101
|
Chen J, Chen Z, Miao F, Song Y, Chen G, Zhu Y, Pang L, Xi J, Zhao C, Chen X. A Randomized Control Study on the Efficacy of Thymectomy in Patients with Nonthymomatous (without Chest Tumor) Myasthenia Gravis. Ann Indian Acad Neurol 2020; 23:141-144. [PMID: 32055143 PMCID: PMC7001440 DOI: 10.4103/aian.aian_138_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ji Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhiming Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Miao
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Song
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yongjun Zhu
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Liewen Pang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Chongbo Zhao
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaofeng Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
102
|
Barnett C, Tabasinejad R, Bril V. Current pharmacotherapeutic options for myasthenia gravis. Expert Opin Pharmacother 2019; 20:2295-2303. [PMID: 31670984 DOI: 10.1080/14656566.2019.1682548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Novel options for immune-based therapy in myasthenia gravis are improving the therapeutic outlook for patients. Multiple clinical trials on immunomodulation, complement inhibitors, and FcR inhibitors are providing evidence for novel immune-based therapies that promise to improve outcomes in myasthenia patients. These more focused immune treatments are reviewed in this paper.Areas covered: This paper outlines classical treatment for myasthenia gravis and then reviews recent clinical trial evidence for novel immune therapies, particularly complement inhibitors and FcR inhibitors. Further, as immune therapies expand in other areas of medicine, such as oncology, iatrogenic myasthenia is being observed as a complication of some novel treatments.Expert opinion: Exciting new options to help patients with myasthenia gravis are now available or in phase 3 trials based on promising phase 2 results. Manipulation of the immune system can also lead to iatrogenic MG. Although novel treatments can improve care for myasthenia gravis patients, future developments that prevent the production of specific abnormal auto-antibodies are desirable.
Collapse
Affiliation(s)
- Carolina Barnett
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Raha Tabasinejad
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto - Neurology, Toronto, Ontario, Canada
| |
Collapse
|
103
|
A novel MuSK cell-based myasthenia gravis diagnostic assay. J Neuroimmunol 2019; 337:577076. [PMID: 31655425 DOI: 10.1016/j.jneuroim.2019.577076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/19/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
To improve the clinical diagnosis of neural autoimmune diseases, we developed an in-house muscle-specific kinase (MuSK) antibody cell-based assay (CBA) and compared its performance with RIA, ELISA, and other CBAs. Sera from patients with myasthenia gravis (MG) and other autoimmune diseases were analyzed. We found 46 (18.3%) MuSK-CBA Ab positive cases among 251 AChR-Ab negative cases [patients] and 4 (0.6%) MuSK-CBA Ab positive cases [among] the 624 AChR-Ab positive samples. Comparing these with available clinic assays, our highly specific CBA method is more sensitive than commercial ELISA and IFA(indirect immunofluorescence assay).
Collapse
|
104
|
Choi K, Hong YH, Ahn SH, Baek SH, Kim JS, Shin JY, Sung JJ. Repeated low-dose rituximab treatment based on the assessment of circulating B cells in patients with refractory myasthenia gravis. Ther Adv Neurol Disord 2019; 12:1756286419871187. [PMID: 31555344 PMCID: PMC6751534 DOI: 10.1177/1756286419871187] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 07/29/2019] [Indexed: 01/28/2023] Open
Abstract
Background: The objective of this study was to evaluate the efficacy and safety of
repeated low-dose rituximab treatment guided by monitoring circulating CD19+
B cells in patients with refractory myasthenia gravis (MG). Methods: Patients with refractory MG who had received rituximab treatment at two
teaching hospitals between September 2013 and January 2017 were reviewed
retrospectively. The treatment protocol consisted of an induction treatment
with low-dose rituximab (375 mg/m2 twice with a 2-week interval),
followed by retreatment (375 mg/m2 once). Retreatment was based
on either circulating CD19+ B-cell repopulation or clinical relapse. Outcome
measures included the MG Foundation of America (MGFA) clinical
classification and postintervention status, prednisolone dose, CD19+ B-cell
counts, clinical relapse, and adverse effects. Results: Of 17 patients, 11 (65%) achieved the primary endpoint, defined as the
minimal manifestation or better status with prednisolone ⩽5 mg/day, after
median 7.6 months (range, 2–17 months) following rituximab treatment. Over a
median follow up of 24 months (range, 7–49 months), a total of 30
retreatments were undertaken due to clinical relapse without B-cell
repopulation (n = 6), on the basis of B-cell repopulation
alone (n = 16) and both (n = 8). B-cell
recovery appeared to be in parallel with clinical relapse on the group
level, although the individual-level association appeared to be modest, with
B-cell repopulation observed only at 57% (8/14) of clinical relapses. Conclusions: The repeated low-dose rituximab treatment based on the assessment of
circulating B-cell depletion could be a cost-effective therapeutic option
for refractory MG. Further studies are needed to verify the potentially
better cost-effectiveness of low-dose rituximab, and to identify biomarkers
that help optimize treatment in MG patients.
Collapse
Affiliation(s)
- Kyomin Choi
- Department of Neurology, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Yoon-Ho Hong
- Department of Neurology, Neuroscience Research Institute, Seoul National University Medical Research Council, Seoul National University College of Medicine, Seoul Metropolitan Boramae Medical Center, Seoul, Republic of Korea
| | - So-Hyun Ahn
- Department of Neurology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Seol-Hee Baek
- Department of Neurology, Korea University College of Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Je-Young Shin
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Joon Sung
- Department of Neurology, Neuroscience Research Institute, Seoul National University Medical Research Council, Seoul National University College of Medicine, Seoul National University Hospital, 28 Yeongeon-dong, Jongno-gu, Seoul, 03080, Republic of Korea
| |
Collapse
|
105
|
Lepedda AJ, Deiana GA, Lobina O, Nieddu G, Baldinu P, De Muro P, Andreetta F, Sechi E, Arru G, Corda DG, Sechi GP, Formato M. Plasma vitronectin is reduced in patients with myasthenia gravis: Diagnostic and pathophysiological potential. J Circ Biomark 2019; 8:1849454419875912. [PMID: 31588250 PMCID: PMC6740073 DOI: 10.1177/1849454419875912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 08/18/2019] [Indexed: 01/03/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease leading to varying degrees of skeletal muscle weakness. It is caused by specific antibodies directed against definite components in the postsynaptic membrane at the neuromuscular junction (NMJ), such as the acetylcholine receptor (AChR) and the muscle-specific kinase (MUSK) receptor. In clinical practice, MG patients may be classified into three main subgroups based on the occurrence of serum autoantibodies directed against AChR or MUSK receptor or antibody-negative. As the MG subgroups differ in terms of clinical characteristics, disease pathogenesis, prognosis, and response to therapies, they could benefit from targeted treatment as well as the detection of other possible disease biomarkers. We performed proteomics on plasma fractions enriched in low-abundance proteins to identify potential biomarkers according to different autoimmune responses. By this approach, we evidenced a significant reduction of vitronectin in MG patients compared to healthy controls, irrespective of the autoantibodies NMJ target. The obtained results were validated by mono- and two-dimensional Western blotting analysis. Vitronectin is a multifunctional glycoprotein involved in the regulation of several pathophysiological processes, including complement-dependent immune response, coagulation, fibrinolysis, pericellular proteolysis, cell attachment, and spreading. The pathophysiological significance of the reduction of plasma vitronectin in MG patients has yet to be fully elucidated. It could be related either to a possible deposition of vitronectin at NMJ to counteract the complement-mediated muscle damage at this level or to a parallel variation of this glycoprotein in the muscle extracellular matrix with secondary induced alteration in clustering of AChRs at NMJ, as it occurs with variation in concentrations of agrin, another extracellular matrix component. The clinical value of measuring plasma vitronectin has yet to be defined. According to present findings, significantly lower plasma values of this glycoprotein might be indicative of an impaired complement-dependent immune response.
Collapse
Affiliation(s)
- Antonio Junior Lepedda
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Giovanni Andrea Deiana
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Omar Lobina
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Gabriele Nieddu
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Paola Baldinu
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Pierina De Muro
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Francesca Andreetta
- Diagnostic Laboratory of Neuroimmunolgy, U.O. Neurologia IV, I.R.C.C.S. Fondazione Istituto Neurologico "C. Besta", Milano, Italy
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Giannina Arru
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Davide Giacomo Corda
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Gian Pietro Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| | - Marilena Formato
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro, Sassari, Italy
| |
Collapse
|
106
|
Tian D, Shiiya H, Sato M, Sun CB, Anraku M, Nakajima J. Tumor location may affect the clinicopathological features and prognosis of thymomas. Thorac Cancer 2019; 10:2096-2105. [PMID: 31499597 PMCID: PMC6825910 DOI: 10.1111/1759-7714.13188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/17/2019] [Accepted: 08/18/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The current staging systems do not consider the tumor location of thymomas, and its clinical relevance is poorly understood. This study aimed to evaluate the impact of tumor location on the clinicopathological features and prognosis of thymomas. METHODS We performed a retrospective review of patients at our institution who underwent an extended thymectomy for a thymoma from 1976 to 2015. The tumor location was classified as either the superior or inferior mediastinum based on the maximum tumor diameter. The clinicopathological characteristics of the thymoma were also evaluated. Kaplan-Meier estimates and Cox proportional hazards models were used to analyze the survival outcomes and risk factors for recurrence. RESULTS A total of 194 patients with thymoma were eligible for this study. Compared with the inferior mediastinum group (n = 167), the superior mediastinum group (n = 27) had a higher frequency of myasthenia gravis (MG), advanced Masaoka-Koga staging, disease progression and recurrence (P < 0.05). The Kaplan-Meier analysis demonstrated thymomas in the superior mediastinum had worse survival outcomes that included overall survival, progression-free survival and disease-free survival (P < 0.05). The multivariate analysis showed tumor location was an independent prognostic factor for all the survival outcomes (P < 0.05). Furthermore, the tumor location (P = 0.004) and Masaoka-Koga stage (P < 0.001) were the only two independent risk factors for recurrence in the multivariate analysis. CONCLUSIONS The clinicopathological features of thymomas on MG, Masaoka-Koga staging, disease progression, and recurrence were different between locations of superior and inferior mediastinum locations. Thymomas in the superior mediastinum tended to be associated with worse survival and increased recurrence.
Collapse
Affiliation(s)
- Dong Tian
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,Department of Thoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.,Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Haruhiko Shiiya
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Chang-Bo Sun
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Masaki Anraku
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Jun Nakajima
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
107
|
Cavalcante P, Mizrachi T, Barzago C, Scandiffio L, Bortone F, Bonanno S, Frangiamore R, Mantegazza R, Bernasconi P, Brenner T, Vaknin-Dembinsky A, Antozzi C. MicroRNA signature associated with treatment response in myasthenia gravis: A further step towards precision medicine. Pharmacol Res 2019; 148:104388. [PMID: 31401213 DOI: 10.1016/j.phrs.2019.104388] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/26/2019] [Accepted: 08/02/2019] [Indexed: 01/01/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting neuromuscular transmission currently treated with chronic immunosuppression. Inter-subject variation in treatment response and side effects highlight the need for personalized therapies by identification of biomarkers predictive of drug efficacy in individual patients, still lacking in MG. MicroRNAs (miRNAs) play a key role in immune response and drug metabolism modulation. This study, part of an Italian-Israeli collaborative project, aimed to identify specific miRNAs as biomarkers associated with immunosuppressive treatment response in MG patients. Whole miRNome sequencing, followed by miRNA validation by real-time PCR, was performed in peripheral blood from Italian MG patients (n = 40) classified as responder and non-responder to immunosuppressive therapies. MiRNA sequencing identified 41 miRNAs differentially expressed in non-responder compared to responder Italian MG patients. Validation phase pointed out three miRNAs, miR-323b-3p, -409-3p, and -485-3p, clustered on chromosome 14q32.31, the levels of which were significantly decreased in non-responder versus responder patients, whereas miR-181d-5p and -340-3p showed an opposite trend. ROC curve analysis showed sensitivity and specificity performance results indicative of miR-323b-3p, -409-3p, and -485-3p predictive value for responsiveness to immunosuppressive drugs in MG. Validated miRNAs were further analyzed in blood from responder and non-responder MG patients of the Israeli population (n = 33), confirming a role for miR-323b-3p, -409-3p, -485-3p, -181d-5p and -340-3p as biomarkers of drug efficacy. Gene Ontology enrichment analysis, mRNA target prediction, and in silico modeling for function of the identified miRNAs disclosed functional involvement of the five miRNAs, and their putative target genes, in both immune (i.e. neurotrophin TRK and Fc-epsilon receptor signaling pathways) and drug metabolism processes. Our overall findings thus revealed a blood "miR-323b-3p, -409-3p, -485-3p, -181d-5p, and -340-3p" signature associated with drug responsiveness in MG patients. Its identification sets the basis for precision medicine approaches based on "pharmacomiRs" as biomarkers of drug responsiveness in MG, promising to improve therapeutic success in a cost/effective manner.
Collapse
Affiliation(s)
- Paola Cavalcante
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Tehila Mizrachi
- Laboratory of Neuroimmunology, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel.
| | - Claudia Barzago
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Letizia Scandiffio
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Federica Bortone
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Silvia Bonanno
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Rita Frangiamore
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Renato Mantegazza
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Pia Bernasconi
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| | - Talma Brenner
- Laboratory of Neuroimmunology, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel.
| | - Adi Vaknin-Dembinsky
- Laboratory of Neuroimmunology, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel.
| | - Carlo Antozzi
- Neurology IV - Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milan, Italy.
| |
Collapse
|
108
|
Chou CC, Su IC, Chou IJ, Lin JJ, Lan SY, Wang YS, Kong SS, Chen YJ, Hsieh MY, Hung PC, Wang HS, Chou ML, Lin KL. Correlation of anti-acetylcholine receptor antibody levels and long-term outcomes of juvenile myasthenia gravis in Taiwan: a case control study. BMC Neurol 2019; 19:170. [PMID: 31319795 PMCID: PMC6637626 DOI: 10.1186/s12883-019-1397-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background Myasthenia gravis is the most common disease affecting the neuromuscular junction. The most common etiology among patients with juvenile myasthenia gravis is the production of antibodies against the acetylcholine receptor. However, the clinical outcome in relation to serum levels of anti-acetylcholine receptor antibodies in juvenile myasthenia gravis has rarely been discussed. We aimed to analyze the correlation between the presence of anti-acetylcholine receptor antibodies and outcome in juvenile myasthenia gravis. Methods Patients diagnosed with juvenile myasthenia gravis younger than of 20 years of age were retrospectively recruited from January 1995 to February 2017 in a tertiary referral medical center. According to the Myasthenia Gravis Foundation of America outcome scale, the primary outcome was complete symptom remission and cessation of medications for at least 1 year measured 2 years after diagnosis. Secondary outcome was complete symptom remission at the last outpatient clinic. Results A total of 54 patients were followed up for over 2 years. Nine patients (9/54, 16.7%) achieved complete remission without medication use at 2 years after diagnosis. Thirteen (24.1%) patients achieved complete remission during longer follow-up periods. Those with negative anti-acetylcholine receptor antibodies were more likely to achieve complete remission at 2 years (6/15 [40%] vs. 3/39 [7.7%], 95% Confidence interval [CI] 1.670 to 38.323) and at the last outpatient clinic follow-up (8/15 [53.3%] vs. 5/39 [12.8%], 95% CI 2.367 to 20.704). Thirteen patients with comorbid autoimmune thyroid diseases were older than those without disease (11.8 ± 5.8 years old vs. 8.0 ± 6.3 years old, 95% CI 0.018 to 7.33). Moreover, patients negative for anti-acetylcholine receptor antibodies were less likely comorbid with autoimmune thyroid disease (1/35 [2.9%] vs. 12/71 [16.9%], 95% CI 0.018 to 1.161). Conclusions Juvenile myasthenia gravis patients without anti-acetylcholine antibodies exhibited significantly increased complete remission rates and a reduced likelihood of comorbid autoimmune thyroid diseases compared with those with anti-acetylcholine receptor antibodies among Chinese. Electronic supplementary material The online version of this article (10.1186/s12883-019-1397-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Cheng-Che Chou
- Division of Paediatrics, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan
| | - I-Chen Su
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.,Division of Paediatrics, Neurocritical Care Centre, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Paediatrics, Saint Paul Hospital, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Shu-Sing Kong
- Division of Paediatrics, Taipei Medical University Shuang Ho Hospital, Zhonghe Dist., New Taipei City, Taiwan
| | - Yun-Ju Chen
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | - Kuang-Lin Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | | |
Collapse
|
109
|
Kim YH, Shin HY, Kim SM. Long-Term Safety and Efficacy of Tacrolimus in Myasthenia Gravis. Yonsei Med J 2019; 60:633-639. [PMID: 31250577 PMCID: PMC6597475 DOI: 10.3349/ymj.2019.60.7.633] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/08/2019] [Accepted: 04/09/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Myasthenia gravis (MG) is a lifelong autoimmune disorder that affects neuromuscular transmission. The long-term treatment plan should include immunotherapy. We investigated the long-term safety and efficacy of tacrolimus for the treatment of MG in real-world clinical practice. MATERIALS AND METHODS We retrospectively reviewed 160 MG patients treated with tacrolimus from 2005 to 2015. Myasthenia Gravis Foundation of America (MGFA) clinical classification, MGFA post-intervention status, myasthenic functional score, and dose of oral prednisolone were investigated. RESULTS Adverse events occurred in 68 patients (42.5%), most of which were minor and well-managed. Clinical severity scales improved after administration of tacrolimus, compared to the baseline. Compared to 6 months before administration of tacrolimus, prednisolone dose significantly decreased at 12 months after treatment (2.85±0.92 mg/day, p=0.002), 18 months after treatment (3.36±0.99 mg/day, p=0.001), and 24 months after treatment (3.71±0.93 mg/day, p<0.001). CONCLUSION Tacrolimus may be effective in reducing the severity of MG and may permit a reduction in the steroid dose prescribed to the patients. Adverse events due to tacrolimus treatment were not serious.
Collapse
Affiliation(s)
- Yool Hee Kim
- Department of Neurology, College of Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
110
|
Abstract
PURPOSE A randomized controlled trial of thymectomy in myasthenia gravis demonstrated improved clinical outcomes in adults, but data surrounding juvenile cases, especially those treated with minimally invasive approaches, are limited. Here, we review our experience with thoracoscopic thymectomy for juvenile myasthenia gravis (JMG) in the largest cohort to date. METHODS All cases of thymectomy for JMG in a single tertiary referral center between 2007 and 2018 were reviewed (N = 50). Patients underwent left thoracoscopic approach with extended dissection and without use of monopolar energy. Demographics, diagnostic criteria, and clinical classification, as well as surgical data were collected. Clinical status and medications were reviewed in follow-up. RESULTS The mean age at surgery was 10.5 ± 0.8 years. Ocular disease and generalized disease each comprised half of the cohort. No patients suffered complications or increased risk of morbidity or mortality with thymectomy. At any interval of follow-up through 3.5 years, 49.8% of patients were improved compared to their pre-operative presentation, and there was a significant trend towards decreased steroid use. CONCLUSION Thoracoscopic thymectomy is a safe treatment for juvenile myasthenia gravis in pediatric patients over a wide range of ages, body masses, and symptoms. Our experience adds evidence that pediatric patients likely benefit from thymectomy with improved clinical status and reduced medications.
Collapse
Affiliation(s)
- Aimee G. Kim
- Division of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Sydney A. Upah
- Division of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - John F. Brandsema
- Division of Neurology, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Sabrina W. Yum
- Division of Neurology, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Thane A. Blinman
- Division of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| |
Collapse
|
111
|
Onesti E, Frasca V, Ceccanti M, Tartaglia G, Gori MC, Cambieri C, Libonati L, Palma E, Inghilleri M. Short-Term Ultramicronized Palmitoylethanolamide Therapy in Patients with Myasthenia Gravis: a Pilot Study to Possible Future Implications of Treatment. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2019; 18:232-238. [DOI: 10.2174/1871527318666190131121827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 12/14/2018] [Accepted: 01/21/2019] [Indexed: 12/19/2022]
Abstract
Background: The cannabinoid system may be involved in the humoral mechanisms at the
neuromuscular junction. Ultramicronized-palmitoylethanolamide (μm-PEA) has recently been
shown to reduce the desensitization of Acetylcholine (ACh)-evoked currents in denervated patients
modifying the stability of ACh receptor (AChR) function.
<p>
Objective: To analyze the possible beneficial effects of μm-PEA in patients with myasthenia gravis
(MG) on muscular fatigue and neurophysiological changes.
<p>
Method: The duration of this open pilot study, which included an intra-individual control, was three
weeks. Each patient was assigned to a 1-week treatment period with μm-PEA 600 mg twice a day. A
neurophysiological examination based on repetitive nerve stimulation (RNS) of the masseteric and the
axillary nerves was performed, and the quantitative MG (QMG) score was calculated in 22 MG patients
every week in a three-week follow-up period. AChR antibody titer was investigated to analyze a
possible immunomodulatory effect of PEA in MG patients.
<p>
Results: PEA had a significant effect on the QMG score (p=0.03418) and on RNS of the masseteric
nerve (p=0.01763), thus indicating that PEA reduces the level of disability and decremental muscle response.
Antibody titers did not change significantly after treatment.
<p>
Conclusion: According to our observations, μm-PEA as an add-on therapy could improve muscular
response to fatigue in MG. The possible modulation of AChR currents as a means of eliciting a direct
effect from PEA on the conformation of ACh receptors should be investigated. The co-role of cytokines
also warrants an analysis. Given the rapidity and reversibility of the response, we suppose that
PEA acts directly on AChR, though further studies are needed to confirm this hypothesis.
Collapse
Affiliation(s)
- Emanuela Onesti
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Vittorio Frasca
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Marco Ceccanti
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Giorgio Tartaglia
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Maria Cristina Gori
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Chiara Cambieri
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Laura Libonati
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Eleonora Palma
- Department of Physiology and Pharmacology, Institute Pasteur- Fondazione Cenci Bolognetti, University of Rome Sapienza, Rome, Italy
| | - Maurizio Inghilleri
- Rare Neuromuscular Diseases Centre, Department of Human Neuroscience, Sapienza University, Rome, Italy
| |
Collapse
|
112
|
Affiliation(s)
- Amelia Evoli
- Institute of Neurology, Università Cattolica del Sacro Cuore, Roma, Italy
- Fondazione Policlinico Gemelli, IRCCS, Roma, Italy
| | - Elisa Meacci
- Fondazione Policlinico Gemelli, IRCCS, Roma, Italy
- Institute of Thoracic Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
| |
Collapse
|
113
|
Gastaldi M, De Rosa A, Maestri M, Zardini E, Scaranzin S, Guida M, Borrelli P, Ferraro OE, Lampasona V, Furlan R, Irani SR, Waters P, Lang B, Vincent A, Marchioni E, Ricciardi R, Franciotta D. Acquired neuromyotonia in thymoma-associated myasthenia gravis: a clinical and serological study. Eur J Neurol 2019; 26:992-999. [PMID: 30714278 PMCID: PMC6593867 DOI: 10.1111/ene.13922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 01/30/2019] [Indexed: 12/27/2022]
Abstract
Background and purpose Acquired neuromyotonia can occur in patients with thymoma, alone or in association with myasthenia gravis (MG), but the clinical prognostic significance of such comorbidity is largely unknown. The clinico‐pathological features were investigated along with the occurrence of neuromyotonia as predictors of tumour recurrence in patients with thymoma‐associated myasthenia. Methods A total number of 268 patients with thymomatous MG were studied retrospectively. Patients with symptoms of spontaneous muscle overactivity were selected for autoantibody testing using immunohistology for neuronal cell‐surface proteins and cell‐based assays for contactin‐associated protein 2 (CASPR2), leucine‐rich glioma inactivated 1 (LGI1), glycine receptor and Netrin‐1 receptor antibodies. Neuromyotonia was diagnosed according to the presence of typical electromyography abnormalities and/or autoantibodies against LGI1/CASPR2. Results Overall, 33/268 (12%) MG patients had a thymoma recurrence. Five/268 (2%) had neuromyotonia, four with typical autoantibodies, including LGI1 (n = 1), CASPR2 (n = 1) or both (n = 2). Three patients had Netrin‐1 receptor antibodies, two with neuromyotonia and concomitant CASPR2+LGI1 antibodies and one with spontaneous muscle overactivity without electromyography evidence of neuromyotonia. Thymoma recurrence was more frequent in those with (4/5, 80%) than in those without (28/263, 10%, P < 0.001) neuromyotonia. Neuromyotonia preceded the recurrence in 4/5 patients. In univariate analysis, predictors of thymoma recurrence were age at thymectomy [odds ratio (OR) 0.95, 95% confidence interval (CI) 0.93–0.97], Masaoka stage ≥IIb (OR 10.73, 95% CI 2.38–48.36) and neuromyotonia (OR 41.78, 95% CI 4.71–370.58). Conclusions De novo occurrence of neuromyotonia in MG patients with previous thymomas is a rare event and may herald tumour recurrence. Neuronal autoantibodies can be helpful to assess the diagnosis. These observations provide pragmatic risk stratification for tumour vigilance in patients with thymomatous MG.
Collapse
Affiliation(s)
- M Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - A De Rosa
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Maestri
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Zardini
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - S Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - M Guida
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - P Borrelli
- Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - O E Ferraro
- Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Pavia, Italy
| | - V Lampasona
- Division of Genetics and Cell Biology, Genomic Unit for the Diagnosis of Human Pathologies, San Raffaele Scientific Institute, Milan, Italy
| | - R Furlan
- Division of Neuroscience, INSPE, San Raffaele Scientific Institute, Milan, Italy
| | - S R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - P Waters
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - B Lang
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - A Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - E Marchioni
- Neuroncology and Neuroinflammation Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - R Ricciardi
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - D Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| |
Collapse
|
114
|
Schneider-Gold C, Hagenacker T, Melzer N, Ruck T. Understanding the burden of refractory myasthenia gravis. Ther Adv Neurol Disord 2019; 12:1756286419832242. [PMID: 30854027 PMCID: PMC6399761 DOI: 10.1177/1756286419832242] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/28/2019] [Indexed: 11/15/2022] Open
Abstract
Myasthenia gravis (MG) is an autoantibody-mediated disease that compromises the acetylcholine receptors or associated structures of the postsynaptic membrane of the neuromuscular junction. This leads to impaired neuromuscular transmission and subsequent fluctuating fatigability and weakness of ocular, bulbar, and limb skeletal muscles. Over the past few decades, there have been significant advances in our understanding of the disease pathophysiology and improvements in prognosis due to intensive care medicine and immunomodulation. Despite this, an estimated 10-20% of patients with MG do not achieve an adequate response, are intolerant to conventional treatment, or require chronic treatment with intravenous immunoglobulins or plasma separation procedures. Such patients are regarded as having MG that is 'refractory' to treatment and may represent a distinct clinical subgroup. Because the majority of patients with MG have well-controlled disease, the burden of illness in the minority with refractory disease is poorly understood and may be underestimated. However, clinically these patients are liable to experience extreme fatigue, considerable disability owing to uncontrolled symptoms, and frequent myasthenic crises and hospitalizations. Both acute adverse effects and an increased risk of comorbidity from treatment regimens may contribute to reduced quality of life. As yet, little is known concerning the impact of refractory MG on mental health and health-related quality of life. This review aims to highlight the burden of disease and unmet needs in patients with refractory MG.
Collapse
Affiliation(s)
- Christiane Schneider-Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, D-44791, Germany
| | | | | | | |
Collapse
|
115
|
Shumei Y, Yi L, Huanyu M, Zhibin L, Wanlin J, Liqun X, Huan Y. IL-2 gene polymorphisms affect tacrolimus response in myasthenia gravis. Eur J Clin Pharmacol 2019; 75:795-800. [PMID: 30729267 DOI: 10.1007/s00228-019-02642-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/29/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE The IL-2 gene polymorphisms have been reported to be associated with the development of autoimmune disease. However, there are no published studies examining the influence of the IL-2 gene polymorphisms on the response of myasthenia gravis (MG) patients to tacrolimus (Tac). The goal of this study was to investigate the relationship between the polymorphisms of IL-2 and Tac response in MG patients. METHODS Ninety-two MG patients treated with Tac were studied, including 57 Tac-effective patients and 35 Tac-ineffective patients. Then, we selected four single-nucleotide polymorphisms (SNPs: rs2069776, rs2069772, rs2069762, rs2069763) in the IL-2 gene. Next, we analyzed the distribution of genotypes, allelic frequencies of SNPs, and haplotype frequencies among polymorphisms in the two groups of patients. RESULTS The distribution of the allelic frequency of the rs2069762 variant differed between the Tac-effective and Tac-ineffective patients (P = 0.02). Genotypes G/T and G/G of rs2069762 were differently distributed between the two groups when the wild genotype T/T was assigned as a reference (P < 0.001 for G/T; P = 0.003 for G/G). Patients with the TAGG haplotype tended to be Tac-ineffective (P < 0.001, OR: 0.15, 95% CI: 0.05-0.43). CONCLUSION Myasthenia gravis patients with the rs2069762 variant, rs2069762 G/T and G/G genotype, and TAGG haplotype for IL-2 tended to respond poorly to Tac treatment.
Collapse
Affiliation(s)
- Yang Shumei
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Li Yi
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Meng Huanyu
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Li Zhibin
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Jin Wanlin
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Xu Liqun
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China
| | - Yang Huan
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha, Hunan, China.
| |
Collapse
|
116
|
Cao YL, Dong W, Li YZ, Han W. MicroRNA-653 Inhibits Thymocyte Proliferation and Induces Thymocyte Apoptosis in Mice with Autoimmune Myasthenia Gravis by Downregulating TRIM9. Neuroimmunomodulation 2019; 26:7-18. [PMID: 30703767 DOI: 10.1159/000494802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/23/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Myasthenia gravis (MG) is an organ-specific autoimmune neuromuscular disorder that occurs as a result of the impairment in neuromuscular junction and autoantibody attack on the postsynaptic receptors. Increasing evidence suggests that microRNAs (miRs) might be involved in the development of MG. Therefore, the present study aimed to investigate the regulatory function of miR-653 on MG and its relationship with tripartite motif 9 (TRIM9). METHODS The thymic tissues obtained from MG patients with thymic hyperplasia were prepared for establishing an MG mouse model in BALB/c mice. Afterwards, the miR-653 and TRIM9 expressions were determined in thymic tissues. A dual-luciferase reporter assay was carried out to validate whether miR-653 directly targets TRIM9. Finally, the thymocytes were exposed to mimics or inhibitors of miR-653, or siRNA against TRIM9 with the use of MTT assays and flow cytometry for the verification of the gain or loss function of miR-653 and TRIM9 on viability, cell cycle progression, and apoptosis of thymocytes. RESULTS There was a decrease in thymocyte miR-653 and an increase in TRIM9 in thymic tissues of MG mice. miR-653 was found to negatively regulate TRIM9. Overexpression of miR-653 or depletion of TRIM9 resulted in the inhibition of cell viability, suppression of cell cycle progression, and induction of apoptosis rate in thymocytes. CONCLUSION The findings from the present study provided evidence that miR-653 impairs proliferation and promotes apoptosis of thymocytes of MG mice by suppressing TRIM9, indicating that miR-653 could be used as potential therapeutic target in the treatment of autoimmune MG.
Collapse
Affiliation(s)
- Yu-Ling Cao
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| | - Wei Dong
- Department of Emergency, Jining No. 1 People's Hospital, Jining, China,
| | - Yu-Zhi Li
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| | - Wei Han
- Department of Neurology, Jining No. 1 People's Hospital, Jining, China
| |
Collapse
|
117
|
Abstract
OBJECTIVE To evaluate transcervical and transsternal thymectomy benefits in large myasthenia gravis (MG) cohort. METHOD We retrospectively evaluated MG patients (n = 184) who had undergone thymectomy between 2004 and 2015 at National Institute of Mental Health and Neurosciences, Bangalore (India). Myasthenia gravis foundation of America guidelines were followed to assess clinical outcome. Anti-acetylcholine receptors (AChR) antibodies, repetitive nerve stimulation (RNS) and Neostigmine tests were performed at pre and post-thymectomy stage. RESULTS Most of the patients were fell under MG grade IIA (82 of 184, 44.56%) and grade IIB (61 of 184, 33.15%). Thymoma and thymic hyperplasia was established in 64 (34.78%) and 89 (48.37%) patients respectively. Other thymic abnormalities such thymic atrophy, cysts and lipoma were established in 31 (16.85%) patients. MG patients were treated either with transcervical (n = 79) or (n = 105) transsternal thymectomy. At the pre-thymectomy stage, the majority of the patients were positive for anti-AChR antibodies (179 of 184, 97.28%), RNS (170 of 184, 92.4%), and Neostigmine (175 of 184, 95.11%). At the post-thymectomy stage, a significant reduction observed in anti-AChR antibodies positivity (p < 0.022) and RNS positivity (p < 0.015). Overall, benefits were observed in 61.41% (113 of 184) of patients. Clinical benefits (complete stable remission, pharmacological remission, minimal manifestation, and improvement) of transcervical and transsternal thymectomy observed in 69.62% (55 of 79) and 55.24% (58 of 105) of patients respectively. MG patients with thymoma showed the least improvement compared to thymic hyperplasia. DISCUSSION Transcervical and transsternal thymectomy showed clinical benefits, however, there was no significant difference between them.
Collapse
Affiliation(s)
- Suresh C Bokoliya
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences , Bangalore , India
| | - Shripad A Patil
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences , Bangalore , India
| |
Collapse
|
118
|
Sabre L, Guptill JT, Russo M, Juel VC, Massey JM, Howard JF, Hobson-Webb LD, Punga AR. Circulating microRNA plasma profile in MuSK+ myasthenia gravis. J Neuroimmunol 2018; 325:87-91. [PMID: 30316681 PMCID: PMC6240475 DOI: 10.1016/j.jneuroim.2018.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022]
Abstract
Muscle-specific tyrosine kinase antibody positive myasthenia gravis (MuSK+ MG) is an immunological subtype with distinctive pathogenic mechanisms and clinical features. The aim of this study was to analyze the circulating plasma microRNA profile of patients with MuSK+ MG. From the discovery cohort miR-210-3p, miR-324-3p and miR-328-3p were further analyzed in the validation cohort. We found a distinct plasma profile of miR-210-3p and miR-324-3p that were significantly decreased in MuSK+ MG patients compared to healthy controls (4.1 ± 1.4 vs 5.1 ± 1.4, p = .006 and 4.7 ± 1.0 vs 5.4 ± 1.3, p = .02). These findings reveal a distinct plasma miRNA profile in MuSK+ MG.
Collapse
Affiliation(s)
- Liis Sabre
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | | | - Melissa Russo
- Department of Neurology, Duke University, Durham, USA
| | - Vern C Juel
- Department of Neurology, Duke University, Durham, USA
| | | | - James F Howard
- Department of Neurology, University of North Carolina - Chapel Hill, Chapel Hill, USA
| | | | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
119
|
Qiu D, Xia Z, Jiao X, Deng J, Zhang L, Li J. Altered Gut Microbiota in Myasthenia Gravis. Front Microbiol 2018; 9:2627. [PMID: 30483222 PMCID: PMC6241162 DOI: 10.3389/fmicb.2018.02627] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/15/2018] [Indexed: 01/01/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune-mediated disorder, the etiology of which involves both environmental factors and genetics. While the exact factors responsible for predisposition to MG remain elusive, it is hypothesized that gut microbiota play a critical role in the pathogenesis of MG. This study investigated whether gut microbiota are altered in MG patients by comparing the fecal microbiota profiles of MG patients to those of age- and sex-matched healthy controls. Phylotype profiles of gut microbial populations were generated using hypervariable tag sequencing of the V4 region of the 16S ribosomal RNA gene. Fecal short-chain fatty acids (SCFAs) were assessed by gas chromatographic analyses. The results demonstrated that, compared to the healthy cohort, the gut microbiota of the MG group was changed in terms of the relative abundances of bacterial taxa, with sharply reduced microbial richness, particularly in the genus Clostridium. The fecal SCFA content was significantly lower in the MG group. Furthermore, microbial dysbiosis was closely related to the levels of inflammatory biomarkers in the sera of MG patients.
Collapse
Affiliation(s)
- Dongxu Qiu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Neurology of Hunan Province, Changsha, China
| | - Zhiwei Xia
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Neurology of Hunan Province, Changsha, China
| | - Xiao Jiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Neurology of Hunan Province, Changsha, China
| | - Jun Deng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Neurology of Hunan Province, Changsha, China
| | - Lei Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Neurology of Hunan Province, Changsha, China
| |
Collapse
|
120
|
Chen P, Li Y, Huang H, Li Y, Huang X, Chen Z, Liu X, Qiu L, Ou C, Huang Z, Lin Z, Ran H, Liu W. Imbalance of the two main circulating dendritic cell subsets in patients with myasthenia gravis. Clin Immunol 2018; 205:130-137. [PMID: 30359772 DOI: 10.1016/j.clim.2018.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/09/2018] [Accepted: 10/20/2018] [Indexed: 10/28/2022]
Abstract
Although it is well documented that circulating dendritic cells (DCs) have specialized features during many kinds of physiological and pathological conditions, there are few reports about the features of DCs in the peripheral blood of myasthenia gravis (MG) patients. We investigated the quantitative and component features of DCs and their implications in MG. Peripheral blood samples from different kinds of MG patients were collected and their clinical characteristics were recorded. Using flow cytometry, we distinguished circulating DC subsets [plasmacytoid DCs (pDCs) and myeloid DCs (mDCs)] and enumerated their densities in peripheral blood. Absolute numbers of circulating pDCs were significantly decreased in naïve MG patients compared with healthy controls, resulting in a markedly lower ratio of the pDC to mDC percentage in total circulating DCs (pDCs/mDCs), suggesting an imbalance in the proportions of the two main circulating DC subsets. The clinical status of MG patients was improved after drug treatment, together with increased pDCs/mDCs. In a longitudinal follow-up, we observed that circulating mDCs were significantly reduced after 1 month of therapy with a corticosteroid and immunosuppressant, resulting in recovery of pDCs/mDCs. Although the exact meaning of the proportion change in circulating DC subsets is unknown, pDCs/mDCs might reflect the balance between the autoimmune response and immune tolerance of a patient. Moreover, changes in pDCs/mDCs during treatment might be a promising marker to predict the efficacy of a specific drug used for MG patients.
Collapse
Affiliation(s)
- Pei Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yingkai Li
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Hao Huang
- Department of Neurology, The First People's Hospital of Nanning, Nanning 530000, China
| | - Yan Li
- Department of Neurosurgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xin Huang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhenguang Chen
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoxi Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Li Qiu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Changyi Ou
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhidong Huang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhongqiang Lin
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou 510006, China.
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China.
| |
Collapse
|
121
|
Rozmilowska I, Czyzewski D, Mazur B, Adamczyk-Sowa M. What is the role of adipokines in myasthenia gravis? Ther Clin Risk Manag 2018; 14:1515-1525. [PMID: 30214215 PMCID: PMC6118871 DOI: 10.2147/tcrm.s163966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Myasthenia gravis (MG) is a disease with autoimmune etiology. The main pathomechanism is related to the production of antibodies against nicotinic acetylcholine receptor. The present study is aimed to compare the serum level of adipokines in patients with MG with that in controls, as well as to study the relation of these levels with disease severity. Patients and methods Fifty patients with MG and 30 healthy individuals were enrolled in our study. Serum concentrations of select adipokines, namely adiponectin, leptin, omentin, visfatin, and resistin were measured. Results The results showed a significant increase in serum concentrations of adiponectin and resistin in the patients with MG compared with the controls. Conclusion Further studies are warranted to assess changes in adipokine concentration levels in patients with MG.
Collapse
Affiliation(s)
| | - Damian Czyzewski
- Department of Thoracic Surgery, Medical University of Silesia, Zabrze, Poland
| | - Bogdan Mazur
- Department of Microbiology, Medical University of Silesia, Zabrze, Poland
| | | |
Collapse
|
122
|
Effects of long-term respiratory muscle endurance training on respiratory and functional outcomes in patients with Myasthenia gravis. Respir Med 2018; 144:7-15. [PMID: 30366587 DOI: 10.1016/j.rmed.2018.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 07/16/2018] [Accepted: 09/02/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is characterized by reduced muscle endurance and often leads to respiratory complications. OBJECTIVE A long-term respiratory muscle endurance training (RMET) based on normocapnic hyperpnea was introduced for the first time in MG patients. We investigated RMET effects on respiratory endurance (RE), MG symptoms, lung function and physical fitness and compared the results with a control group (CG). METHODS The training period consisted of four weeks intensive training (IT; five 30-min training sessions per week) followed by twelve months maintenance training (MT; five 30-min training sessions over two weeks). Eighteen patients with mild to moderate MG participated as the training group (TG), six patients served as CG. RE, lung function, MG score and physical fitness were tested before and after IT and after three to twelve months of MT. RESULTS Only 12 TG patients completed the entire training period. Thirteen months of training significantly increased RE measured as time until exhaustion (Tlim) to 412% of baseline (P < 0.001). The MG score improved from 0.67±0.09 to 0.41 ± 0.1 (p = 0.004), and the number of squats per minute as a measure of physical fitness increased in the TG to 160% of baseline (p = 0.015). While lung function did not change during the training period, we observed a modulation in the breathing pattern at rest with prolonged expiration (122% of baseline, p = 0.028). In addition, TG reported subjective improvements in MG symptoms, respiratory symptoms and physical fitness by 49%, 58% and 64%, respectively (P < 0.001). No significant changes were observed in the CG. CONCLUSION AND SIGNIFICANCE This is the first controlled long-term RMET study in MG patients. The results demonstrated that this normocapnic hyperpnea training is feasible and beneficial for patients with mild to moderate MG and is a valuable supplement to conventional drug treatment.
Collapse
|
123
|
Zhu TY, Fan GH, Geng Q, Kang GJ, Huang J. Predictive value of the thymofatty specimen weight index in outcomes of extended thymectomy due to non-thymomatous myasthenia gravis. Interact Cardiovasc Thorac Surg 2018; 27:290-294. [PMID: 29554262 DOI: 10.1093/icvts/ivy019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/15/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To evaluate the predictive value of the intraoperative thymofatty specimen weight (TFSW) index on predicting the prognosis of extended thymectomy (ET) for non-thymomatous myasthenia gravis. METHODS This is a prospective non-interventional study in which patients who underwent ET between January 2012 and June 2015 were enrolled. Resected thymus and surrounding adipose tissues were weighed using an electronic scale intraoperatively and adjusted to the body surface area (BSA) to calculate the TFSW index. The primary end point was defined as complete stable remission (CSR) according to the Myasthenia Gravis Foundation of America (MGFA) guidelines. RESULTS One hundred and eighteen patients who completed postoperative follow-up were included in this study. After a mean follow-up period of 44 months, 68 (57.6%) patients reached clinical CSR. The MGFA class, histopathology and TFSW index were associated with a postoperative CSR in univariate analysis. When the Cox hazard multiple regression model was used, the TFSW index was found to be an independent predictor for CSR (hazard ratio 2.056; 95% confidence interval 1.182-3.576). Based on ROC analysis, an optimal TFSW index cut-off value (35.9 g/m2) with the highest sensitivity and specificity was determined. CONCLUSIONS The TFSW index is an important independent predictor for mid-term CSR after ET in non-thymomatous myasthenia gravis patients. During the ET surgery, every effort should be made to take a tissue specimen with a TFSW index more than 35.9 g/m2.
Collapse
Affiliation(s)
- Tie-Yuan Zhu
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Guo-Hua Fan
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qing Geng
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Gan-Jun Kang
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jie Huang
- Department of Thoracic Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| |
Collapse
|
124
|
Landon-Cardinal O, Friedman D, Guiguet M, Laforêt P, Heming N, Salort-Campana E, Jouen F, Allenbach Y, Boyer O, Chatenoud L, Eymard B, Sharshar T, Benveniste O. Efficacy of Rituximab in Refractory Generalized anti-AChR Myasthenia Gravis. J Neuromuscul Dis 2018; 5:241-249. [DOI: 10.3233/jnd-180300] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Océane Landon-Cardinal
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Internal Medicine and ClinicalImmunology, Inflammation-Immunopathology-Biotherapy Department (I2B), East Paris Neuromuscular Diseases Reference Center, Inserm U974, Sorbonne Université, Paris 6, Paris, France
| | - Diane Friedman
- Department of IntensiveCare, Raymond Poincare University Hospital, Garches, France
| | - Marguerite Guiguet
- Sorbonne Université, UPMC UnivParis 06, INSERM, Institut Pierre Louis d’Epidemiologie et de Santé Publique (IPLESP UMRS 1136), F75013, Paris, France
| | - Pascal Laforêt
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Neurology, EastParis Neuromuscular Diseases Reference Center, Université Pierre et Marie Curie, Paris 6, Paris, France
| | - Nicholas Heming
- Department of IntensiveCare, Raymond Poincare University Hospital, Garches, France
| | | | - Fabienne Jouen
- Rouen University Hospital, Department of Immunology, Inserm U905, NormandieUniv, IRIB, Rouen, France
| | - Yves Allenbach
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Internal Medicine and ClinicalImmunology, Inflammation-Immunopathology-Biotherapy Department (I2B), East Paris Neuromuscular Diseases Reference Center, Inserm U974, Sorbonne Université, Paris 6, Paris, France
| | - Olivier Boyer
- Rouen University Hospital, Department of Immunology, Inserm U905, NormandieUniv, IRIB, Rouen, France
| | - Lucienne Chatenoud
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France, and INSERM U1151, CNRS UMR 8253, INEM Hôpital Necker-Enfants Malades, Paris, France
| | - Bruno Eymard
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Neurology, EastParis Neuromuscular Diseases Reference Center, Université Pierre et Marie Curie, Paris 6, Paris, France
| | - Tarek Sharshar
- Department of IntensiveCare, Raymond Poincare University Hospital, Garches, France
| | - Olivier Benveniste
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Internal Medicine and ClinicalImmunology, Inflammation-Immunopathology-Biotherapy Department (I2B), East Paris Neuromuscular Diseases Reference Center, Inserm U974, Sorbonne Université, Paris 6, Paris, France
| |
Collapse
|
125
|
3,4-Diaminopyridine for the treatment of myasthenia gravis with electrophysiological patterns of Lambert-Eaton myasthenic syndrome. J Clin Neurosci 2018; 50:194-198. [DOI: 10.1016/j.jocn.2018.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
|
126
|
Yin DT, Huang L, Han B, Chen X, Yin SM, Zhou W, Chu J, Liang T, Yun TY, Liu Y. Independent long-term result of robotic thymectomy for myasthenia gravis, a single center experience. J Thorac Dis 2018; 10:321-329. [PMID: 29600063 DOI: 10.21037/jtd.2017.12.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Robotic thymectomy has been suggested a feasible and safe approach for myasthenia gravis (MG). Few investigations have revealed the independent effect of robotic thymectomy without the confounding impact of immunosuppressive (IM) therapy. Methods Between May 2009 and December 2012, robotic extended thymectomy was carried out for patients with diagnosis of MG. The clinical data, subsequent neurological therapy and postintervention status were collected. Results Data of 37 cases was available for analysis. The mean follow-up was 70.0±13.3 months. The median age was 40 years. Twelve (32.4%) patients kept free of IM therapy, and 25 (67.6%) patients accepted postoperatively. The overall 5-year complete stable remission (CSR) rate was 40.6% and improvement rate was 81.6%. The young (age ≤40) displayed a significant better CSR rate (P=0.015) and a trend of better improvement rate (P=0.050) compared to the old (age >40). Patients without usage of IM therapy showed significant higher CSR rate (P=0.014) and improvement rate (P=0.024) compared to those with usage of IM therapy. Patients with Myasthenia Gravis Foundation of America (MGFA) classes I showed a trend of higher remission rate by multivariate analysis. No significant differences were found for the remission rate according to gender, pathology, and the duration of symptoms. Conclusions The mono-therapy of robotic thymectomy may bring with a satisfactory long-term result for part of MG patients. Precision selection and individualized therapy are of the most importance.
Collapse
Affiliation(s)
- Dong-Tao Yin
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China.,Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Ling Huang
- Department of Neurology, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Bing Han
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Xiu Chen
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Shi-Min Yin
- Department of Neurology, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Wen Zhou
- Department of Cadre's Ward, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Jian Chu
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Tao Liang
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Tian-Yang Yun
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China
| | - Yang Liu
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China
| |
Collapse
|
127
|
Shiomi K, Kitamura E, Ono M, Kondo Y, Naito M, Mikubo M, Matsui Y, Nishiyama K, Suda T, Satoh Y. Feasible and promising modified trans-subxiphoid thoracoscopic extended thymectomy for patients with myasthenia gravis. J Thorac Dis 2018; 10:1747-1752. [PMID: 29707329 DOI: 10.21037/jtd.2018.01.168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We have used a promising, minimally invasive thoracoscopic technique of extended thymectomy for patients with myasthenia gravis (MG). The aim of this study was to report our promising technique, a modified single-port trans-subxiphoid approach (MTXA) and to compare perioperative outcomes and effects on MG between our approach and sternotomy. Methods We retrospectively reviewed records of all patients undergoing extended thymectomy for MG and/or thymoma between January 1, 2010 and December 31, 2016. The patients were divided into the MTXA group and Sternotomy group. Results Of the 50 consecutive patients undergoing extended thymectomy for MG, finally, 13 patients undergoing our MTXA extended thymectomy technique were compared with 20 patients undergoing extended thymectomy via sternotomy. Intraoperative blood loss, postoperative length of stay, and C-reactive protein value on postoperative day 1 were significantly more favorable in the MTXA group than the Sternotomy group (P<0.0001, P=0.0040 and P=0.0073, respectively). Furthermore, no significant differences in the frequency of patients with improvement of their Quantitative Myasthenia Gravis score and/or MG-Activities of Daily Living scale, decrease in the serum level of acetylcholine receptor antibody, and dose reduction of oral prednisone were seen between the two groups. Conclusions Our approach to extended thymectomy might be more favorable than sternotomy in patients with MG.
Collapse
Affiliation(s)
- Kazu Shiomi
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Eiji Kitamura
- Department of Medicine (Neurology), Kitasato University School of Medicine, Kanagawa, Japan
| | - Mototsugu Ono
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yasuto Kondo
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masahito Naito
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masashi Mikubo
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yoshio Matsui
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kazutoshi Nishiyama
- Department of Medicine (Neurology), Kitasato University School of Medicine, Kanagawa, Japan
| | - Takashi Suda
- Division of Thoracic and Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yukitoshi Satoh
- Department of Thoracic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| |
Collapse
|
128
|
Lv F, Guan Y, Ma D, Xu X, Song Y, Li L, Jiang Y, Wang O, Xia W, Xing X, Li M. Effects of alendronate and alfacalcidol on bone in patients with myasthenia gravis initiating glucocorticoids treatment. Clin Endocrinol (Oxf) 2018; 88:380-387. [PMID: 29266368 DOI: 10.1111/cen.13537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Glucocorticoids (GCs) are the first-line treatment for myasthenia gravis (MG) and act as long-term immunosuppressants. However, GCs can induce osteoporosis and bone fractures. In this study, we evaluate the effects of oral alendronate and alfacalcidol, or alfacalcidol alone on the bone of Chinese patients with MG who will initiate treatment with GCs. DESIGN AND METHODS A total of 75 patients were included in this 12-month prospective, open-label, single-centre study. Patients with bone mineral density (BMD) T-score less than -1.0 at baseline were treated with 70 mg of alendronate per week. Patients with BMD T-score greater than -1.0 at baseline were included in the alfacalcidol-alone group. Patients in two groups were treated with 0.25 μg of alfacalcidol every other day and 600 mg of calcium daily. RESULTS After 12 months of treatment, the mean BMD of lumbar spine, femoral neck and total hip increased by 3.4% (P = .002), 1.8% (P = .21) and 2.6% (P = .02), respectively, in alendronate group. In alfacalcidol-alone group, the mean BMD of lumbar spine, femoral neck and total hip decreased by 6.1%, 3.2% and 3.3%, respectively (all P < .001 vs baseline). CONCLUSIONS We demonstrated for the first time that treatment with alendronate combined with alfacalcidol significantly increased BMD, decreased bone turnover biomarker levels and reduced the occurrence of hypercalciuria in a large cohort of Chinese patients with MG who initiated treatment with glucocorticoids. However, treatment with alfacalcidol alone failed to prevent bone loss in patients with MG receiving glucocorticoid therapy.
Collapse
Affiliation(s)
- Fang Lv
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Doudou Ma
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaojie Xu
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuwen Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lujiao Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ou Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mei Li
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
129
|
Lu Q, Zhao J, Wang J, Chen Z, Han Y, Huang L, Li X, Zhou Y. Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis 2018; 10:1711-1720. [PMID: 29707325 DOI: 10.21037/jtd.2018.02.11] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain. Methods From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated via the subxiphoid and subcostal arch approach and the other 36 via the conventional unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Results The thoracoscopic extended thymectomy was performed safely via the subxiphoid and subcostal arch approach. In this approach, no drainage tube was inserted after operation except in the first two patients. Two of the 41 patients were switched to trans-sternal approach due to the tight adhesion between the thymoma and the left innominate vein. No major complications occurred. Compared with the unilateral approach, the duration of the procedure via subxiphoid and subcostal arch was significantly shorter, with less estimated blood loss, shorter hospital-stay and lower postoperative pain (P<0.001). The cosmetic scores were comparable between the two groups (P=0.369). Conclusions The novel subxiphoid and subcostal arch approach is technically feasible and safe. It is an acceptable alternative to conventional thoracoscopic extended thymectomy.
Collapse
Affiliation(s)
- Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Jinbo Zhao
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Juzheng Wang
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Zhao Chen
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Yong Han
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Lijun Huang
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| |
Collapse
|
130
|
Padda SK, Yao X, Antonicelli A, Riess JW, Shang Y, Shrager JB, Korst R, Detterbeck F, Huang J, Burt BM, Wakelee HA, Badve SS. Paraneoplastic Syndromes and Thymic Malignancies: An Examination of the International Thymic Malignancy Interest Group Retrospective Database. J Thorac Oncol 2018; 13:436-446. [PMID: 29191778 PMCID: PMC5983900 DOI: 10.1016/j.jtho.2017.11.118] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Thymic epithelial tumors (TETs) are associated with paraneoplastic/autoimmune (PN/AI) syndromes. Myasthenia gravis is the most common PN/AI syndrome associated with TETs. METHODS The International Thymic Malignancy Interest Group retrospective database was examined to determine (1) baseline and treatment characteristics associated with PN/AI syndromes and (2) the prognostic role of PN/AI syndromes for patients with TETs. The competing risks model was used to estimate cumulative incidence of recurrence (CIR) and the Kaplan-Meier method was used to calculate overall survival (OS). A Cox proportional hazards model was used for multivariate analysis. RESULTS A total of 6670 patients with known PN/AI syndrome status from 1951 to 2012 were identified. PN/AI syndromes were associated with younger age, female sex, thymoma histologic type, earlier stage, and an increased rate of total thymectomy and complete resection status. There was a statistically significant lower CIR in the group with a PN/AI syndrome than in the group without a PN/AI syndrome (10-year CIR 17.3% versus 21.2%, respectively [p = 0.0003]). The OS was improved in the group with a PN/AI syndrome compared to the group without a PN/AI syndrome (median OS 21.6 years versus 17.0 years, respectively [hazard ratio = 0.63, 95% confidence interval: 0.54-0.74, p < 0.0001]). However, in the multivariate model for recurrence-free survival and OS, PN/AI syndrome was not an independent prognostic factor. DISCUSSION Previously, there have been mixed data regarding the prognostic role of PN/AI syndromes for patients with TETs. Here, using the largest data set in the world for TETs, PN/AI syndromes were associated with favorable features (i.e., earlier stage and complete resection status) but were not an independent prognostic factor for patients with TETs.
Collapse
Affiliation(s)
- Sukhmani K Padda
- Department of Medicine, Division of Oncology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California.
| | - Xiaopan Yao
- Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Alberto Antonicelli
- Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan W Riess
- Department of Medicine, Division of Oncology, University of California Davis Cancer Center, Sacramento, California
| | - Yue Shang
- The MathWorks, Natick, Massachusetts
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
| | - Robert Korst
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, New York; Valley/Mount Sinai Comprehensive Cancer Care, Paramus, New Jersey
| | - Frank Detterbeck
- Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - James Huang
- Department of Surgery, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bryan M Burt
- Department of Surgery, Division of Thoracic Surgery, Baylor College of Medicine, Houston, Texas
| | - Heather A Wakelee
- Department of Medicine, Division of Oncology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
| | - Sunil S Badve
- Department of Pathology, Indiana University, Indianapolis, Indiana
| |
Collapse
|
131
|
Van Kolen K, Pierrache L, Heyman S, Pauwels P, Van Schil P. Prognostic factors and genetic markers in thymoma. Thorac Cancer 2018; 1:133-140. [PMID: 27755821 DOI: 10.1111/j.1759-7714.2010.00028.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In this literature review prognostic factors and genetic markers that play a role in the staging of thymomas are discussed. The effect on prognosis of different factors, such as paraneoplastic syndromes, age, gender, classification, capsular invasion and surgical treatment, is evaluated. There is no generally accepted pathological classification of thymomas. More recently developed surgical techniques such as video-assisted or robotic thoracic surgery require longer follow-up times to determine whether they have equal long-term results compared to the classical surgical techniques. Many genetic markers have been described but at the present time no definite guidelines can be provided regarding screening and staging of thymomas.
Collapse
Affiliation(s)
- Katrien Van Kolen
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| | - Laurence Pierrache
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| | - Stijn Heyman
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| | - Patrick Pauwels
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp, Belgium Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| |
Collapse
|
132
|
Marino M, Bartoccioni E, Alboini PE, Evoli A. Rituximab in myasthenia gravis: a “to be or not to be” inhibitor of T cell function. Ann N Y Acad Sci 2018; 1413:41-48. [DOI: 10.1111/nyas.13562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Mariapaola Marino
- Istituto di Patologia Generale; Università Cattolica del Sacro Cuore; Rome Italy
| | - Emanuela Bartoccioni
- Istituto di Patologia Generale; Università Cattolica del Sacro Cuore; Rome Italy
| | | | - Amelia Evoli
- Istituto di Neurologia; Università Cattolica del Sacro Cuore; Rome Italy
| |
Collapse
|
133
|
Jiang L, Depypere L, Rocco G, Chen JS, Liu J, Shao W, Yang H, He J. Spontaneous ventilation thoracoscopic thymectomy without muscle relaxant for myasthenia gravis: Comparison with "standard" thoracoscopic thymectomy. J Thorac Cardiovasc Surg 2017; 155:1882-1889.e3. [PMID: 29249499 DOI: 10.1016/j.jtcvs.2017.11.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 10/19/2017] [Accepted: 11/14/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Myasthenia gravis (MG) benefits from thymectomy. However, its unpredictable response to muscle relaxants and volatile anesthetic agents may result in muscle weakness and subsequently in postoperative myasthenic crisis. The aim of this study was to determine the surgical outcomes after spontaneous ventilation compared with conventional intubated video-assisted thoracoscopic thymectomy (spontaneous-ventilation video-assisted thoracic thymectomy [SV-VATT] vs intubated video-assisted thoracic thymectomy) in patients with MG. METHODS Data from all minimally invasive thymectomy procedures performed at our institute between January 2009 and June 2016 were collected. Patient characteristics, perioperative results, and treatment outcomes between SV-VATT (group 1) and the intubated video-assisted thoracic thymectomy (group 2) groups were compared. Furthermore, a propensity score-matching analysis was generated to control for selection bias due to nonrandom group assignment in a 1:1 manner. RESULTS Thirty-six patients were included in group 1 and 68 in group 2. Matching of patients according to propensity score resulted in a cohort that consisted of 27 patients in both groups. Patients had similar clinical characteristics in both groups. Operating time (P = .07) and lowest pulse oxygen saturation (P = .09) between the procedures were comparable after matching, but peak CO2 level at the end of expiration was significantly greater in group 1 both before and after matching (P < .01). Moreover, the incidence of postoperative myasthenic crisis and postoperative prolonged tracheal intubation was lower in group 1. The postoperative pain visual analog scale score (P < .01) and the length of hospital stay (P = .03) were shorter in group 1. CONCLUSIONS SV-VATT is a feasible procedure in patients with MG. It might be beneficial by reducing postoperative myasthenic crisis and postoperative prolonged tracheal intubation. Further prospective research is needed.
Collapse
Affiliation(s)
- Long Jiang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospital Leuven (Gasthuisberg), Leuven, Belgium
| | - Gaetano Rocco
- Department of Thoracic Surgery, Istituto Nazionale Tumori, Fondazione G. Pascale, IRCCS, Naples, Italy
| | - Jin-Shing Chen
- Department of Thoracic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jun Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China
| | - Wenlong Shao
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China
| | - Hanyu Yang
- Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China; Department of Anesthesiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease, Guangzhou, China.
| | | |
Collapse
|
134
|
Zieliński M, Rybak M, Solarczyk-Bombik K, Wilkojc M, Czajkowski W, Kosinski S, Fryzlewicz E, Nabialek T, Szolkowska M, Pankowski J. Subxiphoid uniportal VATS thymectomy. J Vis Surg 2017; 3:171. [PMID: 29302447 DOI: 10.21037/jovs.2017.09.13] [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: 09/13/2017] [Accepted: 09/25/2017] [Indexed: 11/06/2022]
Abstract
Background To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). Methods Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. Results There were four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity. Conclusions The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.
Collapse
Affiliation(s)
- Marcin Zieliński
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Mariusz Rybak
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Michal Wilkojc
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Sylweriusz Kosinski
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Edward Fryzlewicz
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Tomasz Nabialek
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | | | | |
Collapse
|
135
|
Zieliński M, Rybak M, Solarczyk-Bombik K, Wilkojc M, Czajkowski W, Kosinski S, Fryzlewicz E, Nabialek T, Szolkowska M, Pankowski J. The Zakopane Pulmonary Hospital experience on subxiphoid thymectomy. J Vis Surg 2017; 3:2. [PMID: 29078565 DOI: 10.21037/jovs.2016.12.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 11/16/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND To present the technique of minimally invasive extended thymectomy performed through the subxiphoid-bilateral subcostal video-assisted thoracoscopic surgery (VATS) approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS The whole dissection was performed through the 4-7 cm transverse subxiphoid incision with single 10 mm extra-long bariatric laparoscopy ports inserted subcostally to the right and left chest cavities for videothoracoscope and subsequently for chest tubes. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. RESULTS There were 147 patients (62 patients operated on for thymomas, 75 patients for nonthymomatous MG and 10 for rethymectomies) in the period 1.1.2009-30.3.2016. There was no mortality and morbidity. The mean operative time was 109.1 min (range, 75-150 min). CONCLUSIONS The subxiphoid approach combined with bilateral single port subcostal VATS and double elevation of the sternum enables very extensive thymectomy in case of nonthymomayous MG.
Collapse
Affiliation(s)
- Marcin Zieliński
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Mariusz Rybak
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Michal Wilkojc
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Sylweriusz Kosinski
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Edward Fryzlewicz
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Tomasz Nabialek
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | | | | |
Collapse
|
136
|
Liu Z, Lai Y, Yao S, Feng H, Zou J, Liu W, Lei Y, Zhu H, Cheng C. Clinical Outcomes of Thymectomy in Myasthenia Gravis Patients with a History of Crisis. World J Surg 2017; 40:2681-2687. [PMID: 27312319 DOI: 10.1007/s00268-016-3599-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The use of thymectomy in myasthenia gravis (MG) patients with a history of myasthenic crisis (MC) has not been well established. Here, we determined the efficacy of thymectomy by assessing the long-term clinical outcomes and reviewed thymectomy reports on MC patients. METHODS Subjects included 31 patients who suffered at least one crisis before surgery, with a cumulative total 73 episodes of MC in Southern China between May 2000 and December 2010. Long-term follow-up was performed and clinical outcomes were evaluated. We used complete stable remission (CSR), termed an asymptomatic status without medication for at least 12 months; general complete remission (GCR), termed an asymptomatic status with or without some form of therapy excluding cholinesterase inhibitors, to assess patient outcomes. RESULTS All patients underwent thymectomy with an overall complication rate of 16.1 % and a perioperative mortality rate of 3.2 %. Long-term follow-up occurred between 12.6 and 177 months, at which point 18 (58.1 %) patients experienced improved status, including one patient who achieved CSR; 13 (41.9 %) patients achieved GCR; 6 (19.4 %) showed unchanged status and one worse (3.2 %) status. The remaining 6 patients died, with 3 due to MG-related causes. Using a multivariate Cox regression analysis of GCR by characteristics, patients with better response to medical treatments before thymectomy were positively associated with GCR rates (p = 0.028). CONCLUSIONS Extended transsternal thymectomy is a feasible and effective therapy for MG patients with crisis history, especially for those patients who have shown positive signs of remission after exhausting conventional medical treatments.
Collapse
Affiliation(s)
- Zhenguo Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yingrong Lai
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Shiyuan Yao
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Jianyong Zou
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yiyan Lei
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Hua Zhu
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
| | - Chao Cheng
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China.
| |
Collapse
|
137
|
Li Y, Wang H, Chen P, Chen Z, Su C, Luo C, Feng H, Liu W. Clinical outcome and predictive factors of postoperative myasthenic crisis in 173 thymomatous myasthenia gravis patients. Int J Neurosci 2017; 128:103-109. [PMID: 28803488 DOI: 10.1080/00207454.2017.1366905] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Thymectomy is the first-line therapy for thymomatous myasthenia gravis patients. The aim of this study is to explore the clinical outcome and predictors of postoperative myasthenic crisis (POMC) in these patients. METHOD Clinical data of 173 thymomatous myasthenia gravis patients undergoing thymectomy from January 2000 to March 2013 were, retrospectively reviewed. Variables potentially affecting the occurrence of POMC were evaluated using binary logistic regression analysis. The difference in survival was determined by the log-rank test. RESULT Fifty-one patients experienced POMC. Univariate analysis revealed that events significantly associated with increased risk of POMC include symptom duration before operation >2.75months, preoperative bulbar symptoms, incomplete resection, operation time ≥122.5 min and advanced stages (stage III or IV). Multivariate logistic regression analysis showed that preoperative bulbar symptoms (OR = 3.207 [1.413-7.278]; P = 0.005) and incomplete resection (OR = 4.182 [1.332-13.135]; P = 0.014) were independent risk factors for POMC. Twenty-eight patients (16.9%) died during the follow-up. The log-rank test revealed survival for patients with POMC was significantly worse than that for patients without POMC (P = 0.042). CONCLUSION The important risk factors for developing POMC in thymomatous myasthenia gravis patients include the preoperative bulbar symptoms and incomplete resection of thymoma. Moreover, the patients with POMC had a worse prognosis compared with patients without POMC. Our study highlights the need of appropriate preoperative management of thymomatous myasthenia gravis patients to prevent the occurrence of POMC.
Collapse
Affiliation(s)
- Yan Li
- a Department of Neurosurgical Intensive Care Unit , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| | - Haiyan Wang
- a Department of Neurosurgical Intensive Care Unit , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| | - Pei Chen
- b Department of Neurology , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| | - Zhenguang Chen
- c Department of Thoracic Surgery, Department of Cardiothoracic Surgery of East Division , Lung Cancer Research Center of The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| | - Chunhua Su
- d Department of Thoracic Surgery , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| | - Chuanming Luo
- e Department of Neurology , The Second Clinical College, Guangdong Medical College , Dongguan , China
| | - Huiyu Feng
- b Department of Neurology , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| | - Weibin Liu
- b Department of Neurology , The First Affiliated Hospital of Sun Yat-sen University , Guangzhou , China
| |
Collapse
|
138
|
Popperud TH, Boldingh MI, Rasmussen M, Kerty E. Juvenile myasthenia gravis in Norway: Clinical characteristics, treatment, and long-term outcome in a nationwide population-based cohort. Eur J Paediatr Neurol 2017; 21:707-714. [PMID: 28457757 DOI: 10.1016/j.ejpn.2017.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study aimed to characterize juvenile myasthenia gravis in a national population-based cohort in Norway, and to evaluate long-term outcome and potential differences correlated with prepubertal versus postpubertal disease onset. PATIENTS AND METHODS Patients with onset of myasthenia gravis aged ≤18 years were identified through multiple strategies. Retrospective clinical data were collected by means of medical charts. All patients had an updated clinical examination. Cases were divided into prepubertal and postpubertal onset using age 12 years as the cut off. RESULTS In total, 75 patients were identified of whom 63 were included in the study: 21 in the prepubertal and 42 in the postpubertal onset group. There was a female preponderance in both groups. In total, 59% presented with ocular symptoms, but the great majority of patients in both groups generalized during the two first years of the disease. Myasthenic crisis was more frequent in the prepubertal onset group. All patients were initially treated with pyridostigmine, 26 with steroids, and 17 with other immunosuppressive treatment. The postpubertal cases were more often treated with immunosuppressive therapy. Fifty patients (79%) underwent thymectomy. The general outcome was favourable: 57% became asymptomatic and only four subjects failed to attain clinical improvement. One-third had at least one additional autoimmune disease. CONCLUSION Despite frequent symptom generalization and a subgroup of prepubertal onset with severe disease, the long-term outcome was good, especially in the thymectomized prepubertal onset group. Polyautoimmunity occurred in both groups in one-third.
Collapse
Affiliation(s)
- T H Popperud
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Unit for Hereditary and Inborn Neuromuscular Disorders, Department of Neurology, Oslo University Hospital, Oslo, Norway.
| | - M I Boldingh
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - M Rasmussen
- Unit for Hereditary and Inborn Neuromuscular Disorders, Department of Neurology, Oslo University Hospital, Oslo, Norway; Department of Clinical Neuroscience for Children, Section for Child Neurology, Oslo University Hospital, Oslo, Norway
| | - E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
139
|
Yablonsky P, Pischik V, Tovbina MG, Atiukov M. The results of video-assisted thoracoscopic thymectomies in Saint Petersburg, Russia: 20-year of experience. J Vis Surg 2017; 3:113. [PMID: 29078673 DOI: 10.21037/jovs.2017.06.13] [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] [Received: 02/10/2017] [Accepted: 06/19/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND During the period from 1996 to 2016, we have performed 281 thymectomies in patients with various diseases of the thymus. In 179 patients, thymic pathology was associated with autoimmune myasthenia gravis (MG), and, in 108 patients, thymoma was diagnosed. METHODS The majority of surgeries [254] were performed using video thoracoscopy, 79 of them with an additional cervical approach. The long-term results of video thoracoscopic thymectomies in myasthenic patients were followed up for 1 to 15.5 years. RESULTS In 26% of the patients, a complete and stable remission was achieved, in 47%-clinical manifestation improved. Local recurrence of thymoma developed in one patient (0.9%). CONCLUSIONS Comparison of postoperative complications and long-term results demonstrated that extended video-assisted thoracoscopic thymectomy (VATS-TE) is a radical, efficient, safe, technically feasible and a well-tolerated surgery. It improves the course of MG as a part of multimodality treatment more efficiently than a conservative therapy alone. The course of MG after VATS-TE shows that the cumulative incidence of remissions/improvements reaches its maximum by the 3rd year after the surgery. VATS-TE is radical and safe for removal of noninvasive thymomas up to 8 cm in size. Additional neck incision (VATS-TE + cervical approach) does not provide further advantages, but rather may be a cause of specific postoperative complications.
Collapse
Affiliation(s)
- Piotr Yablonsky
- Faculty of Medicine, Saint Petersburg State University, St. Petersburg, Russia.,St. Petersburg City Hospital #2, St. Petersburg, Russia
| | - Vadim Pischik
- Faculty of Medicine, Saint Petersburg State University, St. Petersburg, Russia.,St. Petersburg City Hospital #2, St. Petersburg, Russia.,Sokolov's Clinical Hospital #122, St. Petersburg, Russia
| | | | - Mikhail Atiukov
- St. Petersburg City Hospital #2, St. Petersburg, Russia.,Sokolov's Clinical Hospital #122, St. Petersburg, Russia
| |
Collapse
|
140
|
Li KK, Qian K, Feng YG, Guo W, Tan QY, Deng B. Predictive factors of prolonged mechanical ventilation, overall survival, and quality of life in patients with post-thymectomy myasthenic crisis. World J Surg Oncol 2017; 15:150. [PMID: 28789662 PMCID: PMC5549389 DOI: 10.1186/s12957-017-1209-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thymectomy is the primary approach for the treatment of myasthenia gravis (MG). This retrospective study aimed to identify the clinical and demographical features that may impact the duration of mechanical ventilation (DMV), the long-term survival, and the quality of life (QOL) in patients with post-thymectomy myasthenic crisis (PTMC). METHODS We reviewed the patients who suffered from PTMC from June 2008 to November 2015. Cox proportional hazard regression analysis was used to identify potential prognostic factors that may impact DMV and long-term survival. Spearman bivariate correlation analysis was used to analyze the relationship between DMV and QOL. Statistical powers were calculated. RESULTS In total, 70 patients with PTMC were enrolled. Alcohol abuse, high scores of Myasthenia Gravis Foundation of America (MGFA) classification and Clavien-Dindo classification were critical factors that remarkably delayed early extubation. High scores of Osserman's classification, MGFA classification, and Clavien-Dindo classification predicted a poor prognosis in PTMC patients. Occupational skills and job status were observed to be negatively affected in PTMC patients. CONCLUSIONS To decrease the duration of mechanical ventilation, we suggest alcohol abstinence before the operation, appropriate preoperative treatment to decrease MGFA classification, and greater attention to the treatment of postoperative complications.
Collapse
Affiliation(s)
- Kun-Kun Li
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Kai Qian
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Yong-Geng Feng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Wei Guo
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Qun-You Tan
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China.
| | - Bo Deng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China.
| |
Collapse
|
141
|
Benefits of Comprehensive Rehabilitation Therapy in Thymectomy for Myasthenia Gravis: A Propensity Score Matching Analysis. Am J Phys Med Rehabil 2017; 96:77-83. [PMID: 28099277 DOI: 10.1097/phm.0000000000000538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To demonstrate the effectiveness of a comprehensive program of rehabilitation therapy in patients undergoing thymectomy for myasthenia gravis (MG). DESIGN From 2005 to 2010, 46 consecutive patients affected by MG underwent a rehabilitation program both before and after thymectomy. We matched each patient with a "control patient" who underwent thymectomy within the period 1999 to 2004 with no preoperative rehabilitation, who had the closest propensity score matching. RESULTS All patients but 2 were able to complete the intended program. Eighteen patients (41%) experienced mild fatigue (>25 at MG quantitative score). Propensity score selected a group of 17 patients for the matching process. The group of patients who underwent the rehabilitation program showed significant preoperative improvement associated with a reduced operative risk, a decreased early postoperative morbidity, a lower rate of postoperative intensive care unit needed (12% vs 35%; P = 0.01) and a shorter hospital stay (3 vs 5 days; P = 0.04). After the expected perioperative decline, all major myasthenic outcomes demonstrated a significant faster recovery at 3 months. Complete stable remission did not reveal significant differences. CONCLUSIONS Exercise is not necessarily a contraindication in MG, and rehabilitation can be safely performed before and after thymectomy, reducing operative risks and decreasing recovery time. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCMECME OBJECTIVES: Upon completion of this article, the reader should be able to do the following: (1) appreciate the benefits of physical therapy in individuals with myasthenia gravis; (2) describe the benefits of physical therapy on postoperative morbidity in myasthenia gravis patients who undergo thymectomy; and (3) incorporate appropriate rehabilitation into the treatment plan of patient with myasthenia gravis. LEVEL AdvancedACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Collapse
|
142
|
Guan Y, Lv F, Meng Y, Ma D, Xu X, Song Y, Wang O, Jiang Y, Xia W, Xing X, Zhang J, Li M. Association between bone mineral density, muscle strength, and vitamin D status in patients with myasthenia gravis: a cross-sectional study. Osteoporos Int 2017; 28:2383-2390. [PMID: 28439619 DOI: 10.1007/s00198-017-4041-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/04/2017] [Indexed: 12/18/2022]
Abstract
UNLABELLED Myasthenia gravis (MG) patients had low proximal hip BMD, which could be explained by reduced muscle strength, elevated bone resorption markers, vitamin D deficiency, and increased PTH levels in those with MG compared to controls. INTRODUCTION Muscle strength is closely correlated with bone mineral density (BMD) and vitamin D status. Here, we evaluated muscle strength, BMD, and vitamin D status in a large sample of Chinese patients with MG. METHODS In this cross-sectional survey, 86 patients with MG without glucocorticoid treatment and 86 healthy controls were included. Serum levels of 25-hydroxyvitamin D [25OHD], parathyroid hormone (PTH), bone turnover markers (BTMs), and BMD were measured and compared between the two groups. Grip strength and one-leg standing time (OLST) were also assessed in MG patients. RESULTS Low grip strength and short OLST were found in 11 (12.8%) and 12 (14.0%) MG patients, respectively. There were 3 (3.5%) MG patients with low bone mass for chronological age. Serum beta C-terminal telopeptide and PTH levels were higher (p < 0.001 and p = 0.001, respectively), and BMD at the femoral neck and trochanter were lower in MG patients (p < 0.001 and p < 0.001, respectively) compared to healthy controls. In patients with MG, grip strength was positively correlated with BMD. Serum 25OHD levels were lower in MG patients than in healthy controls (17.36 ± 6.64 vs. 22.11 ± 7.28 ng/ml, p < 0.001). CONCLUSION Grip strength was positively correlated with BMD in Chinese patients with MG. MG patients tended to have low proximal hip BMD, which may partially be explained by reduced muscle strength, vitamin D deficiency, increased PTH levels, and elevated bone resorption markers compared to controls.
Collapse
Affiliation(s)
- Y Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - F Lv
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Y Meng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - D Ma
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - X Xu
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Y Song
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - O Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - Y Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - W Xia
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - X Xing
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China
| | - J Zhang
- Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - M Li
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health; Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, China.
| |
Collapse
|
143
|
Jing Y, Liu X, Yu L, Li R. Outcomes of Preoperative and Postoperative Corticosteroid Therapies in Myasthenia Gravis. Eur Neurol 2017; 78:86-92. [PMID: 28738395 DOI: 10.1159/000478905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/21/2017] [Indexed: 11/19/2022]
Abstract
AIMS To compare the long-term outcomes of non-thymomatous myasthenia gravis (MG) patients receiving pre-thymectomy (Pre-CS) or post-thymectomy corticosteroid (Post-CS) therapy. METHODS In a retrospective cohort study, 41 patients with MG were treated with Pre-CS therapy, and 110 were treated with Post-CS therapy. RESULTS In the MG cohorts, 9 of 40 patients (22.5%) in the Pre-CS group vs. 28 of 105 patients (26.7%) in the Post-CS group achieved a complete remission (CR) at 1 year, 29.7% (11/37) vs. 38.6% (32/83) at 2 years and 36.4% (8/22) in the Pre-CS group vs. 50.0% (28/56) in the Post-CS group achieved a CR at 5 years. For the entire population, Post-CS therapy (hazard rate [HR] 3.042, p = 0.020) was a positive predictor for remission, and a long preoperative interval (HR 0.936, p = 0.030) was a negative predictor. In 98 original ocular MG patients, Post-CS therapy (HR 2.663, p = 0.014) and an age at onset ≥15 years (HR 4.865, p = 0.001) were positive predictors for remission. DISCUSSION Post-CS therapy with a shorter preoperative interval increases the likelihood of CR in postpubertal and adult patients.
Collapse
Affiliation(s)
- Yun Jing
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xinxin Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lei Yu
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ran Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
144
|
The correlation of neutrophil-to-lymphocyte ratio with the presence and activity of myasthenia gravis. Oncotarget 2017; 8:76099-76107. [PMID: 29100295 PMCID: PMC5652689 DOI: 10.18632/oncotarget.18546] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 06/02/2017] [Indexed: 11/25/2022] Open
Abstract
Though the pathogenesis of myasthenia gravis (MG) is not fully understood, the role of inflammation has been well appreciated in the development of MG. We aimed to investigate the role of neutrophil-to-lymphocyte ratio (NLR) in MG patients and the relationship between the NLR and the activity of the disease. A total number of 172 MG patients and 207 healthy controls (HC) were enrolled in this study. The MG patients were divided into tertiles according to NLR (low NLR < 1.58, n = 57; intermediate NLR 1.58-2.33, n = 57 and high NLR > 2.33, n = 58). The disease activity assessment was performed according to the standard criteria established by the Myasthenia Gravis Foundation of America. Patients with MG had significantly higher NLR when compared with the HC group (P < 0.0001). The NLR levels were higher in the MG patients with severe disease activity than those with mild disease activity (P < 0.001), meanwhile, median NLR was statistically higher in MG patients with myasthenic crisis (MC) than those without MC (P < 0.001). Incidences of severe disease activity and MC were both higher in the high NLR group, compared to low and intermediate NLR groups (both P < 0.001). Multivariate logistic regression analysis suggested that elevated NLR was an independent predictor of severe disease activity (odds ratio = 13.201, CI% = 1.418-122.938, P = 0.023). These results indicate that NLR may be a simple and useful potential marker in indicating disease activity in patients with MG.
Collapse
|
145
|
Validity and reliability of the Polish version of myasthenia gravis - Quality of life questionnaire - 15 item. Neurol Neurochir Pol 2017; 51:311-318. [PMID: 28579082 DOI: 10.1016/j.pjnns.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/27/2017] [Accepted: 05/09/2017] [Indexed: 11/20/2022]
Abstract
AIM The myasthenia gravis-quality of life questionnaire 15 item (MG-QOL15) is a short, and easy to use disease-specific quality of life (QOL) tool in myasthenia gravis. The aim of this study was to validate and adapt the Polish version of the MG-QOL15. MATERIALS AND METHODS The total number of 50 patients with MG were qualified for the examination. Each patient underwent neurological examination and completed the quality of life evaluation questionnaire MQ-QOL 15 after translation and back-translation. Additionally, each patient was asked to evaluate the quality of his/her life by means of questionnaire SF-36 in Polish language version. RESULTS The MG-QOL15 was found to have high internal consistency, test-retest reliability, and concurrent validity. CONCLUSION The MG-QOL15 is accepted to be a valid, reliable, valuable tool for measuring disease-specific QOL in Polish patients with MG.
Collapse
|
146
|
Cordts I, Bodart N, Hartmann K, Karagiorgou K, Tzartos JS, Mei L, Reimann J, Van Damme P, Rivner MH, Vigneron A, Weis J, Schulz JB, Tzartos SJ, Claeys KG. Screening for lipoprotein receptor-related protein 4-, agrin-, and titin-antibodies and exploring the autoimmune spectrum in myasthenia gravis. J Neurol 2017; 264:1193-1203. [DOI: 10.1007/s00415-017-8514-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 05/08/2017] [Indexed: 01/09/2023]
|
147
|
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.
Collapse
|
148
|
Hong Y, Zisimopoulou P, Trakas N, Karagiorgou K, Stergiou C, Skeie GO, Hao HJ, Gao X, Owe JF, Zhang X, Yue YX, Romi F, Wang Q, Li HF, Gilhus NE, Tzartos SJ. Multiple antibody detection in ‘seronegative’ myasthenia gravis patients. Eur J Neurol 2017; 24:844-850. [PMID: 28470860 DOI: 10.1111/ene.13300] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/23/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Y. Hong
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - P. Zisimopoulou
- Department of Neurobiology; Hellenic Pasteur Institute; Athens Greece
| | - N. Trakas
- Department of Neurobiology; Hellenic Pasteur Institute; Athens Greece
| | - K. Karagiorgou
- Department of Neurobiology; Hellenic Pasteur Institute; Athens Greece
- Tzartos NeuroDiagnostics; Athens Greece
| | - C. Stergiou
- Department of Neurobiology; Hellenic Pasteur Institute; Athens Greece
- Tzartos NeuroDiagnostics; Athens Greece
| | - G. O. Skeie
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - H.-J. Hao
- Department of Neurology; Peking University First Hospital; Beijing China
| | - X. Gao
- Department of Neurology; Affiliated Hospital of Qingdao University; Qingdao China
| | - J. F. Owe
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - X. Zhang
- Department of Neurology; Affiliated Hospital of Qingdao University; Qingdao China
| | - Y.-X. Yue
- Department of Neurology; Qilu Hospital of Shandong University; Jinan China
| | - F. Romi
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - Q. Wang
- Department of Neurology; Affiliated Hospital of Qingdao University; Qingdao China
| | - H.-F. Li
- Department of Neurology; Qilu Hospital of Shandong University; Jinan China
| | - N. E. Gilhus
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Neurology; Haukeland University Hospital; Bergen Norway
| | - S. J. Tzartos
- Department of Neurobiology; Hellenic Pasteur Institute; Athens Greece
- Tzartos NeuroDiagnostics; Athens Greece
- University of Patras; Patras Greece
| |
Collapse
|
149
|
Hong Y, Skeie GO, Zisimopoulou P, Karagiorgou K, Tzartos SJ, Gao X, Yue YX, Romi F, Zhang X, Li HF, Gilhus NE. Juvenile-onset myasthenia gravis: autoantibody status, clinical characteristics and genetic polymorphisms. J Neurol 2017; 264:955-962. [PMID: 28364296 DOI: 10.1007/s00415-017-8478-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 01/10/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder mediated by antibodies against proteins at the neuromuscular junction. Juvenile-onset MG (JMG) has been reported to have special characteristics. It is still unclear whether there are any pathogenic and genetic differences between juvenile and adult MG. In this study, we evaluated the clinical characteristics, autoantibody status (antibodies against AChR, MuSK, LRP4, titin and RyR) and genetic susceptibility (CHRNA1, CTLA4 and AIRE) in 114 Chinese JMG patients, and compared with 207 young adult MG patients (onset age 18-40 years). JMG patients were classified into two subgroups: the very early onset group (<8 years) and puberty onset group (8-18 years). The very early onset MG patients had a higher proportion of ocular MG and thymus hyperplasia, compared with puberty onset MG and young adult MG (P < 0.05). AChR antibodies were found in majority of JMG patients and were associated with more severe disease (P < 0.05), while other antibodies were rare in JMG. Moreover, the very early onset MG had a more prominent genetic predisposition than puberty and adult MG, affecting the susceptible genes CHRNA1 and CTLA4. JMG has the same pathogenic background as adult MG, but has typical clinical features and a prominent genetic predisposition in very early onset patients (<8 years). Specific therapeutic considerations are needed.
Collapse
Affiliation(s)
- Yu Hong
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Olve Skeie
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
| | | | - Katerina Karagiorgou
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Tzartos NeuroDiagnostics, Athens, Greece
| | - Socrates J Tzartos
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Tzartos NeuroDiagnostics, Athens, Greece
| | - Xiang Gao
- Department of Neurology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yao-Xian Yue
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Fredrik Romi
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway
| | - Xu Zhang
- Department of Neurology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hai-Feng Li
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, 250012, China.
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
| |
Collapse
|
150
|
Westerberg E, Molin CJ, Lindblad I, Emtner M, Punga AR. Physical exercise in myasthenia gravis is safe and improves neuromuscular parameters and physical performance-based measures: A pilot study. Muscle Nerve 2017; 56:207-214. [PMID: 27935072 DOI: 10.1002/mus.25493] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Due to the shortage of exercise-related research in Myasthenia Gravis (MG), there are no consensus guidelines on physical exercise for MG patients. METHODS In this prospective pilot study, 10 MG patients with mild disease performed supervised aerobic and resistance training twice weekly for 12 weeks. The Myasthenia Gravis Composite (MGC) score, compound motor action potential (CMAP), repetitive nerve stimulation, muscle force, physical performance-based measures, serum levels of interleukin-6, muscle enzymes, and immuno-microRNAs miR-150-5p and miR-21-5p were assessed before and after the training period. RESULTS Physical exercise was well tolerated, and the MGC score was unchanged. Muscle resistance weights and CMAP amplitudes increased for biceps brachii and rectus femoris muscles, and physical performance-based measures improved. Muscle enzymes remained normal, whereas disease-specific microRNAs miR-150-5p and miR-21-5p were reduced after the training period. CONCLUSIONS We propose that general recommendations regarding physical exercise can be applied safely to well-regulated MG patients. Muscle Nerve 56: 207-214, 2017.
Collapse
Affiliation(s)
- Elisabet Westerberg
- Department of Clinical Neurophysiology, Department of Neuroscience, Uppsala University, Box 593, BMC, SE-75124, Sweden.,Department of Neurology, Ryhov County Hospital, Jönköping, Sweden
| | - Carl Johan Molin
- Department of Clinical Neurophysiology, Department of Neuroscience, Uppsala University, Box 593, BMC, SE-75124, Sweden
| | - Ida Lindblad
- Department of Clinical Neurophysiology, Department of Neuroscience, Uppsala University, Box 593, BMC, SE-75124, Sweden
| | - Margareta Emtner
- Department of Physiotherapy, Department of Neuroscience, Uppsala University, Sweden.,Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
| | - Anna Rostedt Punga
- Department of Clinical Neurophysiology, Department of Neuroscience, Uppsala University, Box 593, BMC, SE-75124, Sweden
| |
Collapse
|