.1002/mus.23857] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2013] [Indexed: 11/09/2022]
Affiliation(s)
- M. Omeed Fakiri
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
| | - Dénes L.J. Tavy
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
| | - Ako Dara Hama-Amin
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
| | - Paul W. Wirtz
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
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Lim JM, Hou JH, Singa RM, Aakalu VK, Setabutr P. Relative incidence of blepharoptosis subtypes in an oculoplastics practice at a tertiary care center. Orbit 2013; 32:231-4. [PMID: 23662688 DOI: 10.3109/01676830.2013.788673] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center. METHODS A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient's ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis. RESULTS Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner's syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years). CONCLUSIONS A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.
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Affiliation(s)
- Janet M Lim
- Departments of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Kouyoumdjian JA, Stålberg E. Stimulated jitter with concentric needle in 42 myasthenia gravis patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:237-43. [DOI: 10.1590/0004-282x20130008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 10/26/2012] [Indexed: 11/22/2022]
Abstract
Objective: To estimate jitter parameters in myasthenia gravis in stimulated frontalis and extensor digitorum muscles using the concentric needle electrode. Methods: Forty-two confirmed myasthenia gravis patients, being 22 males (aged 45.6±17.2 years-old) were studied. Jitter was expressed as the mean consecutive difference (MCD). Results: MCD in extensor digitorum was 61.6 µs (abnormal in 85.7%) and in frontalis 57.3 µs (abnormal in 88.1%). Outliers represented 90.5% for extensor digitorum and 88.1% for frontalis. At least one jitter parameter was abnormal in 90.5% of the combined studies. Acetylcholine receptor antibody was abnormal in 85.7% of the cases. Conclusions: Stimulated jitter recordings measured from muscles using concentric needle electrode can be used for myasthenia gravis diagnosis with high sensitivity. Extensive normative studies are still lacking and, therefore, borderline findings should be judged with great caution.
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Affiliation(s)
- João Aris Kouyoumdjian
- Faculdade de Medicina de São José do Rio Preto (FAMERP); Neuromuscular Investigation Laboratory, Brazil
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131
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Abstract
Disorders of the neuromuscular junction, such as myasthenia gravis and Lambert-Eaton myasthenic syndrome, constitute an important and treatable class of diseases. Both disorders are typically caused by an immunologically mediated attack on discrete components of the neuromuscular junction, compromise the efficacy of neurotransmitter transmission, and produce clinically distinct syndromes of fatigable muscle weakness. Although the history, clinical examination, and routine antibody testing can be diagnostic in many cases, specialized neurophysiological tests, such as repetitive nerve stimulation and single-fiber electromyography, are essential tools in the diagnostic evaluation of patients with more complicated or atypical conditions. In this review, we introduce primary disorders of the neuromuscular junction, and discuss the salient clinical and laboratory workup appropriate for recognizing these disorders, and the typical findings seen on electrodiagnostic testing with repetitive nerve stimulation and single-fiber electromyography.
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Abstract
Juvenile myasthenia gravis is an uncommon autoimmune disorder. Its management is not standardized. Juvenile myasthenia gravis is pathophysiologically similar to myasthenia gravis in adults. However, a number of significant particularities related to race, age at onset, severity, and antibody status complicate the management. We summarize the unique clinical features of juvenile myasthenia gravis and review the therapeutic options.
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Affiliation(s)
- Cristian M Ionita
- Connecticut Children's Medical Center, Department of Pediatrics, and Division of Pediatric Neurology, Department of Neurology, University of Connecticut School of Medicine, Hartford, CT 06106, USA.
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Tysseling VM, Janes L, Imhoff R, Quinlan KA, Lookabaugh B, Ramalingam S, Heckman CJ, Tresch MC. Design and evaluation of a chronic EMG multichannel detection system for long-term recordings of hindlimb muscles in behaving mice. J Electromyogr Kinesiol 2013; 23:531-9. [PMID: 23369875 DOI: 10.1016/j.jelekin.2012.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 10/25/2012] [Accepted: 11/15/2012] [Indexed: 01/29/2023] Open
Abstract
Mouse models are commonly used for identifying the behavioral consequences of genetic modifications, progression or recovery from disease or trauma models, and understanding spinal circuitry. Electromyographic recordings (EMGs) are recognized as providing information not possible from standard behavioral analyses involving gross behavioral or kinematic assessments. We describe here a method for recording from relatively large numbers of muscles in behaving mice. We demonstrate the use of this approach for recording from hindlimb muscles bilaterally in intact animals, following spinal cord injury, and during the progression of ALS. This design can be used in a variety of applications in order to characterize the coordination strategies of mice in health and disease.
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Affiliation(s)
- Vicki M Tysseling
- Physiology Department, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Ocular myasthenia gravis in an academic neuro-ophthalmology clinic: clinical features and therapeutic response. J Clin Neuromuscul Dis 2012; 13:46-52. [PMID: 22361625 DOI: 10.1097/cnd.0b013e31821c5634] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The frequency of ocular myasthenia gravis (OMG) in patients referred to an academic neuro-ophthalmology clinic for suspected myasthenia gravis is not known. Our objective was to determine the frequency of ocular OMG in patients referred to an academic neuro-ophthalmologist and determine alternate diagnoses and response to therapy. METHODS We performed a retrospective chart review of patients presenting to the University of Kansas Neuro-Ophthalmology Clinic with suspected OMG over 9 years. We defined OMG as isolated ptosis/diplopia at initial presentation supported by at least one of the following abnormal tests: edrophonium test, ice test, Cogan lid twitch, fatigability on sustained upgaze, acetylcholine receptor binding antibody, greater than 10% decrement on repetitive stimulation, or abnormal single-fiber jitter. We also determined the cause of ptosis/diplopia if it was not the result of OMG. Patients who progressed from OMG to generalized disease were termed transformed myasthenia gravis (TMG). RESULTS One hundred thirty-eight patients were referred with mean age at presentation 58 ± 19 years. Myasthenia gravis was diagnosed in 101 patients; 95 had OMG; six had generalized MG. Diagnosis in the other 37 was cranial nerve palsies (nine), levator dehiscence (five), multiple sclerosis (two), blepharospasm (two), decompensated phorias (three), accommodation spasm (four), exophoria (three), skew deviation (two), Graves disease (one), hypertropia (one), myopathy (one), neurosarcoidosis (one), progressive supranuclear palsy (one), Miller Fisher variant of Guillain-Barre syndrome (one), and obstructive sleep apnea (one). Mean follow-up was 3.0 ± 2.8 years. Test sensitivity/specificity in OMG was fatigability on sustained upgaze 0.80/0.63; ice pack 0.80/0.25; Cogan lid twitch 0.59/1.00; edrophonium 0.88/0.50; acetylcholine receptor binding antibody 0.38/1.00; repetitive nerve stimulation 0.24/1.00; and single-fiber electromyography 0.90/1.00. Pyridostigmine was used without prednisone in 59 of 97 patients with OMG and 12 of 59 developed TMG. Prednisone was used in 38 patients; 21 of 38 (55%) met Myasthenia Gravis Foundation of America improvement status and none had TMG. CONCLUSION The diagnosis of myasthenia gravis was confirmed in the majority of patients referred to our academic neuro-ophthalmology clinic, but 27% did not have myasthenia gravis. It is possible that prednisone treatment of OMG may prevent progression to TMG, but further study is required.
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Neuromuscular medicine competency in physical medicine and rehabilitation residents: a method of development and assessment. Am J Phys Med Rehabil 2012; 92:258-66. [PMID: 23128327 DOI: 10.1097/phm.0b013e3182745ed9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This project endeavored to create an educational module including methodology to instruct physical medicine and rehabilitation residents in the evaluation and appropriate treatment of patients with neuromuscular disorders. It further sought to verify acquired competencies in neuromuscular rehabilitation through objective evaluation methodology. An American Association of Neuromuscular and Electrodiagnostic Medicine board-certified physician with 10 yrs of clinical experience in neuromuscular and general rehabilitation trained 19 residents using a standardized competency-based module. The residents were trained through clinical training, lectures, and review of self-assessment examination concepts from the American Academy of Physical Medicine & Rehabilitation syllabus provided in the Archives of Physical Medicine and Rehabilitation. After delivery of the educational module, knowledge acquisition and skill proficiency were measured in (1) completion of neuromuscular history and physical examination satisfactorily, (2) diagnosis and ability to design a patient care management plan via chart stimulated recall examinations, (3) physician-patient interaction via patient surveys, (4) physician-staff interaction via 360-degree global ratings, and (5) ability to write a comprehensive patient care report and to document a patient care management plan in accordance with Medicare guidelines via written patient reports. Assessment tools developed for this program address the basic competencies outlined by the Accreditation Council for Graduate Medical Education. To test the success of the standardized educational module, data were collected on an ongoing basis. The objective measures compared resident self-assessment examination scores in neuromuscular rehabilitation before and after the institution of the comprehensive neuromuscular competency module in the residency program. Nineteen (100%) of 19 residents successfully demonstrated proficiency in every segment of the evaluation module by the end of the postgraduate year 2 inpatient neuromuscular rehabilitation rotation. Furthermore, the residents' proficiency, as demonstrated by the evaluation after the implementation of the standardized educational module, positively correlated with an increase in the residents' self-assessment examination scores in neuromuscular rehabilitation compared with the residents' scores before the educational module implementation throughout all 3 yrs of training. Resident proficiency in the skills and knowledge pertaining to neuromuscular rehabilitation were objectively verified after completion of the standardized educational module. Validation of the assessment tool is evidenced by the collected data correlating with significantly improved self-assessment examination scores, as outlined in the "RESULTS" section. In addition, the clinical development tool was validated by the residents being individually observed performing history and physical examinations and being deemed competent by the American Association of Neuromuscular and Electrodiagnostic Medicine board-certified physical medicine and rehabilitation physician. The standardized educational module and evaluation methodology provide a potential framework for the definition of baseline competency in the clinical training area of neuromuscular rehabilitation.
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136
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Abstract
This article reviews the use of electrodiagnostic testing in disorders of neuromuscular transmission and discusses the differences between various presynaptic and postsynaptic disorders. Attention is paid to quality control issues that influence the sensitivity of repetitive nerve stimulation and single fiber electromyography. Electrodiagnostic testing, when used as an extension of the clinician's history and physical examination, will provide appropriate direction in establishing the diagnosis.
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Affiliation(s)
- James F Howard
- Neuromuscular Disorders Section, Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7025, USA.
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137
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Abstract
OPINION STATEMENT Myasthenia gravis (MG) is an autoimmune disorder that is characterized by variable weakness and fatigability. Often, MG presents with only ocular symptoms such as ptosis and diplopia. Treatment of ocular MG is aimed at relieving the symptoms of ptosis and diplopia, as well as preventing the development of generalized MG symptoms. Immune suppression with steroids is often the main therapy. Steroid doses must be increased slowly because of a risk of precipitating myasthenic crisis. After achieving the highest target dose, steroids are then slowly tapered down to the lowest effective dose. Often, acetylcholinesterase inhibitors such as pyridostigmine and neostigmine are also employed to help control symptoms. When steroids are contraindicated, acetylcholinesterase inhibitors can be tried as the primary therapy. Steroid-sparing agents such as azathioprine and mycophenolate may also have a role in treating ocular MG. Other treatments for MG include plasmapheresis, intravenous immunoglobulin, and other immunosuppressive agents, but these are rarely required for ocular MG. Patients should also be evaluated for thymoma. Thymoma should be resected surgically. Ocular MG without thymoma is not usually treated with thymectomy. Topical agents may be useful as additional therapy for mild or moderate ptosis. Nonpharmacologic treatments include occlusive devices, prisms, eyelid supports, contact lenses, and (in long-standing, stable cases) strabismus surgery or eyelid elevation surgery.
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138
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Haran M, Schattner A, Mate A, Starobin D, Haran G, Shtalrid M. Can a rare form of myasthenia gravis shed additional light on disease mechanisms? Clin Neurol Neurosurg 2012; 115:562-6. [PMID: 22854280 DOI: 10.1016/j.clineuro.2012.06.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 06/26/2012] [Accepted: 06/30/2012] [Indexed: 02/04/2023]
Abstract
A healthy 43-year-old physician developed gradually progressive and fluctuating fatigable muscle weakness involving ocular, limb, bulbar and respiratory muscles, with episodic acute respiratory failure, eventually necessitating intermittent non-invasive respiratory support (NIV). A mild short episode occurred 15 years earlier with complete resolution. Electromyography (EMG) studies and acetylcholine receptor (AchR) antibodies were repeatedly non-diagnostic. The diagnosis of myasthenia gravis (MG) was finally confirmed by direct measurement of diaphragmatic strength using magnetic nerve stimulation providing clear cut evidence of significant fatigable weakness and the demonstration of muscle-specific kinase (MuSK) serum antibodies using a novel cell-based assay. The cluster of several atypical features and lack of response to commonly used treatment modalities prompted a search for a unifying mechanism and better understanding of the underlying pathophysiology. Review of the literature suggested a possible impairment of excitation-contraction coupling with malfunction of a signaling protein downstream to the AchR, without an accompanying impairment of electrical transmission. This postulated mechanism, resulting in a disturbance of calcium signaling, explained the unusual features in this patient's illness and led to treatment with salbutamol and ephedrine and to significant symptomatic improvement not achieved by any other treatment.
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Affiliation(s)
- Michal Haran
- Hematology Institute, Kaplan Medical Center, Rehovot, Hebrew University Hadassah Medical School, Jerusalem, Israel
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139
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Neurologic emergencies: case studies. Neurol Clin 2012; 30:345-56, x. [PMID: 22284067 DOI: 10.1016/j.ncl.2011.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
During the past 2 decades, the world has witnessed a significant improvement in the understanding of the pathogenesis and treatment of neurologic diseases, which presents emergencies. Every day neurologists are consulted for patients who present with neurologic emergencies to the emergency departments. In this article, we present a series of case reports about patients with acute neurologic and psychiatric problems and discuss their management briefly.
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140
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Techniques and applications of EMG: measuring motor units from structure to function. J Neurol 2012; 259:585-94. [DOI: 10.1007/s00415-011-6350-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 11/30/2011] [Indexed: 12/14/2022]
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141
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Venna N, Gonzalez RG, Zukerberg LR. Case records of the Massachusetts General Hospital. Case 39-2011. A woman in her 90s with unilateral ptosis. N Engl J Med 2011; 365:2413-22. [PMID: 22187989 DOI: 10.1056/nejmcpc1110048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nagagopal Venna
- Department of Neurology, Massachusetts General Hospital, and Harvard Medical School, Boston, USA
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142
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Concentric needle jitter on stimulated frontalis and extensor digitorum in 20 myasthenia gravis patients. Muscle Nerve 2011; 44:912-8. [DOI: 10.1002/mus.22203] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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143
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Stephenson K, Wilkinson J. Non-traumatic neurological emergencies presenting to the intensive care unit. Br J Hosp Med (Lond) 2011; 72:264-9. [PMID: 21647041 DOI: 10.12968/hmed.2011.72.5.264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kerstie Stephenson
- Department of Clinical Oncology, Nottingham City Hospital, Nottingham, UK
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&NA;. Treat myasthenia gravis with individualized doses of acetylcholinesterase inhibitors and immunomodulators. DRUGS & THERAPY PERSPECTIVES 2011. [DOI: 10.2165/11601680-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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145
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Zambelis T, Kokotis P, Karandreas N. Repetitive nerve stimulation of facial and hypothenar muscles: relative sensitivity in different myasthenia gravis subgroups. Eur Neurol 2011; 65:203-7. [PMID: 21412008 DOI: 10.1159/000324915] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/06/2011] [Indexed: 11/19/2022]
Abstract
AIM To assess the utility of repetitive nerve stimulation (RNS) in facial and hypothenar muscles in the clinical groups of myasthenia gravis (MG). PATIENTS AND METHODS We performed RNS study in the orbicularis oculi (O.O.), nasalis and abductor digiti quinti (ADQ) in 115 consecutive myasthenic patients and classified them according to the classifications of the Myasthenia Gravis Foundation of America. Patients were classified into three groups: group 1, group 2 (IIa, IIIa and IVa) and group 3 (IIb, IIIb and IVb). RESULTS RNS was abnormal in 95 patients (82.6%): 78.3% in the O.O., 66.1% in the nasalis and 19.1% in the ADQ. Both facial muscles were statistically more sensitive than the ADQ in all groups of patients. RNS in the O.O. was more frequently abnormal than in the nasalis only in group 1. Sensitivity to acetylcholine antibodies in myasthenic patients was 84%. Acetylcholine receptor (AChR) and muscle-specific tyrosine kinase antibodies were present in 96.7% of the patients with abnormal RNS in both facial muscles. Single-fiber electromyogram (SFEMG) was abnormal in 91.3% of the tested patients. One of the three tests used for the diagnosis of MG (AChR antibodies, SFEMG, RNS) was abnormal in 99.1% of the patients. DISCUSSION O.O. is the most sensitive muscle in all groups of MG followed by nasalis, while the ADQ is the muscle with the lowest sensitivity. Facial muscles, especially the O.O., should be the first to be tested in MG. The negativity of all tests (RNS, AChR antibodies, SFEMG) should question the diagnosis of MG, even in the presence of symptoms consistent with MG.
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Affiliation(s)
- T Zambelis
- Department of Neurology, University of Athens, Aeghinition Hospital, Athens, Greece.
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The man who could not see what he could not eat. Surv Ophthalmol 2011; 56:461-5. [PMID: 21371731 DOI: 10.1016/j.survophthal.2010.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 11/18/2010] [Accepted: 11/23/2010] [Indexed: 11/23/2022]
Abstract
A 55-year-old Hispanic man born in New Mexico presented with progressively worsening bilateral upper eyelid ptosis and dysphagia. External levator advancement 5 years before did not improve his ptosis. A thorough systemic workup for myasthenia gravis was negative, but electromyography suggested a myopathic process. Molecular genetic testing was positive for oculopharyngeal muscular dystrophy.
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147
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Mercelis R, Merckaert V. Diagnostic utility of stimulated single-fiber electromyography of the orbicularis oculi muscle in patients with suspected ocular myasthenia. Muscle Nerve 2011; 43:168-70. [PMID: 21254079 DOI: 10.1002/mus.21853] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Stimulated single-fiber electromyography (SSFEMG) is a valuable diagnostic tool in cases of myasthenia gravis with limited disease. From 1990 to 2008 SSFEMG in the orbicularis oculi muscle (OO) was performed in a cohort of 456 patients referred with clinical suspicion of myasthenia gravis (MG) and exclusively ocular symptoms. A diagnosis of MG was made on clinical grounds in 103 patients. In this patient cohort, the specificity of SSFEMG for myasthenia was 97%, and the sensitivity was 80%. MG patients with a normal SSFEMG had a benign clinical course. This study confirms a high specificity and sensitivity of SSFEMG when it is performed on patients suspected to have ocular MG. In such patients, a normal SSFEMG of the OO predicts a benign clinical course.
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Affiliation(s)
- Rudy Mercelis
- Department of Neurology, Antwerp University Hospital, Wilrijkstraat 10, Antwerp B2650, Belgium.
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148
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Abstract
BACKGROUND In myasthenia gravis, antibody-mediated blockade of acetylcholine receptors at the neuromuscular junction abolishes the naturally occurring 'safety factor' of synaptic transmission. Acetylcholinesterase inhibitors provide temporary symptomatic treatment of muscle weakness, but there is controversy about their long-term efficacy, dosage and side effects. OBJECTIVES To evaluate the efficacy of acetylcholinesterase inhibitors in all forms of myasthenia gravis. SEARCH STRATEGY We searched The Cochrane Neuromuscular Disease Group Specialized Register (5 October 2009), The Cochrane Central Register of Controlled Trials CENTRAL) (The Cochrane Library Issue 3, 2009), MEDLINE (January 1966 to September 2009), EMBASE (January 1980 to September 2009) for randomised controlled trials and quasi-randomised controlled trials regarding usage of acetylcholinesterase inhibitors in myasthenia gravis. Two authors scanned the articles for any study eligible for inclusion. We also contacted the authors and known experts in the field to identify additional published or unpublished data. SELECTION CRITERIA Types of studies: all randomised or quasi-randomised trials. TYPES OF PARTICIPANTS all myasthenia gravis patients diagnosed by an internationally accepted definition.Types of interventions: treatment with any form of acetylcholinesterase inhibitor.Types of outcome measuresPrimary outcome measureImprovement in the presenting symptoms within 1 to 14 days of the start of treatment.Secondary outcome measures(1) Improvement in the presenting symptoms more than 14 days after the start of treatment.(2) Change in impairment measured by a recognised and preferably validated scale, such as the quantitative myasthenia gravis score within 1 to 14 days and more than 14 days after the start of treatment.(3) Myasthenia Gravis Association of America post-intervention status more than 14 days after start of treatment.(4) Adverse events: muscarinic side effects. DATA COLLECTION AND ANALYSIS One author (MMM) extracted the data, which were checked by a second author. We contacted study authors for extra information and collected data on adverse effects from the trials. MAIN RESULTS We did not find any large randomised or quasi-randomised trials of acetylcholinesterase inhibitors in generalised myasthenia gravis. One cross-over randomised trial using intranasal neostigmine in a total of 10 subjects was only available as an abstract. AUTHORS' CONCLUSIONS Except for one small and inconclusive trial of intranasal neostigmine, no randomised controlled trial has been conducted on the use of acetylcholinesterase inhibitors in myasthenia gravis. Response to acetylcholinesterase inhibitors in observational studies is so clear that a randomised controlled trial depriving participants in the placebo arm of treatment would be difficult to justify.
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Affiliation(s)
- Man Mohan Mehndiratta
- Department of Neurology, G.B. Pant Hospital, #502, Academic Block, New Delhi, India, 110002
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Isolated dysphagia due to paraneoplastic myasthenic syndrome with anti-P/Q-type voltage-gated calcium-channel and anti-acetylcholine receptor antibodies. Neuromuscul Disord 2011; 21:126-8. [DOI: 10.1016/j.nmd.2010.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 08/19/2010] [Accepted: 10/01/2010] [Indexed: 11/21/2022]
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150
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Limmer KK, Kernstine KH. Minimally Invasive and Robotic-Assisted Thymus Resection. Thorac Surg Clin 2011; 21:69-83, vii. [DOI: 10.1016/j.thorsurg.2010.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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