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Kessi M, Tang Y, Chen B, Wang G, Zhang C, He F, Peng J, Yin F, Yang L. Pediatric Ocular Myasthenia Gravis: Single-Center Experience. Pediatr Neurol 2024; 153:137-143. [PMID: 38382246 DOI: 10.1016/j.pediatrneurol.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Currently, there is no universally accepted standard treatment for ocular myasthenia gravis (OMG) in children. We aimed to investigate the possible proper regimens and timing of treatment for pediatric OMG cases based on the clinical manifestations: OMG with ptosis only and OMG with other features. METHODS One hundred and forty two OMG cases attended at the Department of Pediatrics, Xiangya Hospital, Central South University, from 2010 to 2019 were included, and information from medical records was reviewed and recorded. Comparisons of clinical characteristics between patients with OMG with ptosis only and patients with OMG with other features as well as between patients treated with glucocorticoid (GC) within or after six months from disease onset were performed. RESULTS OMG with other features constituted about 54.9% of the cases, and 66.2% of the patients achieved optimal outcome. Patients with OMG with ptosis only responded to pyridostigmine alone more than patients with OMG with other features who required several therapies (P < 0.001). Patients with OMG with ptosis only had a larger proportion of optimal outcome than the patients with OMG with other features (P = 0.002), and the difference remained significant even when the individual outcome groups were compared (P < 0.001). Patients who received GC within six months had a greater proportion of optimal outcome than those who received it after six months (P < 0.001). CONCLUSIONS Although OMG with other features is a more common subtype of OMG, it is also more severe than OMG with ptosis only. An earlier addition of GC leads to optimal outcome.
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Affiliation(s)
- Miriam Kessi
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Yulin Tang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Baiyu Chen
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Guoli Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China; Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China; Clinical Research Center for Children Neurodevelopmental Disabilities of Hunan Province, Xiangya Hospital, Central South University, Changsha, China
| | - Ciliu Zhang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China; Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China; Clinical Research Center for Children Neurodevelopmental Disabilities of Hunan Province, Xiangya Hospital, Central South University, Changsha, China
| | - Fang He
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China; Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China; Clinical Research Center for Children Neurodevelopmental Disabilities of Hunan Province, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Peng
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China; Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China; Clinical Research Center for Children Neurodevelopmental Disabilities of Hunan Province, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Yin
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China; Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China; Clinical Research Center for Children Neurodevelopmental Disabilities of Hunan Province, Xiangya Hospital, Central South University, Changsha, China
| | - Lifen Yang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China; Hunan Intellectual and Developmental Disabilities Research Center, Changsha, China; Clinical Research Center for Children Neurodevelopmental Disabilities of Hunan Province, Xiangya Hospital, Central South University, Changsha, China.
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Crisafulli S, Boccanegra B, Carollo M, Bottani E, Mantuano P, Trifirò G, De Luca A. Myasthenia Gravis Treatment: From Old Drugs to Innovative Therapies with a Glimpse into the Future. CNS Drugs 2024; 38:15-32. [PMID: 38212553 DOI: 10.1007/s40263-023-01059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/13/2024]
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease that causes debilitating muscle weakness due to impaired neuromuscular transmission. Since most (about 80-90%) MG patients present autoantibodies against the acetylcholine receptor, standard medical therapy consists of symptomatic treatment with acetylcholinesterase inhibitors (e.g., pyridostigmine). In addition, considering the autoimmune basis of MG, standard therapy includes immunomodulating agents, such as corticosteroids, azathioprine, cyclosporine A, and cyclophosphamide. New strategies have been proposed for the treatment of MG and include complement blockade (i.e., eculizumab, ravulizumab, and zilucoplan) and neonatal Fc receptor antagonism (i.e., efgartigimod and rozanolixizumab). The aim of this review is to provide a detailed overview of the pre- and post-marketing evidence on the five pharmacological treatments most recently approved for the treatment of MG, by identifying both preclinical and clinical studies registered in clinicaltrials.gov. A description of the molecules currently under evaluation for the treatment of MG is also provided.
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Affiliation(s)
| | - Brigida Boccanegra
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
| | - Massimo Carollo
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy
| | - Emanuela Bottani
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy
| | - Paola Mantuano
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy.
| | - Annamaria De Luca
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
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Fang CEH, Bokre D, Wong SH. Clinical Characteristics Associated With Secondary Generalization in Patients With Ocular Myasthenia Gravis: A Systematic Review and Meta-analysis. Neurology 2023; 101:e1594-e1605. [PMID: 37643888 PMCID: PMC10585680 DOI: 10.1212/wnl.0000000000207642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Ocular myasthenia gravis (OMG) is an autoimmune disorder resulting in ocular symptoms such as diplopia and ptosis. The proportion of patients who convert to secondary generalized myasthenia gravis (SGMG) reported in the literature has been varied. The aim of this systematic review was to determine the clinical characteristics of patients with OMG and the proportion of SGMG conversion. METHODS We conducted an electronic database search for randomized controlled trials, prospective nonrandomized studies, observational studies, and retrospective studies in EMBASE, CENTRAL, MEDLINE, and Web of Science. We included studies with patients with OMG who initially presented with ocular symptoms and signs only and were seen in clinical practice, reporting on the characteristics and outcomes of SGMG. We excluded studies with pediatric and congenital myasthenia gravis populations. Eligible studies included articles written in any language and containing data on patients with OMG. The main outcome measured was the proportion of patients with OMG who converted to SGMG and risk factors associated with secondary generalization of OMG. Two independent reviewers screened titles and abstracts and extracted data from full texts, reporting findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The methodology was evaluated using the Joanna Briggs Institute critical appraisal forms. PROSPERO registration number: CRD2021285257. RESULTS Thirty-one studies were included in the quantitative and qualitative analysis. The proportion of generalization ranged from 11% to 84%. The pooled proportion was 39% (95% CI 32%-47%, I 2 = 95.86%, p < 0.001 unweighted, low certainty). The pooled risk ratio of female sex for conversion to SGMG was 1.06 (95% CI 0.96-1.17, I 2 = 0% p = 0.614, 21 studies included, very low certainty), and the pooled risk ratio of acetylcholine receptor (AChR) positivity was 1.30 (95% CI 1.05-1.56, I 2 = 0% p = 0.455, 16 studies included, very low certainty). DISCUSSION Risk factors such as female sex and anti-AChR positivity have been identified to have possible associations with SGMG, but there are not enough quality observational studies. There is a need for a prospective global database of patients with OMG, including all countries with different populations.
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Affiliation(s)
- Clarissa Ern Hui Fang
- From the Department of Ophthalmology (C.E.H.F.), Manchester Royal Eye Hospital; Joint Library of Ophthalmology (D.B.), Moorfields Eye Hospital and University College London; and Moorfields Eye Hospital & Guys & St Thomas' Hospitals (S.H.W.), London, United Kingdom.
| | - Desta Bokre
- From the Department of Ophthalmology (C.E.H.F.), Manchester Royal Eye Hospital; Joint Library of Ophthalmology (D.B.), Moorfields Eye Hospital and University College London; and Moorfields Eye Hospital & Guys & St Thomas' Hospitals (S.H.W.), London, United Kingdom
| | - Sui Hsien Wong
- From the Department of Ophthalmology (C.E.H.F.), Manchester Royal Eye Hospital; Joint Library of Ophthalmology (D.B.), Moorfields Eye Hospital and University College London; and Moorfields Eye Hospital & Guys & St Thomas' Hospitals (S.H.W.), London, United Kingdom
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Proudman W, Kleinig O, Lam L, Collins L, Bagster M, Gupta A, Kovoor J, Bacchi S, Slee M, Chan W. The Icepack Test in the Diagnosis of Myasthenia Gravis with Ocular Features: A Systematic Review of Diagnostic Accuracy, Technique, and Economic Utility. Semin Ophthalmol 2023; 38:679-685. [PMID: 36967601 DOI: 10.1080/08820538.2023.2194984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The diagnosis of myasthenia gravis (MG) may be challenging and require multiple specialised testing modalities. Accessing these investigations can involve significant waiting time and costs. The bedside icepack test (IPT) has been proposed to assist with the diagnosis of MG with ocular features, and may prove an economically viable; however, there have been there is heterogeneity in the literature evaluating the IPT. OBJECTIVES A systematic review was performed examining the accuracy, described techniques, and economic implications of the IPT for the diagnosis of MG with ocular features. METHOD The databases EMBASE, PubMed, and the Cochrane Library were searched from inception to July 2022. The systematic review adhered to PRISMA guidelines. Eligibility determination was undertaken with a standardised form using appropriate inclusion criteria. The Cochrane risk of bias assessment tool for diagnostic test accuracy was employed to evaluate studies that presented the diagnostic performance of the IPT. The Johanna Briggs Institute Critical Appraisal Checklist for Economic Evaluations was used for the assessment of studies presenting economic evaluations of the IPT. RESULTS 20 articles met the specified criteria and included a total of 1264 participants. The IPT had a sensitivity ranging from 38.5% to 100%. Specificity was found to be > 95% in six studies. Excluding two outlier results of 25% and 31.3%, the lowest specificity recorded was 62.5%. The most commonly described method of evaluating the IPT involved applying ice to both eyelids and using a >2 mm change as a threshold for a positive test (evaluated with a ruler). There were no adverse effects described with the IPT. There were no studies that formally examined the economic implications of the IPT. CONCLUSIONS The IPT is a well-tolerated and readily available diagnostic tool that has an important role in the evaluation of possible MG with ocular features in specific contexts. Despite limited economic evaluation of this test, it is likely the use of the IPT may result in significant financial and time savings.
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Affiliation(s)
| | | | - Lydia Lam
- University of Adelaide, Adelaide, SA, Australia
| | - Luke Collins
- Flinders Medical Centre, Bedford Park, SA, Australia
| | | | - Aashray Gupta
- Gold Coast University Hospital, Southport, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, SA, Australia
- Flinders Medical Centre, Bedford Park, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Slee
- Flinders Medical Centre, Bedford Park, SA, Australia
| | - WengOnn Chan
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
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Oculomotor fatigability with decrements of saccade and smooth pursuit for diagnosis of myasthenia gravis. J Neurol 2023; 270:2743-2755. [PMID: 36856847 PMCID: PMC10129983 DOI: 10.1007/s00415-023-11611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND AND OBJECTIVES As the efficacy of current diagnostic methods for myasthenia gravis (MG) remains suboptimal, there is ongoing interest in developing more effective diagnostic models. As oculomotor fatigability is one of the most common and diagnostic symptoms in MG, we aimed to investigate whether quantitative saccadic and smooth-pursuit fatigability analyses with video-oculography (VOG) are useful for diagnosis of MG. METHODS A convenience cohort of 46 MG patients was recruited prospectively, including 35 with ocular and 11 with generalized MG (mean age, 50.9 ± 14.5 years; 17 females); 24 healthy controls (HCs) (mean age, 50.6 ± 16.3 years; 13 females) also were enrolled. Seventy-five repetitive saccades and smooth pursuits were recorded in ranges of 20° (horizontal plane) and 15° (vertical plane) using a three-dimensional VOG system. Based on the oculomotor range of the second saccade and smooth pursuit and the mean ranges of the last five of each, the estimated decrements (%) reflecting oculomotor fatigability were calculated. RESULTS The baseline oculomotor ranges did not show significant difference between the MG and HCs groups. However, following repetitive saccades and pursuits, the oculomotor ranges were decreased substantially during the last five cycles compared to baseline in the MG group. No such decrements were observed in the HC group (p < 0.01, Mann-Whitney U test). Receiver operating characteristic (ROC) analysis revealed that repetitive vertical saccades yielded the best differentiation between the MG and HC groups, with a sensitivity of 78.3% and specificity of 95.8% when using a decrement with an amplitude of 6.4% as the cutoff. CONCLUSION This study presents an objective and reproducible method for measuring decrements of oculomotor ranges after repetitive saccadic and pursuit movements. Quantification of oculomotor fatigability using VOG could be a sensitive and specific diagnostic tool for MG and allows easy, cost-effective, accurate, and non-invasive measurements. CLASSIFICATION OF EVIDENCE This study provides class III evidence that VOG-based quantification of saccadic and pursuit fatigability accurately identifies patients with MG.
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Generalization of ocular myasthenia gravis 10 years after onset. J Neurol 2022; 269:6597-6604. [PMID: 36001142 DOI: 10.1007/s00415-022-11316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/24/2022] [Accepted: 07/28/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Generalization of ocular myasthenia gravis (OMG) represents a pejorative evolution, and no validated generalization-prevention strategy exists. The study aimed to determine the percentage of patients with OMG generalization and identify factors predictive of it to establish a prediction score. METHODS This retrospective, observational study included 151 patients diagnosed with OMG after an initial work-up in our institution. The outcome measure was time to MG generalization. The explanatory variables were age at onset (> 55 years), sex, first-year anti-acetylcholine-receptor antibody-positivity, repetitive nerve stimulation showing electromyogram decrement and corticosteroid use. Kaplan-Meier estimations of the probability of risk of generalization, and descriptive and multivariate Cox model analyses were computed. A nomogram combining explanatory variables was used to establish a score to predict the probability of OMG generalization. RESULTS Among 183 patients' charts identified, 151 had confirmed OMG. Their median follow-up was 5.7 years. Estimations (95% CI) of OMG-generalization risk at 1, 3 and 10 years post-symptom onset, respectively, were: 13.0% (7.3-18.2), 25.1% (17.5-32.0) and 37.8% (27.2-45.2). The p-value-based multivariate analysis associated generalization with female sex, electromyogram decrement and first-year anti-acetylcholine-receptor antibody positivity, and Akaike information criterion-based analysis retained those three parameters and corticosteroid use. A nomogram was built and validated with an optimism-corrected C-statistic of 0.68, and calibration plots showed good fit. CONCLUSIONS Our population's percentage of OMG generalization is in line with recent publications. Using the identified prognostic factors, the nomogram provided a score to predict the probable risk of generalization in our cohort.
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Fan L, Yang Y, Zhang F, Huang F. Clinical Efficacy of Immunoglobulin Combined with Glucocorticoids in the Treatment of Oculomotor Myasthenia Gravis in Children and the Effect on Serum Immunity. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1772881. [PMID: 35844442 PMCID: PMC9286931 DOI: 10.1155/2022/1772881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022]
Abstract
To investigate the effects of treatment with immunoglobulin on clinical outcomes and immune function in children with oculomotor myasthenia gravis. The clinical data of 100 pediatric patients with oculomotor myasthenia gravis treated in our hospital from January 2019 to December 2021 were selected as the subjects of this retrospective study and divided into a comparison group and a treatment group according to the different treatment methods. The comparison group was treated with glucocorticoids, and the treatment group was treated with immunoglobulin on the basis of the comparison group. The differences in the serum indexes, the effects of immune function, and the clinical efficacy of the two groups were observed and compared. It was found the comparison of immunoglobulin G (IgG), immunoglobulin A (IgA), and immunoglobulin M (IgM) after treatment was significantly different and lower in the treatment group than in the comparison group; the comparison of CD4+, CD3+, CD4+/CD8+, and NK cells after treatment was significantly different and higher in the treatment group than in the comparison group. The effective rate of 98.00% in the treatment group was significantly higher than that of 76.00% in the comparison group, and the difference was statistically significant. The clinical efficacy of the two groups showed that the fever, cough, sputum, myasthenia gravis crisis, and gastrointestinal reactions in the treatment group were significantly lower than those in the comparison group. The study indicates that comparative study of children with oculomotor myasthenia gravis treated with immunoglobulin combined with glucocorticoids is more effective, effectively improving the immune level of patients and reducing adverse reactions.
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Affiliation(s)
- Lijun Fan
- Pediatrics, Hubei Suizhou Central Hospital, Suizhou, Hubei 441300, China
| | - Yahui Yang
- Pediatrics, Wuhan Hankou Hospital, Wuhan, Hubei 430012, China
| | - Fan Zhang
- Pediatrics, Hubei Suizhou Maternal and Child Health Hospital, Suizhou, Hubei 441300, China
| | - Fei Huang
- Pediatrics, Hubei Suizhou Central Hospital, Suizhou, Hubei 441300, China
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Nair AG. Commentary: Ocular myasthenia gravis: Interpreting the investigations. Indian J Ophthalmol 2022; 70:1337-1338. [PMID: 35326050 PMCID: PMC9240566 DOI: 10.4103/ijo.ijo_2839_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Akshay Gopinathan Nair
- Department of Ophthalmic Plastic Surgery and Ocular Oncology Services, Advanced Eye Hospital and Institute, Dr. Agarwal's Group of Hospitals, Navi Mumbai, Maharashtra, India
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