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GomezMancilla B, Meriggioli MN, Genge A, Roubenoff R, Espié P, Dupuy C, Hartmann N, Pezous N, Kinhikar A, Tichy M, Dionne A, Vissing J, Andersen H, Schoser B, Meisel A, Jordan B, Devlikamova F, Poverennova I, Stuchevskaya F, Lin TS, Rush JS, Gergely P. Efficacy and safety of iscalimab, a novel anti-CD40 monoclonal antibody, in moderate-to-severe myasthenia gravis: A phase 2 randomized study. J Clin Neurosci 2024; 119:76-84. [PMID: 37988976 DOI: 10.1016/j.jocn.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Increased morbidity in many patients with myasthenia gravis (MG) on long-term immunosuppression highlights the need for improved treatments. The aim of this study is to investigate the safety and efficacy of iscalimab (CFZ533), a fully human anti-CD40 monoclonal antibody, in patients with moderate-to-severe MG receiving standard-of-care (SoC) therapies. METHODS In this double-blind, placebo-controlled phase 2 study, symptomatic patients (n = 44) despite SoC were randomized 1:1 to receive intravenous iscalimab (10 mg/kg; n = 22) or placebo (n = 22) every 4 weeks for 6 doses in total. Patients were followed up for 6 months after the last dose. The total duration of the study was 52 weeks. RESULTS In total, 34 of 44 patients (77.3 %) completed the study. The primary endpoint, Quantitative MG score, did not change significantly between baseline and week 25 for iscalimab (median [90 % CI], -4.07 [-5.67, -2.47]) versus placebo (-2.93 [-4.53, -1.33]); however, non-thymectomized patients (n = 29) showed more favorable results (iscalimab, -4.35 [-6.07, -2.64] vs placebo, -2.26 [-4.16, -0.36]). A statistically significant difference between iscalimab and placebo groups was observed in MG Composite score (adjusted mean change: -4.19 [-6.67, -1.72]; p = 0.007) at week 13, and MG-Activities of Daily Living score (-1.93 [-3.24, -0.62]; p = 0.018) at week 21. Adverse events were comparable between the iscalimab (91 %) and placebo (96 %) groups. CONCLUSION Iscalimab showed favorable safety and improvements compared with placebo in non-thymectomized patients with moderate-to-severe MG. It did not show any protective effect in patients with moderate-to-severe MG.
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Affiliation(s)
| | | | - Angela Genge
- Montreal Neurological Institute and Hospital, Montreal, Canada
| | | | - Pascal Espié
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Cyrielle Dupuy
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nicole Hartmann
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nicole Pezous
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Arvind Kinhikar
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Mia Tichy
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - John Vissing
- Rigshospitalet, University of Copenhagen, Denmark
| | | | - Benedikt Schoser
- Friedrich-Baur-Institute, Dep. of Neurology, LMU Klinikum Muenchen, Muenchen, Germany
| | - Andreas Meisel
- Charité Universitätsmedizin Berlin, Department of Neurology, Germany
| | - Berit Jordan
- Department of Neurology, University Hospital of Halle, Halle, Germany; epartment of Neurology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Irina Poverennova
- Samara Regional Clinical Hospital named after M.I.Kalinin, Samara, Russia
| | | | - Thy-Sheng Lin
- National Cheng Kung University Hospital, Tainan, Taiwan
| | - James S Rush
- Novartis Institutes for BioMedical Research, Basel, Switzerland; Kling Biotherapeuetics BV, Amsterdam, the Netherlands
| | - Peter Gergely
- Novartis Institutes for BioMedical Research, Basel, Switzerland
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Dewilde S, Phillips G, Paci S, De Ruyck F, Tollenaar NH, Janssen MF. The Burden Patients with Myasthenia Gravis Experience in Terms of Breathing, Fatigue, Sleep, Mental Health, Discomfort and Usual Activities in Comparison to the General Population. Adv Ther 2024; 41:271-291. [PMID: 37921955 PMCID: PMC10796601 DOI: 10.1007/s12325-023-02704-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/02/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is a rare neuromuscular disorder marked by a variable combination of weakness of eye, bulbar, respiratory, axial, and limb muscles. This study compared the experience of people with MG regarding breathing, fatigue, sleep, pain/discomfort, mental health, and usual activities with the general population. METHODS The MyRealWorld-MG digital, multinational study enrolled patients with MG and collected demographics, PROMIS-Dyspnea, PROMIS-Sleep Disturbance, FACIT-Fatigue, EQ-5D-5L, Health Utilities Index (HUI-3), Hospital Anxiety and Depression Scale (HADS), MG-Activities of Daily Living (MG-ADL), and MG-Quality-of-Life (MG-QoL-15r). Comparisons with the general population were based on PROMIS population norms, published literature, or on data from a digital, multinational, observational study which enrolled a representative sample of the general population (POPUP). RESULTS In MyRealWorld-MG (N = 2074), patients experienced higher intensity, frequency, and duration of PROMIS shortness of breath than a US population (p < 0.0001). Patients with MG had higher PROMIS-Sleep Disturbance scores than POPUP (53.7 vs 50.0, p < 0.0001), and 54.9% of patients had clinically severe FACIT-Fatigue scores vs 6.8% in POPUP (p < 0.0001). Among patients with MG, 69.6% and 18.5% had moderate-to-severe HADS-Anxiety and HADS-Depression compared to 20.3% and 6.9% in POPUP (p < 0.001). Statistically significant and strong associations were found between fatigue, sleep, dyspnea, usual activities, and emotions. All outcomes worsened with more severe disease. CONCLUSION A considerable burden was observed in this comparison of breathing, sleep, fatigue, mental health, and usual activities between patients with MG and the general population, using data from two international studies and published population norms. Even mildly affected patients had significantly worse outcomes than the general population.
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Affiliation(s)
- S Dewilde
- Services in Health Economics (SHE), Rue JG Eggerickx 36, 1150, Woluwe, Brussels, Belgium.
| | | | - S Paci
- argenx BV, Ghent, Belgium
| | | | - N H Tollenaar
- Services in Health Economics (SHE), Rue JG Eggerickx 36, 1150, Woluwe, Brussels, Belgium
| | - M F Janssen
- Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
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Hehir MK, Conaway M, St Sauveur AB, Feb K, Kolb NA, Waheed W, McNeish BL, Tweedy N, Burns TM. Measuring treatment adverse event burden in myasthenia gravis: Single-center prospective evaluation utilizing the Adverse Event Unit (AEU). Muscle Nerve 2024; 69:32-39. [PMID: 37676119 DOI: 10.1002/mus.27966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION/AIMS We developed a patient- and physician-weighted consensus unit called the adverse event unit (AEU) that quantifies and compares adverse event (AE) burden among any group of medications in neurological patients. In this study we evaluated preliminary validity and feasibility of measuring AE burden with the AEU in myasthenia gravis (MG). METHODS This is a single-center, prospective, 1-year, observational study of adult MG patients presenting for routine care between April 1, 2021 and March 31, 2022. The MG Activities of Daily Living (MG-ADL), the 15-item MG Quality of Life revised (MG-QOL15r), MG-Composite, and AEU scores were obtained at all visits. A priori primary feasibility metric was AEU completion rate equal to (within 3.8%, one-sided 95% confidence interval [CI]) or better than MG-ADL completion rate. Time to administer AEU and MG-ADL/MG-QOL15r, correlation between AEU total score and MG-QOL15r, and median AEU scores for each MG medication were evaluated. RESULTS Fifty-four patients completed 67 study visits; side effects were reported at 75% of the visits. The study met the primary feasibility endpoint; AEU and MG-ADL were recorded at all visits. Times to administer the AEU (median 5 minutes) and MG-ADL/MG-QOL15r were similar. We observed a weak correlation of 0.29 (95% CI 0.03 to 0.51, P = .032) between AEU and MG-QOL15r scores. Non-statistically significant differences in median AEU scores were observed among MG medications. DISCUSSION Our data demonstrate preliminary feasibility and validity of using the AEU to measure AE burden in MG. Future studies will compare AE burden among MG treatments and evaluate clinically meaningful AEU scores in MG.
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Affiliation(s)
- Michael K Hehir
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Mark Conaway
- Division of Translational Research and Applied Statistics, University of Virginia, Charlottesville, Virginia, USA
| | - Avery B St Sauveur
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Kendall Feb
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Noah A Kolb
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Waqar Waheed
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Brendan L McNeish
- Departments of Physical Medicine and Rehabilitation and Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicole Tweedy
- Mission Health Neurology, Asheville, North Carolina, USA
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
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Sansoni J, Menon N, Viali L, White S, Vucic S. Clinical features, treatments, their impact, and quality of life for Myasthenia Gravis patients in Australia. J Clin Neurosci 2023; 118:16-22. [PMID: 37844489 DOI: 10.1016/j.jocn.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/07/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
This survey provides an update on the experience of Myasthenia Gravis (MG) patients in Australia. Items were drawn from the 2011 Australian Survey and a 2019 US survey allowing for comparative discussion of survey findings. Patients were recruited through the Myasthenia Alliance Australia. Following consent, patients completed an online survey using REDCap software. Questions included demographics, clinical features, treatment side-effects and quality of life (QOL) scales. Samples for completion of survey sections ranged from N = 242-280 representing a power level of over 80%. Female and seronegative patients reported a significantly greater symptom load, earlier disease onset, longer time to diagnosis, more MG exacerbations, treatment side-effects, and poorer QOL. For exacerbation management there was a higher rate of oral corticosteroid use (66%), a lower use of Intravenous Immunoglobulin (IVIg, 47%) and particularly, Therapeutic Plasma Exchange (TPE, 4.5%) within this sample. Although steroid induced side-effects were rarer (9-34%), a comparatively high use of corticosteroids was reported for current and overall treatments including those for MG crises (52-83%). Common treatment side-effects reported by 57-85% of patients, included fatigue, weight gain, a decrease in the ability to fight infections, gastrointestinal symptoms, and muscle weakness. The impact of MG on daily activities and QOL was considerable, but those who had a thymectomy reported better QOL. The survey identified areas for potential practice improvement in MG treatments (corticosteroids, IVIg, TPE), particularly for exacerbation management, and review is recommended. Further research on gender and antibody status differentials regarding clinical features is required.
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Affiliation(s)
- Janet Sansoni
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia; Health Outcomes Collaboration, 2 Bramston St, Fadden, ACT 2904, Australia.
| | - Nidhi Menon
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Lachlan Viali
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Susan White
- Myasthenia Alliance Australia, 17 Aldridge Ave, Corrimal East, NSW 2518, Australia; Myasthenia Gravis Association of Queensland Inc., PO Box16, Mt Gravatt, Queensland 4122, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney Concord Clinical School, Concord, NSW 2139, Australia
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Xu RH, Yu S, Liu J, Zhang S, Dong D. Developing the health state classification system for a condition-specific preference-based measure for patients with myasthenia gravis. Disabil Rehabil 2023; 45:3366-3372. [PMID: 36102606 DOI: 10.1080/09638288.2022.2120096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/22/2022] [Accepted: 08/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE This study aimed to generate the health state classification system (HCS) of a condition-specific preference-based measure to capture the health-related quality of life (HRQoL) of patients with myasthenia gravis (MG) from the 15-item Myasthenia Gravis Quality of Life Scale (MG-QoL15r). MATERIALS AND METHODS An HCS was derived from the MG-QoL15r in a large sample of 1739 patients with MG based on psychometric analysis, including factor analysis, item response theory analysis, and discussions with experts. Reliability, construct and convergent validity, and item fit of the HCS were further assessed using another sample. RESULTS The HCS has six dimensions: social activity, hobbies and fun activities, meeting family needs, work performance, mobility, and emotion, and it demonstrates good internal consistency reliability. The unidimensionality of the HCS was confirmed using confirmatory factor analysis. Satisfied convergent validity was supported by a significant association with the 12-item Short Form Survey (SF-12). CONCLUSIONS Based on a solid process of development and consultations with clinical professionals and patients, a valid MG-specific preference-based measure, MGQoL-6D, was developed. Further research will estimate the local preference weight to support the MG-related cost-utility analysis.IMPLICATION FOR REHABILITATIONA new condition-specific health state classification system (HCS) named Myasthenia gravis Quality of Life Scale (MGQoL-6D) is proposed.MGQoL-6D classifies MG health states as a combination of six dimensions with three response levels.The dimensions of the HCS are social activity, hobbies and fun activity, family needs, work performance, mobility, and emotion.The HCS and the upcoming value set of the MGQoL-6D could support the cost-effectiveness analysis of MG-related clinical and rehabilitated interventions.
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Affiliation(s)
- Richard Huan Xu
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Siyue Yu
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Ji Liu
- Beijing Aili Myasthenia Gravis Care Center, Beijing, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Dong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, Guangdong, China
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Aggelina A, Karampli E, Mavrovounis G, Boutsikos I, Pantazopoulos I, Kakavas S, Pavi E, Athanasakis K. Evaluation of the Quality of Life of Patients with Myasthenia Gravis in Greece. J Pers Med 2023; 13:1130. [PMID: 37511743 PMCID: PMC10381620 DOI: 10.3390/jpm13071130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Myasthenia Gravis (MG) patients often report an affected quality of life (QoL). The aim of the current study was to evaluate the QoL of patients with MG in Greece using a specific tool. A cross-sectional online survey was performed. Adult patients were invited to participate. A questionnaire incorporating the MG-QOL15r scale was distributed, following its translation and cultural adaptation into Greek. Overall, 99 valid responses were submitted. The median age (interquartile range) of the participants was 48.50 (13.50) years and 76.80% were females. One third of the patients mentioned that they could not work/changed jobs after their diagnosis (28.30%) and that they face severe restriction of their everyday activities (26.30%). The mean MG-QOL15r score was 13.50 ± 7.70. Patients with important restriction of everyday activities (p < 0.01), patients with more pronounced need of emotional support (p < 0.01), patients with generalized MG (p < 0.01) and patients with myasthenic crises (p < 0.01) reported lower QoL. This study is the first to report on the affected QoL of the Greek population with MG using the MG-QoL15r scale. Further work should be done to incorporate the routine evaluation of QoL in the care of patients with MG.
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Affiliation(s)
- Afrodite Aggelina
- Department of Public Health Policy, University of West Attica Athens, 115 21 Athens, Greece
| | - Eleftheria Karampli
- Laboratory for Health Technology Assessment, Department of Public Health Policy, School of Public Health, University of West Attica, 115 21 Athens, Greece
| | - Georgios Mavrovounis
- Department of Emergency Medicine, Faculty of Medicine, University of Thessaly, 415 00 Larissa, Greece
| | - Ioannis Boutsikos
- Department of Emergency Medicine, Faculty of Medicine, University of Thessaly, 415 00 Larissa, Greece
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, University of Thessaly, 415 00 Larissa, Greece
| | | | - Elpida Pavi
- Laboratory for Health Technology Assessment, Department of Public Health Policy, School of Public Health, University of West Attica, 115 21 Athens, Greece
| | - Kostas Athanasakis
- Laboratory for Health Technology Assessment, Department of Public Health Policy, School of Public Health, University of West Attica, 115 21 Athens, Greece
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Majigoudra G, Duggal AK, Chowdhury D, Koul A, Todi VK, Roshan S. Clinical Profile and Quality of Life in Myasthenia Gravis Using MGQOL15 R(Hindi): An Indian Perspective. Ann Indian Acad Neurol 2023; 26:441-446. [PMID: 37970285 PMCID: PMC10645219 DOI: 10.4103/aian.aian_945_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 04/16/2023] [Accepted: 06/13/2023] [Indexed: 11/17/2023] Open
Abstract
Background Myasthenia Gravis (MG) is a chronic fluctuating illness, due to the dysfunction of neuromuscular junction which is autoimmune in nature. The disease severely affects the Quality Of Life (QOL). Objective The primary objective of our study was to assess the QOL in patients with MG using Short Form 36 (SF 36) and MGQOL 15 R (Hindi translated). The secondary objective was to assess the correlation of age, sex, illness duration, clinical characteristics, severity, and treatment with the QOL in MG patients. Methodology A cross sectional study of 55 MG patients was done to analyse and evaluate the clinical status using Hybrid Myasthenia Gravis Foundation of America (HMGFA), Myasthenia gravis composite score (MGCS) and The Myasthenia Gravis Activities of Daily Living (MG - ADL). QOL was assessed by SF 36 and Hindi version of Myasthenia Gravis Quality of Life 15 - Revised (MG-QOL15R) score. Results 78.2% patients had generalized MG. The mean MGC and MG-ADL scores were 5.27 and 3.29 (95% CI: 2.24 -4.34) respectively. The mean MGQOL15R score was 6.52 ± 7.7 and the score correlated with the symptoms. The SF 36 scores were the best and the worst in the bodily pain (93.72 ± 13.52) and general health subset (61.81 ± 39.64) respectively. Except for steroid dose, there was no significant correlation between SF36 and other factors. Conclusion QOL in MG was found to be affected due to the disease. The MGQOL 15 R scores correlated with the clinical features, remission or active status, steroid use and thymectomy. No Significant association was observed between MG QOL scores and various lab parameters and repetitive nerve stimulation (RNS) test results. Higher dose of steroid was associated with poor QOL, while thymectomy was associated with better QOL scores. MGQOL15R (Hindi) is a quick and simple tool to assess the QOL in MG patients.
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Affiliation(s)
- Ganeshgouda Majigoudra
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Ashish K. Duggal
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Debashish Chowdhury
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Arun Koul
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Vineet K. Todi
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Sujata Roshan
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
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Sanghani N. Utilization of Myasthenia Gravis Quality of Life Revised 15 (MGQOL15r) Scale in India. Ann Indian Acad Neurol 2023; 26:370-371. [PMID: 37970260 PMCID: PMC10645204 DOI: 10.4103/aian.aian_523_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Nirav Sanghani
- Department of Neurology, St Francis Hospital and Medical Center, Hartford, CT, USA
- Department of Neurology, University of Connecticut School of Medicine, Farmington, CT, USA
- Department of Medicine, Frank H. Natter MD School of Medicine, Quinnipiac University, Hamden, CT, USA
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Bril V, Szczudlik A, Vaitkus A, Rozsa C, Kostera-Pruszczyk A, Hon P, Bednarik J, Tyblova M, Köhler W, Toomsoo T, Nowak RJ, Mozaffar T, Freimer ML, Nicolle MW, Magnus T, Pulley MT, Rivner M, Dimachkie MM, Distad BJ, Pascuzzi RM, Babiar D, Lin J, Querolt Coll M, Griffin R, Mondou E. Randomized Double-Blind Placebo-Controlled Trial of the Corticosteroid-Sparing Effects of Immunoglobulin in Myasthenia Gravis. Neurology 2023; 100:e671-e682. [PMID: 36270895 PMCID: PMC9969924 DOI: 10.1212/wnl.0000000000201501] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction at the neuromuscular junction. Treatment frequently includes corticosteroids (CSs) and IV immunoglobulin (IVIG). This study was conducted to determine whether immune globulin (human), 10% caprylate/chromatography purified (IGIV-C) could facilitate CS dose reduction in CS-dependent patients with MG. METHODS In this randomized double-blind placebo-controlled trial, CS-dependent patients with MG (Myasthenia Gravis Foundation of America Class II-Iva; AChR+) received a loading dose of 2 g/kg IGIV-C over 2 days (maximum 80 g/d) or placebo at week 0 (baseline). Maintenance doses (1 g/kg IGIV-C or placebo) were administered every 3 weeks through week 36. Tapering of CS was initiated at week 9 and continued through week 36 unless the patient worsened (quantitative MG score ≥4 points from baseline). CS doses were increased (based on the current CS dose) in patients who worsened. Patients were withdrawn if worsening failed to improve within 6 weeks or if a second CS increase was required. The primary efficacy end point (at week 39) was a ≥50% reduction in CS dose. Secondary and safety end points were assessed throughout the study and follow-up (weeks 42 and 45). The study results and full protocol are available at clinicaltrials.gov/ct2/show/NCT02473965. RESULTS The primary end point (≥50% reduction in CS dose) showed no significant difference between the IGIV-C treatment (60.0% of patients) and placebo (63.3%). There were no significant differences for secondary end points. Safety data indicated that IGIV-C was well tolerated. DISCUSSION In this study, IGIV-C was not more effective than placebo in reducing daily CS dose. These results suggest that the effects of IGIV-C and CS are not synergistic and may be mechanistically different. TRIAL REGISTRATION INFORMATION The trial was registered on clinicaltrialsregister.eu (EudraCT #: 2013-005099-17) and clinicaltrials.gov (identifier NCT02473965). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that IVIG infusions in adult patients with MG do not increase the percentage of patients achieving a ≥50% reduction in corticosteroid dose compared with placebo.
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Affiliation(s)
- Vera Bril
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain.
| | - Andrzej Szczudlik
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Antanas Vaitkus
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Csilla Rozsa
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Anna Kostera-Pruszczyk
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Petr Hon
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Josef Bednarik
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michaela Tyblova
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Wolfgang Köhler
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Toomas Toomsoo
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Richard J Nowak
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Tahseen Mozaffar
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Miriam L Freimer
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael W Nicolle
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Tim Magnus
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael T Pulley
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael Rivner
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Mazen M Dimachkie
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - B Jane Distad
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Robert M Pascuzzi
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Donna Babiar
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Jiang Lin
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Montse Querolt Coll
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Rhonda Griffin
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Elsa Mondou
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
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Wu H, Chen L, Zhou X, Wu Y, Yan Y, Zhu Y, Zhao C, Xue Q. Effect of tacrolimus on soluble costimulatory molecules in patients with refractory myasthenia gravis. J Neuroimmunol 2022; 372:577955. [PMID: 36054935 DOI: 10.1016/j.jneuroim.2022.577955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/07/2022] [Accepted: 08/21/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To investigate the expression and possible role of soluble costimulatory molecules in the treatment of refractory myasthenia gravis. METHODS Thirty-two patients with refractory myasthenia gravis were enrolled into this study and given tacrolimus 3 mg/day. At the beginning of treatment and 12 months follow-up period, clinical data were collected and recorded. The clinical classification of myasthenia gravis Foundation (MGFA) was performed. The MGFA-quantitative myasthenia gravis score (MGFA-QMGS), manual muscle test (MMT), MG activity of daily living (MG-ADL) and the activity of daily living (MG-ADL), the 15-item myasthenia gravis quality of life (MG QOL-15) and the dose change of prednisone were used to evaluate the efficacy. The expression levels of soluble costimulatory molecules and their ligands (sPD-1/sPD-L1, sICOS/sICOSL, sCD40/sCD40L), soluble CD25 and IL-2 in serum were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS We observed that oral administration of 3 mg tacrolimus daily for 1 year can significantly improve the clinical symptoms of patients with refractory myasthenia gravis, which is characterized by a significant reduction in clinical scores, such as QMG, MMT, ADL, MGQOL-15, and a reduction daily oral prednisolone (PSL) dose (P < 0.0001).We also found that the levels of plasma sPD-1, sCD40, IL-2 in refractory MG patients increased significantly, and those decreased significantly 12 months after tacrolimus treatment (P < 0.05). The level of sCD25 was negatively correlated with clinical severity scores (P < 0.05). After tacrolimus treatment, the level of sPD-L1 increased although there was no significant difference. CONCLUSION Tacrolimus could relieve the symptoms of refractory MG and significantly decrease the levels of plasma sPD-1, sICOSL, sCD40, sCD25 and IL-2. Soluble costimulatory molecules might be potential biomarkers for MG and tacrolimus treatment.
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Affiliation(s)
- Hui Wu
- Department of Neurology, Jing'an District Centre Hospital of Shanghai, Shanghai, China
| | - Lan Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China; Department of Neurology, The Second Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Xiaoling Zhou
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yanshi Wu
- Department of Immunology, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, Jiangsu, China
| | - Yu Yan
- Department of Immunology, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, Jiangsu, China
| | - Yibei Zhu
- Department of Immunology, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, Jiangsu, China
| | - Chongbo Zhao
- Huashan Rare Disease Center, Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Qun Xue
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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11
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Mental health in myasthenia gravis patients and its impact on caregiver burden. Sci Rep 2022; 12:19275. [PMID: 36369246 PMCID: PMC9652470 DOI: 10.1038/s41598-022-22078-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
Psychiatric comorbidities are relevant in patients with Myasthenia gravis (MG). Also, MG patients experience a reduced health-related quality of life (HRQoL). We aimed to quantify the impact of depression as well as self-perceived MG severity on HRQoL and caregivers' burden. In this cross-sectional study, we used a survey encompassing demographic, disease-related information, and standardized questionnaires to assess symptoms of depression, anxiety, HRQoL (MG Quality of Life scale; MG-QoL15), and caregiver burden (Burden Scale for Family Caregivers; BSFC). Data from 1399 participating patients (96%) and 1042 caregivers (65%) were eligible for further analysis. Symptoms of depression and anxiety disorder were indicated by 31% and 36% of patients. Self-reported MG severity (MG severity) and MG-QoL15 scores were strongly associated (estimated marginal means for severe versus mild MG severity = 18 95% CI [16; 21]; p ≤ 0.001). Adjusting for symptoms of depression decreased the estimated strength of this association (estimated marginal means for severe versus mild MG severity = 15 [13; 17]; p ≤ 0.001). Caregiver burden was associated to MG disease severity (estimated marginal means for severe vs. mild MG severity = 0.16 [0.13; 0,19); p ≤ 0.001) and also negatively influenced by symptoms of depression (estimated marginal means = 0.12 [0.09; 0.15]). Symptoms of depression and anxiety disorder in MG are frequent. Beyond MG severity, symptoms of depression have negative effects on HRQoL as well as on caregivers' burden. Diagnosis and treatment of psychiatric comorbidities should be considered an important element in MG care. Screening tools for mental health conditions should be implemented at least in specialized MG centers.
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Diez Porras L, Homedes C, Alberti MA, Velez Santamaria V, Casasnovas C. Quality of Life in Myasthenia Gravis and Correlation of MG-QOL15 with Other Functional Scales. J Clin Med 2022; 11:jcm11082189. [PMID: 35456281 PMCID: PMC9025772 DOI: 10.3390/jcm11082189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 01/25/2023] Open
Abstract
Health-related quality of life (HRQOL) in myasthenia gravis (MG) is frequently decreased. Further, there are many validated clinical scales and questionnaires to evaluate the clinical status in MG. We aimed to determine if there was an improvement in HRQOL following an intensive treatment for MG, identify which demographic and clinical features influenced patients’ HRQOL, and investigate if the questionnaire MG-QOL15 correlated with other evaluation scales. We recruited 45 patients with generalised MG who were starting immunomodulatory treatment with intravenous immunoglobulins and prednisone for the first time. At each visit, we administered several validated scales for MG. The mean MG-QOL15 score improved significantly at 4 and 6 weeks of the study. Additionally, the MG-QOL15 score correlated strong with the Myasthenia Gravis-Activities of Daily Living (MG-ADL) and the Neuro-QOL Fatigue and weakest with the Quantitative Myasthenia Gravis Scoring System (QMG). The QMG score prior to study enrolment was associated with HRQOL. We observed that HRQOL in MG improved after receiving an intensive immunomodulatory treatment and achieving better control of the symptoms. The questionnaire MG-QOL15 correlated positively with other clinical measures. As MG is a fluctuating condition, and some symptoms are difficult to examine, we direct physicians toward the use of scales and questionnaires composed of items perceived by the patient.
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Affiliation(s)
- Laura Diez Porras
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
| | - Christian Homedes
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
| | - Maria Antonia Alberti
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street n/n, 08907 L’Hospitalet del Llobregat, Spain
| | - Valentina Velez Santamaria
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street n/n, 08907 L’Hospitalet del Llobregat, Spain
| | - Carlos Casasnovas
- Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l’Hospitalet, 08908 L’Hospitalet de Llobregat, Spain; (L.D.P.); (C.H.); (M.A.A.); (V.V.S.)
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street n/n, 08907 L’Hospitalet del Llobregat, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, 3–5 Monforte de Lemos, Pabellón 121, 28029 Madrid, Spain
- Correspondence:
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13
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Shrubsole K, Davies C, Williams KL. Do people with Myasthenia Gravis need speech-language pathology services? A national survey of consumers' experiences and perspectives. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 24:133-144. [PMID: 34396895 DOI: 10.1080/17549507.2021.1961862] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Purpose: This study explored experiences of bulbar (speech, voice and swallowing) symptoms in Australian adults with Myasthenia Gravis (MG), and the relationship between these symptoms and community participation and quality-of-life. Further, it examined access to and experiences with speech-language pathology (SLP) services, and awareness and perceptions of the SLP's role.Method: A cross-sectional mixed methods online survey collected data using researcher-designed questions and patient-reported outcome measures (PROMs) including the Dysarthria Impact Profile (DIP), Voice Handicap Index (VHI), Dysphagia Handicap Index (DHI), Community Integration Questionnaire-Revised (CIQ-R), and Myasthenia Gravis Quality of Life-Revised 15 (MG-QOL15r). Analyses included descriptive and non-parametric statistics, and content analysis.Result: Participants were 111 adults with MG living in Australia. 74% of respondents reported experiencing symptoms of speech difficulties but only 20% of those were referred to SLP services. Similarly, 85% of respondents reported experiencing swallowing difficulties, but only 26% were referred to SLP. Voice handicap (VHI) was strongly correlated with the psychosocial impact of dysarthria (DIP) and dysphagia handicap (DHI). Increased voice and dysphagia handicap were moderately correlated with worse quality-of-life. There was generally poor awareness of the SLP's role and many were reluctant to attend SLP appointments.Conclusion: These findings highlight unmet consumer needs for MG-related bulbar symptoms, and a lack of awareness of SLP services. It is suggested that, in addition to other strategies, consumer education and increased awareness are required to address these unmet needs.
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Affiliation(s)
- Kirstine Shrubsole
- School of Health and Human Sciences, Southern Cross University, Gold Coast, Australia and
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Chloe Davies
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Katrina L Williams
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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Yu L, Qiu L, Ran H, Ma Q, Lu YR, Liu WB. Studying the relationship between clinical features and mental health among late-onset myasthenia gravis patients. World J Psychiatry 2022; 12:470-482. [PMID: 35433329 PMCID: PMC8968504 DOI: 10.5498/wjp.v12.i3.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 12/17/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mental disorders are common comorbidities among individuals with neurological diseases, and the prevalence of depressive and anxiety-related symptoms in newly referred patients at neurology outpatient clinics is high. There have been few studies on the mental health of patients with late-onset myasthenia gravis (MG).
AIM To examine the relationship between clinical features and the mental health symptoms within late-onset MG patients.
METHODS A total of 105 patients diagnosed with MG were recruited consecutively from a neuromuscular outpatient clinic between December 2020 and February 2021. Patients were classified into two groups: early-onset MG (age at onset < 50 years, n = 63) and late-onset MG (age at onset ≥ 50 years, n = 42). Social demographic data and information about marital status, education level, clinical symptoms, serum antibody levels, and therapies used were collected for all participants. Participants were also evaluated using the Myasthenia Gravis Composite scale, the Myasthenia Gravis Activities of Daily Living scale, the Myasthenia Gravis Quality of Life 15 (MG-QOL-15) questionnaire, the 17-item version of the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A). The relationship between clinical features and mental health in late-onset MG patients was examined using multivariate logistic regression analyses.
RESULTS Late-onset MG patients were more prone to dyspnea, had higher levels of serum anti-acetylcholine receptor antibodies, and higher total scores on the MG-QOL-15, HAM-D, and HAM-A questionnaires, than early-onset MG patients had (P < 0.05). Among those with late-onset MG, female patients had higher total HAM-D and HAM-A scores than male patients had (P < 0.05). High scores on the QOL-15 questionnaire were associated with higher incidences of anxiety and depression, and the association was found to be independent after adjusting for confounding risk factors. In the late-onset subgroup, the areas under the receiver operating characteristic curves for the MG-QOL-15 score-based diagnostic accuracy for anxiety and depression state were 0.816 (P = 0.001) and 0.983 (P < 0.001), respectively.
CONCLUSION Higher MG-QOL-15 scores were a risk factor for anxiety and depression in late-onset MG, and women with late-onset MG were more likely to have anxiety and depression than men were.
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Affiliation(s)
- Lu Yu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Li Qiu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Hao Ran
- School of Pharmaceutical Science, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Qian Ma
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Ya-Ru Lu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
| | - Wei-Bin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong Province, China
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15
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Narayanaswami P, Sanders DB, Bibeau K, Krueger A, Venitz J, Guptill JT. Identifying a patient-centered outcome measure for a comparative effectiveness treatment trial in myasthenia gravis. Muscle Nerve 2021; 65:75-81. [PMID: 34687458 DOI: 10.1002/mus.27443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION/AIMS Data regarding the comparative effectiveness of myasthenia gravis (MG) treatments is not available. We used patient input to identify a patient-centered outcome measure (PCOM) for PROMISE-MG, a comparative effectiveness trial of MG treatments. METHODS First, a questionnaire survey was administered to 58 people with MG at the patient meeting of the Myasthenia Gravis Foundation of America (MGFA), evaluating the impact of MG-related symptoms and MG treatments on patients' lives. Second, an online focus group of 13 patients with MG was conducted. Third, a potential outcome measure was selected. Fourth, the selected PCOM was evaluated by patients to assess how completely and accurately it captured their experiences with MG. RESULTS The patient survey showed that limb weakness had the most impact on patients' lives. Weight gain, mood swings, insomnia, and diarrhea were the most bothersome treatment side effects. Avoiding hospitalization was very important. Focus group participants reported fatigue as one of the most bothersome symptoms and differentiated it from myasthenic weakness. They defined an ideal treatment as having minimal or no side effects and an 80% improvement in symptoms. DISCUSSION Based on patient input, the 15-item Myasthenia Gravis Quality of Life-Revised (MG-QOL15R) scale, a validated patient-reported outcome measure (PRO), was selected as the primary PCOM for PROMISE-MG. Avoiding hospitalization and having minimal to no treatment adverse effects were selected as additional outcome measures. The patient-centeredness of a PRO depends on the context of a study: PROs should be evaluated for appropriateness as a PCOM for every study.
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Affiliation(s)
- Pushpa Narayanaswami
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kathie Bibeau
- Myasthenia Gravis Foundation of America, Seattle, Washington, USA
| | - Andrew Krueger
- Accordant Health Services, Greensboro, North Carolina, USA
| | - Jurgen Venitz
- Department of Pharmaceutics, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
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16
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Thomsen JLS, Vinge L, Harbo T, Andersen H. Gender differences in clinical outcomes in myasthenia gravis: A prospective cohort study. Muscle Nerve 2021; 64:538-544. [PMID: 34036597 DOI: 10.1002/mus.27331] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION/AIMS It is uncertain whether clinical outcomes differ between male and female patients with myasthenia gravis (MG) while receiving standard clinical care. METHODS In a prospective cohort study of 107 patients with MG receiving standard of care from 2012 to 2019, the Quantitative MG (QMG), the MG Composite (MGC), the MG Activities of Daily Living (MG-ADL), and the MG Quality of Life 15-Items (QOL15) were determined. Clinical outcomes were analyzed in relation to gender. RESULTS Mean follow-up time was 4.8 (±0.4) y, and 70 patients completed all follow-up assessments. Patients improved on all clinical scores: QMG -1.8 (P < .001), MGC -1.5 (P < .001), MG-ADL -1.3 (P < .001), and QOL15 -3.0 (P < .001). Females improved less than males on the QMG (P = .01), MGC (P < .001), MG-ADL (P = .006), and QOL15 (P < .001) independent of potential confounders. Males had moderate to strong correlations between changes in all clinical scales (r range 0.52 to 0.73), whereas females had weak correlations between changes in the QMG and MG-ADL (r = 0.13), the QMG and QOL15 (r = 0.27), the MGC and MG-ADL (r = 0.21), the MGC and QOL15 (r = 0.00), and the MG-ADL and QOL15 (r = 0.31). DISCUSSION Females improved less compared to males on objective and patient-reported outcomes. Moreover, females improved more on objective measures than on patient-reported outcomes. These gender differences should receive attention in clinical care and in the design of future trials.
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Affiliation(s)
- Jan L S Thomsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Lotte Vinge
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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17
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Al-Ahmer I, Elshony H. Determinants of quality of life changes with plasmapheresis in patients with myasthenia gravis. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00320-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Immunomodulation, including IVIG and plasma exchange, is useful for a crisis or severe exacerbation. Plasma exchange may be slightly faster and more effective in a myasthenic crisis than IVIG. The aim of the current study was to determine the changes in the quality of life (QOL) after plasmapheresis and factors influencing these changes.
Results
This study was conducted on 98 MG patients diagnosed as moderate to severe myasthenia gravis (according to Myasthenia Gravis Foundation of America classification), 81 patients received alternate day 5 sessions plasmapheresis (TPE group) and 17 patients were on medical treatment only (control group). All patients were subjected to full history, through clinical neurological evaluation and scored with quantitative myasthenia gravis (QMG) score for MG severity at start and after 1 m. Both groups completed the QOL questionnaire at baseline and after 1 month. The MG-QOL-15 scores were computed and we analyzed the change in the QOL scores from baseline to after plasmapheresis groups and compared it with the results for the control group. The scores in QOL scales had significantly decreased after plasmapheresis, and the improvement in QOL scores had a good correlation with the decrease in QMGS. The improvement in QOL and QMG was significantly correlated with younger age, female gender, shorter duration of the illness, presence of AchR antibodies, antibody titer, and thymus hyperplasia.
Conclusion
Plasmapheresis is effective in improving quality of life in myasthenia gravis patients and this improvement influenced by age, gender, duration of illness, presence of AchR antibodies and their titer, and the thymus pathology.
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18
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Zhou Y, Yan C, Gu X, Zhou L, Lu J, Zhu W, Huan X, Luo S, Zhong H, Lin J, Lu J, Zhao C, Xi J. Short-term effect of low-dose rituximab on myasthenia gravis with muscle-specific tyrosine kinase antibody. Muscle Nerve 2021; 63:824-830. [PMID: 33745138 DOI: 10.1002/mus.27233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION/AIMS The study aims to investigate the short-term efficacy of low-dose rituximab and its effect on immunological biomarker levels in myasthenia gravis (MG) patients with antibodies against muscle-specific tyrosine kinase (MuSK-MG). METHODS Twelve MuSK-MG patients were enrolled in this prospective, open-label, self-controlled pilot study. Clinical severity was evaluated at baseline and 6 mo after a single rituximab treatment (600 mg). B lymphocyte subtypes, MuSK antibody titers, together with levels of immunoglobulins, serum B-cell activating factor (BAFF), a proliferation-inducing ligand (APRIL), soluble CD40L, and four exosomal microRNAs were evaluated. A correlation matrix to reveal pairwise relationships among above variables was also generated. RESULTS The single rituximab treatment significantly lowered the clinical severity scores and reduced daily dosage of prednisone (P = .032) at 6 mo. MuSK antibody titers decreased (P = .035) without significant changes in immunoglobulin levels. Serum BAFF level increased (P = .010), which negatively correlated with the percentages of B cells in lymphocytes as well as clinical severity. Additionally, serum exosomal miR-151a-3p showed a reduction of 28.1% (P = .031). DISCUSSION We confirmed the clinical efficacy of low-dose rituximab in MuSK-MG, accompanied by a decrease in MuSK antibody titers and an increase in serum BAFF. Serum BAFF levels negatively correlated with B-cell counts as well as clinical severity.
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Affiliation(s)
- Yufan Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chong Yan
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinyu Gu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhua Zhu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao Huan
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Huahua Zhong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.,Department of Neurology, Jing'an District Centre Hospital of Shanghai, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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19
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Application Prospect of Artificial Intelligence in Rehabilitation and Management of Myasthenia Gravis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5592472. [PMID: 33763475 PMCID: PMC7952150 DOI: 10.1155/2021/5592472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 12/25/2022]
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease of the nervous system, which is still incurable. In recent years, with the progress of immunosuppressive and supportive treatment, the therapeutic effect of MG in the acute stage is satisfactory, and the mortality rate has been greatly reduced. However, there is still no consensus on how to conduct long-term management of stable MG, such as guiding patients to identify relapses, practice exercise, return to work and school, etc. In the international consensus guidance for management of myasthenia gravis published by the Myasthenia Gravis Foundation of America (MGFA) in 2020, for the first time, “the role of physical training/exercise in MG” was identified as the topic of discussion. Finally, due to a lack of high-quality evidence on physical training/exercise in patients with MG, the topic was excluded after the literature review. Therefore, this paper reviewed the current status of MG rehabilitation research and the difficulties faced by stable MG patients in self-management. It is suggested that we should take advantage of artificial intelligence (AI) and leverage it to develop the data-driven decision support platforms for MG management which can be used for adverse event monitoring, disease education, chronic management, and a wide variety of data collection and analysis.
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20
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Prior DE, Cooper BA, Zhang B, Ghosh PS. Developing outcome measures of disease activity in pediatric myasthenia. Muscle Nerve 2021; 63:751-757. [PMID: 33604899 DOI: 10.1002/mus.27208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pediatric myasthenia encompasses juvenile myasthenia gravis (JMG) and congenital myasthenic syndrome (CMS), which are chronic disorders with fluctuating symptoms amenable to medical therapy. Disease activity and treatment response may be difficult to assess, but, unlike adults, outcome measures have not been developed in children. METHODS The study was performed in children (0-18 years of age) at the neuromuscular center of a pediatric hospital over a 3-year period. Patients were recruited prospectively as part of their routine clinical care. Demographic data, diagnosis (JMG/CMS), and the following scales were recorded at each visit: Myasthenia Gravis Foundation of America (MGFA) class, Myasthenia Gravis Composite (MGC), and Pediatric Myasthenia-Quality of Life 15 (PM-QOL15). RESULTS Thirty-three patients (24 JMG, 9 CMS) were included in the study, 22 had two or more visits. We established known-groups validity of the MGC and PM-QOL15 scores as compared with the MGFA class. To establish concurrent validity, we constructed a receiver-operating characteristic curve and calculated threshold values of MGC and PM-QOL15 with optimal sensitivity and specificity for identifying a patient with more severe (MGFA III or higher) disease. Finally, we demonstrated the concordance between the MGC and PM-QOL15 by their statistically significant positive Pearson and Spearman correlations. DISCUSSION Our study suggests that MGC and PM-QOL15 are important disease outcome measures in pediatric myasthenia that are easy to administer and provide reliable assessment of disease activity in the clinic setting. Further studies are needed to validate their use for pediatric clinical research trials.
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Affiliation(s)
- Devin E Prior
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | | | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Partha S Ghosh
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
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21
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Complement inhibition initiated recovery of a severe myasthenic crisis with COVID-19. J Neurol 2021; 268:3125-3128. [PMID: 33537898 PMCID: PMC7857861 DOI: 10.1007/s00415-021-10428-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/25/2021] [Indexed: 12/15/2022]
Abstract
We report on a patient with refractory Myasthenia gravis with acetylcholine receptor antibodies with two prior myasthenic crises suffering from COVID-19 with rapid evolving weakness and respiratory failure. Respiratory failure developed and prolonged mechanical ventilation was necessary. After plasmapheresis, residual, severe generalized and bulbar weakness persisted. Complement inhibition with eculizumab was, therefore, introduced and lead to rapid recovery. In refractory myasthenic crisis individualised therapies could be successful.
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Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disorder that frequently affects young women of reproductive age. The multidirectional interplay between MG, pregnancy, and fetal health poses a complex scenario for pregnant women with MG and the healthcare team. Here, we reviewed our local experience with MG, pregnancy, and outcomes. METHODS We performed a retrospective chart review of patients with MG attending the Prosserman Family Neuromuscular Clinic from 2001 to 2019 and who were referred to a high-risk pregnancy clinic. MG status was defined as stable, better, or worse. Information was collected on the delivery route, pregnancy, and neonatal complications. RESULTS We identified 20 women with MG for a total of 28 pregnancies. Worsening was observed in 50% of pregnancies: 18% during pregnancy, 25% following delivery, and 7% during both. 66.7% of patients with MG duration of 2 years or less had worsening during pregnancy. Three patients who stopped immunosuppressive treatment during pregnancy worsened and one had a crisis. C-section was done in 29% of pregnancies. The rate of delivery complications was 7% and of neonatal MG was 7%. CONCLUSION A high proportion of MG patients worsened during pregnancy, particularly those with disease duration less than 2 years, and those who discontinued immunosuppression during pregnancy. However, pregnancy was largely unaffected, rate of neonatal MG was low, frequencies of C-section, delivery complications, and premature births were similar to the general population. While the study has limitations due to the retrospective nature, these insights provide some guidance when counseling young myasthenic women about family planning.
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Tran C, Biswas A, Mendoza M, Katzberg H, Bril V, Barnett C. Performance of different criteria for refractory myasthenia gravis. Eur J Neurol 2020; 28:1375-1384. [PMID: 33306873 DOI: 10.1111/ene.14675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/03/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Defining refractory myasthenia gravis is important, as this can drive clinical decision making, for example, by escalating treatments in refractory individuals. There are several definitions of refractory myasthenia, and their performances have not been compared. Having valid and reliable criteria can help select patients in whom more aggressive treatments may be needed. METHODS We applied five different refractory myasthenia criteria (Drachman, Mantegazza, Suh, the International Consensus Guideline (ICG), and the randomised controlled trial of eculizumab in refractory, anti-acetylcholine receptor positive, generalised myasthenia gravis (REGAIN), to a cohort of 237 patients. We compared the proportion of refractory patients among different criteria and their scores on disease severity, fatigue, and quality-of-life (QoL) scales. We also assessed the agreement for each criterion between two trained assessors. RESULTS The Drachman, Mantegazza, and Suh criteria resulted in high proportions of refractory individuals (40.1%, 39.2%, and 38.8%, respectively), compared with the ICG and REGAIN criteria (9.7% and 3.0%, respectively). Refractory patients by the ICG and REGAIN criteria had worse disease severity, QoL, and fatigue scores, compared with patients classified as refractory by other criteria. All criteria had high agreement between raters (between 70% and 100%). CONCLUSIONS There is high variability in the proportion of refractory myasthenia gravis patients depending on the criteria used, with ICG and REGAIN criteria capturing patients with worse disease severity. This reflects conceptual differences as to what refractory means. Further multicenter studies are needed to determine appropriate criteria for refractory myasthenia gravis.
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Affiliation(s)
- Christopher Tran
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Aishani Biswas
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meg Mendoza
- Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
| | - Hans Katzberg
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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24
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Thomsen JLS, Andersen H. Outcome Measures in Clinical Trials of Patients With Myasthenia Gravis. Front Neurol 2020; 11:596382. [PMID: 33424747 PMCID: PMC7793650 DOI: 10.3389/fneur.2020.596382] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/06/2020] [Indexed: 01/02/2023] Open
Abstract
Myasthenia gravis (MG) is a heterogeneous disorder whose clinical presentation ranges from mild ocular deficits to severe widespread weakness. This variance poses a challenge when quantifying clinical deficits. Deficits and symptoms are quantified using standardized clinical scales and questionnaires which are often used as outcome measures. The past decades have seen the development of several validated outcome measures in MG, which are used in clinical trials to obtain regulatory approval. In recent years, emphasis has moved from objective assessments to patient-reported outcomes. Despite a growing body of literature on the validity of the MG-specific outcome measures, several unresolved factors remain. As several novel therapeutics are currently in clinical development, knowledge about capabilities and limitations of outcome measures is needed. In the present paper, we describe the most widely used clinical classifications and scales in MG. We highlight the choice of outcome measures in published and ongoing trials, and we denote whether trial efficacy was reached on these outcomes. We discuss advantages and limitations of the individual scales, and discuss some of the unresolved factors relating to outcome assessments in MG.
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Affiliation(s)
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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25
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Sanders DB, Raja SM, Guptill JT, Hobson‐Webb LD, Juel VC, Massey JM. The
D
uke myasthenia gravis clinic registry:
I
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D
escription and demographics. Muscle Nerve 2020; 63:209-216. [DOI: 10.1002/mus.27120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Donald B. Sanders
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Shruti M. Raja
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Jeffrey T. Guptill
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Lisa D. Hobson‐Webb
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Vern C. Juel
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
| | - Janice M. Massey
- Neuromuscular Division, Department of Neurology Duke University Medical Center Durham North Carolina USA
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Szczudlik P, Sobieszczuk E, Szyluk B, Lipowska M, Kubiszewska J, Kostera-Pruszczyk A. Determinants of Quality of Life in Myasthenia Gravis Patients. Front Neurol 2020; 11:553626. [PMID: 33071942 PMCID: PMC7538807 DOI: 10.3389/fneur.2020.553626] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 08/19/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Although approximately half of myasthenia gravis (MG) patents achieve remission, for the remaining group MG is often a life-long disease. Better understanding of the determinants of Quality of Life (QoL) in MG is needed to optimize treatment goals in chronic cases. Materials and Methods: We performed a single center cross-sectional study in 339 MG adult patients (64.9% women), with ocular or generalized disease. SF-36 and a structured questionnaire was administered, including information on previous and current MG severity, medications, comorbidities, education, occupation and BMI of the patient. Mean disease duration was 7.5 + 9.3 years. Current age was 51.6 + 18.3 years, 55% had Early-Onset (<50 years) MG. Results: There were no statistically significant differences in mean SF-36 subscores between women and men. Worse MGFA class was related to lower QoL in physical (PCS) and mental (MCS) subscore (p = 0.000 for both). Patients with MGFA I-II class had significantly better QoL in physical and mental subscores than patients with more severe MG (p < 0.005). Late-onset MG patients had worse QoL than EOMG in physical score domain PCS (p = 0.049). Overweight and obese patients had lower PCS (p = 0.002) and MCS (p = 0.038) than patients with normal BMI. University education was related to statistically higher PCS (p = 0.015) and MCS (p = 0.006). QoL in currently employed was better in PCS and MCS (p = 0.000), with white collar workers reporting higher PCS (p = 0.049) than the remaining group. Patients living with family evaluated their MCS (p = 0.015) better than living alone. Moderate physical activity (twice a week) improved PCS (p = 0.045). Conclusion: Our study confirmed that greater severity of symptoms, age, age of onset but also BMI, type of work, education status and physical activity affect QoL in MG.
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Affiliation(s)
- Piotr Szczudlik
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Sobieszczuk
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Beata Szyluk
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Lipowska
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
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Díez-Porras L, Homedes C, Alberti MA, Vélez-Santamaría V, Casasnovas C. Intravenous immunoglobulins may prevent prednisone-exacerbation in myasthenia gravis. Sci Rep 2020; 10:13497. [PMID: 32782330 PMCID: PMC7421901 DOI: 10.1038/s41598-020-70539-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 07/31/2020] [Indexed: 01/09/2023] Open
Abstract
Corticosteroids may produce a paradoxical worsening of myasthenia gravis (MG) symptoms within the first weeks of treatment. We therefore wanted to assess the hypothesis that a prior infusion of intravenous immunoglobulin (IVIG) may have a protective effect. Our primary objectives were to show that the coadministration of immunoglobulins and glucocorticoids is safe and effective for controlling myasthenic symptoms, and to compare the exacerbation rate with this approach and historical practice without IVIG. We recruited 45 patients with generalized MG who required corticosteroids for the first time and we gave all IVIG before starting the full doses of prednisone. Monitoring was performed with validated scales, questionnaires, and blood tests over a 6-week period. Only 4.4% had severe adverse effects related to IVIG and 86.7% improved clinically. Notably, only 2.2% had a paradoxical symptom exacerbation in the first weeks of starting prednisone, which was statistically lower than the 42% reported in a historical series. We conclude that adjuvant therapy with IVIG when starting prednisone for the first time in patients with generalized MG is safe and effective. Given that the rate of paradoxical worsening was lower than that previously reported, the addition of IVIG may have a protective effect against such exacerbations.
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Affiliation(s)
- Laura Díez-Porras
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Christian Homedes
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Maria Antonia Alberti
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Valentina Vélez-Santamaría
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain.,Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l'Hospitalet, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Carlos Casasnovas
- Neuromuscular Unit. Department of Neurology, Bellvitge University Hospital, Feixa Llarga Street s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain. .,Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), 199 Granvia de l'Hospitalet, L'Hospitalet de Llobregat, 08908, Barcelona, Spain. .,Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, 3-5 Monforte de Lemos, Pabellón 121, 28029, Madrid, Spain.
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Mendoza M, Tran C, Bril V, Katzberg HD, Barnett C. Patient-acceptable symptom states in myasthenia gravis. Neurology 2020; 95:e1617-e1628. [DOI: 10.1212/wnl.0000000000010574] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/18/2020] [Indexed: 12/13/2022] Open
Abstract
ObjectivesTo estimate patient-acceptable symptom state (PASS) cut points for myasthenia gravis (MG) health scales.MethodsWe conducted an electronic survey that included the Myasthenia Gravis Impairment Index (MGII), EuroQol 5-Dimension (EQ5D), and a simple PASS question. PASS-anchored thresholds were estimated for the MGII questionnaire through receiver operating characteristic curves. We used the MGII PASS cut point in a validation cohort of 257 patients to estimate PASS thresholds for other clinically relevant health scales such as the Quantitative Myasthenia Gravis Scale (QMGS), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Composite (MGC), and Myasthenia Quality of Life (MG-QoL15).ResultsOne hundred twenty-four of ≈250 invited patients answered the electronic survey (49% response rate), and 80 considered their current symptom state acceptable (PASS-positive). They had lower MGII scores than PASS-negative patients (7.76 ± 9.37 vs 25.0 ± 13.7, p < 0.0001) and better EQ5D scores (0.86 ± 0.17 vs 0.69 ± 0.18, p < 0.0001). The MGII questionnaire threshold for PASS was ≤10 points. With the use of this threshold in an independent dataset of 257 patients, all patients in remission or minimal manifestation status were PASS-positive. In addition, some patients in Classes I, II, and IIIA also achieved PASS status. PASS thresholds for the QMGS, MG-ADL, MGC, and MG-QoL15 were ≤7, 2, 3, and 8 points, respectively.ConclusionsWe have estimated thresholds for commonly used myasthenia health scales reflecting patient-acceptable states in patients with MG. These thresholds indicate a global state of well being, rather than a change in scores, or being better. Therefore, PASS thresholds can be used as secondary endpoints for myasthenia research.
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Wong SH, Eggenberger E, Cornblath W, Xhepa A, Miranda E, Lee H, Burke A, Barnett C. Preliminary Findings of a Dedicated Ocular Myasthenia Gravis Rating Scale: The OMGRate. Neuroophthalmology 2020; 44:148-156. [PMID: 32395166 DOI: 10.1080/01658107.2019.1660686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 10/25/2022] Open
Abstract
There is a pressing need for a robust rating scale for ocular myasthenia gravis (OMG). Rating scales for myasthenia gravis (MG) research have a predominant focus on generalised disease. We present results of the first dedicated rating scale for OMG: the ocular myasthenia gravis rating scale (OMGRate). The OMGRate was developed through an international collaboration between neuromuscular and neuro-ophthalmology experts in OMG. It comprises two components: a physician- examination (OMGRate-e) and a patient questionnaire (OMGRate-q).. The OMGRate was prospectively validated in patients attending a neuro-ophthalmology clinic from April 2017 to October 2018. External validity and reliability of OMGRate were evaluated using validated MG rating scales: the Myasthenia Gravis Composite (MGC), the Myasthenia Gravis Quality of Life (MG-QOL), and the ocular component from the Myasthenia Gravis Impairment Index questionnaire (MGII). Two hundred and eleven assessments were completed in 104 patients (67 males, mean age 55 y, range 18-86 y). There was very good external validity of the OMGRate: good correlation between OMGRate-e and MGC (r = 0.64, 95% confidence intervals [CI] 0.54-0.74, p < .0001); excellent correlation between OMGRate-q and MGII (r = 0.85, 95% CI 0.78-0.91, p < .0001) and good correlation between OMGRate and MG-QOL (r = 0.68, 95% CI 0.60-0.77, p < .0001). A higher correlation of OMGRate and MG-QOL compared with MGC and MG-QOL (r = 0.47, 95% CI 0.34-0.59, p < .0001) suggests that OMGRate is better able to capture significant QOL information in patients with OMG. It had excellent reliability with an intraclass correlation coefficient of 0.83 (95% CI 0.67-0.92). Feedback from examiners and patients indicated that the OMGRate was easy to use. In conclusion, OMGRate is an easy-to-use, valid and reliable rating scale for monitoring the severity of OMG.
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Affiliation(s)
- Sui Hsien Wong
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Eric Eggenberger
- Department of Neuro-ophthalmology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Wayne Cornblath
- Department of Neuro-ophthalmology, University of Michigan, Ann Arbor, MI, USA
| | - Alba Xhepa
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Eduardo Miranda
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Helena Lee
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Ailbhe Burke
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Carolina Barnett
- Department of Medicine, Neurology, University Health Network and University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Vitturi BK, Pellegrinelli A, Valerio BCO. Medication adherence in patients with myasthenia gravis in Brazil: a cross-sectional study. Acta Neurol Belg 2020; 120:83-89. [PMID: 31555980 DOI: 10.1007/s13760-019-01209-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
Advances in the treatment of MG have allowed most patients to effectively treat their disorder with oral medications. In parallel, non-adherence to medication treatment regimens is a worldwide health problem. Other chronic neurological disorders have already been associated with low adherence to treatment. However, the literature regarding adherence among patients with MG is definitely poor. The purpose of this study was to capture the prevalence and the associated factors of non-adherence to pharmacological treatment in patients with MG. We carried out a cross-sectional cohort study with 58 consecutive patients with MG from a university-affiliated referral hospital in São Paulo, Brazil. We registered clinical and sociodemographic data and patients were classified according to the MGFA classification. Clinical severity was assessed with myasthenia gravis composite (MGC) scale. Neuropsychiatric symptoms were evaluated with the Hospital Anxiety and Depression Scale (HADS) and quality of life with the 15-Item Quality Of Life Instrument for myasthenia gravis scale (MG-QOL15). Adherence to pharmacological treatment was evaluated using the 8-item Morisky Medication Adherence Scale (MMAS-8). There were 26 (44.8%) patients adherent to treatment. Low adherence was associated with poor educational attainment, longer time of disease and greater daily number of pills (p < 0.05). Patients with poor compliance to treatment presented worse quality of life and increased neuropsychiatric symptoms (p < 0.05). Adherence can be relatively challenging in patients with MG. Medical approach should recognize that therapeutic success in the treatment of MG goes through adherence to treatment.
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Abstract
No consensus has been reached on the ideal therapeutic algorithm for myasthenia gravis (MG). Most patients with MG require induction therapy with high doses of corticosteroids and maintenance with an immunosuppressant. Severe cases and acute worsening require intravenous immunoglobulin or plasmapheresis before oral immunosuppressants start having an effect. However, biologics are emerging as important therapeutic tools that promise to provide better corticosteroid sparing effects than standard treatments and can even induce remission. In particular, eculizumab, a monoclonal antibody against complement C5, has been approved by the FDA for refractory MG on the basis of a phase III trial. Rituximab, an anti-CD20 monoclonal antibody that depletes peripheral B cells, has also been effective in many large uncontrolled series, although was not in a small phase III trial. Whether the newer anti-CD20 agents ocrelizumab, ofatumumab, obinutuzumab, ublituximab or inebilizumab will be more effective remains unclear. Belimumab, an antibody against the B cell trophic factor BAFF, was ineffective in phase III trials, and efgartigimod, which depletes antibodies, was effective in a phase II study. Some anti-cytokine agents relevant to MG immunopathogenesis also seem promising. Checkpoint inhibitors can trigger MG in some patients, necessitating early intervention. Increased availability of new biologics provides targeted immunotherapies and the opportunities to develop more specific therapies.
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Bacci ED, Coyne KS, Poon JL, Harris L, Boscoe AN. Understanding side effects of therapy for myasthenia gravis and their impact on daily life. BMC Neurol 2019; 19:335. [PMID: 31864345 PMCID: PMC6925439 DOI: 10.1186/s12883-019-1573-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 12/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background Myasthenia gravis is a chronic, autoimmune, neuromuscular junction disorder characterized by skeletal muscle weakness. Current therapies for myasthenia gravis are associated with significant side effects. The objective of this study was to characterize the side effects, and associated health-related quality of life and treatment impacts, of traditional myasthenia gravis treatments. Methods This study had two phases; a Phase 1 interview and a 2-part web-based survey in Phase 2 that included brainstorming (Step 1) and rating (Step 2) exercises using group concept mapping. In Phase 1, all 14 participants reported experiencing side effects from myasthenia gravis treatments which had significant impacts on daily life. In Phase 2, 246 participants contributed to Step 1; 158 returned for Step 2. Results The brainstorming exercise produced 874 statements about side effects and their impact, which were reduced to 35 side effects and 23 impact-on-daily life statements. When rating these statements on severity, frequency, and tolerability, blood clots, infections/decreased immunity, weight gain, and diarrhea were the least tolerable and most severely rated. The most frequent and severe impacts were sleep interference and reduced physical and social activities. Conclusions Based on these findings, there appears to be a need for better and more tolerable treatments for myasthenia gravis patients.
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Affiliation(s)
- Elizabeth Dansie Bacci
- Patient-Centered Research, Evidera, 1417 Fourth Avenue Suite 510, Seattle, WA, 98101, USA.
| | - Karin S Coyne
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | - Jiat-Ling Poon
- Patient-Focused Outcomes Center of Expertise, Eli Lilly, Indianapolis, IN, USA
| | - Linda Harris
- Global Health Outcomes Research, Alexion Pharmaceuticals Inc, New Haven, CT, USA
| | - Audra N Boscoe
- Health Economics and Outcomes Research, Agios Pharmaceuticals, Cambridge, MA, USA
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Alanazy MH, Binabbad RS, Alromaih NI, Almansour RA, Alanazi SN, Alhamdi MF, Alazwary N, Muayqil T. Severity and depression can impact quality of life in patients with myasthenia gravis. Muscle Nerve 2019; 61:69-73. [PMID: 31573094 DOI: 10.1002/mus.26719] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND The revised 15-item Myasthenia Gravis (MG) Quality of Life Questionnaire (MGQoL15R) is a validated scale of quality of life in patients with MG. We aimed to study the factors causing the variability within the Arabic version of the MGQoL15R (MGQoL15R-A). METHOD A standardized questionnaire was completed by 118 patients. Correlations and hierarchical regression analyses were used to assess the contribution of sociodemographic variables, clinical factors, Patient Health Questionnaire-9 (PHQ9-A), and Generalized Anxiety Disorder-7 (GAD7-A) to the variability in the MGQoL15R-A. RESULTS The MGQoL15R-A was highly correlated with PHQ9-A (r = 0.76), and moderately correlated with GAD7-A (r = 0.52). Clinical factors and PHQ9-A independently explained 30.4% and 34.5% of the variability, respectively. Among the clinical factors, uncontrolled MG status, relapse within the past year, and a higher number of current MG therapies were significantly associated with a higher MGQoL15R-A score. CONCLUSIONS MG severity and depressive symptoms (measured by PHQ9-A) can affect the MGQoL15R-A score.
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Affiliation(s)
- Mohammed H Alanazy
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rahaf S Binabbad
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Norah I Alromaih
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Raghad A Almansour
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Shahad N Alanazi
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Malak F Alhamdi
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Naael Alazwary
- Department of Internal Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Cutter G, Xin H, Aban I, Burns TM, Allman PH, Farzaneh-Far R, Duda PW, Kaminski HJ. Cross-sectional analysis of the Myasthenia Gravis Patient Registry: Disability and treatment. Muscle Nerve 2019; 60:707-715. [PMID: 31487038 PMCID: PMC6899582 DOI: 10.1002/mus.26695] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 08/05/2019] [Accepted: 08/30/2019] [Indexed: 12/11/2022]
Abstract
Introduction The Myasthenia Gravis Patient Registry (MGR) is a voluntary, patient‐submitted database dedicated to improve understanding of care/burden of myasthenia gravis (MG). Methods In this study we present analyses of baseline records through July 2017 (n = 1140) containing data on the MG—Activities of Daily Living (MG‐ADL) and the MG 15‐item Quality of Life (MG‐QOL15) instruments, two validated scales assessing quality of life in MG patients at sign‐up into the MGR. Results Most registrants reported moderate to severe impairment of health‐related quality of life, with a median MG‐ADL score of 6 and a median MG‐QOL15 score of 21. Seventy‐one percent of the patients had received pyridostigmine. Corticosteroids, mycophenolate mofetil, and azathioprine were the most common immunomodulators/immunosuppressants, with 85% of participants having ever using one of these agents. Forty‐seven registrants reported receiving intravenous immunoglobulin, and 30% received plasma exchange. Twelve percent reported other treatments, and 40% were unsure whether they received less common therapies. Forty percent had undergone thymectomy. Discussion The MGR data correlate well with other MG cohorts. Many MG patients remain negatively impacted despite treatment.
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Affiliation(s)
- Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Haichang Xin
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia
| | - Phillip H Allman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ramin Farzaneh-Far
- Department of Clinical Research, Ra Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Petra W Duda
- Department of Clinical Research, Ra Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington, DC
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Barnett C, Herbelin L, Dimachkie MM, Barohn RJ. Measuring Clinical Treatment Response in Myasthenia Gravis. Neurol Clin 2019; 36:339-353. [PMID: 29655453 DOI: 10.1016/j.ncl.2018.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In this article we provide an overview of health-related outcome measurement-to better understand what different outcomes used in myasthenia actually measure-and to provide some guidance when choosing measures based on the clinical context and question. In myasthenia, the most commonly used outcome measures are aimed at assessing the signs and symptoms. In this review, we provide a summary of the most commonly used outcome measures. We discuss instruments that gauge disease overall health impact, such as on disability and quality of life. Finally, we discuss other relevant outcomes such as steroid-sparing effects and the role of surrogate markers.
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Affiliation(s)
- Carolina Barnett
- Neurology (Medicine), University of Toronto, University Health Network, Toronto, Ontario, Canada.
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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Quality of Life of Myasthenia Gravis Patients in Regard to Epidemiological and Clinical Characteristics of the Disease. Neurologist 2019; 24:115-120. [DOI: 10.1097/nrl.0000000000000238] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Boscoe AN, Xin H, L'Italien GJ, Harris LA, Cutter GR. Impact of Refractory Myasthenia Gravis on Health-Related Quality of Life. J Clin Neuromuscul Dis 2019; 20:173-181. [PMID: 31135620 PMCID: PMC6571178 DOI: 10.1097/cnd.0000000000000257] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Myasthenia gravis (MG) may be refractory to traditional therapies. Quality of life (QOL) and disease burden in patients with refractory and nonrefractory MG were compared using Myasthenia Gravis Foundation of America MG Patient Registry data. METHODS Adults aged 18 years or older with MG diagnosed ≥2 years before enrollment were included. Participants with refractory MG had received ≥2 previous and 1 current MG treatment and had MG Activities of Daily Living Scale total score ≥6 at enrollment; other participants had nonrefractory MG. MG QOL 15-item scale (MG-QOL15) scores were compared. RESULTS In total, 56 participants with refractory and 717 participants with nonrefractory MG enrolled. Participants with refractory MG had significantly higher mean (SD) MG-QOL15 total scores [31.4 (11.1) vs. 20.8 (15.0), P < 0.0001] and were more likely to have had exacerbations, emergency department visits, and recent hospitalizations. CONCLUSIONS Participants with refractory MG experience worse QOL and greater clinical burden than those with nonrefractory disease.
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Affiliation(s)
- Audra N. Boscoe
- Alexion Pharmaceuticals, New Haven, CT. Dr. Boscoe is now with Agios Pharmaceuticals, Cambridge, MA. Dr. L'Italien is now with Biohaven Pharmaceuticals, New Haven, CT
| | - Haichang Xin
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL; and
| | - Gilbert J. L'Italien
- Alexion Pharmaceuticals, New Haven, CT. Dr. Boscoe is now with Agios Pharmaceuticals, Cambridge, MA. Dr. L'Italien is now with Biohaven Pharmaceuticals, New Haven, CT
| | - Linda A. Harris
- Alexion Pharmaceuticals, New Haven, CT. Dr. Boscoe is now with Agios Pharmaceuticals, Cambridge, MA. Dr. L'Italien is now with Biohaven Pharmaceuticals, New Haven, CT
| | - Gary R. Cutter
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against the acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or other AChR-related proteins in the postsynaptic muscle membrane. Localized or general muscle weakness is the predominant symptom and is induced by the antibodies. Patients are grouped according to the presence of antibodies, symptoms, age at onset and thymus pathology. Diagnosis is straightforward in most patients with typical symptoms and a positive antibody test, although a detailed clinical and neurophysiological examination is important in antibody-negative patients. MG therapy should be ambitious and aim for clinical remission or only mild symptoms with near-normal function and quality of life. Treatment should be based on MG subgroup and includes symptomatic treatment using acetylcholinesterase inhibitors, thymectomy and immunotherapy. Intravenous immunoglobulin and plasma exchange are fast-acting treatments used for disease exacerbations, and intensive care is necessary during exacerbations with respiratory failure. Comorbidity is frequent, particularly in elderly patients. Active physical training should be encouraged.
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Alanazy MH, Abuzinadah AR, Muayqil T. Translation and validation of the arabic version of the myasthenia gravis activities of daily living scale. Muscle Nerve 2019; 59:583-586. [PMID: 30697753 DOI: 10.1002/mus.26435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/20/2019] [Accepted: 01/26/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION We translated the myasthenia gravis (MG)-specific activities of daily living (MG-ADL) scale into Arabic (MG-ADL-A) and assessed its psychometric properties. METHODS We assessed reliability using Cronbach's α, reproducibility using the intraclass correlation coefficient, and validity using Spearman's correlations with MG composite (MGC) score, MG-specific manual muscle test (MG-MMT), and MG quality-of-life revised Arabic version (MGQOL15R-A). Differences in MG-ADL-A scores among patients with different disease severity were evaluated by using the Kruskal-Wallis test. Sensitivity to change was examined by using the Wilcoxon signed-rank test. RESULTS We recruited 87 patients. The mean MG-ADL-A score was 3.38 ± 3.38 (α = 0.77, ICC = 0.99). The correlation coefficients between the MG-ADL-A and MGQOL15R-A, MGC, and MG-MMT were 0.63, 0.74, and 0.61, respectively (P < 0.001). The MG-ADL-A discriminated between different severity groups and was responsive to clinical improvement at follow-up. DISCUSSION The MG-ADL-A has rigorous psychometric properties and can be used with Arabic-speaking patients with MG. Muscle Nerve 59:583-583, 2019.
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Affiliation(s)
- Mohammed H Alanazy
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad R Abuzinadah
- Department of Internal Medicine, King Abdulaziz University Hospital and College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Taim Muayqil
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Farrugia ME, Di Marco M, Kersel D, Carmichael C. A Physical and Psychological Approach to Managing Fatigue in Myasthenia Gravis: A Pilot Study. J Neuromuscul Dis 2018; 5:373-385. [PMID: 29889078 DOI: 10.3233/jnd-170299] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BackgroundFatigue in myasthenia gravis (MG) is common and difficult to manage. Unlike myasthenic weakness it is not amenable to drug therapies.ObjectiveOur primary aim was to investigate whether a combination of physical and psychological therapy would help address symptoms of fatigue in MG patients, who have stable disease but residual problematic fatigue. Our secondary aim was to quantitate fatigue by applying different scores and to ascertain which would be most relevant to apply in MG.MethodsWe recruited 10 MG patients with stable disease and who suffer from fatigue. Nine of these 10 patients participated in a 10-week program that involved physical and psychological intervention. We quantified their fatigue using the modified fatigue impact scale (MFIS), the visual analogue fatigue scale (VAFS) and the fatigue severity scale (FSS) at the start of the study, at various intervals during the program and 3 months later.ResultsDuring the program, there was a small improvement in the physical and psychosocial subscale of the MFIS. There was a significant improvement (p < 0.01) in the VAFS at the end of the program. No clear improvement was noted in FSS. Three months later, all fatigue scores declined to baseline but 50% of patients had made some life-style changes.ConclusionsThis is a small pilot study, which utilized a combined approach with physical and psychological therapy, and showed some benefit in improving fatigue in patients with MG. The improvement was small and unsustained. Because of the small patient cohort, one cannot derive any firm conclusions and a larger study is required to investigate this further.
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Affiliation(s)
- Maria E Farrugia
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Marina Di Marco
- Neuromuscular Physiotherapy, Clinical Genetics, West of Scotland Genetic Services, Queen Elizabeth University Hospital, Glasgow, UK
| | - Denyse Kersel
- Department of Clinical Psychology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Caroline Carmichael
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
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Treatment of Myasthenia Gravis With High-Dose Cholinesterase Inhibitors and Calcineurin Inhibitors Caused Spontaneous Muscle Cramps in Patients. Clin Neuropharmacol 2018; 41:164-170. [PMID: 30130259 DOI: 10.1097/wnf.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the influence of treatment with cholinesterase inhibitors (ChEIs) and calcineurin inhibitors (CNIs) on the occurrence of cramps in myasthenia gravis (MG) patients. METHODS The frequency and duration of cramp and serum electrolytes were evaluated in 81 patients with MG. The patients were classified using Myasthenia Gravis Foundation of America postintervention status scores based on the treatment and the responsiveness to the treatment. Quantitative MG score, MG activities of daily living score, MG composite score, or MG quality of life 15 score was used to assess the health-related quality of life (QOL). RESULTS Muscle cramps developed in 44 (54.3%) of 81 MG patients. The scores of MG activities of daily living, MG composite, or MG-QOL 15-item questionnaire in patients with cramp were significantly higher than those in patients without cramps (P = 0.002, P = 0.01, or P = 0.0022, respectively). The serum magnesium concentrations were lower in patients treated with CNI (n = 16) than in those not treated with CNI (n = 65) (P = 0.002). The probability of cramps was significantly higher in patients treated with ChEIs (≥180 mg/d) in addition to CNI than in patients who were treated with a low dose of ChEIs (≤60 mg/d) without concomitant CNI treatment (P = 0.017). CONCLUSIONS Our data suggested that treatment with a high dose of ChEI and CNI accelerated the probability of cramps and reduced the QOL in MG patients.
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Lee I, Kaminski HJ, Xin H, Cutter G. Gender and quality of life in myasthenia gravis patients from the myasthenia gravis foundation of America registry. Muscle Nerve 2018; 58:90-98. [PMID: 29466829 DOI: 10.1002/mus.26104] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/12/2018] [Accepted: 02/17/2018] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Quality of life (QOL) has been poorly characterized among patients with myasthenia gravis (MG) other than assessments performed within the clinical setting. METHODS Patients age ≥ 18 years who were diagnosed with MG and registered with the MG patient registry between July 1, 2013, and June 30, 2016, were included. Demographic information, disease related history, and QOL were compared between men and women using multivariable analysis. RESULTS A total of 1,315 subjects (827 women) were included. Women were significantly younger, had a younger age at symptom onset, and were more likely to have thymoma and thymectomy. The 15-item Myasthenia Gravis Quality of Life scale (MG-QOL15) was significantly worse in women. MG-QOL15 score was comparable between women who had thymectomy and men with or without thymectomy. DISCUSSION QOL among MG patients is worse in women compared with men, but this disparity is eliminated in women who have undergone thymectomy. Muscle Nerve, 2018.
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Affiliation(s)
- Ikjae Lee
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Henry J Kaminski
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Haichang Xin
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Tran C, Bril V, Katzberg HD, Barnett C. Fatigue is a relevant outcome in patients with myasthenia gravis. Muscle Nerve 2018; 58:197-203. [PMID: 29342314 DOI: 10.1002/mus.26069] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with myasthenia gravis often experience fatigue, but its effect on quality of life (QoL) is underestimated, and fatigue is rarely measured in clinical trials. METHODS Two hundred fifty-seven myasthenic patients completed the Neuro-QoL-Fatigue and measures of disease severity and QoL. We studied the relationship between fatigue and clinical and demographic variables. Finally, we studied the responsiveness of the Neuro-QoL-Fatigue in 95 patients receiving treatments for myasthenia and estimated the minimal important difference (MID). RESULTS Fatigue correlated with greater disease severity (r = 0.52-0.69, P < 0.0001) and worse QoL (r = 0.65-0.75, P < 0.0001). Patients in remission, with minimal manifestations, and pure ocular symptoms reported minimal fatigue. Regression modeling showed that, in addition to its relationship with disease severity, fatigue was worse in females, patients with generalized disease, and those with anxiety/depression. Fatigue improved after immunomodulation (P < 0.0001), and the MID was 5.3 points. DISCUSSION Fatigue in myasthenia correlates with disease severity, affects QoL, and can improve after treatment. Muscle Nerve 58: 197-203, 2018.
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Affiliation(s)
- Christopher Tran
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University Health Network and University of Toronto, 200 Elizabeth Street, 5EC Room 344, Toronto, Ontario, M5G 2C4, Canada
| | - Hans D Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University Health Network and University of Toronto, 200 Elizabeth Street, 5EC Room 344, Toronto, Ontario, M5G 2C4, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University Health Network and University of Toronto, 200 Elizabeth Street, 5EC Room 344, Toronto, Ontario, M5G 2C4, Canada
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Birnbaum S, Hogrel JY, Porcher R, Portero P, Clair B, Eymard B, Demeret S, Bassez G, Gargiulo M, Louët E, Berrih-Aknin S, Jobic A, Aegerter P, Thoumie P, Sharshar T. The benefits and tolerance of exercise in myasthenia gravis (MGEX): study protocol for a randomised controlled trial. Trials 2018; 19:49. [PMID: 29347991 PMCID: PMC5774148 DOI: 10.1186/s13063-017-2433-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 12/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research exploring the effects of physical exercise in auto-immune myasthenia gravis (MG) is scarce. The few existing studies present methodological shortcomings limiting the conclusions and generalisability of results. It is hypothesised that exercise could have positive physical, psychological as well as immunomodulatory effects and may be a beneficial addition to current pharmacological management of this chronic disease. The aim of this study is to evaluate the benefits on perceived quality of life (QOL) and physical fitness of a home-based physical exercise program compared to usual care, for patients with stabilised, generalised auto-immune MG. METHODS MGEX is a multi-centre, interventional, randomised, single-blind, two-arm parallel group, controlled trial. Forty-two patients will be recruited, aged 18-70 years. Following a three-month observation period, patients will be randomised into a control or experimental group. The experimental group will undertake a 40-min home-based physical exercise program using a rowing machine, three times a week for three months, as an add-on to usual care. The control group will receive usual care with no additional treatment. All patients will be followed up for a further three months. The primary outcome is the mean change in MGQOL-15-F score between three and six months (i.e. pre-intervention and immediately post-intervention periods). The MGQOL-15-F is an MG-specific patient-reported QOL questionnaire. Secondary outcomes include the evaluation of deficits and functional limitations via MG-specific clinical scores (Myasthenia Muscle Score and MG-Activities of Daily Living scale), muscle force and fatigue, respiratory function, free-living physical activity as well as evaluations of anxiety, depression, self-esteem and overall QOL with the WHO-QOL BREF questionnaire. Exercise workload will be assessed as well as multiple safety measures (ECG, biological markers, medication type and dosage and any disease exacerbation or crisis). DISCUSSION This is the largest randomised controlled trial to date evaluating the benefits and tolerance of physical exercise in this patient population. The comprehensive evaluations using standardised outcome measures should provide much awaited information for both patients and the scientific community. This study is ongoing. TRIAL REGISTRATION ClinicalTrials.gov, NCT02066519 . Registered on 13 January 2014.
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Affiliation(s)
- Simone Birnbaum
- Institute of Myology, Pitié-Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- Bioingénierie, Tissus et Neuroplasticité (BIOTN) EA 7377, University Paris-Est, UPEC, Créteil, France
| | - Jean-Yves Hogrel
- Institute of Myology, Pitié-Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Raphael Porcher
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS-UMR1153), Hôtel-Dieu, AP-HP, Paris, France
| | - Pierre Portero
- Bioingénierie, Tissus et Neuroplasticité (BIOTN) EA 7377, University Paris-Est, UPEC, Créteil, France
- Rothschild Hospital, AP-HP, Paris, France
| | - Bernard Clair
- Intensive Care Unit, Raymond Poincaré Hospital, AP-HP, Garches, France
| | - Bruno Eymard
- Institute of Myology, Pitié-Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Sophie Demeret
- Neurological Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Bassez
- Institute of Myology, Pitié-Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
| | - Marcela Gargiulo
- Institute of Myology, Pitié-Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- Laboratory of Clinical Psychology, Psychopathology, and Psychoanalysis (EA 4056) Paris Descartes University – Sorbonne Paris Cité, Paris, France
| | - Estelle Louët
- Laboratory of Clinical Psychology, Psychopathology, and Psychoanalysis (EA 4056) Paris Descartes University – Sorbonne Paris Cité, Paris, France
| | - Sonia Berrih-Aknin
- UMRS 974 UPMC, INSERM, FRE 3617 CNRS, AIM, Centre of Research in Myology, Paris, France
| | - Asmaa Jobic
- Unité de Recherche Clinique Paris ÎIle- de- France Ouest (URCPO), Ambroise Paré Hospital, Boulogne Billancourt, France
- Raymond Poincaré Hospital, AP-HP, Garches, France
| | - Philippe Aegerter
- Unité de Recherche Clinique Paris ÎIle- de- France Ouest (URCPO), Ambroise Paré Hospital, Boulogne Billancourt, France
- Raymond Poincaré Hospital, AP-HP, Garches, France
- UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, Versailles, France
- INSERM, U1168 VIMA, Villejuif, France
| | | | - Tarek Sharshar
- Intensive Care Unit, Raymond Poincaré Hospital, AP-HP, Garches, France
- University of Versailles, Saint-Quentin-en-Yvelines, France
- Department of Histopathology and Animal Models, Institut Pasteur, Paris, France
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Alanazy MH, Abuzinadah AR, Muayqil T. Translation and validation of the arabic version of the revised 15‐item myasthenia gravis quality‐of‐life questionnaire. Muscle Nerve 2017; 57:581-585. [DOI: 10.1002/mus.25948] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/12/2017] [Accepted: 08/27/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Mohammed H. Alanazy
- Division of NeurologyDepartment of Internal Medicine, King Saud UniversityPO Box 7805, Riyadh11472 Saudi Arabia
| | | | - Taim Muayqil
- Division of NeurologyDepartment of Internal Medicine, King Saud UniversityPO Box 7805, Riyadh11472 Saudi Arabia
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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.
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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
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Mazzoli M, Ariatti A, Valzania F, Kaleci S, Tondelli M, Nichelli PF, Galassi G. Factors affecting outcome in ocular myasthenia gravis. Int J Neurosci 2017. [PMID: 28625092 DOI: 10.1080/00207454.2017.1344237] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIM OF THE STUDY 50%-60% of patients with ocular myasthenia gravis (OMG) progress to generalized myasthenia gravis (GMG) within two years. The aim of our study was to explore factors affecting prognosis of OMG and to test the predictive role of several independent clinical variables. MATERIALS AND METHODS We reviewed a cohort of 168 Caucasian patients followed from September 2000 to January 2016. Several independent variables were considered as prognostic factors: gender, age of onset, results on electrophysiological tests, presence and level of antibodies against acetylcholine receptors (AChR Abs), treatments, thymic abnormalities. The primary outcome was the progression to GMG and/or the presence of bulbar symptoms. Secondary outcomes were either achievement of sustained minimal manifestation status or worsening in ocular quantitative MG subscore (O-QMGS) or worsening in total QMG score (T-QMGS), assessed by Myasthenia Gravis Foundation of America (MGFA) quantitative scores. Changes in mental and physical subscores of health-related quality of life (HRQoL) were assessed with SF-36 questionnaire. Variance analysis was used to interpret the differences between AChR Ab titers at different times of follow up among the generalized and non-generalized patients. RESULTS Conversion to GMG occurred in 18.4% of patients; it was significantly associated with sex, later onset of disease and anti-AChR Ab positivity. Antibody titer above the mean value of 25.8 pmol/mL showed no significant effect on generalization. Sex and late onset of disease significantly affected T-QMGS worsening. None of the other independent variables significantly affected O-QMGS and HRQoL. CONCLUSIONS Sex, later onset and anti-AChR Ab positivity were significantly associated with clinical worsening.
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Affiliation(s)
- Marco Mazzoli
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Alessandra Ariatti
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Franco Valzania
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Shaniko Kaleci
- b Department of Diagnostic Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Manuela Tondelli
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Paolo F Nichelli
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
| | - Giuliana Galassi
- a Department of Biomedical, Metabolic and Neural Sciences , University Hospital , Modena , Italy
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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.
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Strijbos E, Gärtner FR, Verschuuren JJ. Translation and validation of the 15-item Myasthenia Gravis Quality of life scale in Dutch. Muscle Nerve 2017; 57:206-211. [DOI: 10.1002/mus.25641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Ellen Strijbos
- Department of Neurology; Leiden University Medical Center; Albinusdreef 2, 2333 ZA, Leiden The Netherlands
| | - Fania R. Gärtner
- Department of Medical Decision Making; Leiden University Medical Center; Leiden The Netherlands
| | - Jan J. Verschuuren
- Department of Neurology; Leiden University Medical Center; Albinusdreef 2, 2333 ZA, Leiden The Netherlands
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Morren JA, Levin KH, Shields RW. Diagnostic Accuracy of Single Fiber Electromyography for Myasthenia Gravis in Patients Followed Longitudinally. J Clin Neurophysiol 2017; 33:469-474. [PMID: 27749461 DOI: 10.1097/wnp.0000000000000285] [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] Open
Abstract
INTRODUCTION The literature lacks data on accuracy of single fiber electromyography (SFEMG) for myasthenia gravis (MG) patients followed longitudinally. METHODS We included patients with a clinical suspicion of MG who received SFEMG and follow-up at our institution between 2003 and 2013. Data collected included demographics, symptom details, clinical deficits, other diagnostic testing results, MG medication regimen, duration on treatment, response to therapy, and ultimate diagnosis after follow-up. When available, information was also extracted from the MG-specific Activities of Daily Living, MG Quality of Life, and European Quality of Life assessments before and after SFEMG. RESULTS Three hundred forty eight SFEMG patients met inclusion criteria. Myasthenia gravis was ultimately diagnosed in 31% (19% ocular, 12% generalized). A sensitivity of 78% was seen for MG regardless of subtype, 73% for ocular MG, and 85% for generalized MG. A specificity of 91% was obtained for MG of either ocular or generalized subtype. CONCLUSIONS The diagnostic accuracy of SFEMG using this methodology minimizing incorporation bias is more reliable than that usually described in previous studies. There is utility in increasing diagnostic yield when SFEMG results are combined with clinical data and those from other diagnostic tests, particularly serology.
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Affiliation(s)
- John A Morren
- *Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.; and †Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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