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Morganroth J, Zuroff L, Guidon AC, Liu GT, Bird SJ, Singhal S, Wolfe GI, Hamedani AG. Trends and Disparities in the Utilization of Thymectomy for Myasthenia Gravis in the United States. Neurol Clin Pract 2024; 14:e200335. [PMID: 38919930 PMCID: PMC11194790 DOI: 10.1212/cpj.0000000000200335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Abstract
Background and Objectives In 2016, a randomized controlled trial demonstrated the clinical efficacy of trans-sternal thymectomy for patients with non-thymomatous myasthenia gravis (MG). Whether large-scale changes occurred in clinical practice after this trial is unknown. Methods We performed a retrospective longitudinal cross-sectional analysis using National Inpatient Sample (NIS) data from 2012 to 2019. Our study included hospitalized adults at least 18 years of age diagnosed with MG without an associated thymoma. We used joinpoint regression to analyze annual trends in thymectomy volume and surgical approach (minimally invasive vs trans-sternal) from 2012 to 2019. Using logistic regression models, we examined patient and hospital-level factors that may have influenced whether thymectomy was performed, such as age, sex, race, insurance payor, hospital size and teaching status, and Elixhauser Comorbidity Index. Sampling weights were applied to account for the complex survey design of NIS. Results The total number of thymectomy procedures increased by 69.8% per year (95% CI 40.1-105.8) between 2012 and 2019. Trans-sternal thymectomies increased by 62.8% per year (95% CI 35.8-95.2) and minimally invasive thymectomies by 83.7% per year (95% CI 38.1-144.3). Thymectomies were significantly more likely to occur in 2017-2019 compared with 2012-2016 (OR 1.93, 95% CI 1.62-2.31). In a multivariable regression model, several factors decreased the odds of patients with MG having a thymectomy: older age, Black race (OR 0.62, 95% CI 0.49-0.77), female (OR 0.73, 95% CI 0.63-0.86), and higher Elixhauser Comorbidity Index. Patients in medium (OR 1.82, 95% CI 1.30-2.55) or large (OR 2.81, 95% CI 2.07-3.82) size and urban teaching hospitals (OR 6.09, 95% CI 2.65-13.97) were more likely to undergo thymectomy. Discussion Thymectomy is being performed more frequently for non-thymomatous MG, especially after 2016 after publication of a positive phase III clinical trial. There are several disparities in thymectomy utilization that warrant further attention.
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Affiliation(s)
- Jennifer Morganroth
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Leah Zuroff
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amanda C Guidon
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Grant T Liu
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shawn J Bird
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sunil Singhal
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gil I Wolfe
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ali G Hamedani
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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Zhang J, Chen Y, Zhang H, Yang Z, Zhang P. Effects of thymectomy on late-onset non-thymomatous myasthenia gravis: systematic review and meta-analysis. Orphanet J Rare Dis 2021; 16:232. [PMID: 34016126 PMCID: PMC8139042 DOI: 10.1186/s13023-021-01860-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/07/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The effects of thymectomy on late-onset non-thymomatous myasthenia gravis (NTMG) remain controversial. The objective of this study was to conduct a systematic review in order to answer two questions pertinent to late-onset NTMG: (1) do patients with late-onset NTMG experience the same effects from thymectomy as their early-onset counterparts? (2) Compared with conservative treatment, does thymectomy have any benefits for late-onset NTMG patients? METHODS We searched the PubMed, EMBASE, and Cochrane Library databases for studies published from January 1, 1950 to March 10, 2021. Outcomes were measured via clinical stable remission/pharmacological remission (CSR/PR) and improvement rates. We used Stata software to analyze the data. RESULTS We ultimately included a total of 12 observational articles representing the best evidence answering the questions of our study objective. Of these, nine studies, which included 896 patients overall (766 early-onset and 230 late-onset), compared postoperative outcomes between early- and late-onset NTMG. The remaining three articles, which included 216 patients (75 in the thymectomy group and 141 in the conservative-treatment group), compared thymectomy with conservative treatment for late-onset NTMG. The early- versus late-onset NTMG studies demonstrated that patients in the former category were 1.95× likelier than their late-onset counterparts to achieve clinical remission (odds ratio [OR] 1.95; 95% confidence interval [CI] 1.39-2.73; I2 = 0%). No difference was seen in improvement or remission + improvement rates between these two groups. When comparing thymectomy with conservative treatments in late-onset NTMG patients, neither did we observe any difference in CSR/PR. CONCLUSION We found that late-onset NTMG patients had a lower chance of achieving CSR after thymectomy than early-onset patients. Thymectomy in late-onset NTMG also yielded no benefit to CSR or PR compared with conservative treatments. In late-onset NTMG patients, thymectomy should therefore be performed with caution, and the appropriate cutoff between early- and late-onset MG should be further explored in order to tailor and execute the proper therapeutic strategies.
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Affiliation(s)
- Jinwei Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Yuan Chen
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Hui Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Zhaoyu Yang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China.
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Farrugia ME, Goodfellow JA. A Practical Approach to Managing Patients With Myasthenia Gravis-Opinions and a Review of the Literature. Front Neurol 2020; 11:604. [PMID: 32733360 PMCID: PMC7358547 DOI: 10.3389/fneur.2020.00604] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/25/2020] [Indexed: 12/14/2022] Open
Abstract
When the diagnosis of myasthenia gravis (MG) has been secured, the aim of management should be prompt symptom control and the induction of remission or minimal manifestations. Symptom control, with acetylcholinesterase inhibitors such as pyridostigmine, is commonly employed. This may be sufficient in mild disease. There is no single universally accepted treatment regimen. Corticosteroids are the mainstay of immunosuppressive treatment in patients with more than mild MG to induce remission. Immunosuppressive therapies, such as azathioprine are prescribed in addition to but sometimes instead of corticosteroids when background comorbidities preclude or restrict the use of steroids. Rituximab has a role in refractory MG, while plasmapheresis and immunoglobulin therapy are commonly prescribed to treat MG crisis and in some cases of refractory MG. Data from the MGTX trial showed clear evidence that thymectomy is beneficial in patients with acetylcholine receptor (AChR) antibody positive generalized MG, up to the age of 65 years. Minimally invasive thymectomy surgery including robotic-assisted thymectomy surgery has further revolutionized thymectomy and the management of MG. Ocular MG is not life-threatening but can be significantly disabling when diplopia is persistent. There is evidence to support early treatment with corticosteroids when ocular motility is abnormal and fails to respond to symptomatic treatment. Treatment needs to be individualized in the older age-group depending on specific comorbidities. In the younger age-groups, particularly in women, consideration must be given to the potential teratogenicity of certain therapies. Novel therapies are being developed and trialed, including ones that inhibit complement-induced immunological pathways or interfere with antibody-recycling pathways. Fatigue is common in MG and should be duly identified from fatigable weakness and managed with a combination of physical therapy with or without psychological support. MG patients may also develop dysfunctional breathing and the necessary respiratory physiotherapy techniques need to be implemented to alleviate the patient's symptoms of dyspnoea. In this review, we discuss various facets of myasthenia management in adults with ocular and generalized disease, including some practical approaches and our personal opinions based on our experience.
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Affiliation(s)
- Maria Elena Farrugia
- Neurology Department, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - John A Goodfellow
- Neurology Department, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom.,Neuroimmunology Laboratory, Laboratory Medicine and Facilities Building, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Yang H, Liu D, Hong X, Sun H, Zheng Y, Yang B, Wang W. Effectiveness and safety of thymectomy plus prednisone compares with prednisone monotherapy for the treatment of non-thymomatous Myasthenia Gravis: Protocol for a systematic review. Medicine (Baltimore) 2020; 99:e20832. [PMID: 32569233 PMCID: PMC7310738 DOI: 10.1097/md.0000000000020832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The pathogenesis of myasthenia gravis (MG) has strong connection with thymic abnormalities. Thymic hyperplasia or thymoma can be found with most patients. Thymectomy is currently one of the regular treatment in clinic, which is, however, still controversial for non-thymomatous MG. This research will assess the effectiveness and safety of thymectomy plus prednisone compared to prednisone monotherapy for the treatment of non-thymomatous MG systematically. METHODS According to eligibility and ineligibility criteria, 8 databases, including PubMed, EMBASE, the Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Wan-fang Database, Chinese Biomedical Literature Database (CBM), China Science and Technology Journal Database (CSTJ), will be searched to gather the up-to-standard articles from September 2000 to September 2025. Inclusion criteria are as follows: randomized controlled trials of thymectomy plus prednisone for the treatment of non-thymomatous MG. The quantitative myasthenia gravis score (QMG) and the dose of prednisone required will be accepted as the main outcomes. Data synthesis, subgroup analysis, sensitivity analysis, and meta-regression analysis will be conducted using RevMan 5.3 software. We will use Egger or Begg test to evaluate symmetry on a funnel plot which is made to assess reporting bias, and use trial sequential analysis (TSA) to exclude the probability of false positives. RESULTS This systematic review will measure the QMG and the dose of prednisone required, the myasthenia gravis activities of daily living scale scores (MG-ADL), treatment-associated complications, incidence of myasthenic crisis and other aspects to comprehensively assess the clinical benefits of thymectomy plus prednisone for MG patients without thymoma. CONCLUSION The conclusion of this study will achieve convincing evidence to evaluate the effectiveness and safety of thymectomy plus prednisone for the treatment of non-thymomatous MG. PROSPERO REGISTRATION NUMBER CRD 42020167735.
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Affiliation(s)
- Huili Yang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine
- Department of Neurology, Guangdong Provincial Hospital of Chinese Medicine
- Department of Graduate School, Guangzhou University of Chinese Medicine
| | - Dandan Liu
- Department of Graduate School, Guangzhou University of Chinese Medicine
- General Hospital of Southern Theater Command of PLA, Guangzhou
| | - Xinxin Hong
- The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen
| | - Haonan Sun
- Traditional Chinese Medicine Hospital, Xinjiang Medical University, Urumqi, China
| | - Yu Zheng
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine
- Department of Neurology, Guangdong Provincial Hospital of Chinese Medicine
| | - Biying Yang
- The Second Clinical Medical College of Guangzhou University of Chinese Medicine
- Department of Neurology, Guangdong Provincial Hospital of Chinese Medicine
| | - Wanshun Wang
- Department of Graduate School, Guangzhou University of Chinese Medicine
- General Hospital of Southern Theater Command of PLA, Guangzhou
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