1
|
Paganelli R, Di Lizia M, D'Urbano M, Gatta A, Paganelli A, Amerio P, Parronchi P. Insights from a Case of Good's Syndrome (Immunodeficiency with Thymoma). Biomedicines 2023; 11:1605. [PMID: 37371700 DOI: 10.3390/biomedicines11061605] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
Immunodeficiency with thymoma was described by R.A. Good in 1954 and is also named after him. The syndrome is characterized by hypogammaglobulinemia associated with thymoma and recurrent infections, bacterial but also viral, fungal and parasitic. Autoimmune diseases, mainly pure red cell aplasia, other hematological disorders and erosive lichen planus are a common finding. We describe here a typical case exhibiting all these clinical features and report a detailed immunophenotypic assessment, as well as the positivity for autoantibodies against three cytokines (IFN-alpha, IL-6 and GM-CSF), which may add to known immune abnormalities. A review of the published literature, based on case series and immunological studies, offers some hints on the still unsolved issues of this rare condition.
Collapse
Affiliation(s)
- Roberto Paganelli
- Department of Medicine and Sciences of Aging, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
- Internal Medicine, School of Medicine, UniCamillus, Saint Camillus International University of Health Sciences, 00131 Rome, Italy
| | - Michela Di Lizia
- Allergology ASL Teramo, Hospital of Giulianova, 64021 Giulianova, Italy
| | - Marika D'Urbano
- Laboratory Unit, Hospital S. Annunziata, 67039 Sulmona, Italy
| | - Alessia Gatta
- Allergology Service, ASL Chieti, 66100 Chieti, Italy
| | - Alessia Paganelli
- PhD Course in Clinical and Experimental Medicine, University of Modena-Reggio Emilia, 41121 Modena, Italy
| | - Paolo Amerio
- Department of Medicine and Sciences of Aging, University "G. D'Annunzio" of Chieti-Pescara, 66100 Chieti, Italy
| | - Paola Parronchi
- Department of Experimental Medicine, University of Florence, 50121 Florence, Italy
| |
Collapse
|
2
|
Novel treatment strategies for acetylcholine receptor antibody-positive myasthenia gravis and related disorders. Autoimmun Rev 2022; 21:103104. [PMID: 35452851 DOI: 10.1016/j.autrev.2022.103104] [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: 04/05/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022]
Abstract
The presence of autoantibodies directed against the muscle nicotinic acetylcholine receptor (AChR) is the most common cause of myasthenia gravis (MG). These antibodies damage the postsynaptic membrane of the neuromuscular junction and cause muscle weakness by depleting AChRs and thus impairing synaptic transmission. As one of the best-characterized antibody-mediated autoimmune diseases, AChR-MG has often served as a reference model for other autoimmune disorders. Classical pharmacological treatments, including broad-spectrum immunosuppressive drugs, are effective in many patients. However, complete remission cannot be achieved in all patients, and 10% of patients do not respond to currently used therapies. This may be attributed to production of autoantibodies by long-lived plasma cells which are resistant to conventional immunosuppressive drugs. Hence, novel therapies specifically targeting plasma cells might be a suitable therapeutic approach for selected patients. Additionally, in order to reduce side effects of broad-spectrum immunosuppression, targeted immunotherapies and symptomatic treatments will be required. This review presents established therapies as well as novel therapeutic approaches for MG and related conditions, with a focus on AChR-MG.
Collapse
|
3
|
Gelinas D, Parvin-Nejad S, Phillips G, Cole C, Hughes T, Silvestri N, Govindarajan R, Jefferson M, Campbell J, Burnett H. The humanistic burden of myasthenia gravis: A systematic literature review. J Neurol Sci 2022; 437:120268. [DOI: 10.1016/j.jns.2022.120268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/14/2022] [Accepted: 04/16/2022] [Indexed: 11/25/2022]
|
4
|
Vigneshwaran B, Bhoi SK, Sable MN, Muduly D, Sultania M, Jha M, Mohakud S, Kar M. Factors predicting perioperative outcomes in patients with myasthenia gravis or thymic neoplasms undergoing thymectomy by video-assisted thoracoscopic approach. J Minim Access Surg 2022; 18:111-117. [PMID: 35017401 PMCID: PMC8830562 DOI: 10.4103/jmas.jmas_261_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: The purpose of this study was to identify the factors which predict the perioperative outcomes after video-assisted thoracoscopic surgery (VATS) thymectomy in patients with myasthenia gravis (MG) or thymic neoplasms Patients and Methods: Data of consecutive patients who had undergone VATS thymectomy in our institution from August 2016 to April 2018 were collected retrospectively from a prospectively maintained database followed by prospective recruitment of patients who underwent VATS thymectomy from April 2018 to February 2020. Results: A total of 31 patients were included. Females were more common (51.6%), and 29 patients (93.5%) had MG. The most common indication for thymectomy was the presence of both MG and thymoma (51.6%). Most MG patients had moderate disease (55.2%) or severe (24.1%) disease preoperatively. Mean operative time and blood loss were 196.9 ± 63.5 min and 122.5 ± 115.3 ml, respectively. Mean hospital stay was 7.9 ± 6.7 days. The rate of major and minor complications was 16.18% and 35.4%, respectively. Multivariate linear regression analysis established that MG symptoms >12 months, prolonged invasive ventilation (intubation ≥24 h), and complications were associated significantly with a prolonged hospital stay. Adjusting for outliers, pre-operative disease severity (MG Foundation of America class), and intubation ≥24 h were the only factors that had a significant impact on perioperative outcomes. Conclusion: Pre-operative disease severity and post-operative invasive ventilation are strong determinants of perioperative outcomes. Pre-operative optimisation and early extubation protocols can further reduce morbidity in patients undergoing thymectomy by the VATS approach.
Collapse
Affiliation(s)
- B Vigneshwaran
- Department of Surgical Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sanjeev Kumar Bhoi
- Department of Neurology, All India Institute of Medical Sciences, Odisha, India
| | - Mukund Namdev Sable
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Dillip Muduly
- Department of Surgical Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Mahesh Sultania
- Department of Surgical Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Menkha Jha
- Department of Neurology, All India Institute of Medical Sciences, Odisha, India
| | - Sudipta Mohakud
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Madhabananda Kar
- Department of Surgical Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| |
Collapse
|
5
|
Du A, Li X, An Y, Gao Z. Risk factors of prolonged ventilation after thymectomy in thymoma myasthenia gravis patients. J Cardiothorac Surg 2021; 16:275. [PMID: 34579751 PMCID: PMC8475491 DOI: 10.1186/s13019-021-01668-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To explore the risk factors for prolonged ventilation after thymectomy in patients with thymoma associated with myasthenia gravis (TAMG). METHODS We reviewed the records of 112 patients with TAMG after thymectomy between January 2010 and December 2019 in Peking University People's Hospital. Demographic, pathological, preoperative data and the Anesthesia, surgery details were assessed with multivariable logistic regression analysis to predict the risk of prolonged ventilation after thymectomy. A nomogram to predict the probability of post-thymectomy ventilation was constructed with R software. Discrimination and calibration were employed to evaluate the performance of the nomogram. RESULTS By multivariate analysis, male, low vital capacity (VC), Osserman classification (IIb, III, IV), total intravenous anesthesia, and long operation time were identified as the risk factors and entered into the nomogram. The nomogram showed a robust discrimination, with an area under the receiver operating characteristic curve (AUC) of 0. 835 (95% confidence interval [CI], 0.757-0.913). The calibration plot indicated that the nomogram-predicted probabilities compared very well with the actual probabilities (Hosmer-Lemeshow test: P = 0.921). CONCLUSION The nomogram is a valuable predictive tool for prolonged ventilation after thymectomy in patients with TAMG.
Collapse
Affiliation(s)
- Anqi Du
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China
| | - Xiao Li
- Department of Thoracic Surgery, Peking University People's Hospital, Beijing, People's Republic of China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China.
| | - Zhancheng Gao
- Department of Respiratory and Critical Care Medicine, Peking University People's Hospital, Beijing, People's Republic of China.
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
Alqarni F, Almalki D, Aljohani Z, Ali A, AlSaleem A, Alotaibi N, Odeh S, Dalbhi SA. Prevalence and risk factors of myasthenia gravis recurrence post-thymectomy. ACTA ACUST UNITED AC 2021; 26:4-14. [PMID: 33530037 PMCID: PMC8015504 DOI: 10.17712/nsj.2021.1.20190041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/30/2020] [Indexed: 12/13/2022]
Abstract
Objectives: To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy. Methods: Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported. Results: Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7–22.0%; 1865/7287). Evident heterogeneity was observed (I2=93.6%; p<0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; p=0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, p=0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue. Conclusion: A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.
Collapse
Affiliation(s)
- Fatmah Alqarni
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Daifallah Almalki
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ziyad Aljohani
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Abdulrahman Ali
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Alanood AlSaleem
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Noura Alotaibi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Shahla Odeh
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Sultan Al Dalbhi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| |
Collapse
|
8
|
Svahn J, Chenevier F, Bouhour F, Vial C. Miastenia e sindromi miasteniche. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44012-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
9
|
Padilla Londoño N, Martínez-Ruiz D, Sánchez ÁJ, Velásquez M. Descripción de las características clínicas y la respuesta a tratamiento en pacientes con miastenia grave sin timoma sometidos a timectomía en una institución de alta complejidad de Cali, Colombia, 2010-2017. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La miastenia grave es una enfermedad autoinmunitaria con una prevalencia mundial de 150 a 250 casos por 1´000.000 de habitantes. El tratamiento recomendado para la miastenia grave sin timoma es la timectomía total, la cual es la única alternativa de curación.
Métodos. Se llevó a cabo un estudio descriptivo y retrospectivo de una serie de casos de pacientes adultos con miastenia grave sin timoma sometidos a timectomía, durante el periodo de 2010 a 2017. En el análisis estadístico descriptivo, se utilizaron frecuencias absolutas y porcentajes para las variables cualitativas y, para las variables cuantitativas, se utilizaron la mediana y el rango intercuartílico.
Resultados. Veintiocho pacientes con miastenia grave sin timoma se sometieron a timectomía desde el año 2010 hasta el 2017. Se categorizaron según la clasificación del estado posterior a la intervención de la Myasthenia Gravis Foundation of America y se evidenció que 4 (14,3 %) pacientes presentaban remisión completa y el grado 3 de manifestaciones clínicas mínimas fue el más frecuente en 19 (67,9 %); 26 (92,9 %) tuvieron mejoría con respecto al cambio del estado clínico, en 2 (7,1 %) no se documentaron cambios y en ningún paciente hubo empeoramiento, exacerbación o muerte secundaria a la enfermedad.
Conclusiones. A lo largo de siete años se practicó timectomía a 28 pacientes con diagnóstico de miastenia grave sin timoma, aproximadamente, en el 15 % de los pacientes hubo remisión completa, el grado 3 de manifestaciones mínimas fue el más frecuente y el 93 % presentó mejoría de su estatus clínico.
Collapse
|
10
|
Chen J, Chen Z, Miao F, Song Y, Chen G, Zhu Y, Pang L, Xi J, Zhao C, Chen X. A Randomized Control Study on the Efficacy of Thymectomy in Patients with Nonthymomatous (without Chest Tumor) Myasthenia Gravis. Ann Indian Acad Neurol 2020; 23:141-144. [PMID: 32055143 PMCID: PMC7001440 DOI: 10.4103/aian.aian_138_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ji Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhiming Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Feng Miao
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Song
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yongjun Zhu
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Liewen Pang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Chongbo Zhao
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaofeng Chen
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
11
|
Geng Y, Zhang H, Wang Y. Risk factors of myasthenia crisis after thymectomy among myasthenia gravis patients: A meta-analysis. Medicine (Baltimore) 2020; 99:e18622. [PMID: 31895819 PMCID: PMC6946543 DOI: 10.1097/md.0000000000018622] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of the study was to determine the risk factors of post-surgery myasthenia crisis (PMC) among myasthenia gravis (MG) patients. METHODS A meta-analysis to synthesize all eligible literatures was conducted to analyze PMC predictors among MG patients. RESULTS A total of 15 trials with 2626 patients were included for the meta-analysis. As a result, patients with history of MC (RR = 3.36, 95%CI: 2.46-4.59, P < .001), generalized MG (RR = 0.39, 95%CI: 0.26-0.59, P < .001), bulbar symptom (RR = 3.59,95%CI:2.53-5.09, P < .001), thymoma (RR = 2.10, 95%CI:1.37-3.21, P = .001), post-surgery morbidity presence(RR = 2.59, 95%CI:1.90-3.54, P < .001), high-dose pyridostigmine usage (SMD = 0.480, 95%CI: 0.35-0.61 P < .001) tended to develop PMC. Large dose of steroid may reduce the incidence of PMC (RR = 0.41 95%CI: 0.18-0.94, P = .036). Regular steroid use (P = .066), immunosuppressive therapy (P = .179), gender (P = .774), and age at thymectomy (P = .212) had no impact upon PMC development. CONCLUSION History of PMC, thymoma, generalized MG, bulbar symptom, and concomitant complication are the risk factors of PMC.
Collapse
|
12
|
Affiliation(s)
- Amelia Evoli
- Institute of Neurology, Università Cattolica del Sacro Cuore, Roma, Italy
- Fondazione Policlinico Gemelli, IRCCS, Roma, Italy
| | - Elisa Meacci
- Fondazione Policlinico Gemelli, IRCCS, Roma, Italy
- Institute of Thoracic Surgery, Università Cattolica del Sacro Cuore, Roma, Italy
| |
Collapse
|
13
|
Thymectomy for Nonthymomatous Myasthenia Gravis: Comparison of Video-Assisted Thoracoscopic and Transsternal Thymectomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:77-80. [PMID: 29683813 DOI: 10.1097/imi.0000000000000490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Thymectomy considered as a standard procedure in treatment of all the steps of myasthenia gravis. Video-assisted thoracoscopic surgery (VATS) thymectomy is one of the minimally invasive procedures that because of the short duration of hospitalization, less postoperative pain, and scar after surgery, nowadays it is replaced the traditional methods of surgery for patients with myasthenia gravis, but there are still differences and concerns. The aim of this study was to compare outcomes of two different techniques of surgery, VATS versus transsternal (TS) in the treatment of myasthenia gravis. METHODS In this pilot study, 42 patients with myasthenia gravis and without a thymus tumor were evaluated based on Myasthenia Gravis Foundation of America classification and drug consumption. Then, they randomly underwent two different techniques of surgery: VATS versus TS. Patients were evaluated based on preoperative and postoperative variables. RESULTS Duration of intensive care unit stay and hospitalization has been reduced in patients who underwent VATS thymectomy operation technique. In addition, duration of surgical procedure has been reduced significantly in these patients. These patients have less blood loss during surgery compared with TS group. The Myasthenia Gravis Foundation of America postoperative status in VATS thymectomy revealed that the number of patients with complete stable remission was higher and number of persons remained unchanged was lower in this group. CONCLUSIONS VATS thymectomy is a safe and appropriate approach comparing with traditional methods such as TS thymectomy for patients with myasthenia gravis. This method has better results after surgery and can be used as a minimally invasive alternative method instead of TS thymectomy.
Collapse
|
14
|
Cataneo AJM, Felisberto Jr. G, Cataneo DC. Thymectomy in nonthymomatous myasthenia gravis - systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:99. [PMID: 29940999 PMCID: PMC6020196 DOI: 10.1186/s13023-018-0837-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 06/05/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The objective of this study is to evaluate by means of a systematic review, the efficacy of thymectomy as compared to medical treatment for non-thymomatous myasthenia gravis (MG). METHODS Medline, Embase, and Lilacs were searched for experimental and observational studies that compared non-surgical (drug therapy) and surgical treatment of non-thymomatous MG (thymectomy performed by the transsternal approach). Inclusion criteria were: studies that compared the two types of treatment and had at least 10 adult patients in each group. Exclusion criteria were articles published before 1970, as well as those that included patients treated before 1950. The outcomes evaluated were: remission, and improvement rates. RevMan 5.3 software provided by the Cochrane Collaboration was used. When the heterogeneity between the studies was greater than 75%, a meta-analysis was not performed according to RevMan guidelines. RESULTS The total number of patients evaluated in 19 articles selected was 5841 (2911 surgical and 2930 non-surgical). Two included randomized clinical trials showed superiority of the surgical treatment over the non-surgical. Four retrospective studies with 379 patients paired by gender, age, and other confounders, also showed superiority of surgical treatment (OR 4.10, 95% CI 2.25 to 7.44; I2 = 20%). In meta-analyses, remission assessed in 17 studies (5686 patients) was greater in patients who underwent surgical treatment (OR 2.34, 95% CI 1.79 to 3.05; I2 = 56%). For improvement assessed in 13 studies (3063 patients) were not appropriate to carry out the meta-analysis due to the high heterogeneity among the studies in the outcome (87%). CONCLUSION Thymectomy may be considered effective in the treatment for non-thymomatous MG, with remission rate higher than for non-surgical treatment.
Collapse
Affiliation(s)
- Antônio J. M. Cataneo
- Division of Thoracic Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, Botucatu, SP CEP 18.618-970 Brazil
| | - Gilmar Felisberto Jr.
- Post-Graduation Program General Bases of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Daniele C. Cataneo
- Division of Thoracic Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, Botucatu, SP CEP 18.618-970 Brazil
| |
Collapse
|
15
|
Bagheri R, Boonstani R, Sadrizadeh A, Salehi M, Afghani R, Rahnama A, Azmounfar V, Hakimian S, Firoozabadi MB. Thymectomy for Nonthymomatous Myasthenia Gravis. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Reza Bagheri
- Lung Disease Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Boonstani
- Division of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Sadrizadeh
- Lung Disease Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Salehi
- Division of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Afghani
- Department of General Surgery, 5th of Azar Hospital, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Ali Rahnama
- Department of General Surgery, Mashhad University of Medical Science, Mashhad, Iran
| | | | | | | |
Collapse
|
16
|
Li KK, Qian K, Feng YG, Guo W, Tan QY, Deng B. Predictive factors of prolonged mechanical ventilation, overall survival, and quality of life in patients with post-thymectomy myasthenic crisis. World J Surg Oncol 2017; 15:150. [PMID: 28789662 PMCID: PMC5549389 DOI: 10.1186/s12957-017-1209-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thymectomy is the primary approach for the treatment of myasthenia gravis (MG). This retrospective study aimed to identify the clinical and demographical features that may impact the duration of mechanical ventilation (DMV), the long-term survival, and the quality of life (QOL) in patients with post-thymectomy myasthenic crisis (PTMC). METHODS We reviewed the patients who suffered from PTMC from June 2008 to November 2015. Cox proportional hazard regression analysis was used to identify potential prognostic factors that may impact DMV and long-term survival. Spearman bivariate correlation analysis was used to analyze the relationship between DMV and QOL. Statistical powers were calculated. RESULTS In total, 70 patients with PTMC were enrolled. Alcohol abuse, high scores of Myasthenia Gravis Foundation of America (MGFA) classification and Clavien-Dindo classification were critical factors that remarkably delayed early extubation. High scores of Osserman's classification, MGFA classification, and Clavien-Dindo classification predicted a poor prognosis in PTMC patients. Occupational skills and job status were observed to be negatively affected in PTMC patients. CONCLUSIONS To decrease the duration of mechanical ventilation, we suggest alcohol abstinence before the operation, appropriate preoperative treatment to decrease MGFA classification, and greater attention to the treatment of postoperative complications.
Collapse
Affiliation(s)
- Kun-Kun Li
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Kai Qian
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Yong-Geng Feng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Wei Guo
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Qun-You Tan
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China.
| | - Bo Deng
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China.
| |
Collapse
|
17
|
Brenna G, Antozzi C, Montomoli C, Baggi F, Mantegazza R. A propensity score analysis for comparison of T-3b and VATET in myasthenia gravis. Neurology 2017; 89:189-195. [DOI: 10.1212/wnl.0000000000004082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 03/15/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:We performed propensity score (PS) models to compare the outcome of patients with myasthenia gravis (MG) submitted to 2 different surgical approaches: extended transsternal (T-3b) or thoracoscopic extended thymectomy (VATET).Methods:Patients' clinical data were retrieved from the MG database of the C. Besta Neurologic Institute Foundation. In the PS analysis, a matching ratio of 1:1 of the main clinical variables was obtained for the 2 groups of patients and treatment effect was estimated by comparing their outcome.Results:A total of 210 patients met the inclusion criteria, by having a complete set of clinical data, and were included in the PS model; a matched dataset of 122 participants (61 per group) showed an adequate balance of all the covariates. Our analysis demonstrated that 68.9% of patients who had thymectomy by the VATET technique reached the pharmacologic remission/remission status at 2 years from thymectomy compared to 34.4% of those operated on by the T-3b technique (p < 0.001), had a lower INCB-MG score (p < 0.001), and had less muscle fatigability (p = 0.004). Similar results were found considering only nonthymomatous patients with MG. Results were also confirmed by paired statistical tests.Conclusions:Our PS matching analysis showed that VATET is a reliable and effective surgical approach alternative to T-3b in patients with MG who are candidates for thymectomy.Classification of evidence:This study provides Class IV evidence that for patients with MG, VATET is more effective than T-3b thymectomy.
Collapse
|
18
|
Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| |
Collapse
|
19
|
Bambauer R, Latza R, Burgard D, Schiel R. Therapeutic Apheresis in Immunologic Renal and Neurological Diseases. Ther Apher Dial 2017; 21:6-21. [PMID: 28078733 DOI: 10.1111/1744-9987.12499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 08/17/2016] [Indexed: 12/18/2022]
Abstract
Since the mid 1970s, when membrane modules became available, plasma separation techniques have gained in importance especially in the past few years. The advantages of this method are a complete separation of the corpuscular components from the plasma and due to increased blood flow rate and higher efficacy. Systemic autoimmune diseases based on an immune pathogenesis produce autoantibodies and circulating immune complexes, which cause inflammation in the tissues of various organs. In most cases, these diseases have a poor prognosis without treatment. Therapeutic apheresis (TA) in combination with immunosuppressive therapies has led to a steady increase in survival rates over the last 40 years. The updated information on immunology and molecular biology of different immunologic diseases are discussed in relation to the rationale for apheresis therapy and its place in combination with other modern treatments. The different diseases can be treated by various apheresis methods such as therapeutic plasma exchange (TPE) with substitution solution, or with online plasma or blood purification using adsorption columns, which contain biological or non-biological agents. Here, the authors provide an overview of the most important pathogenic aspects indicating that TA can be a supportive therapy in systemic autoimmune diseases such as renal and neurological disorders. For the immunological diseases that can be treated with TA, the guidelines of the German Working Group of Clinical Nephrology and of the Apheresis Committee of the American Society for Apheresis are cited.
Collapse
Affiliation(s)
- Rolf Bambauer
- Formerly: Institute for Blood Purification, Homburg, Germany
| | | | | | - Ralf Schiel
- Inselklinik Heringsdorf GmbH, Seeheilbad Heringsdorf, Germany
| |
Collapse
|
20
|
Comparison of Conservative Treatment and Thymectomy on Myasthenia Gravis Outcome. Ann Thorac Surg 2016; 102:1805-1813. [DOI: 10.1016/j.athoracsur.2016.08.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/13/2016] [Accepted: 08/09/2016] [Indexed: 11/19/2022]
|
21
|
Barnett C, Katzberg HD, Keshavjee S, Bril V. Thymectomy for non-thymomatous myasthenia gravis: a propensity score matched study. Orphanet J Rare Dis 2014; 9:214. [PMID: 25539860 PMCID: PMC4296689 DOI: 10.1186/s13023-014-0214-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/12/2014] [Indexed: 11/10/2022] Open
Abstract
Background The efficacy of thymectomy in patients with non-thymomatous Myasthenia Gravis (MG) is still unclear. Main limitations have been variable outcome definitions, lack of a control group and adjustment for confounding. Objective To study the efficacy of thymectomy in achieving remission or minimal manifestation (R/MM) status in patients with non-thymomatous MG. Methods Patients with generalized MG and minimum follow-up of 6 months were included. Demographic data and treatments were recorded, as well as the MGFA post-intervention status at the last visit. Propensity scores were used to create a matched cohort of treated and untreated patients. Standard and Bayesian Cox models were used to study treatment effects. Results Of 395 patients included, 183(46%) had a thymectomy. Thymectomy patients were younger (p < 0.001), with more females (p < 0.001) and more patients in MGFA classes 4–5 at diagnosis (p = 0.01). A matched cohort of thymectomized patients and controls (n = 98) was created. The hazard ratio (HR) for the matched cohort was 1.9 (CI:1.6-2.3), favoring thymectomy. The predicted R/MM rate was 21% in treated and 6% in controls at 5 years (Absolute difference:15%). A Bayesian Cox model for the matched cohort had an estimated probability of thymectomy efficacy (HR > 1) of 96% using a non-informative prior, and 79% using a skeptical prior. Discussion When controlling for potential confounders, thymectomized patients had a higher probability of achieving R/MM status through time compared to controls. This study provides class III evidence of the efficacy of thymectomy in non-thymomatous myasthenia gravis.
Collapse
Affiliation(s)
- Carolina Barnett
- Division of Neurology - Department of Medicine, University of Toronto and University Health Network, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Hans D Katzberg
- Division of Neurology - Department of Medicine, University of Toronto and University Health Network, Toronto, Canada.
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Department of Surgery, University Health Network, Toronto, Canada.
| | - Vera Bril
- Division of Neurology - Department of Medicine, University of Toronto and University Health Network, Toronto, Canada.
| |
Collapse
|
22
|
Luo Y, Pan DJ, Chen FF, Zhu MH, Wang J, Zhang M. Effectiveness of thymectomy in non-thymomatous myasthenia gravis: a systematic review. ACTA ACUST UNITED AC 2014; 34:942-949. [DOI: 10.1007/s11596-014-1378-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 05/28/2014] [Indexed: 10/24/2022]
|
23
|
Iwasa K, Yoshikawa H, Samuraki M, Shinohara M, Hamaguchi T, Ono K, Nakamura H, Yamada M. Myasthenia gravis: predictive factors associated with the synchronized elevation of anti-acetylcholine receptor antibody titer in Kanazawa, Japan. J Neuroimmunol 2013; 267:97-101. [PMID: 24388223 DOI: 10.1016/j.jneuroim.2013.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 12/13/2013] [Accepted: 12/17/2013] [Indexed: 12/01/2022]
Abstract
For a brief period, an increased incidence of elevated anti-acetylcholine receptor antibody titer was observed in patients with myasthenia gravis (MG) in Kanazawa, Japan. The purpose of this study was to examine the predictive factors associated with this antibody titer elevation. Decreased odds of titer elevation were seen in patients with early-onset MG than in those with late-onset MG. In patients with non-thymoma-related MG, thymectomy prevented the antibody titer elevation. Our data suggest that late-onset MG may have a different immunogenic response and the thymus might play an immunoregulatory role against extrinsic factors in some types of MG.
Collapse
Affiliation(s)
- Kazuo Iwasa
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
| | | | - Miharu Samuraki
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Moeko Shinohara
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Tsuyoshi Hamaguchi
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Kenjiro Ono
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Hiroyuki Nakamura
- Department of Environmental and Preventive Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Masahito Yamada
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| |
Collapse
|
24
|
Raggi A, Schiavolin S, Leonardi M, Antozzi C, Baggi F, Maggi L, Mantegazza R. Development of the MG-DIS: an ICF-based disability assessment instrument for myasthenia gravis. Disabil Rehabil 2013; 36:546-55. [PMID: 23781909 DOI: 10.3109/09638288.2013.804591] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To develop a preliminary version of a disease-specific, patient-reported disability assessment instrument for myasthenia gravis (MG) based on the International Classification of Functioning, Disability and Health (ICF): the MG-DIS. METHODS Five consecutive steps were taken: literature review and selection of outcome measures; linking of measures' concepts to ICF categories and selection of those reported by 30% of the instruments; comparison of linking results with a previous selection of MG-relevant ICF categories; patient interview; development of questions based on retained ICF categories. RESULTS Thirty-one papers containing 21 different outcome measures were found: 13 ICF categories were linked to them. Fifty-five items were retained after the comparison with the list of MG-specific categories, and were used for patient interview. Thirteen interviews were conducted before saturation of data was reached and the final list was composed of 42 categories: based upon them, 44 questions were developed. CONCLUSIONS The preliminary version of the MG-DIS contains more information than each single MG-specific tool, in particular, for the component of environmental factors. Further research is needed to test its psychometric properties. IMPLICATIONS FOR REHABILITATION It is important that patient-reported outcome is incorporated in MG patient's assessment. MG features can be evaluated with ICF-based methods. An MG-specific patient-reported disability assessment instrument can be used to monitor changes of functioning in patients on MG-specific treatments, and can be used in clinical trials as outcome measure.
Collapse
|
25
|
Spillane J, Hayward M, Hirsch NP, Taylor C, Kullmann DM, Howard RS. Thymectomy: role in the treatment of myasthenia gravis. J Neurol 2013; 260:1798-801. [PMID: 23508539 DOI: 10.1007/s00415-013-6880-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 02/14/2013] [Accepted: 02/16/2013] [Indexed: 11/26/2022]
Abstract
Thymectomy is a frequently used treatment for myasthenia gravis (MG) and is virtually always indicated in MG patients who have a thymoma. However, the evidence for thymectomy in non-thymomatous MG remains less certain-no randomised controlled trials have been published to date, although one is currently underway. We reviewed the management and clinical outcome of patients with MG who underwent thymectomy over a 12 year period. Eighty-nine patients who underwent transsternal thymectomy were identified. A thymoma was identified on histology in 24 %, whereas 48, 9 and 19 % had hyperplastic, atrophic and normal thymic histology, respectively. One patient developed post operative myasthenic crisis but generally the procedure was well tolerated. Outcome was favourable for the majority of patients, with 34 % achieving complete stable remission (CSR) and an additional 33 % achieving pharmacological remission. Moreover, steroid requirements fell progressively during follow-up. Patients with a hyperplastic gland had a significantly greater chance of achieving CSR compared to other histological subtypes and the incidence of CSR increased with a longer duration of follow-up. Thymectomy for MG is generally safe and well tolerated and is associated with a sustained improvement of symptoms in the majority of patients.
Collapse
Affiliation(s)
- J Spillane
- UCL, Institute of Neurology, Queen Square, London, WC1N3BG, UK.
| | | | | | | | | | | |
Collapse
|
26
|
Changes of Treg-Associated Molecules on CD4+CD25+Treg Cells in Myasthenia Gravis and Effects of Immunosuppressants. J Clin Immunol 2012; 32:975-83. [DOI: 10.1007/s10875-012-9685-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Accepted: 03/14/2012] [Indexed: 11/25/2022]
|
27
|
Liu Z, Feng H, Yeung SCJ, Zheng Z, Liu W, Ma J, Zhong FT, Luo H, Cheng C. Extended transsternal thymectomy for the treatment of ocular myasthenia gravis. Ann Thorac Surg 2012; 92:1993-9. [PMID: 22115207 DOI: 10.1016/j.athoracsur.2011.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 08/01/2011] [Accepted: 08/02/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal treatment for ocular myasthenia gravis (OMG) remains controversial. We conducted a review of the long-term clinical outcomes of Chinese patients with OMG after extended transsternal thymectomy (ETT) to determine the efficacy of this procedure as a treatment for OMG. METHODS We reviewed the cases of 115 consecutive patients with OMG who underwent ETT at our Myasthenia Gravis Research Center between January 2006 and December 2008. Extended transsternal thymectomy was done in patients who had thymoma, resistance to pyridostigmine therapy, or relapse after immunosuppressive therapy. The patients' postoperative responses were defined as strict complete remission (SCR), consisting of an asymptomatic status without medication for more than 12 months; general complete remission (GCR), consisting of an asymptomatic status with low-dose single-drug therapy or without medication for more than 12 months; or improvement, consisting of fewer symptoms or less of a need for medication than before surgery. RESULTS The overall complication rate was 7.8%. None of the patients experienced a myasthenic crisis, progression to generalized myasthenia gravis, or mortality. Hyperplasia of the thymus was present in 106 of the 115 patients (92.2%). Among 110 patients on whom follow-up was done postoperatively, 29 (26.4%) were in SCR, 64 (58.2%) showed improvement, 7 (6.4%) remained unchanged, and 10 (9.1%) had a worsening of their conditions. Kaplan-Meier analysis revealed rates of GCR of 41.8% at 24 months and 47.3% at 48 months after surgery, and rates of SCR of 24.5% at 24 months and 26.4% at 48 months. Both univariate analysis and multivariate Cox regression analysis revealed that only preoperative duration of illness was positively associated with GCR (p < 0.001). CONCLUSIONS The results of the review indicate that ETT is a safe and effective treatment for OMG, especially in patients with illness of shorter duration.
Collapse
Affiliation(s)
- Zhenguo Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Peoples' Republic of China
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Cavalcante P, Le Panse R, Berrih-aknin S, Maggi L, Antozzi C, Baggi F, Bernasconi P, Mantegazza R. The thymus in myasthenia gravis: Site of “innate autoimmunity”? Muscle Nerve 2011; 44:467-84. [DOI: 10.1002/mus.22103] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
29
|
Rudzka-Nowak A, Piechota M. Anaesthetic management of a patient with myasthenia gravis for abdominal surgery using sugammadex. Arch Med Sci 2011; 7:361-4. [PMID: 22291783 PMCID: PMC3258733 DOI: 10.5114/aoms.2011.22094] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 08/05/2010] [Accepted: 08/13/2010] [Indexed: 12/19/2022] Open
Abstract
We report a case of a patient with tumor of the caecum with coexistent myasthenia gravis (a form according to Osserman II A), requiring general anesthesia for abdominal surgery. To reverse the neuromuscular block induced by vecuronium was used sugammadex.
Collapse
Affiliation(s)
- Alina Rudzka-Nowak
- Department of Anaesthesiology and Intensive Therapy, Military Medical Academy University Hospital in Lodz, Medical University of Lodz, Poland
| | | |
Collapse
|
30
|
Miastenie e sindromi miasteniche. Neurologia 2011. [DOI: 10.1016/s1634-7072(11)70655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
31
|
Twork S, Wiesmeth S, Klewer J, Pöhlau D, Kugler J. Quality of life and life circumstances in German myasthenia gravis patients. Health Qual Life Outcomes 2010; 8:129. [PMID: 21070628 PMCID: PMC2994799 DOI: 10.1186/1477-7525-8-129] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 11/11/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is a chronic neuromuscular disease. Advances in medical therapy have continuously increased the life expectancy of MG patients, without definitively curing the disease. To analyze life circumstances and quality of life (QoL), a large German MG cohort was investigated. METHODS AND SAMPLE In cooperation with the German Myasthenia Association, 2,150 patients with confirmed MG were asked to respond to a mailed questionnaire. The standardized questions related to demographic data, impairments, therapeutic course, use of complementary therapies, illness-related costs, and quality of life (SF-36). In total, 1,518 patients participated, yielding a response rate of 70.6%. The average age was 56.7 years, and the proportion of females 58.6%. RESULTS Despite receiving recommended therapy, many patients still suffered from MG-related impairments. In particular, mobility and mental well-being were reduced; moreover, quality of life was markedly reduced. Stepwise linear regression analysis revealed illness stability, impairments, mental conditions, comorbid diseases, and employment to be determinants of QoL. CONCLUSION Results indicate that despite prolonged life expectancy among MG patients, health-related quality of life is low. This outcome resulted mainly from impaired mobility and depression. Physical and mental well-being might be improved by additional therapy options. Additionally, health care resources could be used more efficiently in these patients.
Collapse
Affiliation(s)
- Sabine Twork
- Department of Health Sciences/Public Health, Faculty of Medicine "Carl Gustav Carus" at the University of Technology Dresden, Germany
| | - Susanne Wiesmeth
- Department of Health Sciences/Public Health, Faculty of Medicine "Carl Gustav Carus" at the University of Technology Dresden, Germany
| | - Jörg Klewer
- Department of Health Sciences/Public Health, Faculty of Medicine "Carl Gustav Carus" at the University of Technology Dresden, Germany
| | - Dieter Pöhlau
- Department of Neurology, Kamillus-Hospital, Asbach, Germany
| | - Joachim Kugler
- Department of Health Sciences/Public Health, Faculty of Medicine "Carl Gustav Carus" at the University of Technology Dresden, Germany
| |
Collapse
|
32
|
|
33
|
Pruitt JA, Ilsen PF. On the frontline: what an optometrist needs to know about myasthenia gravis. ACTA ACUST UNITED AC 2010; 81:454-60. [PMID: 20655284 DOI: 10.1016/j.optm.2009.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 09/11/2009] [Accepted: 09/25/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease that affects the voluntary skeletal muscles. It is characterized by transient weakness of the muscles that improves with rest. Muscle weakness involving the eyes can produce signs or symptoms of diplopia, blurred vision, ptosis, and ophthalmoplegia. Ptosis is defined as an abnormal eyelid "drooping" beyond the normal 1 to 2 mm of the upper limbus of the cornea. Hence, most patients with MG have ophthalmic manifestations. Among all patients with MG, up to half will have exclusively ocular symptoms. In these cases, the condition is referred to as ocular myasthenia. CASE REPORT A 60-year-old man was referred from a neurology clinic for management of intermittent diplopia for greater than 1 year and intermittent bilateral ptosis for the prior year. He reported that he first noticed symptoms of MG at the age of 42, but did not receive the diagnosis until 1 year before his aforementioned neurology examination. He was prescribed spectacles with bilateral ptosis crutches. A diagnosis of severe seronegative MG was subsequently confirmed with neurologic examination and antibody testing. CONCLUSIONS Because patients with undiagnosed myasthenia gravis may present initially with ocular signs or symptoms, it is important for the optometrist to be familiar with the condition and the simple "in-office" tests that can be performed to establish a tentative diagnosis and management plan. The optometrist can also participate in the management of ocular manifestations of myasthenia and should be familiar with the use of a ptosis crutch (in addition to prism spectacles or occlusion therapies if indicated) as a nonsurgical intervention for ptosis.
Collapse
Affiliation(s)
- Joseph A Pruitt
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.
| | | |
Collapse
|
34
|
Falcoz PE. Invited Commentary. Ann Thorac Surg 2009; 88:1123. [DOI: 10.1016/j.athoracsur.2009.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 06/02/2009] [Accepted: 06/09/2009] [Indexed: 11/26/2022]
|