1
|
Cai Q, Batista AE, Börsum J, Zhang Q, Isheden G, Kunovszki P, Gandhi K, Heerlein K, Brauner S. Long-Term Healthcare Resource Utilization and Costs among Patients with Myasthenia Gravis: A Swedish Nationwide Population-Based Study. Neuroepidemiology 2024:1-10. [PMID: 38631321 DOI: 10.1159/000538640] [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: 09/27/2023] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Healthcare costs and societal impact of myasthenia gravis (MG), a potentially life-threatening rare, chronic neuromuscular disease, are sparsely studied. We assessed healthcare resource utilization (HCRU) and associated costs among patients with newly diagnosed (ND) and preexisting (PE) MG in Sweden. METHODS This observational, retrospective cohort study used data from four linkable Swedish nationwide population-based registries. Adult MG patients receiving pharmacological treatment for MG and having ≥24-month follow-up during the period January 1, 2010, to December 31, 2017, were included. RESULTS A total of 1,275 patients were included in the analysis, of which 554 patients were categorized into the ND MG group and 721 into the PE MG group. Mean (±SD) age was 61.3 (±17.4) years, and 52.3% were female. In the first year post-diagnosis, ND patients had significantly higher utilization of acetylcholinesterase inhibitors (96.0% vs. 83.9%), corticosteroids (59.6% vs. 45.8%), thymectomy (12.1% vs. 0.7%), and plasma exchange (3.8% vs. 0.6%); had higher all-cause (70.9% vs. 35.8%) and MG-related (62.5% vs. 18.4%) hospitalization rates with 11 more hospitalization days (all p < 0.01) and an increased risk of hospitalization (odds ratio [95% CI] = 4.4 [3.43, 5.64]) than PE MG. In year 1 post-diagnosis, ND MG patients incurred EUR 7,302 (p < 0.01) higher total all-cause costs than PE MG, of which 84% were estimated to be MG-related and the majority (86%) were related to inpatient care. These results remained significant also after controlling for baseline demographics and comorbidities (p < 0.01). In year 2 post-diagnosis, the all-cause medical costs decreased by ∼55% for ND MG from year 1 and were comparable with PE MG. CONCLUSION In this population-based study, MG patients required significantly more healthcare resources in year 1 post-diagnosis than PE MG primarily due to more pharmacological treatments, thymectomies, and associated hospitalizations. These findings highlight the need to better understand potential factors including disease characteristics associated with increased health resource use and costs and need for more efficacious treatments early in the disease course.
Collapse
Affiliation(s)
- Qian Cai
- Janssen Global Services, Titusville, New Jersey, USA
| | | | | | - Qiaoyi Zhang
- Janssen Global Services, Titusville, New Jersey, USA
| | | | | | - Kavita Gandhi
- Janssen Global Services, Titusville, New Jersey, USA
| | | | - Susanna Brauner
- Department of Clinical Neuroscience, Karolinska Institute and Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
2
|
Salort-Campana E, Laforet P, de Pouvourville G, Crochard A, Chollet G, Nevoret C, Emery C, Bouée S, Tard C. Epidemiology of myasthenia gravis in France: A retrospective claims database study (STAMINA). Rev Neurol (Paris) 2024; 180:202-210. [PMID: 37945494 DOI: 10.1016/j.neurol.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/04/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The objectives of this observational study were to report the incidence and prevalence of myasthenia gravis (MG) in France, describe patients' characteristics and treatment patterns, and estimate mortality. METHODS A historical cohort analysis was performed using the French National Health Data System (SNDS) database between 2008 and 2020. Patients with MG were identified based on ICD-10 codes during hospitalization and/or long-term disease (ALD) status, which leads to a 100% reimbursement for healthcare expenses related to MG. The study population was matched to a control group based on age, sex and region of residence. RESULTS The overall incidence of MG was estimated at 2.5/100,000 in 2019 and the overall prevalence at 34.2/100,000. The mean age was 58.3 years for incident patients and 58.6 for prevalent patients. Among patients with MG, 57.1% were women. In the first year after identification of MG, acetylcholinesterase inhibitors were the most commonly used treatments (87.0%). Corticosteroids were delivered to 58.3% of patients, intravenous immunoglobulin to 34.4%, and azathioprine to 29.9%. Additionally, 8% of patients underwent thymectomy. The proportions of patients with exacerbations and crises were 59.7% and 13.5% respectively in the first year after MG identification. All-cause mortality was significantly higher in patients with MG compared to matched controls (HR=1.82 (95% CI [1.74;1.90], P<0.0001)). CONCLUSION In this study, the incidence and prevalence of MG estimated in France were found to be higher than previously reported. Most exacerbations and crises occurred within the first year after MG identification. MG was associated with increased mortality compared to a control population matched on age, gender, and geographical region.
Collapse
Affiliation(s)
- E Salort-Campana
- Service du Pr Attarian, Centre de référence des maladies neuromusculaires PACA Réunion Rhône Alpes, AP-HM, Marseille, France
| | - P Laforet
- Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence des maladies neuromusculaires Nord-Est-Ile de France, FHU Phenix, Garches, France
| | | | | | | | | | - C Emery
- CEMKA, Bourg-La-Reine, France
| | - S Bouée
- CEMKA, Bourg-La-Reine, France
| | - C Tard
- Service de neurologie, U1172, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, CHU de Lille, Lille, France
| |
Collapse
|
3
|
Sansoni J, Menon N, Viali L, White S, Vucic S. Clinical features, treatments, their impact, and quality of life for Myasthenia Gravis patients in Australia. J Clin Neurosci 2023; 118:16-22. [PMID: 37844489 DOI: 10.1016/j.jocn.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/07/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
This survey provides an update on the experience of Myasthenia Gravis (MG) patients in Australia. Items were drawn from the 2011 Australian Survey and a 2019 US survey allowing for comparative discussion of survey findings. Patients were recruited through the Myasthenia Alliance Australia. Following consent, patients completed an online survey using REDCap software. Questions included demographics, clinical features, treatment side-effects and quality of life (QOL) scales. Samples for completion of survey sections ranged from N = 242-280 representing a power level of over 80%. Female and seronegative patients reported a significantly greater symptom load, earlier disease onset, longer time to diagnosis, more MG exacerbations, treatment side-effects, and poorer QOL. For exacerbation management there was a higher rate of oral corticosteroid use (66%), a lower use of Intravenous Immunoglobulin (IVIg, 47%) and particularly, Therapeutic Plasma Exchange (TPE, 4.5%) within this sample. Although steroid induced side-effects were rarer (9-34%), a comparatively high use of corticosteroids was reported for current and overall treatments including those for MG crises (52-83%). Common treatment side-effects reported by 57-85% of patients, included fatigue, weight gain, a decrease in the ability to fight infections, gastrointestinal symptoms, and muscle weakness. The impact of MG on daily activities and QOL was considerable, but those who had a thymectomy reported better QOL. The survey identified areas for potential practice improvement in MG treatments (corticosteroids, IVIg, TPE), particularly for exacerbation management, and review is recommended. Further research on gender and antibody status differentials regarding clinical features is required.
Collapse
Affiliation(s)
- Janet Sansoni
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia; Health Outcomes Collaboration, 2 Bramston St, Fadden, ACT 2904, Australia.
| | - Nidhi Menon
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Lachlan Viali
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Susan White
- Myasthenia Alliance Australia, 17 Aldridge Ave, Corrimal East, NSW 2518, Australia; Myasthenia Gravis Association of Queensland Inc., PO Box16, Mt Gravatt, Queensland 4122, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney Concord Clinical School, Concord, NSW 2139, Australia
| |
Collapse
|
4
|
Gilhus NE. Myasthenia gravis, respiratory function, and respiratory tract disease. J Neurol 2023:10.1007/s00415-023-11733-y. [PMID: 37101094 PMCID: PMC10132430 DOI: 10.1007/s00415-023-11733-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
Myasthenia gravis (MG) is characterized by muscle weakness caused by autoantibodies that bind to the postsynaptic membrane at the neuromuscular junction and impair acetylcholine receptor function. Weakness of respiratory muscles represents the most severe MG manifestation, and 10-15% of all patients experience an MG crisis with the need of mechanical ventilatory support at least once in their life. MG patients with respiratory muscle weakness need active immunosuppressive drug treatment long term, and they need regular specialist follow-up. Comorbidities affecting respiratory function need attention and optimal treatment. Respiratory tract infections can lead to MG exacerbations and precipitate an MG crisis. Intravenous immunoglobulin and plasma exchange are the core treatments for severe MG exacerbations. High-dose corticosteroids, complement inhibitors, and FcRn blockers represent fast-acting treatments that are effective in most MG patients. Neonatal myasthenia is a transient condition with muscle weakness in the newborn caused by mother's muscle antibodies. In rare cases, treatment of respiratory muscle weakness in the baby is required.
Collapse
Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| |
Collapse
|
5
|
Zhang D, Luo L, Lu F, Li B, Lai X. Transcriptional landscape of myasthenia gravis revealed by weighted gene coexpression network analysis. Front Genet 2023; 14:1106359. [PMID: 37051601 PMCID: PMC10083720 DOI: 10.3389/fgene.2023.1106359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Background: As one of the most common autoimmune diseases, myasthenia gravis (MG) severely affects the quality of life of patients. Therefore, exploring the role of dysregulated genes between MG and healthy controls in the diagnosis of MG is beneficial to reveal new and promising diagnostic biomarkers and clinical therapeutic targets.Methods: The GSE85452 dataset was downloaded from the Gene Expression Omnibus (GEO) database and differential gene expression analysis was performed on MG and healthy control samples to identify differentially expressed genes (DEGs). The functions and pathways involved in DEGs were also explored by functional enrichment analysis. Significantly associated modular genes were identified by weighted gene co-expression network analysis (WGCNA), and MG dysregulated gene co-expression modular-based diagnostic models were constructed by gene set variance analysis (GSVA) and least absolute shrinkage and selection operator (LASSO). In addition, the effect of model genes on tumor immune infiltrating cells was assessed by CIBERSORT. Finally, the upstream regulators of MG dysregulated gene co-expression module were obtained by Pivot analysis.Results: The green module with high diagnostic performance was identified by GSVA and WGCNA. The LASSO model obtained NAPB, C5orf25 and ERICH1 genes had excellent diagnostic performance for MG. Immune cell infiltration results showed a significant negative correlation between green module scores and infiltration abundance of Macrophages M2 cells.Conclusion: In this study, a diagnostic model based on the co-expression module of MG dysregulated genes was constructed, which has good diagnostic performance and contributes to the diagnosis of MG.
Collapse
|
6
|
Ozdemir HN, Karasoy H, Yuceyar AN, Ekmekci O. Effects of comorbid diseases on clinical outcomes in patients with myasthenia gravis. Neurol Sci 2023:10.1007/s10072-023-06750-8. [PMID: 36943588 DOI: 10.1007/s10072-023-06750-8] [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: 12/12/2022] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND This cross-sectional study was undertaken to evaluate the existence and distribution of comorbid disorders among myasthenia gravis (MG) patients according to subgroups and to identify the effects of the comorbid diseases of MG patients on clinical outcomes. METHODS The patients were divided into six subgroups according to serum antibodies, age at onset, and thymoma presence. All patients were treated in line with the International Consensus Guidance for Management of Myasthenia Gravis. To assess the clinical outcome after treatment for MG, we used the MGFA Post-intervention Status. In generalized MG patients, the good prognosis group included patients who were classified as having minimal-manifestation status or better. In ocular MG patients, the remission subgroup included patients who were classified as having complete stable remission or pharmacological remission status. RESULTS Our study included 168 MG patients, 85 were female while 83 were male. Comorbid diseases were present in 124 (73.8%) MG cases. After at least 1 year of follow-up, 106 (86.8%) of the generalized MG patients were in the good prognosis group and 16 (13.2%) generalized MG patients were in the poor prognosis group. 27 (58.6%) ocular MG patients were in the remission group and 19 (41.3%) ocular MG patients were in the non-remission group. Hypertension increased the risk of poor prognosis by 3.55-fold among patients with generalized MG and type 2 DM increased the risk of not achieving remission by 9.32-fold among patients with ocular MG. CONCLUSION Hypertension and type 2 DM had negative effects on the clinical outcomes of MG.
Collapse
Affiliation(s)
| | - Hatice Karasoy
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Ayse Nur Yuceyar
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Ozgul Ekmekci
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey.
| |
Collapse
|
7
|
Tang YL, Ruan Z, Su Y, Guo RJ, Gao T, Liu Y, Li HH, Sun C, Li ZY, Chang T. Clinical Characteristics and Prognosis of Very late-onset Myasthenia Gravis in China. Neuromuscul Disord 2023; 33:358-366. [PMID: 36990040 DOI: 10.1016/j.nmd.2023.02.013] [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: 10/24/2022] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
Alteration in onset-age distribution in myasthenia gravis (MG) and its increasing prevalence among the elderly underscores the need for a better understanding of the clinical course of MG and the establishment of personalized treatment. In this study we reviewed the demographics, clinical profile, and treatment of MG. Based on onset age, eligible patients were classified as early-onset MG (onset age ≥18 and <50 years), late-onset MG (onset age ≥50 and <65 years), and very late-onset MG (onset age ≥65 years). Overall, 1160 eligible patients were enrolled. Patients with late- and very late-onset MG showed a male predominance (P=0.02), ocular MG subtype (P=0.001), and seropositivity for acetylcholine receptors and titin antibodies (P<0.001). In very late-onset MG, a lower proportion of patients retained minimal manifestations status or better, a higher proportion of patients had MG-related deaths (P<0.001), and a shorter maintenance time of minimal manifestation status or better was seen at the last follow-up (P=0.007) than that in patients with early- and late-onset MG. Non-immunotherapy may associated with a poor prognosis in patients in the very late-onset group. Further studies on very late-onset MG patients should be performed to evaluate the relationship between immunotherapy and prognosis.
Collapse
Affiliation(s)
- Yong-Lan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China.
| | - Yue Su
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Rong-Jing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Yu Liu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Huan-Huan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Zhu-Yi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China.
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China.
| |
Collapse
|
8
|
Mevius A, Jöres L, Biskup J, Heidbrede T, Mahic M, Wilke T, Maywald U, Lehnerer S, Meisel A. Epidemiology and treatment of myasthenia gravis: a retrospective study using a large insurance claims dataset in Germany. Neuromuscul Disord 2023; 33:324-333. [PMID: 36921445 DOI: 10.1016/j.nmd.2023.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 03/05/2023]
Abstract
Myasthenia gravis (MG) is a rare, chronic autoimmune disease with symptoms of fluctuating muscular weakness and fatigability. The aim of this retrospective cohort study was to estimate the prevalence and incidence of MG in Germany, and to understand the burden of disease and treatment patterns, based on anonymized German claims data. Two patient samples were identified: (1) incident MG patients with newly onset disease between 2015 and 2019, and (2) prevalent MG patients in 2019. In total, 775 incident MG patients with a mean age of 66.9 years; and 1,247 prevalent MG patients with a mean age of 68.6 years were included. The prevalence for Germany was estimated to be 39.3/100,000 on 31/12/2019; the incidence in 2019 was 4.6 cases/100,000 persons. The 12-month mortality was 5.7. For 31.5% of the incident patients, no MG treatment was observed in the first year after the index date. Of all incident patients, 29.9% experienced an exacerbation, and 6.7% a myasthenic crisis during the observation. Our study indicates that a substantial proportion of MG patients remains untreated. Many MG patients still experience exacerbations / MG crises. MG seems to be associated with an excess mortality in comparison to the general non-MG population.
Collapse
Affiliation(s)
- Antje Mevius
- Ingress-health HWM GmbH, Alter Holzhafen 19, Wismar 23966, Germany.
| | - Lars Jöres
- UCB Pharma, Alfred-Nobel-Str. 10,Monheim 40789, Germany
| | - Jutta Biskup
- UCB Pharma, Alfred-Nobel-Str. 10,Monheim 40789, Germany
| | | | | | - Thomas Wilke
- IPAM e.V., University of Wismar, Alter Holzhafen 19, Wismar 23966, Germany
| | - Ulf Maywald
- AOK PLUS, Sternplatz 7, Dresden 01067, Germany
| | - Sophie Lehnerer
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany; BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany; BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| |
Collapse
|
9
|
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease where muscle antibodies form against the acetylcholine receptor (AChR), MuSK, or LRP4 at the neuromuscular junction leading to weakness. Patients worry about consequences for pregnancy, giving birth, nursing, and child outcome. AREAS COVERED This review lists the pharmacological treatments for MG in the reproductive age and gives recommendations. Consequences for pregnancy, giving birth, breastfeeding, and child outcome are discussed. EXPERT OPINION Pyridostigmine, corticosteroids in low doses, and azathioprine are regarded as safe during pregnancy and should be continued. Mycophenolate mofetil, methotrexate, and cyclophosphamide should not be used in reproductive age. Rituximab should not be given during pregnancy. Other monoclonal IgG antibodies such as eculizumab and efgartigimod should be given only when regarded strictly necessary to avoid long-term and severe incapacity. Intravenous and subcutaneous immunoglobulin and plasma exchange are safe treatments during pregnancy and are recommended for exacerbations with moderate or severe generalized weakness. Most MG women have spontaneous vaginal deliveries. Indications for Cesarean section are obstetrical and similar to non-MG women. Neonatal myasthenia manifests as a transient weakness caused by the mother's IgG muscle antibodies and affects 10% of the babies. MG women should be supported in their wish to have children.
Collapse
Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
10
|
Le Tanno P, Latypova X, Rendu J, Fauré J, Bourg V, Gauthier M, Billy-Lopez G, Jouk PS, Dieterich K. Diagnostic workup in children with arthrogryposis: description of practices from a single reference centre, comparison with literature and suggestion of recommendations. J Med Genet 2023; 60:13-24. [PMID: 34876503 DOI: 10.1136/jmedgenet-2021-107823] [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: 03/02/2021] [Accepted: 11/18/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Arthrogryposis multiplex congenita (AMC) refers to a clinical presentation of congenital contractures involving two or more body areas. More than 400 distinct conditions may lead to AMC, making the aetiological diagnosis challenging. The objective of this work was to set up evidence-based recommendations for the diagnosis of AMC by taking advantage of both data from our nation-wide cohort of children with AMC and from the literature. MATERIAL AND METHODS We conducted a retrospective single-centre observational study. Patients had been evaluated at least once at a paediatric age in the AMC clinic of Grenoble University Hospital between 2007 and 2019. After gathering data about their diagnostic procedure, a literature review was performed for each paraclinical investigation to discuss their relevance. RESULTS One hundred and twenty-five patients were included, 43% had Amyoplasia, 27% had distal arthrogryposis and 30% had other forms. A definitive aetiological diagnosis was available for 66% of cases. We recommend a two-time diagnostic process: first, non-invasive investigations that aim at classifying patients into one of the three groups, and second, selected investigations targeting a subset of patients. CONCLUSION The aetiological management for patients with AMC remains arduous. This process will be facilitated by the increasing use of next-generation sequencing combined with detailed phenotyping. Invasive investigations should be avoided because of their limited yield.
Collapse
Affiliation(s)
- Pauline Le Tanno
- Univ. Grenoble Alpes, Inserm, U1209, CHU Grenoble Alpes, Institut of Advanced Biosciences, 38000 Grenoble, France
| | - Xenia Latypova
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute of Neurosciences, 38000 Grenoble, France
| | - John Rendu
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute of Neurosciences, 38000 Grenoble, France
| | - Julien Fauré
- Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institute of Neurosciences, 38000 Grenoble, France
| | - Véronique Bourg
- Service de Médecine Physique et Réhabilitation pédiatrique, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Marjolaine Gauthier
- Service de Génétique, Génomique et Procréation, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Gipsy Billy-Lopez
- Service de Génétique, Génomique et Procréation, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Pierre-Simon Jouk
- Service de Génétique, Génomique et Procréation, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Klaus Dieterich
- Univ. Grenoble Alpes, Inserm, U1209, CHU Grenoble Alpes, Institut of Advanced Biosciences, 38000 Grenoble, France
| |
Collapse
|
11
|
Abstract
Myasthenia gravis is an autoimmune disorder caused by antibodies against elements in the postsynaptic membrane at the neuromuscular junction, which leads to muscle weakness. Congenital myasthenic syndromes are rare and caused by mutations affecting pre- or postsynaptic function at the neuromuscular synapse and resulting in muscle weakness. MG has a prevalence of 150-250 and an annual incidence of 8-10 individuals per million. The majority has disease onset after age 50 years. Juvenile MG with onset in early childhood is more common in East Asia. MG is subgrouped according to type of pathogenic autoantibodies, age of onset, thymus pathology, and generalization of muscle weakness. More than 80% have antibodies against the acetylcholine receptor. The remaining have antibodies against MuSK, LRP4, or postsynaptic membrane antigens not yet identified. A thymoma is present in 10% of MG patients, and more than one-third of thymoma patients develop MG as a paraneoplastic condition. Immunosuppressive drug therapy, thymectomy, and symptomatic drug therapy with acetylcholine esterase inhibitors represent cornerstones in the treatment. The prognosis is good, with the majority of patients having mild or moderate symptoms only. Most congenital myasthenic syndromes are due to dysfunction in the postsynaptic membrane. Symptom debut is in early life. Symptomatic drug treatment has sometimes a positive effect.
Collapse
Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| |
Collapse
|
12
|
Lehnerer S, Jacobi J, Schilling R, Grittner U, Marbin D, Gerischer L, Stascheit F, Krause M, Hoffmann S, Meisel A. Burden of disease in myasthenia gravis: taking the patient's perspective. J Neurol 2022; 269:3050-3063. [PMID: 34800167 PMCID: PMC9120127 DOI: 10.1007/s00415-021-10891-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/10/2021] [Accepted: 11/02/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) leads to exertion-dependent muscle weakness, but also psychological and social well-being are limited. We aim to describe the burden of disease in MG including sociodemographic, economical, psychosocial as well as clinical aspects, to compare health-related quality of life (HRQoL) of patients with MG to the general population (genP) and to explore risk factors for a lower HRQoL. METHODS This case-control study was conducted with MG patients of the German Myasthenia Association. A questionnaire-based survey included sociodemographic and clinical data as well as standardized questionnaires, e.g. the Short Form Health (SF-36). HRQoL was compared to genP in a matched-pairs analysis. Participants of the German Health Interview and Examination Survey for Adults (DEGS1) served as control group. RESULTS In our study, 1660 MG patients participated and were compared to 2556 controls from the genP. Patients with MG showed lower levels of physical functioning (SF-36 mean 56.0, SD 30.3) compared to the genP (mean 81.8, SD 22.1, adjusted difference: 25, 95% CI 22-29) and lower mental health sub-score (SF-36 mean 67.3, SD 19.8, vs. 74.1, SD 16.7, adjusted difference: 5, 95% CI 2-8). Female gender, higher age, low income, partnership status, lower activities of daily life, symptoms of depression, anxiety and fatigue and self-perceived low social support were associated with a lower HRQoL in MG patients. DISCUSSION HRQoL is lower in patients with MG compared to genP. The burden of MG on patients includes economic and social aspects as well as their emotional well-being. New therapies must achieve improvements for patients in these areas. TRIAL REGISTRATION INFORMATION Clinicaltrials.gov, NCT03979521, submitted: June 7, 2019, first patient enrolled: May 1, 2019, https://clinicaltrials.gov/ct2/show/NCT03979521.
Collapse
Affiliation(s)
- Sophie Lehnerer
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Jonas Jacobi
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ralph Schilling
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medicine Berlin, Luisenstraße 57, 10117, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Core Facility Genomics, Berlin Institute of Health at Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Derin Marbin
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, Charité University Medicine Berlin at St. Hedwig Hospital, Große Hamburger Straße 5-11, 10115, Berlin, Germany
| | - Lea Gerischer
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Maike Krause
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| |
Collapse
|
13
|
Lupica A, Di Stefano V, Iacono S, Pignolo A, Quartana M, Gagliardo A, Fierro B, Brighina F. Impact of COVID-19 in AChR Myasthenia Gravis and the Safety of Vaccines: Data from an Italian Cohort. Neurol Int 2022; 14:406-416. [PMID: 35645352 PMCID: PMC9149833 DOI: 10.3390/neurolint14020033] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 12/21/2022] Open
Abstract
Background and aims. Patients with Myasthenia gravis (MG) are considered vulnerable as they may present with respiratory muscle weakness and because they are on immunosuppressive treatment; thereby, COVID-19 may have a detrimental effect on these patients. Vaccines against COVID-19 are currently available and it has been shown as they can prevent severe COVID-19 in vulnerable patients. Notwithstanding their efficacy, vaccine hesitancy has not been completely dispelled in the general population. Unfortunately, there is limited data about the safety of these vaccines in MG patients. The aims of this study are to evaluate the impact of COVID-19 in a MG cohort, the adherence to COVID-19 vaccination in Italy and vaccine safety in MG patients. Methods. A retrospective cohort study of MG patients attending the Neuromuscular Clinic of the University Hospital “Paolo Giaccone” of Palermo, Italy, was performed. Patients underwent telephone interviews with a dedicated questionnaire on SARS-CoV-2 vaccination and infection. Vaccine safety was assessed though the evaluation of vaccine-related adverse events (AEs) and comparisons of MG-ADL scores before and after vaccination. Patient worsening was defined as two or more point increases in MG-ADL scores. Results. From a total of 90 participants, 75 answered the questionnaire and 70.5% of them (n = 53) received the vaccine; ten patients did not receive vaccination and 3 patients were partially vaccinated. Among the vaccinated patients, about 45% (n = 24) experienced at least one AE, with a complete resolution within one week. No serious AEs and life-threatening conditions were observed. Globally, MG-ADL scores did not worsen after vaccination. Nine unvaccinated patients experienced SARS-CoV2 infection and four of them (44%) died—one patient required respiratory support, whereas three patients were asymptomatic. Conclusions. COVID-19 significantly impacted MG patients with an increase in mortality due to respiratory sequelae. Vaccines against SARS-CoV-2 showed good short-term safety in MG patients, who may take advantage of vaccination to avoiding life-threatening complications such as COVID-19 pneumonia.
Collapse
|
14
|
Exploring the Gut Microbiome in Myasthenia Gravis. Nutrients 2022; 14:nu14081647. [PMID: 35458209 PMCID: PMC9027283 DOI: 10.3390/nu14081647] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 12/13/2022] Open
Abstract
The human gut microbiota is vital for maintaining human health in terms of immune system homeostasis. Perturbations in the composition and function of microbiota have been associated with several autoimmune disorders, including myasthenia gravis (MG), a neuromuscular condition associated with varying weakness and rapid fatigue of the skeletal muscles triggered by the host’s antibodies against the acetylcholine receptor (AChR) in the postsynaptic muscle membrane at the neuromuscular junction (NMJ). It is hypothesized that perturbation of the gut microbiota is associated with the pathogenesis of MG. The gut microbiota community profiles are usually generated using 16S rRNA gene sequencing. Compared to healthy individuals, MG participants had an altered gut microbiota’s relative abundance of bacterial taxa, particularly with a drop in Clostridium. The microbial diversity related to MG severity and the overall fecal short-chain fatty acids (SCFAs) were lower in MG subjects. Changes were also found in terms of serum biomarkers and fecal metabolites. A link was found between the bacterial Operational Taxonomic Unit (OTU), some metabolite biomarkers, and MG’s clinical symptoms. There were also variations in microbial and metabolic markers, which, in combination, could be used as an MG diagnostic tool, and interventions via fecal microbiota transplant (FMT) could affect MG development. Probiotics may influence MG by restoring the gut microbiome imbalance, aiding the prevention of MG, and lowering the risk of gut inflammation by normalizing serum biomarkers. Hence, this review will discuss how alterations of gut microbiome composition and function relate to MG and the benefits of gut modulation.
Collapse
|
15
|
Su M, Liu X, Wang L, Song J, Zhou Z, Luo S, Zhao C. Risk factors for pregnancy-related clinical outcome in myasthenia gravis: a systemic review and meta-analysis. Orphanet J Rare Dis 2022; 17:52. [PMID: 35172854 PMCID: PMC8848664 DOI: 10.1186/s13023-022-02205-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/06/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Myasthenia gravis (MG) is an autoimmune disorder that frequently affects females at reproductive age. Herein, we aimed to assess the associations of clinical factors with pregnancy-related outcome in MG. METHODS We searched PubMed and EMBASE for case-control and cohort studies that reported the MG status during or after pregnancy and relevant clinical variables. The data was extracted in proportions and odds ratios (ORs) with 95% confidence intervals (CIs) in subsequent meta-analysis. RESULTS Fifteen eligible articles reporting on 734 pregnancies with 193 worsening and 51 improved episodes were included out of 1765 records. The estimated worsening proportions in total, antepartum and postpartum periods were 0.36 (95% CI 0.25-0.40), 0.23 (95% CI 0.14-0.34) and 0.11 (95% CI 0.04-0.22) respectively. The proportion of pregnancy-related improvement in enrolled patients was 0.28 (95% CI 0.17-0.40), with 0.07 (95% CI 0.00-0.28) during pregnancy and 0.14 (95% CI 0.02-0.34) after pregnancy. No significant associations were disclosed between the clinical factors and MG worsening. Thymectomy before delivery is a strong predictor for MG improvement in postpartum period (OR 4.85, 95% CI 1.88-12.50, p = 0.001). CONCLUSION The total proportion of pregnancy-related MG worsening and improvement in MG was 0.36 (95% CI 0.25-0.40) and 0.28 (95% CI 0.17-0.40), respectively. Thymectomy before the delivery may aid in clinical improvements associated with pregnancy. Future prospective cohort studies are required to determine more relevant factors.
Collapse
Affiliation(s)
- Manqiqige Su
- Huashan Rare Disease Center, Department of Neurology, Huashan Hospital, Fudan University, 200040, Shanghai, China
- National Center for Neurological Disorders, Shanghai, 200040, China
| | - Xiaoqing Liu
- Inner Mongolia Medical University, 010110, Inner Mongolia, China
| | - Liang Wang
- Huashan Rare Disease Center, Department of Neurology, Huashan Hospital, Fudan University, 200040, Shanghai, China
- National Center for Neurological Disorders, Shanghai, 200040, China
| | - Jie Song
- Huashan Rare Disease Center, Department of Neurology, Huashan Hospital, Fudan University, 200040, Shanghai, China
- National Center for Neurological Disorders, Shanghai, 200040, China
| | - Zhirui Zhou
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Sushan Luo
- Huashan Rare Disease Center, Department of Neurology, Huashan Hospital, Fudan University, 200040, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
| | - Chongbo Zhao
- Huashan Rare Disease Center, Department of Neurology, Huashan Hospital, Fudan University, 200040, Shanghai, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
| |
Collapse
|
16
|
Salari N, Fatahi B, Bartina Y, Kazeminia M, Fatahian R, Mohammadi P, Shohaimi S, Mohammadi M. Global prevalence of myasthenia gravis and the effectiveness of common drugs in its treatment: a systematic review and meta-analysis. J Transl Med 2021; 19:516. [PMID: 34930325 PMCID: PMC8686543 DOI: 10.1186/s12967-021-03185-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Myasthenia gravis is a neuromuscular autoimmune disorder characterized by weakness and disability in the voluntary muscles. There have been several preliminary studies on the epidemiology of myasthenia gravis in different parts of the world and the effectiveness of common drugs in its treatment, but there has been no comprehensive study of the efficacy of common drugs in the treatment of myasthenia gravis. Therefore, this study aimed to determine the epidemiology of myasthenia gravis globally and the effectiveness of common drugs in its treatment using systematic review and meta-analysis. METHODS Research studies were extracted from IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Sciences (WoS), ProQuest, Medline (PubMed), Scopus and Google Scholar based on Cochran's seven-step guidelines using existing keywords extracted in MeSH browser. The I2 test was used to calculate the heterogeneity of studies, and Begg and Mazumdar rank correlation tests were used to assess publication bias. Data were analyzed using Comprehensive Meta-Analysis software (Version 2). RESULTS In the search for descriptive studies based on the research question, 7374 articles were found. After deleting articles unrelated to the research question, finally, 63 articles with a sample size of 1,206,961,907 people were included in the meta-analysis. The prevalence of MG worldwide was estimated to be 12.4 people (95% CI 10.6-14.5) per 100,000 population. For analytical studies on the effectiveness of common myasthenia gravis drugs, 4672 articles were found initially, and after removing articles unrelated to the research question, finally, 20 articles with a sample size of 643 people in the drug group and 619 people in the placebo group were included in the study. As a result of the combination of studies, the difference between the mean QMGS score index after taking Mycophenolate and Immunoglobulin or plasma exchange drugs in the group of patients showed a significant decrease of 1.4 ± 0.77 and 0.62 ± 0.28, respectively (P < 0.01). CONCLUSION The results of systematic review of drug evaluation in patients with myasthenia gravis showed that Mycophenolate and Immunoglobulin or plasma exchange drugs have positive effects in the treatment of MG. It also represents the positive effect of immunoglobulin or plasma exchange on reducing SFEMG index and QMGS index and the positive effect of Mycophenolate in reducing MG-ADL index, SFEMG and Anti-AChR antibodies index. In addition, based on a meta-analysis of the random-effect model, the overall prevalence of MG in the world is 12.4 people per 100,000 population, which indicates the urgent need for attention to this disease for prevention and treatment.
Collapse
Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnaz Fatahi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yalda Bartina
- Department of Translation Studies, Faculty of Literature, Istanbul University, Istanbul, Turkey
| | - Mohsen Kazeminia
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Fatahian
- Department of Neurosurgery, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Payam Mohammadi
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor Malaysia
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran
| |
Collapse
|
17
|
Pharmacological Management of Myasthenia Gravis: A Century of Expert Opinions in Cecil Textbook of Medicine. Am J Ther 2021; 28:e631-e637. [PMID: 34757964 DOI: 10.1097/mjt.0000000000001454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Advances in drug therapy for myasthenia gravis have had a significant impact on the quality of life and work potential of a substantial majority of affected persons and has contributed to a remarkable decrease in the frequency and severity of complications, hospitalizations, and mortality. STUDY QUESTION What are the milestones of the changes in the expert approach to the pharmacological management of myasthenia in the past century? STUDY DESIGN To determine the changes in the experts' approach to the management of myasthenia gravis, as presented in a widely used textbook in the United States. DATA SOURCES The chapters presenting the management of myasthenia gravis in the 26 editions of Cecil Textbook of Medicine published from 1927 to 2020. RESULTS Adequate feeding, absolute rest in bed, and "tonics" were the only interventions recommended for the care of patients with myasthenia gravis in 1927. Ephedrine and glycine were used in the early 1930s. Treatment with the anticholinesterases physostigmine and neostigmine was recommended in 1937, 3 years after Mary Walker discovered it in the United Kingdom. Immunosuppressant pharmacological interventions with prednisone and azathioprine have been considered the standard since 1975, and intravenous immune globulin was added to usual care in 1996. The newer immunosuppressant drugs mycophenolate, cyclosporine, and tacrolimus have expanded the arsenal since 2008, and the monoclonal antibodies rituximab and eculizumab have been mentioned in the textbooks published in 2012-2020. The first randomized clinical trial of drug therapy for myasthenia gravis was published in 1987. CONCLUSIONS The pharmacological management of myasthenia gravis was revolutionized by the epiphany of an astute clinician in the 1930s. Immunosuppressant treatment was a logical step once the autoimmune nature of the condition was established. The major therapeutic advances highlight the values of empiricism and persistent attention to detail in treating relatively rare chronic disorders.
Collapse
|
18
|
Gilhus NE, Verschuuren JJGM, Hovland SIB, Simmonds H, Groot F, Palace J. Myasthenia gravis: do not forget the patient perspective. Neuromuscul Disord 2021; 31:S0960-8966(21)00583-6. [PMID: 34635387 DOI: 10.1016/j.nmd.2021.07.396] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| | | | | | - Huw Simmonds
- Myaware, College Business Centre, Derby, England
| | - Floor Groot
- Dutch Neuromuscular disease Association, Baarn, The Netherlands
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Hospitals Trust, Oxford, England
| |
Collapse
|
19
|
Creary LE, Gangavarapu S, Caillier SJ, Cavalcante P, Frangiamore R, Lie BA, Bengtsson M, Harbo HF, Brauner S, Hollenbach JA, Oksenberg JR, Bernasconi P, Maniaol AH, Hammarström L, Mantegazza R, Fernández-Viña MA. Next-Generation Sequencing Identifies Extended HLA Class I and II Haplotypes Associated With Early-Onset and Late-Onset Myasthenia Gravis in Italian, Norwegian, and Swedish Populations. Front Immunol 2021; 12:667336. [PMID: 34163474 PMCID: PMC8215161 DOI: 10.3389/fimmu.2021.667336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/27/2021] [Indexed: 11/13/2022] Open
Abstract
Genetic susceptibility to myasthenia gravis (MG) associates with specific HLA alleles and haplotypes at the class I and II regions in various populations. Previous studies have only examined alleles at a limited number of HLA loci that defined only broad serotypes or alleles defined at the protein sequence level. Consequently, genetic variants in noncoding and untranslated HLA gene segments have not been fully explored but could also be important determinants for MG. To gain further insight into the role of HLA in MG, we applied next-generation sequencing to analyze sequence variation at eleven HLA genes in early-onset (EO) and late-onset (LO) non-thymomatous MG patients positive for the acetylcholine receptor (AChR) antibodies and ethnically matched controls from Italy, Norway, and Sweden. For all three populations, alleles and haplotype blocks present on the ancestral haplotype AH8.1 were associated with risk in AChR-EOMG patients. HLA-B*08:01:01:01 was the dominant risk allele in Italians (OR = 3.28, P = 1.83E-05), Norwegians (OR = 3.52, P = 4.41E-16), and in Swedes HLA-B*08:01 was the primary risk allele (OR = 4.24, P <2.2E-16). Protective alleles and haplotype blocks were identified on the HLA-DRB7, and HLA-DRB13.1 class II haplotypes in Italians and Norwegians, whereas in Swedes HLA-DRB7 exhibited the main protective effect. For AChR-LOMG patients, the HLA-DRB15.1 haplotype and associated alleles were significantly associated with susceptibility in all groups. The HLA-DR13-HLA-DR-HLA-DQ haplotype was associated with protection in all AChR-LOMG groups. This study has confirmed and extended previous findings that the immunogenetic predisposition profiles for EOMG and LOMG are distinct. In addition, the results are consistent with a role for non-coding HLA genetic variants in the pathogenesis of MG.
Collapse
Affiliation(s)
- Lisa E Creary
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States.,Histocompatibility, Immunogenetics and Disease Profiling Laboratory, Stanford Blood Center, Palo Alto, CA, United States
| | - Sridevi Gangavarapu
- Histocompatibility, Immunogenetics and Disease Profiling Laboratory, Stanford Blood Center, Palo Alto, CA, United States
| | - Stacy J Caillier
- Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Paola Cavalcante
- Neurology IV Unit Neuroimmunology and Neuromuscular Diseases, Fondazione I.R.C.C.S Istituto Neurologico Carlo Besta (INCB), Milan, Italy
| | - Rita Frangiamore
- Neurology IV Unit Neuroimmunology and Neuromuscular Diseases, Fondazione I.R.C.C.S Istituto Neurologico Carlo Besta (INCB), Milan, Italy
| | - Benedicte A Lie
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Medical Genetics, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Mats Bengtsson
- Department of Immunology, Genetics and Pathology (IGP), Rudbeck Laboratory, Uppsala University and University Hospital, Uppsala, Sweden
| | - Hanne Flinstad Harbo
- Department of Neurology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Susanna Brauner
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jill A Hollenbach
- Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Jorge R Oksenberg
- Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Pia Bernasconi
- Neurology IV Unit Neuroimmunology and Neuromuscular Diseases, Fondazione I.R.C.C.S Istituto Neurologico Carlo Besta (INCB), Milan, Italy
| | | | - Lennart Hammarström
- The Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Renato Mantegazza
- Neurology IV Unit Neuroimmunology and Neuromuscular Diseases, Fondazione I.R.C.C.S Istituto Neurologico Carlo Besta (INCB), Milan, Italy.,Department of Clinical Research and Innovation, Fondazione I.R.C.C.S Istituto Neurologico Carlo Besta (INCB), Milan, Italy
| | - Marcelo A Fernández-Viña
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States.,Histocompatibility, Immunogenetics and Disease Profiling Laboratory, Stanford Blood Center, Palo Alto, CA, United States
| |
Collapse
|
20
|
Ashraf H, Vayzband V. Clinically Worsening Myasthenia-Related Respiratory Distress Notwithstanding Normal Markers of Respiratory Function. Cureus 2021; 13:e15250. [PMID: 34188989 PMCID: PMC8230280 DOI: 10.7759/cureus.15250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
An 81-year-old female with a past medical history of myasthenia gravis presented to the Emergency Department with difficulty breathing. At presentation, the patient also complained of fatigue, diplopia, and ptosis. Vitals and laboratory tests were largely benign. The patient was diagnosed as having a myasthenia gravis exacerbation, which eventually advanced to myasthenic crisis, with the patient requiring admission to the intensive care unit and supplementation of high-flow oxygen. Throughout the course of the patient's hospitalization, the measurements of her negative inspiratory force and vital capacity were found to be normal and unchanged despite shifting and unsteady respiratory symptoms. This uncommon case seeks to highlight the importance of complementing clinical context with the markers of respiratory function to assess the status of myasthenia-related respiratory distress.
Collapse
Affiliation(s)
- Hamza Ashraf
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Vlad Vayzband
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| |
Collapse
|
21
|
STATE ANXIETY ASSESSMENT IN PATIENTS WITH MYASTHENIA GRAVIS. WORLD OF MEDICINE AND BIOLOGY 2021. [DOI: 10.26724/2079-8334-2021-2-76-48-52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
22
|
Bubuioc AM, Kudebayeva A, Turuspekova S, Lisnic V, Leone MA. The epidemiology of myasthenia gravis. J Med Life 2021; 14:7-16. [PMID: 33767779 PMCID: PMC7982252 DOI: 10.25122/jml-2020-0145] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/14/2020] [Indexed: 11/17/2022] Open
Abstract
Neuromuscular junction (NMJ) disorders include several dysfunctions that ultimately lead to muscle weakness. Myasthenia gravis (MG) is the most prevalent NMJ disorder with a highly polymorphic clinical presentation and many different faces. Being an autoimmune disease, MG correlates with the presence of detectable antibodies directed against the acetylcholine receptor, muscle-specific kinase, lipoprotein-related protein 4, agrin, titin, and ryanodine in the postsynaptic membrane at the NMJ. MG has become a prototype serving to understand both autoimmunity and the function of the NMJ better. The aim of this review is to synthesize some of the epidemiological data available. Epidemiological data regarding MG are important for postulating hypotheses regarding its etiology and facilitating the description of MG subtypes. Thus, adequate documentation through broad databases is essential. The incidence and prevalence of MG reported around the globe have been rising steadily and consistently over the past decades. Ethnic aspects, gender-related differences, and environmental risk factors have been described, implying that these might contribute to a specific phenotype, further suggesting that MG may be considered an umbrella term that covers several clinical entities.
Collapse
Affiliation(s)
- Ana-Maria Bubuioc
- Department of Neurology, Nicolae Testemitanu State University of Medicine and Pharmacy Chisinau, the Republic of Moldova
| | - Aigerim Kudebayeva
- Department of Neurology, Kazakh Medical University of Continuing Education, Almaty, Kazakhstan
| | - Saule Turuspekova
- Department of Nervous Diseases with course of Neurosurgery, Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - Vitalie Lisnic
- Department of Neurology, Nicolae Testemitanu State University of Medicine and Pharmacy Chisinau, the Republic of Moldova
| | - Maurizio Angelo Leone
- Neurology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| |
Collapse
|
23
|
Incidence, mortality, and economic burden of myasthenia gravis in China: A nationwide population-based study. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 5:100063. [PMID: 34327399 PMCID: PMC8315547 DOI: 10.1016/j.lanwpc.2020.100063] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
Background Myasthenia gravis (MG) is the most common primary disorder of neuromuscular transmission, but the incidence of MG in China is unknown. We conducted the first nationwide study to determine the incidence and mortality rates of MG in all age groups at the national level in China. Methods This national population-based registry study is based on the database of the Hospital Quality Monitoring System of National Health Commission, which covers 1665 hospitals providing myasthenia gravis care in 31 provinces and municipalities across China. 94,638 hospital admissions for 59,243 myasthenia gravis patients were identified from January 1st, 2016 to December 31st, 2018. Myasthenia gravis was identified by ICD-10 codes (G70). Incidence of myasthenia gravis was stratified by age, sex, and province. Findings Of 59,243 patients, 30,503 individuals with myasthenia gravis were newly diagnosed. Age and sex adjusted incidence of myasthenia gravis was 0.68 per 100,000 person-years, with highest in the age group of 70–74 years. The incidence in females was 0.76 per 100,000 and 0.60 per 100,000 in males. The admission mortality rate was 14.69‰. Respiratory failure was the leading cause of death in patients with myasthenic crisis. There were 14,840 patients with thymomas, encompassing 14,636 (26.5%) adults and 204 (7.1%) juveniles. 9453 (63.7%) patients with thymomas underwent thymomectomy. The median length of hospital stay was 8 days (interquartile range (IQR) 4 to 15 days) with median hospitalization cost $1037 (IQR $493 to $2925). The Basic Medical Insurance was the most common payment method, covering 67.4% of patients. Interpretation The age and sex adjusted incidence of MG was 0.68 per 100,000 person-years in China. The admission mortality rate was 14.69‰. Most cases of new onset MG occurred in the seventh decade of life. Funding National Science Foundation of China (91642205, and 81830038); Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing
Collapse
|
24
|
Tan A, Fraser C, Khoo P, Watson S, Ooi K. Statins in Neuro-ophthalmology. Neuroophthalmology 2020; 45:219-237. [PMID: 34366510 PMCID: PMC8312600 DOI: 10.1080/01658107.2020.1755872] [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: 11/11/2019] [Revised: 04/05/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022] Open
Abstract
Statins are effective and well-tolerated hypolipidaemic agents which have been increasingly studied for their pleiotropic immunomodulatory and anti-inflammatory effects. Statins have potential therapeutic benefit in a range of neuro-ophthalmological conditions but may also induce or exacerbate certain neurological disorders. This literature review examines evidence from clinical and in vitro studies assessing the effects of statins in myasthenia gravis, myopathy, multiple sclerosis, neuromyelitis optica, idiopathic intracranial hypertension (pseudotumour cerebri), migraine, giant cell arteritis, Bell's palsy, ocular ischaemia, stroke, Alzheimer's disease and Parkinson's disease.
Collapse
Affiliation(s)
- Alvin Tan
- Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
| | - Clare Fraser
- Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
| | - Pauline Khoo
- Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
| | - Stephanie Watson
- Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
| | - Kenneth Ooi
- Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
| |
Collapse
|
25
|
Gilhus NE. Myasthenia Gravis Can Have Consequences for Pregnancy and the Developing Child. Front Neurol 2020; 11:554. [PMID: 32595594 PMCID: PMC7304249 DOI: 10.3389/fneur.2020.00554] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/15/2020] [Indexed: 12/24/2022] Open
Abstract
Myasthenia gravis (MG) with onset below 50 years, thymic hyperplasia and acetylcholine receptor (AChR) antibodies is more common in females than in males. For a relatively large group of MG patients, pregnancy represents therefore an important question. The muscle weakness, the circulating autoantibodies, the hyperplastic thymus, the MG drug treatment, and any autoimmune comorbidity may all influence both mother and child health during pregnancy and also during breastfeeding in the postpartum period. Mother's MG remains stable in most patients during pregnancy. Pyridostigmine, prednisolone, and azathioprine are regarded as safe during pregnancy. Mycophenolate, methotrexate and cyclophosphamide are teratogenic and should not be used by women with the potential to become pregnant. Rituximab should not be given during the last few months before conception and not during pregnancy. Intravenous immunoglobulin and plasma exchange can be used for exacerbations or when need for intensified therapy. Pregnancies in MG women are usually without complications. Their fertility is near normal. Vaginal delivery is recommended. MG patients have an increased rate of Cesarean section, partly due to their muscle weakness and to avoid exhaustion, partly as a precaution that is often unnecessary. Around 10% of the newborn develop neonatal myasthenia during the first few days after birth. This is transient and usually mild with some sucking and swallowing difficulties. In rare cases, transplacental transfer of AChR antibodies leads to permanent muscle weakness in the child, and arthrogryposis with joint contractures. Repeated spontaneous abortions have been described due to AChR antibodies. MG women should always give birth at hospitals with experience in newborn intensive care. MG does not represent a reason for not having children, and the patients should be supported in their wish of becoming pregnant.
Collapse
Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
26
|
Koźmiński P, Halik PK, Chesori R, Gniazdowska E. Overview of Dual-Acting Drug Methotrexate in Different Neurological Diseases, Autoimmune Pathologies and Cancers. Int J Mol Sci 2020; 21:ijms21103483. [PMID: 32423175 PMCID: PMC7279024 DOI: 10.3390/ijms21103483] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
Methotrexate, a structural analogue of folic acid, is one of the most effective and extensively used drugs for treating many kinds of cancer or severe and resistant forms of autoimmune diseases. In this paper, we take an overview of the present state of knowledge with regards to complex mechanisms of methotrexate action and its applications as immunosuppressive drug or chemotherapeutic agent in oncological combination therapy. In addition, the issue of the potential benefits of methotrexate in the development of neurological disorders in Alzheimer’s disease or myasthenia gravis will be discussed.
Collapse
|
27
|
Fang W, Li Y, Mo R, Wang J, Qiu L, Ou C, Lin Z, Huang Z, Feng H, He X, Wang W, Xu P, Wang L, Ran H, Liu W. Hospital and healthcare insurance system record-based epidemiological study of myasthenia gravis in southern and northern China. Neurol Sci 2020; 41:1211-1223. [PMID: 31897952 DOI: 10.1007/s10072-019-04146-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 11/07/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This is the first cross-region epidemiological study of myasthenia gravis (MG) in China. We estimated the incidence, prevalence, and medical costs of MG in southern China and explored the differences between the southern and northern Chinese populations. METHODS We collected and analyzed records from 20 hospitals in the southern city, Guangzhou, 13 hospitals in the northern city, Harbin, and two healthcare insurance systems: job based and residence based in Guangzhou during 2000-2017. RESULTS (1) The estimated annual incidence of MG was 1.55-3.66 per 100,000, and the estimated prevalence of MG was 2.19-11.07 per 100,000 in southern China based on insurance records. (2) The proportion of hospitalized MG patients in the south-based hospital records was three times as high as that in the north-based hospital records. (3) Female MG prevalence was significantly higher than male MG prevalence in Guangzhou, while the similar gender difference in Harbin was not statistically significant due to higher variation in earlier years. (4) The average expense was $35-42 for each outpatient service and $2526-2673 for each hospitalization expense in the south. (5) Contrary to the increase of insurance-based estimate of MG prevalence, the proportion of hospitalized MG patients did not increase over the years, suggesting rising awareness and utilization of health insurance. CONCLUSIONS The southern MG population had a significantly higher prevalence and a lower response threshold to medication than the northern MG population. These results are calling for further investigations on the genetic, cultural, and environmental variations of the Chinese MG populations between north and south.
Collapse
Affiliation(s)
- Wei Fang
- School of Earth and Environmental Sciences, Queens College, City University of New York, Queens, NY, USA
| | - Yan Li
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China.,Department of Neurosurgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Rong Mo
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jianjian Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Li Qiu
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Chuangyi Ou
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zhongqiang Lin
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zhidong Huang
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xuetao He
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Weizhi Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Peipei Xu
- Faculty of Geographical Science, Beijing Normal University, Beijing, People's Republic of China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China.
| | - Hao Ran
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, People's Republic of China.
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, #58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong, People's Republic of China.
| |
Collapse
|
28
|
Epilepsy and autoimmune diseases: Comorbidity in a national patient cohort. Seizure 2019; 75:89-95. [PMID: 31918165 DOI: 10.1016/j.seizure.2019.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/05/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To examine if autoimmune disorders occur with an increased frequency in patients with epilepsy. An autoimmune etiology of epilepsies has been suggested. By using data from The Norwegian Prescription Database (NorPD) we have surveyed a national cohort of patients with active epilepsy treated with antiepileptic drugs. METHODS NorPD contains all prescriptions of drugs dispensed at pharmacies in Norway since 2004. We received data of all drugs prescribed January 2004 - June 2014 for patients receiving an antiepileptic drug.79 751 patients receiving at least two prescriptions of antiepileptic drugs with the reimbursement code for epilepsy were included. To examine autoimmune comorbidity, medications specific for autoimmune diseases were retrieved. Standardized Incidence Ratios (SIR) with 95 % confidence interval (CI) were used to determine whether the occurrence of the prescribed autoimmune drugs in the epilepsy group deviated from the general population. Subgroups stratified for sex and age were examined. RESULTS The epilepsy patients were more often treated with insulin and insulin analogs, SIR 1.8 (95 % CI 1.7-1.9); thyroid substitution, SIR 1.7 (95 % CI 1.7-1.8); pyridostigmine, SIR 1.5 (95 % CI 1.1-2.1); multiple sclerosis (MS) medications, SIR 4.9 (95 % CI 4.6-5.3); and immunosuppressive drugs SIR 1.2 (95 % CI 1.1-1.2). All epilepsy subgroups were more often than expected treated with thyroid substitution. CONCLUSIONS Based on a large, unselected patient cohort we find that epilepsy patients more often are prescribed medications used to treat type 1 diabetes mellitus, hypothyroidism, myasthenia gravis and MS. This was true for both men and women, and in most age-groups.
Collapse
|
29
|
Sipilä JO, Soilu-Hänninen M, Rautava P, Kytö V. Hospital admission and prevalence trends of adult myasthenia gravis in Finland in 2004–2014: A retrospective national registry study. J Neurol Sci 2019; 407:116520. [DOI: 10.1016/j.jns.2019.116520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 01/09/2023]
|
30
|
Nguyen-Cao TM, Gelinas D, Griffin R, Mondou E. Myasthenia gravis: Historical achievements and the "golden age" of clinical trials. J Neurol Sci 2019; 406:116428. [PMID: 31574325 DOI: 10.1016/j.jns.2019.116428] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/17/2019] [Accepted: 08/14/2019] [Indexed: 02/07/2023]
Abstract
Since the death of Chief Opechankanough >350 years ago, the myasthenia gravis (MG) community has gained extensive knowledge about MG and how to treat it. This review highlights key milestones in the history of treatment and discusses the current "golden age" of clinical trials. Although originally thought by many clinicians to be a disorder of hysteria and fluctuating weakness without observable cause, MG is one the most understood autoimmune neurologic disorders. However, studying it in clinical trials has been challenging due to the fluctuating nature of the medical condition which impacts MG clinical outcomes. Clinical trials must also account for the possibility of a placebo effect. Because MG is a rare incurable autoimmune disorder, it limits the number of potential patients available to participate in clinical trials. In the last 15 years, however, significant progress has been made with MG randomized clinical trials, resulting in a new drug (eculizumab) for physicians' treatment repertoire and an old technique (thymectomy) confirmed effective for MG. Some of the therapies (eg, thymectomy, corticosteroids, plasma exchange, and intravenous immunoglobulin [IVIg]) have survived the test of time. Others (eg, eculizumab and neonatal Fc receptor inhibitor) are novel and hold promise.
Collapse
Affiliation(s)
- Tam M Nguyen-Cao
- Scientific and Medical Affairs, Grifols, 79 TW Alexander Drive 4101 Research Commons, Research Triangle Park, NC 27709, USA.
| | - Deborah Gelinas
- Scientific and Medical Affairs, Grifols, 79 TW Alexander Drive 4101 Research Commons, Research Triangle Park, NC 27709, USA.
| | - Rhonda Griffin
- Grifols Bioscience Research Group, Grifols, 79 TW Alexander Drive 4201 Research Commons, Research Triangle Park, NC 27709, USA.
| | - Elsa Mondou
- Grifols Bioscience Research Group, Grifols, 79 TW Alexander Drive 4201 Research Commons, Research Triangle Park, NC 27709, USA.
| |
Collapse
|
31
|
Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against the acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or other AChR-related proteins in the postsynaptic muscle membrane. Localized or general muscle weakness is the predominant symptom and is induced by the antibodies. Patients are grouped according to the presence of antibodies, symptoms, age at onset and thymus pathology. Diagnosis is straightforward in most patients with typical symptoms and a positive antibody test, although a detailed clinical and neurophysiological examination is important in antibody-negative patients. MG therapy should be ambitious and aim for clinical remission or only mild symptoms with near-normal function and quality of life. Treatment should be based on MG subgroup and includes symptomatic treatment using acetylcholinesterase inhibitors, thymectomy and immunotherapy. Intravenous immunoglobulin and plasma exchange are fast-acting treatments used for disease exacerbations, and intensive care is necessary during exacerbations with respiratory failure. Comorbidity is frequent, particularly in elderly patients. Active physical training should be encouraged.
Collapse
|
32
|
Italian recommendations for the diagnosis and treatment of myasthenia gravis. Neurol Sci 2019; 40:1111-1124. [PMID: 30778878 DOI: 10.1007/s10072-019-03746-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
Myasthenia gravis is a well-treatable disease, in which a prompt diagnosis and an adequate management can achieve satisfactory control of symptoms in the great majority of patients. Improved knowledge of the disease pathogenesis has led to recognition of patient subgroups, according to associated antibodies, age at onset and thymus pathology, and to a more personalized treatment. When myasthenia gravis is suspected on clinical grounds, diagnostic confirmation relies mainly on the detection of specific antibodies. Neurophysiological studies and, to a lesser extent, clinical response to cholinesterase inhibitors support the diagnosis in seronegative patients. In these cases, the differentiation from congenital myasthenia can be challenging. Treatment planning must consider weakness extension and severity, disease subtype, thymus pathology, together with patient characteristics and comorbidities. Since most subjects with myasthenia gravis require long-term immunosuppressive therapy, surveillance of expected and potential adverse events is critical. For patients refractory to conventional immunosuppression, the use of biologic agents is highly promising. These recommendations are addressed to non-experts on neuromuscular transmission disorders. The diagnostic procedures and therapeutic approaches hereafter described are largely accessible in Italy.
Collapse
|
33
|
Aktas A, Rojas E, Parikh HA, Pergament K. Myasthenia gravis crisis coinciding with asthma exacerbation in a patient with recent heroin use: three causes of acute hypercarbic respiratory failure. BMJ Case Rep 2018; 2018:bcr-2018-224176. [PMID: 30297489 DOI: 10.1136/bcr-2018-224176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 57-year-old woman with a history of asthma, hypertension and substance abuse disorder was admitted to the medical intensive care unit with hypercapnic respiratory failure. After the history was obtained, patient admitted heroin use earlier that day. The initial physical examination revealed right eye ptosis, diplopia, fatigability of neck flexion and extension. She also presented with wheezing and a prolonged expiratory phase. Pupils were 4 mm, with sluggish response to light bilaterally. CT chest with contrast showed a large mediastinal mass. Three different processes coexisted in this patient: simultaneous occurrence of a myasthenia gravis crisis, asthma exacerbation and a component of heroin use. This case highlights a series of overlapping clinical features that could lead to potential confounding and misdiagnosis. Respiratory symptoms improved after initial treatment for asthma exacerbation, but ptosis, diplopia and fatigability of neck muscles persisted.
Collapse
Affiliation(s)
- Adem Aktas
- Department of Internal Medicine, Rutgers University, The State University of New Jersey, Newark, New Jersey, USA
| | - Edward Rojas
- Department of Internal Medicine, Rutgers University, The State University of New Jersey, Newark, New Jersey, USA
| | - Hardik A Parikh
- Department of Internal Medicine, Rutgers University, The State University of New Jersey, Newark, New Jersey, USA
| | - Kathleen Pergament
- Department of Internal Medicine, Rutgers University, The State University of New Jersey, Newark, New Jersey, USA
| |
Collapse
|
34
|
Cea G, Martinez D, Salinas R, Vidal C, Hoffmeister L, Stuardo A. Clinical and epidemiological features of myasthenia gravis in Chilean population. Acta Neurol Scand 2018; 138:338-343. [PMID: 29845611 DOI: 10.1111/ane.12967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide an estimated prevalence and describe the clinical features of myasthenia gravis (MG) in Chile. METHOD We carried out (i) a prevalence study of MG using the capture-recapture method and the hospital register of pyridostigmine prescription in South-East Santiago (ii) a nationwide survey of MG patients. RESULTS Prevalence in adults in South-East Santiago was estimated to be 8.36/100 000 inhabitants (CI: 95%, 7.98-8.80). From the nationwide survey, 405 questionnaires were analysed, there was a female/male ratio of 2.2:1. The mean age of onset of symptoms was 38.7 years (range 1-89). The onset was ocular in 46.4%, oculobulbar in 11.6%, bulbar in 8.9%, limbs in 11.6% and generalized in 21.4%. Of the 13.3% of patients who had had a diagnosis of thymoma, only four of these patients were >60 years old at onset. Thymomas were commoner in patients living in mining counties. Patients ≥60 years old at onset of MG formed 19.5% of the sample, female/male ratio 0.97:1. Associated autoimmune diseases were reported in 14% of patients and in family members of 31.8% of patients. A total of 78 patients had to change work due to MG and 68 needed help in carrying out daily activities. CONCLUSIONS This study reduces the gap in information about MG in South America. The prevalence of MG in Chile is within the range described worldwide. We did not see an increase in male frequency in the older age of onset group and thymoma was more frequent in the fifth and sixth decades.
Collapse
Affiliation(s)
- G. Cea
- Facultad de Medicina; Departamento de Ciencias Neurológicas; Universidad de Chile; Santiago Chile
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| | | | - R. Salinas
- Facultad de Medicina; Departamento de Ciencias Neurológicas; Universidad de Chile; Santiago Chile
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| | - C. Vidal
- Escuela de Salud Pública; Universidad Mayor; Santiago Chile
| | - L. Hoffmeister
- Escuela de Salud Pública; Universidad Mayor; Santiago Chile
| | - A. Stuardo
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| |
Collapse
|
35
|
Gilhus NE, Hong Y. Maternal myasthenia gravis represents a risk for the child through autoantibody transfer, immunosuppressive therapy and genetic influence. Eur J Neurol 2018; 25:1402-1409. [PMID: 30133097 DOI: 10.1111/ene.13788] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/17/2018] [Indexed: 12/16/2022]
Abstract
Females with myasthenia gravis (MG) worry about their disease having negative consequences for their children. Autoimmune disease mechanisms, treatment and heredity could all have an impact on the child. This is a subject review where Web of Science was searched for relevant keywords and combinations. Controlled and prospective studies were included, and also results from selected and unselected patient cohorts, guidelines, consensus papers and reviews. Neonatal MG with temporary muscle weakness occurs in 10% of newborn babies where the mother has MG, due to transplacental transfer of antibodies against acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or lipoprotein receptor-related protein 4 (LRP4). Arthrogryposis and fetal AChR inactivation syndrome with contractures and permanent myopathy are rare events caused by mother's antibodies against fetal type AChR. The MG drugs pyridostigmine, prednisolone and azathioprine are regarded as safe during pregnancy and breastfeeding. Methotrexate, mycophenolate mofetil and cyclophosphamide are teratogenic. Mother's MG implies at least a 10-fold increased risk for MG and other autoimmune diseases in the child. MG females should receive specific information about pregnancy and giving birth. First-line MG treatments should usually be continued during pregnancy. Intravenous immunoglobulin and plasma exchange represent safe treatments for exacerbations. Neonatal MG risk means that MG women should give birth at hospitals experienced in neonatal intensive care. Neonatal MG needs supportive care, rarely also acetylcholine esterase inhibition or intravenous immunoglobulin. Women with MG should be supported in their wish to have children.
Collapse
Affiliation(s)
- N E Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Y Hong
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
36
|
Basta I, PekmezoviĆ T, Peric S, NikoliĆ A, RakoČeviĆ-StojanoviĆ V, SteviĆ Z, LavrniĆ D. Survival and mortality of adult-onset myasthenia gravis in the population of Belgrade, Serbia. Muscle Nerve 2018; 58:708-712. [DOI: 10.1002/mus.26132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/14/2018] [Accepted: 03/18/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Ivana Basta
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine; University of Belgrade; Dr Subotica 6, Belgrade 11000 Serbia
| | - Tatjana PekmezoviĆ
- Institute of Epidemiology, Faculty of Medicine; University of Belgrade; Belgrade Serbia
| | - Stojan Peric
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine; University of Belgrade; Dr Subotica 6, Belgrade 11000 Serbia
| | - Ana NikoliĆ
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine; University of Belgrade; Dr Subotica 6, Belgrade 11000 Serbia
| | - Vidosava RakoČeviĆ-StojanoviĆ
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine; University of Belgrade; Dr Subotica 6, Belgrade 11000 Serbia
| | - Zorica SteviĆ
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine; University of Belgrade; Dr Subotica 6, Belgrade 11000 Serbia
| | - Dragana LavrniĆ
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine; University of Belgrade; Dr Subotica 6, Belgrade 11000 Serbia
| |
Collapse
|
37
|
Raknes G, Simonsen P, Småbrekke L. The Effect of Low-Dose Naltrexone on Medication in Inflammatory Bowel Disease: A Quasi Experimental Before-and-After Prescription Database Study. J Crohns Colitis 2018; 12:677-686. [PMID: 29385430 PMCID: PMC5972567 DOI: 10.1093/ecco-jcc/jjy008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/17/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Low-dose naltrexone [LDN] is a controversial off-label treatment used by many Crohn's disease [CD] and ulcerative colitis [UC] patients. A small number of preliminary studies indicate that LDN might be beneficial in CD, but evidence is too scarce to demonstrate efficacy. We sought to examine whether initiation of LDN therapy by patients with inflammatory bowel disease [IBD] was followed by changes in dispensing of relevant medication. METHODS We performed a quasi-experimental before-and-after study following a sudden increase in LDN use in the Norwegian population in 2013. IBD patients were identified from among all the patients who had at least one LDN prescription recorded in the Norwegian Prescription Database [NorPD] in 2013. Drug dispensing 2 years before and after the first LDN prescription was compared. RESULTS We identified 582 IBD patients who had received LDN. Of the 256 patients who became persistent LDN users, there were reductions in the number of users for [i] all examined drugs [-12%], [ii] intestinal anti-inflammatory agents [-17%], [iii] other immunosuppressants [-29%], [iv] intestinal corticosteroids [-32%] and [v] aminosalicylates [-17%]. In subgroups of identified CD and UC patients, there were significant reductions in the number of users of intestinal corticosteroids [CD: -44%, UC: -53%] and systemic corticosteroids [UC: -24%]. No significant differences in cumulative defined daily doses were observed. CONCLUSIONS Our findings imply that the initiation of LDN in IBD is followed by reduced dispensing of several drugs considered essential in the treatment of CD and UC.
Collapse
Affiliation(s)
- Guttorm Raknes
- Regional Medicines Information and Pharmacovigilance Centre [RELIS], University Hospital of North Norway, Tromsø, Norway,Raknes Research, Ulset, Norway,Corresponding author: Guttorm Raknes, RELIS, Box 79, 9038 Tromsø, Norway. E-mail:
| | | | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT – The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
38
|
Martinka I, Fulova M, Spalekova M, Spalek P. Epidemiology of Myasthenia Gravis in Slovakia in the Years 1977-2015. Neuroepidemiology 2018; 50:153-159. [PMID: 29558746 DOI: 10.1159/000487886] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/20/2018] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The objective of the study was to evaluate changes of epidemiological parameters in patients with myasthenia gravis (MG) in Slovakia during the period 1977-2015. METHODS Data from medical records of MG patients registered in Slovakia were analyzed. Epidemiological rates (incidence, prevalence, mortality) were assessed for several periods to identify changes and drifts over the period of study. RESULTS Out of 2,074 patients, 892 were males (43.0%) and 1,193 were females (57.0%). The thymoma associated MG (TAMG) was diagnosed in 123 patients (5.9%). The mean age at onset shifted from 35.8 years in 1977-1989 to 60.0 years in -2010-2015. The crude incidence increased from 0.36/100,000 in 1977-1989 to 1.74/100,000 in 2010-2015. The average annual incidence of TAMG was 0.05/100,000. Maximum increase of MG incidence was registered among the elderly (≥50 years), particularly in the group of patients in the age range 70-79 years (0.34/100,000 in 1977-1989→7.10/100,000 in 2010-2015) and 80-89 years (0.00/100,000 in 1977-1989→5.31/100,000 in 2010-2015). The crude MG prevalence on December 31, 2015 was 24.75/100,000. The average MG mortality was 0.27/100,000. CONCLUSION The age at onset and incidence increased significantly over the study period due to marked increase of MG incidence in elderly, particularly over 70 years. Possible reasons for this trend are discussed.
Collapse
Affiliation(s)
- Ivan Martinka
- Centre for Neuromuscular Diseases, Department of Neurology, University Hospital Bratislava, Ruzinov, Slovakia
| | - Miriam Fulova
- Institute of Epidemiology, Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Margita Spalekova
- Institute of Epidemiology, Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Peter Spalek
- Centre for Neuromuscular Diseases, Department of Neurology, University Hospital Bratislava, Ruzinov, Slovakia
| |
Collapse
|
39
|
Gilhus NE, Romi F, Hong Y, Skeie GO. Myasthenia gravis and infectious disease. J Neurol 2018; 265:1251-1258. [DOI: 10.1007/s00415-018-8751-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/13/2022]
|
40
|
HLA and age of onset in myasthenia gravis. Neuromuscul Disord 2017; 27:650-654. [DOI: 10.1016/j.nmd.2017.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/09/2017] [Accepted: 04/04/2017] [Indexed: 12/13/2022]
|
41
|
Abstract
Neuromuscular disorders as a group are linked by anatomy with significant differences in pathogenetic mechanisms, clinical expression, and time course of disease. Each neuromuscular disease is relatively uncommon, yet causes a significant burden of disease socioeconomically. Epidemiologic studies in different global regions have demonstrated certain neuromuscular diseases have increased incidence and prevalence rates over time. Understanding differences in global epidemiologic trends will aid clinical research and policies focused on prevention of disease. There is a critical need to understand the global impact of neuromuscular diseases using metrics currently established for communicable and noncommunicable diseases.
Collapse
Affiliation(s)
- Jaydeep M Bhatt
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY 10016, USA.
| |
Collapse
|
42
|
Yang HW, Lei P, Xie YC, Han ZL, Li D, Wang SH, Sun ZL. Correlations of TNF-α gene promoter polymorphisms with the risk of thymoma-associated myasthenia gravis in a northern Chinese Han population. Cancer Gene Ther 2017; 24:259-266. [DOI: 10.1038/cgt.2017.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/02/2017] [Accepted: 03/04/2017] [Indexed: 11/09/2022]
|
43
|
Santos E, Coutinho E, Moreira I, Silva AM, Lopes D, Costa H, Silveira F, Nadais G, Morais H, Martins J, Branco MC, Veiga A, Silva RS, Ferreira A, Sousa F, Freijo M, Matos I, André R, Negrão L, Fraga C, Santos M, Sampaio M, Lopes C, Leite MI, Gonçalves G. Epidemiology of myasthenia gravis in Northern Portugal: Frequency estimates and clinical epidemiological distribution of cases. Muscle Nerve 2016; 54:413-21. [PMID: 26851892 DOI: 10.1002/mus.25068] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/25/2016] [Accepted: 02/01/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In this study we estimated the prevalence, incidence, and mortality of myasthenia gravis (MG) in northern Portugal and characterized the clinical features of the patients identified. METHODS We used 2 data sources: clinical records from the hospitals and pyridostigmine prescription registers. RESULTS On December 31, 2013, we estimated a point prevalence of 111.7 patients per million population. The highest prevalence was observed in the group >65 years of age, especially in men (288.1 per million). During 2013, we estimated an incidence rate of 6.3 per million per year. Among women, the incidence rate was highest in the 15-49-year age group; in men, incidence increased with age up to 22.1 per million in those >65 years old. The MG-related mortality rate was 0.5 per million. CONCLUSIONS These figures are in keeping with similar studies and emphasize the importance of diagnosis and management of MG in elderly populations. Muscle Nerve 54: 413-421, 2016.
Collapse
Affiliation(s)
- Ernestina Santos
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Ester Coutinho
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, University of Oxford, UK
| | - Isabel Moreira
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal
| | - Ana Martins Silva
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Dina Lopes
- Centro Hospitalar do Porto, Porto, Portugal
| | - Henrique Costa
- Neurology Department, Hospital Sao Joao, Porto, Portugal
| | | | - Goreti Nadais
- Neurology Department, Hospital Sao Joao, Porto, Portugal
| | - Hugo Morais
- Neurology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Gaia, Portugal
| | - João Martins
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Maria Ceu Branco
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal.,Neurology Department, Hospital de Sao Pedro, Centro Hospitalar do Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Andreia Veiga
- Neurology Department, Hospital de Sao Pedro, Centro Hospitalar do Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Rosa Santos Silva
- Neurology Department, Centro Hospitalar do Alto Minho, Viana do Castelo, Portugal
| | - Augusto Ferreira
- Neurology Department, Centro Hospitalar Entre Douro e Vouga, Feira, Portugal
| | - Filipa Sousa
- Neurology Department, Hospital de Braga, Braga, Portugal
| | - Marta Freijo
- Neurology Department, Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Ilda Matos
- Neurology Department, Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Rui André
- Neurology Department, Hospital de São Teotonio, Viseu, Portugal
| | - Luís Negrão
- Neurology Department, Centro Hospitalar Universitario de Coimbra, Coimbra, Portugal
| | - Carla Fraga
- Neurology Department, Centro Hospitalar do Vale do Sousa, Penafiel, Portugal
| | - Manuela Santos
- Neuropediatrics Department, Centro Materno Infantil Norte, Centro Hospitalar Porto, Porto, Portugal
| | - Mafalda Sampaio
- Neuropediatrics Department, Hospital de Sao Joao, Porto, Portugal
| | - Carlos Lopes
- Instituto de Ciencias Biomedicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, University of Oxford, UK
| | - Guilherme Gonçalves
- Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| |
Collapse
|
44
|
Breiner A, Widdifield J, Katzberg HD, Barnett C, Bril V, Tu K. Epidemiology of myasthenia gravis in Ontario, Canada. Neuromuscul Disord 2015; 26:41-6. [PMID: 26573434 DOI: 10.1016/j.nmd.2015.10.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/05/2015] [Accepted: 10/19/2015] [Indexed: 12/19/2022]
Abstract
Incidence and prevalence estimates in myasthenia gravis have varied widely. Recent studies based on administrative health data have large sample sizes but lack rigorous validation of MG cases, and have not examined the North American population. Our aim was to explore trends in MG incidence and prevalence for the years 1996-2013 in the province of Ontario, Canada (population 13.5 million). We employed a previously validated algorithm to identify MG cases. Linking with census data allowed for the calculation of crude- and age/sex-standardized incidence and prevalence rates for the years 1996-2013. The regional distribution of MG cases throughout the province was examined. Mean age at the first myasthenia gravis encounter was 60.2 ± 17.1 years. In 2013, there were 3611 prevalent cases in Ontario, and the crude prevalence rate was 32.0/100,000 population. Age- and sex-standardized prevalence rates rose consistently over time from 16.3/100,000 (15.4-17.1) in 1996 to 26.3/100,000 (25.4-27.3) in 2013. Standardized incidence rates remained stable between 1996 (2.7/100,000; 95% CL 2.3-3.0) and 2013 (2.3/100,000; 2.1-2.6). Incidence was highest in younger women and older men, and geographic variation was evident throughout the province. In conclusion, this large epidemiological study shows rising myasthenia gravis prevalence with stable incidence over time, which is likely reflective of patients living longer, possibly due to improved disease treatment. Our findings provide accurate information on the Canadian epidemiology of myasthenia gravis and burden for health care resources planning for the province, respectively.
Collapse
Affiliation(s)
- Ari Breiner
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
| | - Jessica Widdifield
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; McGill University, Montreal, Quebec, Canada
| | - Hans D Katzberg
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Karen Tu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto Western Hospital Family Health Team, Toronto, Ontario, Canada
| |
Collapse
|
45
|
Blum S, Lee D, Gillis D, McEniery DF, Reddel S, McCombe P. Clinical features and impact of myasthenia gravis disease in Australian patients. J Clin Neurosci 2015; 22:1164-9. [PMID: 26021730 DOI: 10.1016/j.jocn.2015.01.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 12/21/2022]
Abstract
We performed a community-based survey of 165 Australian patients with a physician-confirmed diagnosis of myasthenia gravis (MG). MG is an autoimmune disease of the neuromuscular junction causing fatiguable muscle weakness. Patients with early onset MG (<40 years of age) were more frequently female (22 males, 60 females) whereas patients with late onset MG (>40 years of age) were more frequently male (50 males, 28 females; p < 0.001). Triggering and exacerbating factors included physical and emotional stress, infections, surgery or trauma, seasonal changes and medications. The co-occurrence of other immune-related diseases was reported by 54% of patients. The median MG quality of life (QOL) score was 92 (range: 24-186). The factor most strongly associated with poor QOL was depression. Only 40.6% of patients were working at the time of the survey and of these, almost half had required sick leave due to MG in the past 12 months. A further 39.4% had stopped work due to MG and 19.4% having to change occupation. Full-time or part-time care was required by 29% of patients and government financial support was received by 52.7%.
Collapse
Affiliation(s)
- Stefan Blum
- Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia; University of Queensland, Centre of Clinical Research, Herston, QLD, Australia.
| | - David Lee
- Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia
| | - David Gillis
- Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia; Pathology Queensland, Herston, QLD, Australia
| | | | - Stephen Reddel
- University of Sydney, Concord Hospital, Concord, NSW, Australia
| | - Pamela McCombe
- Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia; University of Queensland, Centre of Clinical Research, Herston, QLD, Australia
| |
Collapse
|
46
|
Abstract
An 85-year-old man presented to hospital as an emergency having difficulties with swallowing and speech. In the emergency department, he was assessed as having acute onset dysphagia and dysarthria in keeping with an acute stroke. Subsequently, it became apparent that although the symptoms were indeed of relatively acute onset, there was a clear description by the patient of fatigability and diurnal variation, prompting a working clinical diagnosis of myasthenia gravis. The patient followed a turbulent clinical course, and interpretation of investigation results proved not to be straightforward in the acute setting. Myasthenia gravis is an uncommon disorder but it is more common in the elderly. This case provides key learning points, particularly highlighting the value of prompt, accurate clinical assessment and the importance of adhering to the clinical diagnostic formulation.
Collapse
Affiliation(s)
| | | | - Hedley C A Emsley
- Department of Neurology, Royal Preston Hospital, Preston, UK, and University of Manchester, Manchester, UK
| |
Collapse
|
47
|
Joensen P. Myasthenia gravis incidence in a general North Atlantic isolated population. Acta Neurol Scand 2014; 130:222-8. [PMID: 24981565 DOI: 10.1111/ane.12270] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There are no previous studies undertaken about myasthenia gravis in the Faroe Islands. The aim of this study was to establish the incidence of onset of this disease in the Faroese population. METHOD Patients were ascertained and registered prospectively from 1986 to 2013 when they were examined at the Neurological Clinic of the Faroese National Hospital or at a private neurological practice, which constitutes all the available neurological services in the Faroe Islands. RESULT Twelve new diagnoses were made over a 27-year period, providing an incidence density rate of 9.4 per million person-years (95% confidence limit 4.9-16.5). At presentation, nine of 12 patients had generalized myasthenia gravis and two patients had pure ocular disease, and in one patient, the symptoms were restricted to the bulbo-facial muscles. The sex ratio was 2:1, F/M. In nine of the cases, a positive result of acetylcholine receptor antibody assay was documented. In all patients, there was a beneficial response to anticholinesterase administration. CONCLUSION The result yielded no strong evidence of a difference in incidence between that found in the Faroe Islands and those in most European studies, apart from recent studies from London, UK; Norway; Spain, and Italy in which incidences from 21 to 30 per million person-years had been reported.
Collapse
Affiliation(s)
- P. Joensen
- Department of Medicine and Neuro-physiology Laboratory; National Hospital of the Faroe Islands; Torshavn Faroe Islands
| |
Collapse
|
48
|
Andersen JB, Owe JF, Engeland A, Gilhus NE. Total drug treatment and comorbidity in myasthenia gravis: a population-based cohort study. Eur J Neurol 2014; 21:948-55. [PMID: 24712740 PMCID: PMC4238850 DOI: 10.1111/ene.12439] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/06/2014] [Indexed: 11/29/2022]
Abstract
Background and purpose Comorbidity in myasthenia gravis (MG) is important for diagnosis, treatment and prognosis. Disease complexity was assessed by examining total drug treatment, immune therapy and comorbidity in a complete national MG cohort. Methods All recipients of the MG-specific drug pyridostigmine 2004–2010 registered in the compulsory Norwegian Prescription Database who met the inclusion criteria were included. The pyridostigmine group was compared with the general Norwegian population. Results Myasthenia gravis patients received co-medication more often than the controls for nearly all groups of medication, including insulins (95% confidence interval 2.0–3.7), thyroid therapy (1.7–2.5), antidepressants (1.3–1.7), anti-infectives (1.2–1.4), lipid-modifying agents (1.1–1.4) and immunomodulating agents (6.8–8.8). Conclusions Myasthenia gravis patients are more often treated with non-MG prescription drugs than controls, reflecting frequent co-medication and comorbidity.
Collapse
Affiliation(s)
- J B Andersen
- Department of Clinical Medicine, Section for Neurology, University of Bergen, Bergen, Norway
| | | | | | | |
Collapse
|