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Effect of thymectomy in elderly patients with non-thymomatous generalized myasthenia gravis. J Neurol 2019; 266:960-968. [PMID: 30726532 DOI: 10.1007/s00415-019-09222-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 01/25/2019] [Accepted: 01/30/2019] [Indexed: 01/09/2023]
Abstract
Whether thymectomy is beneficial in elderly patients with myasthenia gravis (MG) is unclear. Thus, we assessed whether conducting thymectomy in MG patients aged ≥ 50 years is beneficial. This retrospective cohort study included patients with MG between 1990 and 2018. Thymectomy and control cohorts were selected from among the population of MG patients with an age at onset of ≥ 45 years and elevated concentrations of acetylcholine-receptor antibodies. Patients with evidence of thymic malignancy were excluded. Of these patients, those who underwent thymectomy at the age of ≥ 50 years were designated as the thymectomy group and those who received only medical treatment were designated as the medical treatment group. We compared the Myasthenia Gravis Foundation of America post-intervention status between the thymectomy and medical treatment groups. Landmark analysis was conducted with the landmark set at 24 months. A total of 34 and 105 patients were classified into the thymectomy and medical treatment groups, respectively. Before landmark analysis, the thymectomy group had a higher cumulative incidence of pharmacologic remission (p = 0.009) and complete stable remission (p = 0.022) than the medical treatment group. After landmark analysis, the thymectomy group had a 2.22-fold (95% confidence interval 1.01-4.80) increased chance of achieving pharmacologic remission compared to the medical treatment group after adjustment for age, sex, and disease severity. No significant difference was observed in the rate of relapse after pharmacological remission between the thymectomy (16.7%) and medical treatment groups (21.4%). In conclusion, thymectomy may have a beneficial effect in elderly patients with non-thymomatous generalized MG.
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Tang M, Li W, Liu P, He F, Ji F, Meng F. Blepharospasm with elevated anti-acetylcholine receptor antibody titer. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:522-526. [PMID: 30231125 DOI: 10.1590/0004-282x20180076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 05/04/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To determine whether serum levels of anti-acetylcholine receptor antibody (anti-AChR-Abs) are related to clinical parameters of blepharospasm (BSP). METHODS Eighty-three adults with BSP, 60 outpatients with hemifacial spasm (HFS) and 58 controls were recruited. Personal history, demographic factors, response to botulinum toxin type A (BoNT-A) and other neurological conditions were recorded. Anti-AChR-Abs levels were quantified using an enzyme-linked immunosorbent assay. RESULTS The anti-AChR Abs levels were 0.237 ± 0.022 optical density units in the BSP group, which was significantly different from the HFS group (0.160 ± 0.064) and control group (0.126 ± 0.038). The anti-AChR Abs level was correlated with age and the duration of response to the BoNT-A injection. CONCLUSION Patients with BSP had an elevated anti-AChR Abs titer, which suggests that dysimmunity plays a role in the onset of BSP. An increased anti-AChR Abs titer may be a predictor for poor response to BoNT-A in BSP.
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Affiliation(s)
- Min Tang
- Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China
| | - Wu Li
- Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, Province, P.R. China
| | - Ping Liu
- Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China
| | - Fangping He
- Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China
| | - Fang Ji
- Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China
| | - Fanxia Meng
- Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China
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Nakahara K, Nakane S, Nakajima M, Yamashita S, Mori T, Ando Y. Effect of thymectomy for thymic atrophy in myasthenia gravis: A retrospective study on 93 patients. J Neuroimmunol 2017; 305:182-185. [PMID: 28100409 DOI: 10.1016/j.jneuroim.2017.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/22/2016] [Accepted: 01/11/2017] [Indexed: 12/28/2022]
Abstract
To clarify the efficacy of thymectomy among myasthenia gravis (MG) patients with and without thymoma. We classified MG patients who underwent thymectomy into 3 groups, such as thymic atrophy group, thymic follicular hyperplasia (TFH) group and thymoma group. We compared the data of clinical features and postoperative prognosis at very short-term, short-term, and medium-term. The clinical course of MG patients with atrophic thymus after thymectomy was even better than those of TFH or thymoma, in this retrospective study. However, we found no significant differences in the comparison of mean dose of prednisolone between the 3 groups at each time point.
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Affiliation(s)
- Keiichi Nakahara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan.
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Satoshi Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Takeshi Mori
- Department of Thoracic Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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Nishikawa N, Nagai M, Tsujii T, Kyaw WT, Tanabe N, Iwaki H, Yabe H, Ando R, Nomoto M. Treatment of Myasthenia Gravis in Patients with Elderly Onset at Advanced Age. JAPANESE CLINICAL MEDICINE 2015; 6:9-13. [PMID: 26279637 PMCID: PMC4514170 DOI: 10.4137/jcm.s29601] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/15/2015] [Accepted: 06/18/2015] [Indexed: 11/15/2022]
Abstract
The number of patients with late-onset myasthenia gravis (MG) among patients ≥50 years has been increasing recently. We encountered three patients who developed elderly-onset MG at a particularly advanced age (≥80 years). All were female and positive for anti-acetylcholine receptor antibodies. About 4 years have passed since MG onset in all three patients and symptoms have been controlled without recurrence using a combination of oral low-dose prednisolone and tacrolimus. As many cases of elderly-onset MG do not require strong immunosuppression, we recommend minimum immunosuppressive treatment to avoid adverse events, particularly in patients at an advanced age of ≥80 years.
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Affiliation(s)
- Noriko Nishikawa
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Masahiro Nagai
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Tomoaki Tsujii
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Win T Kyaw
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Nachi Tanabe
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Hirotaka Iwaki
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Hayato Yabe
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Rina Ando
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
| | - Masahiro Nomoto
- Department of Neurology and Clinical Pharmacology, Ehime University Graduate School of Medicine, Shitsukawa Tohon, Ehime, Japan
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Kadota Y, Horio H, Mori T, Sawabata N, Goto T, Yamashita SI, Nagayasu T, Iwasaki A. Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014. Gen Thorac Cardiovasc Surg 2015; 63:201-15. [PMID: 25608954 DOI: 10.1007/s11748-015-0518-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 01/21/2023]
Abstract
Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.
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Affiliation(s)
- Yoshihisa Kadota
- Guidelines Committees of Japanese Association for Chest Surgery, Kyoto, Japan,
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The association of PTPN22 R620W polymorphism is stronger with late-onset AChR-myasthenia gravis in Turkey. PLoS One 2014; 9:e104760. [PMID: 25119822 PMCID: PMC4132102 DOI: 10.1371/journal.pone.0104760] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/14/2014] [Indexed: 11/19/2022] Open
Abstract
A functional single nucleotide polymorphism (SNP) of the PTPN22 gene encoding a protein tyrosine phosphatase has been associated with autoimmune disorders including myasthenia gravis (MG). As the PTPN22 R620W polymorphism has a wide variation of allele frequencies among different populations, this polymorphism was investigated in MG in Turkey. An emphasis is put on MG subgroups according to autoantibody (Abs) production and presence of thymoma. DNA samples from 416 patients with clinically diagnosed generalized MG (231 with Abs to acetylcholine receptor, AChR-MG), 53 with Abs to muscle-specific kinase (MuSK-MG), 55 patients with no detectable Abs (SN-MG), 77 patients with thymoma (TAMG) and 293 healthy controls (HC) were genotyped for the SNP (PTPN22 R620W, C1858T, rs2476601). The PTPN22 T allele was increased in AChR-MG patients (odds ratio [OR]: 2.5, 95%CI: 1.2–5.1). The association was stronger in late disease-onset AChR (LOMG, OR: 3.1, 95%CI: 1.2–8.2). MuSK-MG, SN-MG and TAMG groups did not carry the variant allele more frequently than the HC. In contrast to findings in other autoimmune diseases, the distribution of the PTPN22 polymorphism in this population provides a susceptibility marker for AChR-MG. The strongest association is detected in patients with LOMG.
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Chuang WY, Ströbel P, Bohlender-Willke AL, Rieckmann P, Nix W, Schalke B, Gold R, Opitz A, Klinker E, Inoue M, Müller-Hermelink HK, Saruhan-Direskeneli G, Bugert P, Willcox N, Marx A. Late-onset myasthenia gravis - CTLA4(low) genotype association and low-for-age thymic output of naïve T cells. J Autoimmun 2013; 52:122-9. [PMID: 24373506 DOI: 10.1016/j.jaut.2013.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 12/08/2013] [Indexed: 11/28/2022]
Abstract
Late-onset myasthenia gravis (LOMG) has become the largest MG subgroup, but the underlying pathogenetic mechanisms remain mysterious. Among the few etiological clues are the almost unique serologic parallels between LOMG and thymoma-associated MG (TAMG), notably autoantibodies against acetylcholine receptors, titin, ryanodine receptor, type I interferons or IL-12. This is why we checked LOMG patients for two further peculiar features of TAMG - its associations with the CTLA4(high/gain-of-function) +49A/A genotype and with increased thymic export of naïve T cells into the blood, possibly after defective negative selection in AIRE-deficient thymomas. We analyzed genomic DNA from 116 Caucasian LOMG patients for CTLA4 alleles by PCR/restriction fragment length polymorphism, and blood mononuclear cells for recent thymic emigrants by quantitative PCR for T cell receptor excision circles. In sharp contrast with TAMG, we now find that: i) CTLA4(low) +49G(+) genotypes were more frequent (p = 0.0029) among the 69 LOMG patients with age at onset ≥60 years compared with 172 healthy controls; ii) thymic export of naïve T cells from the non-neoplastic thymuses of 36 LOMG patients was lower (p = 0.0058) at diagnosis than in 77 age-matched controls. These new findings are important because they suggest distinct initiating mechanisms in TAMG and LOMG and hint at aberrant immuno-regulation in the periphery in LOMG. We therefore propose alternate defects in central thymic or peripheral tolerance induction in TAMG and LOMG converging on similar final outcomes. In addition, our data support a 60-year-threshold for onset of 'true LOMG' and an LOMG/early-onset MG overlapping group of patients between 40 and 60.
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Affiliation(s)
- Wen-Yu Chuang
- Institute of Pathology, University of Würzburg, Würzburg, Germany; Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Philipp Ströbel
- Institute of Pathology, University of Würzburg, Würzburg, Germany; Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68135 Mannheim, Germany.
| | - Anna-Lena Bohlender-Willke
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68135 Mannheim, Germany.
| | - Peter Rieckmann
- Department of Neurology, University of Würzburg, Würzburg, Germany.
| | - Wilfred Nix
- Department of Neurology, University of Mainz, Langenbeckstrasse 1, D-55101 Mainz, Germany.
| | - Berthold Schalke
- Department of Neurology, University of Regensburg, Bezirkskrankenhaus, D-93042 Regensburg, Germany.
| | - Ralf Gold
- Department of Neurology, University of Bochum, Bochum, Germany.
| | - Andreas Opitz
- Department of Transfusion Medicine, University of Würzburg, Josef-Schneider-Strasse 2, D-97080 Würzburg, Germany.
| | - Erdwine Klinker
- Department of Transfusion Medicine, University of Würzburg, Josef-Schneider-Strasse 2, D-97080 Würzburg, Germany.
| | - Masayoshi Inoue
- Institute of Pathology, University of Würzburg, Würzburg, Germany.
| | | | - Güher Saruhan-Direskeneli
- Department of Physiology, University of Istanbul, Istanbul Tip Fakultesi, Temel Bilimler, 34093 CAPA-Istanbul, Turkey.
| | - Peter Bugert
- Department of Transfusion Medicine and Immunology, University Medical Centre Mannheim, University of Heidelberg, Germany.
| | - Nick Willcox
- Department of Clinical Neurology, Weatherall Institute for Molecular Medicine, University of Oxford, WIMM, Headington OX3 9DS, UK.
| | - Alexander Marx
- Institute of Pathology, University of Würzburg, Würzburg, Germany; Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68135 Mannheim, Germany.
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Alkhawajah NM, Oger J. Late-onset myasthenia gravis: A review when incidence in older adults keeps increasing. Muscle Nerve 2013; 48:705-10. [DOI: 10.1002/mus.23964] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2013] [Indexed: 01/26/2023]
Affiliation(s)
- Nuha M. Alkhawajah
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
| | - Joel Oger
- Division of Neurology, Department of Medicine and Brain Research Centre, UBC Hospital; University of British Columbia; 2211 Westbrook Mall Vancouver British Columbia V6T 2B5 Canada
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Abstract
Myasthenia gravis (MG) is caused by the failure of neuromuscular transmission mediated by autoantibodies against acetylcholine receptors (AChR) and muscle-specific receptor tyrosine kinase (MuSK). These seropositivity rates in AChR positive and MuSK positive MG in Japan are 80-85% and 5-10%, respectively. The incidence of late-onset MG has been increasing all over the world. A nationwide epidemiological survey in Japan also revealed that the rates of late-onset MG (onset after 50 years) had increased from 20% in 1987 to 42% in 2006. In 2010, a guideline for standard treatments in late-onset MG was published from Japanese Scoiety of Neurological Therapeutics. Based on individual experiences and the limited evidence, epidemiological characteristics of MG onset age, clinical features, and the standard treatment for late-onset patients are included in it. In this guideline summary, the ocular form was more frequent in late-onset compared to early-onset group, the indication of thymectomy in late-onset MG is less than that of early-onset MG and the combination of corticosteroids and immunosuppressive agents are recommended in order to reduce doses of corticosteroids in late-onset MG.
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Affiliation(s)
- Masakatsu Motomura
- Department of Clinical Neuroscience and Neurology, Graduate School of Biomedical Scineces, Nagasaki University
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Liu JF, Wang WX, Xue J, Zhao CB, You HZ, Lu JH, Gu Y. Comparing the Autoantibody Levels and Clinical Efficacy of Double Filtration Plasmapheresis, Immunoadsorption, and Intravenous Immunoglobulin for the Treatment of Late-onset Myasthenia Gravis. Ther Apher Dial 2010; 14:153-60. [DOI: 10.1111/j.1744-9987.2009.00751.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tang YC, Thoman M, Linton PJ, Deisseroth A. Use of CD40L immunoconjugates to overcome the defective immune response to vaccines for infections and cancer in the aged. Cancer Immunol Immunother 2009; 58:1949-57. [PMID: 19444444 PMCID: PMC11030823 DOI: 10.1007/s00262-009-0718-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 04/20/2009] [Indexed: 10/20/2022]
Abstract
Multiple investigators have reported the presence of defects in the immune response of the elderly [Castle In: Clin Infect Dis 31:578, 2000; Ortqvist et al. In: Eur Respir J 30:414-422, 2007; Saurwein-Teissl et al. In: J Immunol 168:5893, 2002; Haynes et al. In: Proc Natl Acad Sci USA 100:15053-15058, 2003]. These defects reduce the magnitude of the immune response to infection and to vaccination. In individuals greater than 55 years of age, the probability of developing a fully protective neutralizing antibody response to the yearly multivalent particle inactivated influenza vaccine is less than 20% [Jefferson et al. In: Lancet 264:1165-1174, 2005; Goodwin et al. In: Vaccine 24:1159-1169, 2006; Jackson et al. In: Lancet 372:398-405, 2008; Simonsen and Taylor In: Lancet 7:658-666, 2007]. The defects in the aged immune system that are responsible for this limited response to vaccination in the older age groups include functional defects of the antigen presenting cells, functional defects in CD4 helper CD4 T cells and monocytes, and an altered microenvironment [Eaton et al. In: J Exp Med 200:1613-1622, 2004; Dong et al. In: J Gen Virol 84:1623-1628, 2003; Deng et al. In: Immunology 172:3437-3446, 2004; Cella et al. In: J Exp Med 184:747-752, 1996]. Starting at puberty, the involution of the thymus and the consequent reduction of the export of naïve T cells specific to neo-antigens leads to the reduction of the ratio of antigen naïve to memory cells as chronological age advances [Prelog In: Autoimmun Rev 5:136-139, 2006; McElhaney et al. In: J Immunology 176:6333-6339, 2006]. Changes in glycosylation of T cells and target antigens acquired during the aging process and the antibodies to these new glycopeptides and glycoproteins may also contribute to a reduction in the functioning of the adaptive immune response [Ishii et al. In: J Clin Neurosci 14:110-115, 2007; Shirai et al. In: Clin Exp Immunol 12:455-464, 1972; Adkins and Riley In: Mech Ageing Dev 103:147-164, 1998; Ben-Yehuda and Weksler In: Cancer Investigation 10:525-531, 1992]. One of the more interesting examples of the functional defects in the cells of the adaptive immune response is a reduced level of expression in the surface cytoadhesion and activation receptor molecules on CD4 helper T cells undergoing activation during vaccination. Upon infection or vaccination, CD40L is typically increased on the surface of CD4 helper T cells during activation, and this increased expression is absolutely essential to the CD40L promotion of expansion of antigen-specific B cells and CD 8 effector T cells in response to infection or vaccination [Singh et al. In: Protein Sci 7:1124-1135, 1998; Grewal and Flavell In: Immunol Res 16: 59-70, 1997; Kornbluth In: J Hematother Stem Cell Res 11:787-801, 2002; Garcia de Vinuesa et al. In: Eur J Immunol 29:3216-3224, 1999]. In aged human beings and mice, the reduced levels of expression of CD40 ligand (CD40L) in activated CD4 helper T cells is dramatically reduced [Eaton et al. In: J Exp Med 200:1613-1622, 2004; Dong et al. In: J Gen Virol 84:1623-1628, 2003]. To circumvent the reduction in CD40L expression and the subsequent reduction in immune response in the elderly, we have developed a chimeric vaccine comprised of the CD40L linked to the target antigen, in a replication incompetent adenoviral vector and in booster protein. This review will discuss the implementation the potential use of this approach for the vaccination of the older populations for cancer and infection.
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Affiliation(s)
- Yu Cheng Tang
- Sidney Kimmel Cancer Center, San Diego, CA 92121 USA
| | | | | | - Albert Deisseroth
- Sidney Kimmel Cancer Center, San Diego, CA 92121 USA
- Present Address: USFDA, Office of Oncology Drug Products, 10903 New Hampshire Avenue, Bldg. 22, Room 6378, Silver Spring, MD 20993 USA
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Expanded TCR Vβ subsets of CD8+ T-cells in late-onset myasthenia gravis: Novel parallels with thymoma patients. J Neuroimmunol 2009; 216:85-91. [DOI: 10.1016/j.jneuroim.2009.08.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 08/26/2009] [Accepted: 08/28/2009] [Indexed: 11/22/2022]
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Lane R, Wade J, McGonagle D. Myasthenia gravis precipitated by trauma: Latent myasthenia and the concept of ‘threshold’. Neuromuscul Disord 2009; 19:773-5. [DOI: 10.1016/j.nmd.2009.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 04/26/2009] [Accepted: 07/31/2009] [Indexed: 11/28/2022]
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