Fatigue, physical activity and associated factors in 779 patients with myasthenia gravis

Quality of life in hypokalemic periodic paralysis - a survey

Primary hypokalemic periodic paralysis (HypoPP) is a skeletal muscle channelopathy most commonly caused by pathogenic variants in the calcium channel gene, CACNA1S. HypoPP can present with attacks of paralysis and/or permanent muscle weakness. Previous studies have shown that patients with HypoPP can have impaired quality of life (QoL). In this cross-sectional study, we aimed to describe the QoL in patients with HypoPP caused by pathogenic variants in CACNA1S using The Individualized Neuromuscular Quality of Life (INQoL) questionnaire, a validated tool to measure the QoL of patients with neuromuscular diseases (higher score, worse QoL). We showed that muscle weakness and fatigue were the symptoms with the greatest impact on participants' lives and that "activities", in the life domain of the INQoL, was most affected by HypoPP. Furthermore, we showed that the total INQoL score increased with age. Low QoL was primarily driven by progressive permanent muscle weakness and not attacks of paralysis, although half of the participants reported that attacks of paralysis challenged their daily life. The results suggest that special attention should be given to muscle weakness and fatigue in patients with HypoPP.

Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment

BACKGROUND

Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research.

METHODS

MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings.

RESULTS

Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended.

CONCLUSIONS

Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.

Expert consensus recommendations for improving and standardising the assessment of patients with generalised myasthenia gravis

BACKGROUND

Regular and consistent disease assessment could provide a clearer picture of burden in generalised myasthenia gravis (gMG) and improve patient care; however, the use of assessment tools in practice lacks standardisation. This modified Delphi approach was taken to review current evidence on assessment tool use in gMG and develop expert-derived consensus recommendations for good practice.

METHODS

A European expert panel of 15 experienced gMG neurologists contributed to development of this consensus, four of whom formed a lead Sub-committee. The PICO (Population, Intervention, Control, Outcomes) framework was used to define six clinical questions on gMG assessment tools, a systematic literature review was conducted, and evidence-based statements were developed. According to a modified Delphi voting process, consensus was reached when ≥70% of the experts rated agreement with a statement as ≥8 on a scale of 1-10.

RESULTS

Eighteen expert- and evidence-based consensus statements based on six themes were developed. Key recommendations include: consistent use of the Myasthenia Gravis Activities of Daily Living score (MG-ADL) across clinical settings, followed by a simple question (e.g., Patient Acceptable Symptom State [PASS]) or scale to determine patient satisfaction in clinical practice; use of a Quantitative Myasthenia Gravis [QMG] or quality of life [QoL] assessment when the MG-ADL indicates disease worsening; and consideration of symptom state to determine the timing and frequency of recommended assessments. Expert panel consensus was reached on all 18 statements after two voting rounds.

CONCLUSIONS

This process provided evidence- and expert consensus-based recommendations for the use of objective and subjective assessment tools across gMG research and care to improve management and outcomes for patients.

Therapeutic Effect and Side Effects of Pharmacotherapy in Patients With Parkinson Disease and Myasthenia Gravis: A Systematic Review of Case Reports and Case Series Studies

PURPOSE

The co-existence of Parkinson disease (PD) and myasthenia gravis (MG) in an individual should be exceptionally rare. The purpose of this study was to systematically review the current literature regarding the therapeutic effect and side effects of pharmacotherapy on patients with PD and MG.

METHODS

Five bioscience and engineering databases (MEDLINE via PubMed, Cochrane Library, Scopus, EMBASE, and China National Knowledge Infrastructure) were searched from inception through February 21, 2022. Case reports and case series studies investigating pharmacotherapy in patients with PD and MG were included. Procedures were followed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The methodologic quality of included studies was evaluated by using the National Institutes of Health Quality Assessment Tool for Case Series Studies.

FINDINGS

Sixteen case reports and 5 case series studies with 32 participants met the inclusion criteria. Eight studies were rated as good quality, 10 were fair quality, and 3 were poor quality. The side effects of pharmacotherapy for PD or MG led to another disease, indicating an imbalance between dopamine and acetylcholine within human bodies.

IMPLICATIONS

When treating a patient who has PD or MG, health providers should be cautious about the occurrence of another disease. Timely treatment must rely on monitoring new symptoms as soon as the pharmacotherapy for PD or MG is initiated. Physical therapy may be helpful in decreasing the side effects of pharmacotherapy in patients with PD and MG. A new treatment pattern of pharmacotherapy + physical therapy for patients with PD and MG warrants further research. International Prospective Register of Systematic Reviews identifier: CRD42022308066.

Fatigue measured with the Multidimensional Fatigue Inventory in a population of intensive care patients at the post-intensive care clinic: A prospective longitudinal study

OBJECTIVES

Fatigue is a common symptom in former intensive care unit patients. Earlier research suggests that it is a lasting problem. This study aimed to further investigate the incidence of fatigue through the Multidimensional fatigue inventory (MFI-20) up to three years post intensive care.

METHOD/SAMPLE

In this prospective longitudinal study 56 former patients accepted inclusion and 55 patients filled out the questionnaire MFI-20 on one, two or three occasions; 49 at the visit at the post intensive care clinic, 21 after one year and 29 at three years after discharge from intensive care. MFI-20 can be interpreted through its total score or divided into five sub scores: general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue. Baseline characteristics were collected, and statistical significance was measured with the help of SPSS software.

RESULTS

The median ages for the three time points were 59, 61 and 62 respectively. There were more men in each group; 59, 57 and 62 %, but there were no significant differences in baseline characteristics between the groups. Based on the total fatigue score 67 % (n = 33) had severe fatigue 2-9 months after intensive care. The incidence of severe fatigue for one and three years was 48 % (n = 10) and 45 % (n = 13). Younger patients had significantly higher fatigue scores in general fatigue, reduced motivation and total score at the first two time points. After one year they also had significantly higher scores in the reduced activity subscale. Women had significantly higher fatigue scores than men in mental fatigue.

CONCLUSIONS

Fatigue is a common symptom in intensive care patients up to three years post intensive care. Younger patients have higher fatigue scores than older patients up to one year after intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals in hospitals and in out-patient care need knowledge about fatigue in former critically ill patients in order to support the management of their fatigue.

Correlation of fatigue on walking ability in myasthenia gravis patients: a cross-sectional study

Introduction

Myasthenia gravis (MG) is a neuromuscular junction autoimmune disease characterised of intermittent muscle weakness that increases with activity and recovers with rest.

Objective

Analysing the correlation of fatigue on walking ability in MG patients.

Methods

This study used a cross-sectional design with consecutive sampling. Participants MG patients took in this trial. Data collection encompasses fatigue and walking ability, with fatigue being assessed using the fatigue severity scale (FSS) and walking ability being assessed using the 10-metre walking test. The 10-metre walking test assessment contains three components: comfortable walking speed (CWS), maximum walking speed (MWS), and natural cadence. The statistical analysis used in this study includes the Pearson correlation and Spearman rank tests with P<0.05.

Results

The number of participants was 23 MG patients, and most of the participant was female (69.6%). The participant's fatigue value was 5.46±1.13, including MGFA 1=5.32±1.15, MGFA 2A=5.5±1.11, and MGFA 2B=5.61±1.30. Meanwhile, the participant's walking abilities included CWS of 1.10±0.11 m/s, MWS of 1.31±0.15 m/s, and natural cadence of 110.91±7.74 steps/min. No significant correlation of fatigue on walking ability including FSS vs. CWS (r=-0.141; P=0.520), FSS vs MWS (r=-0.169; P=0.442), and FSS vs. natural cadence (r=-0.050; P=0.822).

Conclusion

There was no significant correlation between fatigue and walking ability in MG patients who had MGFA 1, MGFA 2A, and MGFA 2B.

Fatigue and associated factors in 172 patients with McArdle disease: An international web-based survey

McArdle disease is an autosomal recessive inherited disease caused by pathogenic variants in the PYGM gene, resulting in virtual absence of the myophosphorylase enzyme in skeletal muscle. Patients experience physical activity intolerance, muscle pain, and muscle fatigue. This study aimed to investigate other fatigue domains with the Multidimensional Fatigue Inventory (MFI-20) along with an investigation of potential contributing factors, including relevant disease and lifestyle-related factors. We conducted a survey in an international cohort of patients with McArdle disease. The survey included questions on demographics and McArdle disease-related symptoms, and the questionnaires: MFI-20, Insomnia Severity Index (ISI), and International Physical Activity Questionnaire Short-Form (IPAQ-SF). One hundred seventy-four responses were included in the data analyses. We found relatively high fatigue scores in all five domains (general fatigue (12.9 ± 2.2), mental fatigue (10.1 ± 4.1), physical fatigue (13.7 ± 4.1), reduced activity (12.1 ± 4.1), and reduced motivation (10.4 ± 3.4)). Fatigue associated with McArdle symptom severity (p < 0.005), lower levels of physical activity (assessed by IPAQ-SF) (p < 0.05), and poor sleep (assessed by ISI) (p < 0.05). These findings call for clinical focus and future research into fatigue, sleep and mental health in patients with McArdle disease.

Measuring Overall Severity of Myasthenia Gravis (MG): Evidence for the Added Value of the MG Symptoms PRO

INTRODUCTION

Accurate measurement of myasthenia gravis (MG) severity is required for appropriate clinical monitoring of patients with MG and assessment of the benefit of new treatments in clinical trials. Our objective was to explore how MG severity can be measured and to determine how the newly developed MG Symptoms Patient-Reported Outcome (PRO) instrument complements the available measures of MG severity.

METHODS

The conceptual coverage of the Quantitative MG (QMG), MG Composite (MGC), MG-Activities of Daily Living (MG-ADL), and MG Symptoms PRO was scrutinized against core symptoms of MG: muscle weakness in three muscle groups (ocular, bulbar, and respiratory), muscle weakness fatigability, and physical fatigue. Post hoc analyses of the MG0002 study, a Phase 2a clinical trial of rozanolixizumab in adults with moderate to severe generalized MG, included correlation and Rasch model analyses.

RESULTS

The qualitative appraisal highlighted that only the MG Symptoms PRO captured physical fatigue. Data from 541 assessments (43 unique patients) were used for the analyses. Correlations ranged between 0.56 and 0.74 for the MG-ADL, QMG, MGC, and MG Symptoms PRO Muscle Weakness Fatigability score, and between 0.20 and 0.71 for the MG Symptoms PRO scores focusing on independent muscle groups. Analyses with the Rasch model estimated a meaningful continuum of severity of MG, including all items, except ocular muscles, from the four instruments. The QMG and MG Symptoms PRO had the broadest coverage of the MG severity continuum. Muscle fatigability and physical fatigue were more characteristic of low severity while bulbar weakness indicated more severe MG.

CONCLUSION

The severity of MG can be reflected in a meaningful continuum underpinned by the MG-specific outcome measures. Only ocular muscle manifestations were shown to reflect a possibly different facet of MG severity. With its modular nature and comprehensive content, the MG Symptoms PRO provides complementary information to the outcome measures widely used in MG.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03052751.

Genetically predicted effects of physical activity and sedentary behavior on myasthenia gravis: evidence from mendelian randomization study

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction. Despite the potential benefits of higher physical activity and lower sedentary behavior in MG patients, evidence from observational studies for the effect of physical activity on the risk of MG is limited and inconclusive.

METHODS

We employed linkage disequilibrium score (LDSC) regression, two-sample Mendelian randomization (MR), and its multivariable extension analyses (MVMR) to assess the relationship between leisure screen time (LST), moderate-to-vigorous intensity physical activity during leisure time (MVPA) and the risk of MG using genome-wide association studies (GWAS) summary datasets. MR analyses were performed using the inverse-variance-weighted (IVW), weighted-median, and MR-Egger regression. Sensitivity analyses were further performed using alternative instruments to test the robustness of our findings.

RESULTS

We found evidence of genetic overlap between LST (rg = 0.113, P = 0.023) and MG, as well as between MVPA (rg=-0.220, P = 0.0001) and MG, using LDSC method. The results of the MR suggested an association between genetic liability to LST and increased risk of MG (IVW OR = 1.609, 95% CI = 1.153 to 2.244; P = 0.005). This association was particularly notable for late-onset MG (IVW OR = 1.698, 95% CI = 1.145 to 2.518; P = 0.008), but not for early-onset MG. Consistent findings were obtained in the MVMR analysis using BMI as covariate (IVW OR = 1.593, 95% CI 1.167 to 2.173, P = 0.003). However, the MR analysis does not support a substantial causal effect of MVPA on the risk of MG.

CONCLUSION

Our findings support a causal effect of sedentary behavior as measured by LST on MG, indicating that lack of exercise may play a role in the development of MG. Longitudinal and interventional studies of this association are warranted.

Exploring impairments and allied health professional utilisation in people with myasthenia gravis: A cross-sectional study

This study aimed to explore how people with myasthenia gravis experience impairments in vision, dizziness, hearing, and fatigue, and how these relate to balance confidence, community participation, and health-related quality of life. Additionally, this study investigated the utilisation and perception of the allied health role in managing these impairments in the Australian context. Visual and hearing impairments, along with fatigue, were found to be correlated with health-related quality of life and community participation to varying degrees, while visual impairment and dizziness were correlated with balance confidence. Perception and utilisation of allied health professionals was variable; common barriers to better utilisation included participant perception of clinicians having poor knowledge around myasthenia gravis, previous poor experiences with clinicians, uncertainty about the clinicians' role, and lack of awareness that symptoms were associated with myasthenia gravis. Further research exploring clinicians' knowledge of myasthenia gravis is recommended, along with education for people with the disease about symptoms associated and how to appropriately access care.

Neurologic Disorders in Women and Sleep

Sleep disorders in women remain underrecognized and underdiagnosed mainly because of gender bias in researching and characterizing sleep disorders in women. Symptoms of common sleep disorders are frequently missed in the general female population and are expected to be further overlooked because of overlapping symptoms in women with neurologic disorders. Given the bidirectional relationship with sleep and neurologic disorders, it remains critical to be aware of the presentation and impact of sleep disorders in this patient population. This article reviews available data on sleep disorders in women with neurologic disorders and discusses their distinctive features.

Effect of Exercise on β-Endorphin and Its Receptors in Myasthenia Gravis Patients

This is a prospective observational study evaluating the change in β-endorphin (BE) and its receptors following exercise in patients with myasthenia gravis (MG) and their association with clinical improvement. Fifteen patients with mild to moderate MG, aged 16-70 years, who were able to do 6-Minute Walk Test (6-MWT) and had MG Quality of Life-15 (MGQoL-15) ≤ 45 without any contraindication for exercise were included. The patients walked 30 min daily for 3 months. The primary outcome at 3 months was > 50% improvement in MGQoL-15 from the baseline, and the secondary outcomes were MG Activities of Daily Living (MGADL), Hospital Anxiety and Depression Scale (HADS), number of steps, and distance covered on 6-MWT and adverse events. Plasma BE level, μ-opioid receptor (MOR), and δ-opioid receptor (DOR) were measured on admission and at 1 and 3 months. Twelve age- and gender-matched healthy controls who were not on regular exercise were included for comparison of BE, MOR, and DOR levels. Plasma BE level (P = 0.007) and DOR expression (P = 0.001) were lower in MG patients compared to the healthy controls. After 3 months of exercise, 6 patients improved. Plasma BE, MOR, and DOR levels increased in the first and decreased in the third month. MGQoL-15 (P < 0.001), HADS (P < 0.0001), number of steps (P < 0.007), distance (P = 0.030), and MGADL (P < 0.001) significantly improved compared to baseline. At 3 months, MGQoL-15 was associated with HADS score (P = 0.001), reduced depression (P = 0.013), MGADL (P = 0.035), and distance travelled on the 6-WMW test (P = 0.050). The improvement in depression was associated with higher BE level.

Physical Activity and Sedentary Behaviour in People with Myasthenia Gravis: A Cross-Sectional Study

BACKGROUND

Despite improvements in the medical management of myasthenia gravis (MG) in recent years, patients continue to report poor health and wellbeing outcomes such as high levels of fatigue, reduced quality of life (QoL), walking limitation and lowered balance confidence. Physical activity has been shown to be associated with these outcomes in other populations, however, there has been limited research in adults with MG.

OBJECTIVE

To describe physical activity and sedentary behaviour in adults with MG and to explore associations between these behaviours and fatigue, QoL, balance confidence and walking limitation.

METHODS

A self-report online survey was used to assess physical activity, sedentary behaviour, fatigue, QoL, balance confidence and walking limitation in adults with MG. Multiple linear regression was used to examine associations and descriptive statistics were used to analyse participant characteristics, physical activity, and sedentary behaviour.

RESULTS

Eighty-five adults with MG were included (mean age 48±16 years). Over half of participants (n = 53, 62.4%) reported sufficient physical activity to meet public health guidelines. Participants reported an average of 9 h/day of sedentary time (mean 9.0±3.5). Physical activity and fatigue (R2 = 0.196), QoL (R2 = 0.330), walking limitation (R2 = 0.305) and balance confidence (R2 = 0.304) were significantly (p <  0.05) and positively correlated, with no associations found for sedentary behaviour. When patterns of physical activity and sedentary behaviour were combined, lower fatigue (R2 = 0.213), higher QoL (R2 = 0.364), reduced walking limitation (R2 = 0.341) and higher balance confidence (R2 = 0.279) was observed in patients who had greater physical activity levels (>  150 mins/week) and lower sedentary time (<  10 h/day).

CONCLUSIONS

Higher physical activity and lower sedentary behaviour is associated with favorable health and wellbeing outcomes in adults with MG. Further research is required to ascertain whether these behaviours may be an appropriate target intervention to improve outcomes in this population.