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Liang F, Yin Z, Li Y, Li G, Ma J, Zhang H, Xia X, Yao M, Pang X, Wang J, Chang X, Guo J, Zhang W. Constructing and Validating a Nomogram Model for Short-Term Prognosis of Patients with AChR-Ab+ GMG. Neurol Ther 2024; 13:551-562. [PMID: 38427273 PMCID: PMC11136915 DOI: 10.1007/s40120-024-00590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE This study aimed to establish and validate a nomogram prognostic model for predicting short-term efficacy of acetylcholine receptor antibody-positive (AChR-Ab+) generalized myasthenia gravis (GMG). METHODS A retrospective observational study was conducted at the First Hospital of Shanxi Medical University, enrolling patients diagnosed with AChR-Ab+ GMG from May 2020 to September 2022. The primary outcome was the change in the Myasthenia Gravis Foundation of America (MGFA) post-intervention status after 6 months of standard treatment. Predictive factors were identified through univariate and multivariate logistic regression analyses, with significant factors incorporated into the nomogram. The bootstrap test was used for internal validation of the nomogram model. Model performance was assessed using calibration curves, receiver-operating characteristic curve analysis, and decision curve analysis (DCA). RESULTS A total of 90 patients were enrolled, of whom 30 achieved unchanged or worse status after 6 months of standard therapy. Univariate logistic regression analysis showed that quantitative myasthenia gravis score, gender, body mass index, course of disease, hemoglobin levels, and white blood cell counts were six potential predictors. These factors were used for multivariate logistic regression analysis, and a nomogram was constructed. The calibration curve showed that the predicted value was in good agreement with the actual value (p = 0.707), and the area under the curve value (0.792, 95% CI 0.686-0.899) indicated good discrimination ability. DCA suggests that this model has potential clinical application value. CONCLUSION The constructed nomogram, based on key patient indicators, shows promise as a clinically useful tool for predicting the short-term efficacy of treatment of AChR-Ab+ GMG. Validation in larger, multicenter cohorts is needed to further substantiate its applicability.
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Affiliation(s)
- Feng Liang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Zhaoxu Yin
- Department of Neurology, Taiyuan City Central Hospital, Taiyuan, China
| | - Yaqian Li
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Guanxi Li
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Jing Ma
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Huiqiu Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Xiaoqian Xia
- First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Make Yao
- Shanxi Medical University, Taiyuan, China
| | - Xiaomin Pang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Juan Wang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Xueli Chang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Junhong Guo
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China
| | - Wei Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, No. 85, Jiefang South Street, Taiyuan, China.
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Ghimire A, Kunwar B, Aryal B, Gaire A, Bist A, Shah B, Mainali A, Ghimire B, Gajurel BP. Assessing the comparative efficacy of plasmapheresis and Intravenous immunoglobulin in myasthenia gravis treatment: A systematic review and meta-analysis. J Clin Neurosci 2024; 121:1-10. [PMID: 38306763 DOI: 10.1016/j.jocn.2024.01.025] [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: 10/07/2023] [Revised: 11/28/2023] [Accepted: 01/29/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by muscle weakness, posing significant challenges to patients' daily lives. Intravenous immunoglobulin (IVIG) and plasmapheresis are two prominent immunomodulatory therapies used in MG management, but the choice between them remains a clinical dilemma. This systematic review and meta-analysis aim to evaluate the comparative efficacy of IVIG versus plasmapheresis in MG management. METHODS We adhered to PRISMA guidelines and prospectively registered the review protocol in PROSPERO. Systematic search across electronic databases identified 14 studies meeting inclusion criteria. Data from these studies were extracted, and assessed risk of bias. Primary outcomes included clinical efficacy, while secondary outcomes encompassed hospitalization, ventilation, antibody titers, and treatment-related complications. Statistical analysis was conducted using R software. RESULTS The pooled results indicated that patients receiving plasmapheresis had higher odds of any improvement in MG symptoms compared to IVIG. However, change in severity scores did not significantly differ between the two treatments. Hospitalization durations were similar, but IVIG-treated patients tended to have shorter stays. Antibody titers, particularly anti-MUSK antibodies, favored plasmapheresis treatment. Complication rates were comparable between two groups. However, severe complications were more common in plasmapheresis. CONCLUSION This comprehensive analysis suggests that plasmapheresis may offer superior short-term symptom improvement in MG compared to IVIG, while IVIG may lead to shorter hospital stays and lower complication rates. The choice between these treatments should be tailored to individual patient needs and disease characteristics. Further research is needed to explore long-term outcomes and mortality rates in MG management.
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Affiliation(s)
- Anup Ghimire
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal.
| | - Bijay Kunwar
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Binay Aryal
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Arjun Gaire
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Anil Bist
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Bilash Shah
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Atul Mainali
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Bikal Ghimire
- Kantipur Dental College Teaching Hospital &, Research Center, Basundhara, Kathmandu, Nepal
| | - Bikram Prasad Gajurel
- Department of Neurology, Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
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Lasek-Bal A, Wagner-Kusz A, Rogoż B, Cisowska-Babraj M, Gajewska G. Efficacy and Safety of Intravenous Immunoglobulin Treatment in Selected Neurological Diseases-One Centre's Experience Based on the Therapy of 141 Patients. J Clin Med 2023; 12:5983. [PMID: 37762922 PMCID: PMC10531894 DOI: 10.3390/jcm12185983] [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: 08/07/2023] [Revised: 08/28/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Intravenous immunoglobulins (IVIg) are the first-choice drugs for the treatment of certain neuroimmune diseases. The aim of this study was to evaluate the efficacy and safety of IVIg in patients with selected nervous system diseases. METHODS The study enrolled patients who received IVIg in programmes financed by the National Health Fund in Poland. The status of patients upon inclusion and during treatment was assessed using scales dedicated to specific neurological diseases. RESULTS The study enrolled 141 patients aged 56.28 ± 14.72 (51.77% female): 21 patients with myasthenia gravis (MG), 65 with chronic inflammatory demyelinating polyneuropathy (CIDP), 30 with Guillain-Barré syndrome (GBS), 12 with neuromyelitis optica spectrum disorder (NMOSD) and 13 patients with autoimmune encephalitis (AE). Neurological improvement was found in 14 (66.66%) MG patients (with a reduction of at least three points on the Quantitative Myasthenia Gravis Score (QMGS) within 14 days from the completion of the cycle), and in 34 (52.3%) GBS patients (with a reduction of at least one point on the Medical Research Council Scale within 14 days from the completion of the cycle). The parameters with the strongest effect on clinical improvement in MG patients were age [OR 1.033, CI 95% [0.09-1.09], p = 0.049] and baseline QMGS [OR 0.505; CI 95% [0.24-0.87], p = 0.038]. In the majority of CIDP patients (27, 97%) and NMOSD patients (6, 50%), neurological stabilisation was observed (without clinical improvement, defined for CIDP patients as an increase of at least two points on the Lovett Scale after three courses of IVIg were administered, and for NMOSD patients as an increase of at least one point on the Medical Research Council Scale and/or a shift of at least 0.3 logMAR after three courses of treatment). Deep-vein thrombosis was only one serious adverse event in the total group of patients treated with IVIg. CONCLUSIONS The use of IVIg in patients with MG and GBS mostly results in neurological improvement, while in patients with NMOSD and CIDP, it mostly results in disease stabilisation. This could indicate the predominant anti-idiotypic antibody activity of IVIg in acute neuroimmune diseases or during exacerbations in chronic autoimmune diseases. The therapy of AE in comorbid neoplastic disease is burdened with an elevated risk of failure for IVIg. The results of our study confirm the improved safety of IVIg for selected neurological diseases.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, Ziołowa Str. 45/47, 40-735 Katowice, Poland;
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Anna Wagner-Kusz
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, Ziołowa Str. 45/47, 40-735 Katowice, Poland;
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Barbara Rogoż
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Małgorzata Cisowska-Babraj
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
| | - Gabriela Gajewska
- Department of Neurology, Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-735 Katowice, Poland; (B.R.); (M.C.-B.); (G.G.)
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Pinto AA, De Seze J, Jacob A, Reddel S, Yudina A, Tan K. Comparison of IVIg and TPE efficacy in the treatment of neurological disorders: a systematic literature review. Ther Adv Neurol Disord 2023; 16:17562864231154306. [PMID: 37006460 PMCID: PMC10064470 DOI: 10.1177/17562864231154306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/15/2023] [Indexed: 03/31/2023] Open
Abstract
Background: Intravenous immunoglobulin (IVIg) and therapeutic plasma exchange (TPE) are among the main immunotherapies for neurological disorders. Their benefit is greatest in immune-mediated conditions, but their distinct efficacy cannot be simply explained. Objectives: This review aimed to systematically identify studies comparing the efficacy of TPE and IVIg treatments for selected autoimmune neurological disorders and identify optimal therapies for each condition. Data Sources and Methods: PubMed, MEDLINE and Embase databases were searched for original publications from 1990 to 2021. Additional publications were identified via expert recommendations. Conference abstracts older than 2017, review articles and articles without information on TPE and IVIg comparison in title and abstract were excluded. Risks of bias were descriptively addressed, without a meta-analysis. Results: Forty-four studies were included on Guillain–Barré syndrome (20 studies – 12 adult, 5 paediatric, 3 all ages), myasthenia gravis (11 studies –8 adult, 3 paediatric), chronic immune–mediated polyradiculoneuropathy (3 studies –1 adult, 2 paediatric), encephalitis (1 study in adults), neuromyelitis optica spectrum disorders (5 studies –2 adult, 3 all ages) and other conditions (4 studies – all ages). TPE and IVIg were mostly similarly efficacious, measured by clinical outcomes and disease severity scores. Some studies recommended IVIg as easy to administer. TPE procedures, however, have been simplified and the safety has been improved. TPE is currently recommended for management of neuromyelitis optica spectrum disorder relapses and some myasthenia gravis subtypes, in which rapid removal of autoantibodies is crucial. Conclusion: Despite some limitations (e.g. the low evidence levels), this review provides an extensive 30-year-long overview of treatments for various conditions. Both IVIg and TPE are usually comparably efficacious options for autoimmune neurological disorders, with few exceptions. Treatment choices should be patient-tailored and based on available clinical resources. Better designed studies are needed to provide higher-level quality of evidence regarding clinical efficacy of TPE and IVIg treatments.
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Affiliation(s)
| | - Jerome De Seze
- Department of Neurology, CHU Strasbourg, Strasbourg, France
| | - Anu Jacob
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Stephen Reddel
- Department of Neurology, University of Sydney, Sydney, NSW, Australia
| | - Anna Yudina
- Terumo Blood and Cell Technologies, Zaventem, Belgium
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore
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Li Y, Yang S, Dong X, Li Z, Peng Y, Jin W, Chen D, Zhou R, Jiang F, Yan C, Yang H. Factors affecting minimal manifestation status induction in myasthenia gravis. Ther Adv Neurol Disord 2022; 15:17562864221080520. [PMID: 35371293 PMCID: PMC8968991 DOI: 10.1177/17562864221080520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 01/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Minimal manifestation status (MMS) is an important landmark in the treatment of myasthenia gravis (MG), and predictors of MMS induction have rarely been identified in previous studies. Objective: The objective of this study is to evaluate the clinical factors associated with MMS induction among patients with MG. Design: This two-step retrospective cohort study with a single center investigated the factors that may be associated with MMS induction and retested these predictors in a test cohort. Methods: A total of 388 diagnosed MG patients who visited Xiangya Hospital between 1 July 2015 and 1 July 2019 were involved. We performed detailed chart reviews and recorded all cases achieving MMS. Demographics and clinical characteristics were also collected and their relationships to achieving MMS were investigated. Results: MMS was achieved in 124 patients (50.2%), and the median time to achieve MMS was 26 months. Several factors were found to be associated with MMS induction in exploring cohort, including muscle-specific tyrosine-protein kinase receptor (MuSK) antibody positivity (adjusted hazard ratio, HR = 4.333, 95% confidence interval, CI: 1.862–10.082), isolated ocular involvement (adjusted HR = 1.95, 95% CI: 1.284–2.961), and low baseline quantitative myasthenia gravis score (QMG score; adjusted HR = 2.022, 95% CI: 1.086–3.764). These factors were then retested in the test cohort. Isolated ocular involvement or low baseline QMG scores were factors found to be beneficial for MMS induction were confirmed. Conclusion: Isolated ocular involvement and low baseline QMG score are predictors of MMS induction in MG patients.
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Affiliation(s)
- Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Shumei Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Xiaohua Dong
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Zhibin Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Yuyao Peng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Wanlin Jin
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Di Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Ran Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Fei Jiang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Chengkai Yan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
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Salari N, Fatahi B, Bartina Y, Kazeminia M, Fatahian R, Mohammadi P, Shohaimi S, Mohammadi M. Global prevalence of myasthenia gravis and the effectiveness of common drugs in its treatment: a systematic review and meta-analysis. J Transl Med 2021; 19:516. [PMID: 34930325 PMCID: PMC8686543 DOI: 10.1186/s12967-021-03185-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Myasthenia gravis is a neuromuscular autoimmune disorder characterized by weakness and disability in the voluntary muscles. There have been several preliminary studies on the epidemiology of myasthenia gravis in different parts of the world and the effectiveness of common drugs in its treatment, but there has been no comprehensive study of the efficacy of common drugs in the treatment of myasthenia gravis. Therefore, this study aimed to determine the epidemiology of myasthenia gravis globally and the effectiveness of common drugs in its treatment using systematic review and meta-analysis. METHODS Research studies were extracted from IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Sciences (WoS), ProQuest, Medline (PubMed), Scopus and Google Scholar based on Cochran's seven-step guidelines using existing keywords extracted in MeSH browser. The I2 test was used to calculate the heterogeneity of studies, and Begg and Mazumdar rank correlation tests were used to assess publication bias. Data were analyzed using Comprehensive Meta-Analysis software (Version 2). RESULTS In the search for descriptive studies based on the research question, 7374 articles were found. After deleting articles unrelated to the research question, finally, 63 articles with a sample size of 1,206,961,907 people were included in the meta-analysis. The prevalence of MG worldwide was estimated to be 12.4 people (95% CI 10.6-14.5) per 100,000 population. For analytical studies on the effectiveness of common myasthenia gravis drugs, 4672 articles were found initially, and after removing articles unrelated to the research question, finally, 20 articles with a sample size of 643 people in the drug group and 619 people in the placebo group were included in the study. As a result of the combination of studies, the difference between the mean QMGS score index after taking Mycophenolate and Immunoglobulin or plasma exchange drugs in the group of patients showed a significant decrease of 1.4 ± 0.77 and 0.62 ± 0.28, respectively (P < 0.01). CONCLUSION The results of systematic review of drug evaluation in patients with myasthenia gravis showed that Mycophenolate and Immunoglobulin or plasma exchange drugs have positive effects in the treatment of MG. It also represents the positive effect of immunoglobulin or plasma exchange on reducing SFEMG index and QMGS index and the positive effect of Mycophenolate in reducing MG-ADL index, SFEMG and Anti-AChR antibodies index. In addition, based on a meta-analysis of the random-effect model, the overall prevalence of MG in the world is 12.4 people per 100,000 population, which indicates the urgent need for attention to this disease for prevention and treatment.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnaz Fatahi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yalda Bartina
- Department of Translation Studies, Faculty of Literature, Istanbul University, Istanbul, Turkey
| | - Mohsen Kazeminia
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Fatahian
- Department of Neurosurgery, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Payam Mohammadi
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor Malaysia
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran
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Ipe TS, Davis AR, Raval JS. Therapeutic Plasma Exchange in Myasthenia Gravis: A Systematic Literature Review and Meta-Analysis of Comparative Evidence. Front Neurol 2021; 12:662856. [PMID: 34531809 PMCID: PMC8439193 DOI: 10.3389/fneur.2021.662856] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/12/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Patients with Myasthenia Gravis (MG) can be treated acutely with therapeutic plasma exchange (TPE) or intravenous immune globulin (IVIG). To date, there is no definitive understanding of which of the two treatments is more effective and safer. The purpose of this study was to systematically review the literature on the comparative efficacy and safety of TPE to other available treatments for MG. Methods: A systematic literature search for studies published between 1997 and 2017 was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using two database sources, MEDLINE (through the PubMed database) and Cochrane Library. Results: The search strategy resulted in 535 articles whose abstracts were reviewed. Among these, 165 full texts articles were reviewed for eligibility and 101 articles were excluded. Of the 165 articles, 64 articles were included for a systematic literature and 11 articles for a meta-analysis. Conclusions: This systematic literature review and meta-analysis of treatment options showed that there was a higher response rate with TPE than IVIG in acute MG patients and patients undergoing thymectomy. There was no difference in mortality between the two treatment options. Our findings highlight the need for additional randomized clinical trials in these patients with MG.
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Affiliation(s)
- Tina S. Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Adeola R. Davis
- Terumo Blood and Cell Technologies, Lakewood, CO, United States
| | - Jay S. Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM, United States
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Zhao R, Wang Y, Huan X, Zhong H, Zhou Z, Xi J, Da Y, Lei L, Chang T, Ruan Z, Luo L, Li S, Yang H, Li Y, Luo S, Zhao C. Nomogram for short-term outcome assessment in AChR subtype generalized myasthenia gravis. J Transl Med 2021; 19:285. [PMID: 34193193 PMCID: PMC8247112 DOI: 10.1186/s12967-021-02961-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/24/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND An accurate prediction for prognosis can help in guiding the therapeutic options and optimizing the trial design for generalized myasthenia gravis (gMG). We aimed to develop and validate a predictive nomogram to assess the short-term outcome in patients with the anti-acetylcholine receptor (AChR) subtype gMG. METHODS We retrospectively reviewed 165 patients with AChR subtype gMG who were immunotherapy naïve at the first visit from five tertiary centers in China. The short-term clinical outcome is defined as the achievement of minimal symptom expression (MSE) at 12 months. Of them, 120 gMG patients from Huashan Hospital were enrolled to form a derivation cohort (n = 96) and a temporal validation cohort (n = 24) for the nomogram. Then, this nomogram was externally validated using 45 immunotherapy naïve AChR subtype gMG from the other four hospitals. Multivariate logistic regression was used to screen independent factors and construct the nomogram. RESULTS MSE was achieved in 70 (72.9%), 20 (83.3%), and 33 (73.3%) patients in the training, temporal validation, and external validation cohort, respectively. The duration ≤ 12 months (p = 0.021), ocular score ≤ 2 (p = 0.006), QMG score > 13 (p = 0.008), and gross motor score ≤ 9 (p = 0.006) were statistically associated with MSE in AChR subtype gMG. The nomogram has good performance in predicting MSE as the concordance indexes are 0.81 (95% CI, 0.72-0.90) in the development cohort, 0.944 (95% CI, 0.83-1.00) in the temporal validation cohort, and 0.773 (95% CI, 0.63-0.92) in the external validation cohort. CONCLUSION The nomogram achieved an optimal prediction of MSE in AChR subtype gMG patients using the baseline clinical characters.
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Affiliation(s)
- Rui Zhao
- Department of Neurology, Huashan Hospital Fudan University, No.12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Ying Wang
- Department of Pharmacy, Huashan Hospital Fudan University, Shanghai, China
| | - Xiao Huan
- Department of Neurology, Huashan Hospital Fudan University, No.12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Huahua Zhong
- Department of Neurology, Huashan Hospital Fudan University, No.12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Zhirui Zhou
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital Fudan University, No.12 Middle Wulumuqi Road, Shanghai, 200040, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lin Lei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital, Wuhan, China
| | - Shengnan Li
- Department of Neurology, Wuhan No.1 Hospital, Wuhan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital Fudan University, No.12 Middle Wulumuqi Road, Shanghai, 200040, China.
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital Fudan University, No.12 Middle Wulumuqi Road, Shanghai, 200040, China.
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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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Galassi G, Mazzoli M, Ariatti A, Kaleci S, Valzania F, Nichelli PF. Antibody profile may predict outcome in ocular myasthenia gravis. Acta Neurol Belg 2018; 118:435-443. [PMID: 29858757 DOI: 10.1007/s13760-018-0943-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/15/2018] [Indexed: 02/04/2023]
Abstract
An unsolved issue remains whether there are clinical and immunological features to predict in a single patient the risk of conversion from ocular Myasthenia Gravis (OMG) to generalized disease (GMG) as 50-60% of patients may progress within 1-2 years since onset. Anti-acetylcholine receptor antibodies (AChR Abs) are found in up to 50% of OMG patients; muscle-specific tyrosine kinase antibodies (MuSK-Abs) are present in about 70% of the whole seronegative (SN), who usually develop a severe disease with bulbar involvement. We surveyed a cohort of 175 OMG patients with purely ocular symptoms and we compare the outcome of patients with antibodies to AChR or to MuSK with those seronegative for both Abs (DSN). All patients had purely ocular signs for at least 24 months. Gender, age at onset, time to generalization or to worsening in quantitative ocular QMG scores, electrophysiological results were analyzed. Males were 58.9%, females 41.1%. Patients with late onset of symptoms after 50 years (LOMG) were 78.3%. We assayed anti-MuSK-Abs in 4.7%, anti-AChR Abs in 38.5%; 57.3% were defined DSN. Thirty-seven patients (21.1%) progressed to GMG during the observational time: 23 were females, 62% of the whole group of the generalized subjects, 75% of MuSK-positive OMG converted to GMG versus the 26.2% of AChR positive and 13.7% of DSN. Statistical analysis showed that gender and presence of antibodies either to AChR or to MuSK were independent predictors of worse outcome; the DSN subjects had lower risk of conversion to GMG.
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Affiliation(s)
- Giuliana Galassi
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy.
| | - Marco Mazzoli
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy
| | - Shaniko Kaleci
- Department of Diagnostic Clinical Medicine and Public Health, University of Modena, Modena, Italy
| | - Franco Valzania
- Department of Neurology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Paolo F Nichelli
- Department of Biomedical, Metabolic and Neural Sciences, University Hospital, Modena, Italy
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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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Single-fiber electromyography of facial and limb muscles in diabetic patients with or without neuropathy. J Clin Neurophysiol 2015; 31:450-5. [PMID: 25271685 DOI: 10.1097/wnp.0000000000000087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE In diabetic patients, single-fiber electromyography (SFEMG) is often abnormal in the limb muscles and is considered unreliable in diagnosis of synaptic disorders. We aimed to compare SFEMG abnormalities of frontalis muscle (FM) and extensor digitorum communis muscle in diabetic patients with neuropathy and without neuropathy. METHODS Stimulation SFEMG of FM and extensor digitorum communis muscle was performed in matched groups of 30 diabetic patients with neuropathy and 20 diabetic patients without neuropathy. RESULTS Single-fiber electromyography in the FM was abnormal in four diabetic patients with neuropathy and in one diabetic patient without neuropathy. Changes were rather mild. Extensor digitorum communis abnormalities were significantly more frequent-in 20 diabetic patients with neuropathy and in 7 diabetic patients without neuropathy (P < 0.001). We never observed a patient with abnormal FM but normal extensor digitorum communis muscle. CONCLUSIONS In diabetes, FM exhibits rare and quite mild SFEMG changes. This muscle may be suitable for SFEMG in diabetic patients with clinical suspicion for synaptic disorder.
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Alabdali M, Barnett C, Katzberg H, Breiner A, Bril V. Intravenous immunoglobulin as treatment for myasthenia gravis: current evidence and outcomes. Expert Rev Clin Immunol 2014; 10:1659-65. [PMID: 25331319 DOI: 10.1586/1744666x.2014.971757] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We examined the current evidence for the efficacy of IV immunoglobulin (IVIG) in myasthenia gravis (MG) and the outcomes used to demonstrate this efficacy. There is class 1 evidence for the use of short-term IVIG in MG patients worsening MG and also good evidence for IVIG use in myasthenic crisis. For long-term maintenance therapy, controlled studies are lacking and the evidence is limited to class III retrospective studies. The clinical scales, serological, electrophysiological, and patient-reported quality of life outcomes with IVIG have been assessed. At this time, the quantitative myasthenia gravis score, a functional scale, remains the preferable outcome measure as it has demonstrated responsiveness in the clinical trial setting, but a scale incorporating patient-reported outcomes and the patients complaint of fatigue is likely to be preferable. The MG-composite is such a scale, but has measurement limitations that may reduce its sensitivity. Across trials, IVIG has generally been well tolerated.
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Affiliation(s)
- Majed Alabdali
- Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, M5A 4H9, Canada
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14
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Katzberg HD, Barnett C, Merkies IS, Bril V. Minimal clinically important difference in myasthenia gravis: Outcomes from a randomized trial. Muscle Nerve 2014; 49:661-5. [DOI: 10.1002/mus.23988] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 01/22/2023]
Affiliation(s)
- Hans D. Katzberg
- University Health Network, Division of Neurology; Toronto General Hospital; 200 Elizabeth Street, 5ES-306 Toronto Ontario M5G 2C4 Canada
| | - Carolina Barnett
- University Health Network, Division of Neurology; Toronto General Hospital; 200 Elizabeth Street, 5ES-306 Toronto Ontario M5G 2C4 Canada
| | - Ingemar S.J. Merkies
- Department of Neurology; Spaarne Hospital, Hoofddorp and Maastricht University Medical Centre; Maastricht The Netherlands
| | - Vera Bril
- University Health Network, Division of Neurology; Toronto General Hospital; 200 Elizabeth Street, 5ES-306 Toronto Ontario M5G 2C4 Canada
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Ariatti A, Stefani M, Miceli P, Benuzzi F, Galassi G. Prognostic factors and health-related quality of life in ocular Myasthenia Gravis (OMG). Int J Neurosci 2013; 124:427-35. [PMID: 24228829 DOI: 10.3109/00207454.2013.853664] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluate the factors predictive of prognosis in 91 Caucasian patients affected by ocular myasthenia gravis (OMG), followed at our Institution during an observational time, ranging from 12 to 240 months. The Myasthenia Gravis Foundation of America (MGFA) clinical classification was used to grade the disease severity. We considered as outcome measures the variation in two subscores, ocular (O-QMG) and nonocular (NO-QMG); the last one reflected bulbar, neck, extremity functions. None of the independent variables evaluated for association with the outcome, as age of onset, type of therapy, length of interval between first and last examinations, and presence of antibodies to acetylcholine receptors (AChR-Abs) significantly affected the evolution of O-QMG and of NO-QMG. Health-related quality of life (HRQol) was assessed in 63 patients. Variations of diplopia or ptosis did not affect significantly physical (PCS) or mental composite subscores (MCS) of the Short-Form Health Survey (SF-36). Human leukocyte antigen (HLA) genotyping was studied to explore whether HLA class I and II allelic distribution differed among MG patients and controls. None of the studied HLA alleles significantly differed between OMG patients and controls. Similarly, none of the alleles with frequencies higher than 15% either in OMG patients or in controls was significantly associated, after Bonferroni correction, with the presence or absence of anti-AChR-Abs in serum.
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Affiliation(s)
- Alessandra Ariatti
- Department of Neurosciences, and Department of Onco-Haematology, University Hospitals of Modena & Reggio Emilia , Italy
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Ebadi H, Barth D, Bril V. Safety of plasma exchange therapy in patients with myasthenia gravis. Muscle Nerve 2013; 47:510-4. [DOI: 10.1002/mus.23626] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2012] [Indexed: 12/17/2022]
Affiliation(s)
- Hamid Ebadi
- Division of Neurology, University Health Network; University of Toronto; 5EC-309, 200 Elizabeth Street Toronto Ontario M5G 2C4 Canada
| | - David Barth
- Division of Hematological Pathology, Department of Laboratory Medicine; University Health Network, University of Toronto; Toronto Ontario Canada
| | - Vera Bril
- Division of Neurology, University Health Network; University of Toronto; 5EC-309, 200 Elizabeth Street Toronto Ontario M5G 2C4 Canada
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Bril V, Barnett-Tapia C, Barth D, Katzberg HD. IVIG and PLEX in the treatment of myasthenia gravis. Ann N Y Acad Sci 2012; 1275:1-6. [DOI: 10.1111/j.1749-6632.2012.06767.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Li HF, Liu T, Hong Y, Zhang HL. Potential predictors of response to immunomodulation in patients with myasthenia gravis. Muscle Nerve 2012; 46:982-3; author reply 983. [PMID: 23225397 DOI: 10.1002/mus.23495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 06/06/2012] [Accepted: 06/07/2012] [Indexed: 11/11/2022]
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