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Myllynen C, Tuulasvaara A, Atula S, Laakso SM. Intensive care due to myasthenia gravis: Risk factors and prognosis. Eur J Neurol 2024:e16522. [PMID: 39435628 DOI: 10.1111/ene.16522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 09/01/2024] [Accepted: 10/03/2024] [Indexed: 10/23/2024]
Abstract
BACKGROUND AND PURPOSE Exacerbation of myasthenia gravis (MG) with respiratory failure requires intensive care. We aimed to study the risk factors for intensive care unit admission for MG exacerbation and myasthenic crisis (MC) and the prognosis of people with MG (pwMG) thereafter. METHODS This retrospective study investigated patients in the Helsinki and Uusimaa hospital district during the years 2008-2021. PwMG (International Classification of Diseases, 10th revision code G70.0) were identified through a data repository search, followed by a chart review of patient records. Risk factors for intensive care due to MG exacerbation were evaluated as compared with the patients only treated in the outpatient clinic and those treated in the neurological ward for MG exacerbation. The outcomes of patients in intensive care for any reason were also compared with those of patients in intensive care for exacerbation of bronchial asthma. RESULTS Of 577 pwMG, 35 (6.1%) needed intensive care for MG within a median of 5.3 months from diagnosis. The mean (±SD) age at MG diagnosis was higher in the intensive care group (60.5 [±16.1] years) compared to the outpatient (48.3 [±20.9] years; p < 0.001) and neurological ward groups (53.4 [±20.8] years; p = 0.044). Thymoma (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.19-19.43; p = 0.028) and female sex (OR 2.1, 95% CI 1.02-4.48; p = 0.045) were independent risk factors for intensive care. In-hospital mortality was 4% for MC patients. Six-month mortality after intensive care for MG exacerbation (14.3%) was twice that for asthma exacerbation (7.7%). CONCLUSION Our study shows an increased risk of intensive care treatment for patients with late-onset MG, female sex or thymoma, occurring usually within 6 months from diagnosis, which emphasises the importance of early treatment choices.
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Affiliation(s)
- Chris Myllynen
- Department of Neurosciences, University of Helsinki, Helsinki, Finland
| | - Anni Tuulasvaara
- Department of Neurosciences, University of Helsinki, Helsinki, Finland
- Department of Neurology, Brain Center, Helsinki University Hospital, Helsinki, Finland
| | - Sari Atula
- Department of Neurosciences, University of Helsinki, Helsinki, Finland
- Department of Neurology, Brain Center, Helsinki University Hospital, Helsinki, Finland
| | - Sini M Laakso
- Department of Neurosciences, University of Helsinki, Helsinki, Finland
- Department of Neurology, Brain Center, Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
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Zhang N, Wang Z, Sun D, Chen H, Zhou H. The Risk of Exacerbation of Myasthenia Gravis After COVID-19 Omicron Infection. Brain Behav 2024; 14:e70074. [PMID: 39428557 PMCID: PMC11491296 DOI: 10.1002/brb3.70074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 08/30/2024] [Accepted: 09/08/2024] [Indexed: 10/22/2024] Open
Abstract
OBJECTIVE The aim of this study is to ascertain whether COVID-19 Omicron infection is associated with exacerbations in these myasthenia gravis (MG) patients. RESULT In total, 289 MG patients (comprising 60% females, with an average age of 46 ± 15 years) were enrolled. A total of 80.9% of MG patients reported a COVID-19 infection, with the majority experiencing a benign course (88%). MG patients who experienced COVID-19 infection demonstrated a higher likelihood of MG exacerbation, compared to those without the infection (18.8% vs. 7.3%, p = 0.039). In the survival analysis, after adjusting for confounding factors, the hazard ratio (HR) for exacerbation post-infection was found to be 3.38 (95% CI 1.20-9.53, p = 0.021). Compared to the exacerbation rates observed in JTA21, an increase was noted in DTM23 among COVID-19-infected MG patients (4.4% vs. 17.2%, p < 0.001). CONCLUSION The COVID-19 is the risk of MG exacerbation.
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Affiliation(s)
- Nana Zhang
- Department of Neurology, West China HospitalSichuan UniversityChengduSichuan ProvincePR China
| | - Ziya Wang
- Department of Neurology, West China HospitalSichuan UniversityChengduSichuan ProvincePR China
| | - Dongren Sun
- Department of Neurology, West China HospitalSichuan UniversityChengduSichuan ProvincePR China
| | - Hongxi Chen
- Department of Neurology, West China HospitalSichuan UniversityChengduSichuan ProvincePR China
| | - Hongyu Zhou
- Department of Neurology, West China HospitalSichuan UniversityChengduSichuan ProvincePR China
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Mantegazza R, Saccà F, Antonini G, Bonifati DM, Evoli A, Habetswallner F, Liguori R, Pegoraro E, Rodolico C, Schenone A, Sgarzi M, Pappagallo G. Therapeutic challenges and unmet needs in the management of myasthenia gravis: an Italian expert opinion. Neurol Sci 2024:10.1007/s10072-024-07577-7. [PMID: 38967883 DOI: 10.1007/s10072-024-07577-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/03/2024] [Indexed: 07/06/2024]
Abstract
Myasthenia gravis (MG) is a rare, autoimmune, neurological disorder. Most MG patients have autoantibodies against acetylcholine receptors (AChRs). Some have autoantibodies against muscle-specific tyrosine kinase (MuSK) or lipoprotein-receptor-related protein 4 (LRP4), and some are seronegative. Standard of care, which includes anti-cholinesterase drugs, thymectomy, corticosteroids (CS), and off-label use of non-steroidal immunosuppressive drugs (NSISTs), is bounded by potential side effects and limited efficacy in refractory generalized MG (gMG) patients. This highlights the need for new therapeutic approaches for MG. Eculizumab, a monoclonal antibody that inhibits the complement system, has been recently approved in Italy for refractory gMG. A panel of 11 experts met to discuss unmet therapeutic needs in the acute and chronic phases of the disease, as well as the standard of care for refractory patients. Survival was emphasized as an acute phase outcome. In the chronic phase, persistent remission and early recognition of exacerbations to prevent myasthenic crisis and respiratory failure were considered crucial. Refractory patients require treatments with fast onset of action, improved tolerability, and the ability to slow disease progression and increase life expectancy. The Panel agreed that eculizumab would presumably meet the therapeutic needs of many refractory gMG patients. The panel concluded that the unmet needs of current standard of care treatments for gMG are significant. Evaluating new therapeutic options accurately is essential to find the best balance between efficacy and tolerability for each patient. Collecting real-world data on novel molecules in routine clinical practice is necessary to address unmet needs.
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Affiliation(s)
- Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy.
| | - Francesco Saccà
- NSRO Department, Federico II University of Naples, Naples, Italy
| | - Giovanni Antonini
- Department of Neurosciences, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Domenico Marco Bonifati
- Neurology Unit, Cerebro-Cardiovascular Department, Ca' Foncello Hospital Treviso, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - Amelia Evoli
- Neuroscience Department, Facolta Di Medicina E Chirurgia, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | | | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Angelo Schenone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University and IRCCS San Martino Hospital, Genoa, Italy
| | - Manlio Sgarzi
- Department of Neurology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Giovanni Pappagallo
- School of Clinical Methodology, IRCCS "Sacred Heart - Don Calabria", Negrar Di Valpolicella, Italy
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Gilhus NE, Andersen H, Andersen LK, Boldingh M, Laakso S, Leopoldsdottir MO, Madsen S, Piehl F, Popperud TH, Punga AR, Schirakow L, Vissing J. Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment. Eur J Neurol 2024; 31:e16229. [PMID: 38321574 PMCID: PMC11236053 DOI: 10.1111/ene.16229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.
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Affiliation(s)
- Nils Erik Gilhus
- Department of NeurologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | | | - Linda Kahr Andersen
- Copenhagen Neuromuscular Center, Department of NeurologyCopenhagen University HospitalCopenhagenDenmark
| | | | - Sini Laakso
- Department of Neurology, Brain CenterHelsinki University HospitalHelsinkiFinland
- Translational Immunology Research ProgramUniversity of HelsinkiHelsinkiFinland
| | | | - Sidsel Madsen
- The National Rehabilitation Center for Neuromuscular DiseasesAarhusDenmark
| | - Fredrik Piehl
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of NeurologyKarolinska University HospitalStockholmSweden
| | | | - Anna Rostedt Punga
- Department of Medical SciencesUppsala UniversityUppsalaSweden
- Department of Clinical NeurophysiologyUppsala University HospitalUppsalaSweden
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of NeurologyCopenhagen University HospitalCopenhagenDenmark
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Morar R, Seedat F, Richards GA. Clinical features and outcomes of patients with myasthenia gravis admitted to an intensive care unit: A 20-year retrospective study. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2023; 39:10.7196/SAJCC.2023.v39i2.561. [PMID: 37547769 PMCID: PMC10399547 DOI: 10.7196/sajcc.2023.v39i2.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 05/28/2023] [Indexed: 08/08/2023] Open
Abstract
Background There are limited data on the clinical characteristics and outcomes of patients with myasthenia gravis (MG) admitted to the intensive care unit (ICU) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Objectives The aim was to study the clinical characteristics and outcomes of patients with MG admitted to the CMJAH over two decades. Methods A retrospective study was undertaken of patients with MG admitted to the multidisciplinary ICU of CMJAH over a 20-year period, from 1998 to 2017. Demographic data, clinical features, management and outcomes of patients were assessed and reviewed from the case records. Results Thirty-four patients with MG were admitted to the ICU during this period: 24 female and 10 male. The mean age ± SD was 37.4 ± 13.0 years, with a range of 16 - 66 years. Four patients were human immunodeficiency virus (HIV)-positive. The mean length of stay (LOS) in ICU was 10.6 ± 20.1 days, ranging from 1 to 115 days. Two patients were diagnosed with MG in the ICU after failure to wean from the ventilator. Overall, 22 patients were intubated and ventilated on admission. Morbidities included self-extubation, aspiration pneumonia and iatrogenic pneumothorax. History of thymectomy was present in 12 patients. The treatments received for MG included pyridostigmine (73.5%), corticosteroids (55.9%), azathioprine (35.3%), plasmapheresis (26.5%) and intravenous immunoglobulin (8.8%). The overall mortality in the ICU was 5.9%. Conclusion MG is a serious disorder with considerable morbidity and mortality. It is, however, a potentially manageable disease, provided that appropriate ICU resources are available. Contributions of the study This study provides further insight into the characteristics and outcomes of myasthenia gravis patients in ICU, within a South African context.
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Affiliation(s)
- R Morar
- School of Clinical Medicine, Faculty of Health Sciences; Division of Pulmonology and Critical Care, Department of Internal Medicine, Charlotte
Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - GEMP 2 Group 6 of 2018 (M Amod, F Chappel, L Ebbeling, L Fikizolo, A Glover, K Gutu,
C Lawson, R Maswinyaneng, M Mohunlal, K Morar, D Rooken-Smith, K Seale, D Shai)
- GEMP 2 Group 6 of 2018, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Seedat
- School of Clinical Medicine, Faculty of Health Sciences; Division of Pulmonology and Critical Care, Department of Internal Medicine, Charlotte
Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - G A Richards
- School of Clinical Medicine, Faculty of Health Sciences; Division of Pulmonology and Critical Care, Department of Internal Medicine, Charlotte
Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Ozyurt Kose S, Nazli E, Tutkavul K, Gilhus NE. Occurrence and severity of myasthenic crisis in an unselected Turkish cohort of patients with myasthenia gravis. Front Neurol 2023; 14:1201451. [PMID: 37521306 PMCID: PMC10374359 DOI: 10.3389/fneur.2023.1201451] [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: 04/06/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
Myasthenia gravis (MG) is a disorder of the neuromuscular junction that can deteriorate into myasthenic crisis, involving weakness of bulbar and respiratory muscles. In this study, we describe the clinical manifestations of myasthenic crisis, identify risk factors, and examine treatments and outcomes. All 95 patients with generalized MG treated at our center during the last 10 years were included in this retrospective study. We collected data from the patients' records, including clinical follow-ups, muscle antibodies, thymic status, and treatments. The characteristics of patients who did and did not experience myasthenic crisis were compared. Features of all myasthenic crises were also assessed. Twelve patients (13%) developed myasthenic crisis during the observation period. Men were more often affected at older ages. Seven patients experienced multiple myasthenic crises. Thymoma increased the risk of a crisis, whereas thymic hyperplasia decreased the risk. Myasthenic crises were more common in the summer months. No patients died during a myasthenic crisis. Risk factors for myasthenic crisis were thymoma, older age, MuSK antibodies, and previous crises. Individualized and active immunosuppressive treatment and optimal intensive care during crises provide a good outcome for patients with generalized MG.
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Affiliation(s)
- Selen Ozyurt Kose
- Department of Clinical Neurophysiology, Marmara University Pendik Teaching and Research Hospital, Istanbul, Turkey
| | - Ezgi Nazli
- Department of Neurology, Health Sciences University Haydarpasa Numune Teaching and Research Hospital, Istanbul, Turkey
| | - Kemal Tutkavul
- Department of Neurology, Health Sciences University Haydarpasa Numune Teaching and Research Hospital, Istanbul, Turkey
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Gilhus NE. Myasthenia gravis, respiratory function, and respiratory tract disease. J Neurol 2023; 270:3329-3340. [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] [MESH Headings] [Grants] [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.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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8
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Claytor B, Cho SM, Li Y. Myasthenic crisis. Muscle Nerve 2023. [PMID: 37114503 DOI: 10.1002/mus.27832] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/06/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023]
Abstract
Myasthenic crisis (MC) is a life-threatening manifestation of myasthenia gravis (MG) defined by respiratory insufficiency that requires the use of invasive or non-invasive ventilation. This is often the result of respiratory muscle weakness but can also be due to bulbar weakness with upper airway collapse. MC occurs in approximately 15%-20% of patients with MG usually within the first 2 to 3 y of the disease course. Many crises have a specific trigger with respiratory infections being most common; however, no specific trigger is found in 30%-40% of patients. MG patients with a history of MC, severe disease, oropharyngeal weakness, muscle-specific kinase (MuSK) antibodies and thymoma appear to be at higher risk. Most episodes of MC do not occur suddenly, providing a window of opportunity for prevention. Immediate treatment is directed toward airway management and removing any identified triggers. Plasmapheresis is preferred over intravenous immune globulin as the treatments of choice for MC. The majority of patients are able to be weaned from mechanical ventilation within 1 mo and the outcomes of MC are generally favorable. The mortality rate in United States cohorts is less than 5% and mortality in MC seems to be driven by age and other medical co-morbidities. MC does not appear to affect long-term prognosis as many patients are able to eventually achieve good MG control.
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Affiliation(s)
- Benjamin Claytor
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuebing Li
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Xu P, Zhang Y, Chang T, Jiang L, Lv Z, Zhang Y, Xu H, Zhang D, Lan T, Cui Y, Hua Z, Gao C, Lu J, Huang Q, Tian J, Ma J, Wang J. Comparative the efficacy and acceptability of immunosuppressive agents for myasthenia gravis: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101:e31454. [PMID: 36550882 PMCID: PMC9771229 DOI: 10.1097/md.0000000000031454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunosuppressive drugs are routinely used to treat myasthenia gravis (MG). However, current recommendations provide limited evidence to support treatment options, leading to considerable variation in practice among healthcare specialists. Hence, we present a protocol for a systematic review and network meta-analysis (NMA) to update the evidence by comparing the efficacy and acceptability of oral immunosuppressive drugs for the treatment of MG. METHODS We will conduct a systematic review and NMA of all randomized controlled trials evaluating the following oral immunosuppressive drugs for the treatment of MG. Published studies will be searched using the following databases from inception to November 23, 2021: CENTRAL, the CINAHL, MEDLINE, Embase, PsycINFO, Web of Science, and 3 Chinese databases (Chinese Biomedical Literatures Database, CNKI, and Wan Fang database). Assessment of study eligibility and data extraction will be conducted independently by 2 reviewers. The main outcome will be a quantitative MG scoring system. We will conduct Bayesian NMA to synthesize all evidence for each outcome and obtain a comprehensive ranking of all treatments. The quality of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations framework. RESULTS The objective of this study was to assess the relative clinical efficacy and acceptability of first-line immunosuppressants for the treatment of MG, using a systematic review and NMA approach. CONCLUSION In the absence of head-to-head trials comparing therapies, evidence from this NMA of available clinical trials will inform clinicians, patients, and families the risk-benefit profiles of different treatment options.
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Affiliation(s)
- Peng Xu
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Ying Zhang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Tianying Chang
- GCP Department, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Li Jiang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Zhiguo Lv
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Yibin Zhang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Hanying Xu
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Dongmei Zhang
- Scientific Research Office, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Tianye Lan
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Yingzi Cui
- GCP Department, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Zhen Hua
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Chengfei Gao
- Department of Physical Medicine and Rehabilitation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Jing Lu
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Qingxia Huang
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou, Gansu Province, China
| | - Jihui Ma
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jian Wang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
- * Correspondence:Jian Wang, Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China (e-mail: )
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Shah SMI, Yasmin F, Memon RS, Jatoi NN, Savul IS, Kazmi S, Monawwer SA, Zafar MDB, Asghar MS, Tahir MJ, Lee KY. COVID-19 and myasthenia gravis: A review of neurological implications of the SARS-COV-2. Brain Behav 2022; 12:e2789. [PMID: 36306401 PMCID: PMC9759145 DOI: 10.1002/brb3.2789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/10/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION This review highlights the potential mechanisms of neuromuscular manifestation of COVID-19, especially myasthenia gravis (MG). METHODS An extensive literature search was conducted by two independent investigators using PubMed/MEDLINE and Google Scholar from its inception to December 2020. RESULTS Exacerbations of clinical symptoms in patients of MG who were treated with some commonly used COVID-19 drugs has been reported, with updated recommendations of management of symptoms of neuromuscular disorders. Severe acute respiratory syndrome coronavirus 2 can induce the immune response to trigger autoimmune neurological disorders. CONCLUSIONS Further clinical studies are warranted to indicate and rather confirm if MG in the setting of COVID-19 can pre-existent subclinically or develop as a new-onset disease.
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Affiliation(s)
| | - Farah Yasmin
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Roha Saeed Memon
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nadia Nazir Jatoi
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Ilma Saleh Savul
- Department of Internal Medicine, St. Joseph Medical Center, Houston, Texas, USA
| | - Sana Kazmi
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Muhammad Daim Bin Zafar
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | - Ka Yiu Lee
- Swedish Winter Sports Research Centre, Department of Health Sciences, Mid Sweden University, Östersund, Sweden
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Zdraljevic M, Peric S, Jeremic M, Lavrnic D, Basta I, Hajdukovic L, Jovanovic DR, Berisavac I. Myasthenia gravis treated in the neurology intensive care unit: a 14-year single-centre experience. Neurol Sci 2022; 43:6909-6918. [DOI: 10.1007/s10072-022-06379-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
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12
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Reyes-Leiva D, López-Contreras J, Moga E, Pla-Juncà F, Lynton-Pons E, Rojas-Garcia R, Turon-Sans J, Querol L, Olive M, Álvarez-Velasco R, Caballero-Ávila M, Carbayo Á, Vesperinas-Castro A, Domingo P, Illa I, Gallardo E, Cortés-Vicente E. Immune Response and Safety of SARS-CoV-2 mRNA-1273 Vaccine in Patients With Myasthenia Gravis. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/4/e200002. [PMID: 35728947 PMCID: PMC9219516 DOI: 10.1212/nxi.0000000000200002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/24/2022] [Indexed: 01/08/2023]
Abstract
Background and Objectives Evidence regarding the safety and efficacy of messenger RNA (mRNA) vaccines in patients with myasthenia gravis (MG) after immunosuppressive therapies is scarce. Our aim is to determine whether the mRNA-1273 vaccine is safe and able to induce humoral and cellular responses in patients with MG. Methods We performed an observational, longitudinal, prospective study including 100 patients with MG of a referral center for MG in our country, conducted from April 2021 to November 2021 during the vaccination campaign. The mRNA-1273 vaccine was scheduled for all participants. Blood samples were collected before vaccination and 3 months after a second dose. Clinical changes in MG were measured using the MG activities of daily life score at baseline and 1 week after the first and second doses. A surveillance of all symptoms of coronavirus disease 2019 (COVID-19) was conducted throughout the study. Humoral and cellular immune responses after vaccination were assessed using a spike-antibody ELISA and interferon gamma release assay in plasma. The primary outcomes were clinically significant changes in MG symptoms after vaccination, adverse events (AEs), and seroconversion and T-cell immune response rates. Results Ninety-nine patients completed the full vaccination schedule, and 98 had 2 blood samples taken. A statistically significant worsening of symptoms was identified after the first and second doses of the mRNA-1273 vaccine, but this was not clinically relevant. Mild AEs occurred in 14 patients after the first dose and in 21 patients after the second dose. Eighty-seven patients developed a humoral response and 72 patients showed a T-cell response after vaccination. A combined therapy with prednisone and other immunosuppressive drugs correlated with a lower seroconversion ratio (OR = 5.97, 95% CI 1.46–24.09, p = 0.015) and a lower T-cell response ratio (OR = 2.83, 95% CI 1.13–7.13, p = 0.024). Discussion Our findings indicate that the mRNA vaccination against COVID-19 is safe in patients with MG and show no negative impact on the disease course. Patients achieved high humoral and cellular immune response levels. Classification of Evidence This study provides Class IV evidence that patients with MG receiving the mRNA-1273 vaccine did not show clinical worsening after vaccination and that most of the patients achieved high cellular or immune response levels.
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13
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Mergenthaler P, Stetefeld HR, Dohmen C, Kohler S, Schönenberger S, Bösel J, Gerner ST, Huttner HB, Schneider H, Reichmann H, Fuhrer H, Berger B, Zinke J, Alberty A, Kleiter I, Schneider-Gold C, Roth C, Dunkel J, Steinbrecher A, Thieme A, Lee DH, Linker RA, Angstwurm K, Meisel A, Neumann B. Seronegative myasthenic crisis: a multicenter analysis. J Neurol 2022; 269:3904-3911. [PMID: 35389099 PMCID: PMC8988104 DOI: 10.1007/s00415-022-11023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
Abstract
Myasthenic crisis (MC) is a life-threatening condition for patients with myasthenia gravis (MG). Seronegative patients represent around 10–15% of MG, but data on outcome of seronegative MCs are lacking. We performed a subgroup analysis of patients who presented with MC with either acetylcholine-receptor-antibody-positive MG (AChR-MG) or seronegative MG between 2006 and 2015 in a retrospective German multicenter study. We identified 15 seronegative MG patients with 17 MCs and 142 AChR-MG with 159 MCs. Seronegative MCs were younger (54.3 ± 14.5 vs 66.5 ± 16.3 years; p = 0.0037), had a higher rate of thymus hyperplasia (29.4% vs 3.1%; p = 0.0009), and were more likely to be female (58.8% vs 37.7%; p = 0.12) compared to AChR-MCs. Time between diagnosis of MG and MC was significantly longer in seronegative patients (8.2 ± 7.6 vs 3.1 ± 4.4 years; p < 0.0001). We found no differences in duration of mechanical ventilation (16.2 ± 15.8 vs 16.5 ± 15.9 days; p = 0.94) and length of stay at intensive care unit (17.6 ± 15.2 vs 17.8 ± 15.4 days; p = 0.96), or in-hospital mortality (11.8% vs. 10.1%; p = 0.69). We conclude that MC in seronegative MG affects younger patients after a longer period of disease, but that crisis treatment efficacy and outcome do not differ compared to AChR-MCs.
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Affiliation(s)
- Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Academy, 10117 Berlin, Germany
| | - Henning R. Stetefeld
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Christian Dohmen
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Cologne, Germany
- Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Siegfried Kohler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
| | | | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Giesen, Germany
| | - Hagen B. Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Giesen, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Mönchengladbach, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen Für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | | | - Andrea Thieme
- Department of Neurology, Helios Klinikum Erfurt, Erfurt, Germany
| | - De-Hyung Lee
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Ralf A. Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charite-Universitatsmedizin Berlin, Berlin, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
- Present Address: Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
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Gelinas D, Parvin-Nejad S, Phillips G, Cole C, Hughes T, Silvestri N, Govindarajan R, Jefferson M, Campbell J, Burnett H. The humanistic burden of myasthenia gravis: A systematic literature review. J Neurol Sci 2022; 437:120268. [DOI: 10.1016/j.jns.2022.120268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/14/2022] [Accepted: 04/16/2022] [Indexed: 11/25/2022]
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15
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Sobieszczuk E, Napiórkowski Ł, Szczudlik P, Kostera‐Pruszczyk A. Myasthenia gravis-treatment and severity in nationwide cohort. Acta Neurol Scand 2022; 145:471-478. [PMID: 34981830 DOI: 10.1111/ane.13576] [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: 09/03/2021] [Revised: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is a rare autoimmune disorder of neuromuscular junction. MG healthcare burden has not been studied in Poland before. METHODS Data were drawn from the National Health Fund database; MG patient was defined as a person who received at least once medical service with ICD-10 code MG (G70) and at least two reimbursed prescriptions for pyridostigmine bromide or ambenonium chloride in two consecutive years. We have analyzed treatment: immunosuppression, intravenous immunoglobulins (IVIg), plasma exchange (PE), the number and length of hospitalizations (LOS), intensive care unit (ICU) care, and deaths between 2013 and 2018. RESULTS In 2018, there were 9012 MG patients (F:M 1.62:1), and 30.6% had early -onset MG (<50 years). 66.3% received symptomatic treatment only, 33.7%-glucocorticoids (CS) and/or other immunosuppressants (IS), 64.6%-CS only, 17.5%-azathioprine plus CS, 11%-azathioprine only, 4.6%-CS plus other IS (methotrexate, mycophenolate mofetil, cyclosporine, or tacrolimus), and 2%-other IS only. In 2018, 42.3% of patients were hospitalized at least once (mean 2.05/year), 13.7% due to MG (1.47/year). In 2018, 1.63% patients received PE, 2.33% IVIg. In 2013-2018, 2.7%-3.2% of MG patients required hospitalization in ICU. ICU mean LOS 2013-2018 was 11.5-15.0 days/per patient/year. 2.1% of all MG patients had myasthenic crisis. Mean age at death was 75.7 years for MG and 73.9 for general population (p = .006). All-cause mortality was higher for men (4.1%-5.1%) than for women (2.5%-3.1%), p < .01. CONCLUSIONS Our findings confirm significant healthcare burden of MG, comprising a tool to plan resources needed for MG patients.
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Affiliation(s)
- Ewa Sobieszczuk
- Department of Analyses and Innovation National Health Fund Warsaw Poland
| | - Łukasz Napiórkowski
- Department of Neurology ERN EURO‐NMD Medical University of Warsaw Warsaw Poland
| | - Piotr Szczudlik
- Department of Analyses and Innovation National Health Fund Warsaw Poland
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Abbas AS, Hardy N, Ghozy S, Dibas M, Paranjape G, Evanson KW, Reierson NL, Cowie K, Kamrowski S, Schmidt S, Tang Y, Davis AR, Touchette JC, Kallmes KM, Hassan AE, Tarchand R, Mehta M, Pederson JM, Abdelmegeed M. Characteristics, treatment, and outcomes of Myasthenia Gravis in COVID-19 patients: A systematic review. Clin Neurol Neurosurg 2022; 213:107140. [PMID: 35091255 PMCID: PMC8782728 DOI: 10.1016/j.clineuro.2022.107140] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 12/28/2022]
Abstract
Objective Recent studies suggest that the clinical course and outcomes of patients with coronavirus disease 2019 (COVID-19) and myasthenia gravis (MG) are highly variable. We performed a systematic review of the relevant literature with a key aim to assess the outcomes of invasive ventilation, mortality, and hospital length of stay (HLoS) for patients presenting with MG and COVID-19. Methods We searched the PubMed, Scopus, Web of Science, and MedRxiv databases for original articles that reported patients with MG and COVID-19. We included all clinical studies that reported MG in patients with confirmed COVID-19 cases via RT-PCR tests. We collected data on patient background characteristics, symptoms, time between MG and COVID-19 diagnosis, MG and COVID-19 treatments, HLoS, and mortality at last available follow-up. We reported summary statistics as counts and percentages or mean±SD. When necessary, inverse variance weighting was used to aggregate patient-level data and summary statistics. Results Nineteen studies with 152 patients (mean age 54.4 ± 12.7 years; 79/152 [52.0%] female) were included. Hypertension (62/141, 44.0%) and diabetes (30/141, 21.3%) were the most common comorbidities. The mean time between the diagnosis of MG and COVID-19 was7.0 ± 6.3 years. Diagnosis of COVID-19 was confirmed in all patients via RT-PCR tests. Fever (40/59, 67.8%) and ptosis (9/55, 16.4%) were the most frequent COVID-19 and MG symptoms, respectively. Azithromycin and ceftriaxone were the most common COVID-19 treatments, while prednisone and intravenous immunoglobulin were the most common MG treatments. Invasive ventilation treatment was required for 25/59 (42.4%) of patients. The mean HLoS was 18.2 ± 9.9 days. The mortality rate was 18/152 (11.8%). Conclusion This report provides an overview of the characteristics, treatment, and outcomes of MG in COVID-19 patients. Although COVID-19 may exaggerate the neurological symptoms and worsens the outcome in MG patients, we did not find enough evidence to support this notion. Further studies with larger numbers of patients with MG and COVID-19 are needed to better assess the clinical outcomes in these patients.
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Cortés-Vicente E, Álvarez-Velasco R, Pla-Junca F, Rojas-Garcia R, Paradas C, Sevilla T, Casasnovas C, Gómez-Caravaca MT, Pardo J, Ramos-Fransi A, Pelayo-Negro AL, Gutiérrez-Gutiérrez G, Turon-Sans J, López de Munain A, Guerrero-Sola A, Jericó I, Martín MA, Mendoza MD, Morís G, Vélez-Gómez B, Garcia-Sobrino T, Pascual-Goñi E, Reyes-Leiva D, Illa I, Gallardo E. Drug-refractory myasthenia gravis: Clinical characteristics, treatments, and outcome. Ann Clin Transl Neurol 2022; 9:122-131. [PMID: 35080153 PMCID: PMC8862423 DOI: 10.1002/acn3.51492] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 01/20/2023] Open
Abstract
Objective To describe the clinical characteristics and outcomes in patients with refractory myasthenia gravis (MG) and to determine the effectiveness and side effects of the drugs used for their treatment. Methods This observational retrospective cross‐sectional multicenter study was based on data from the Spanish MG Registry (NMD‐ES). Patients were considered refractory when their MG Foundation of America post‐interventional status (MGFA‐PIS) was unchanged or worse after corticosteroids and two or more other immunosuppressive agents. Clinical and immunologic characteristics of drug‐refractory patients, efficiency and toxicity of drugs used, and outcome (MGFA‐PIS) at end of follow‐up were studied. Results We included 990 patients from 15 hospitals. Eighty‐four patients (68 of 842 anti‐acetylcholine receptor [AChR], 5 of 26 anti‐muscle‐specific tyrosine kinase [MusK], 10 of 120 seronegative, and 1 of 2 double‐seropositive patients) were drug refractory. Drug‐refractory patients were more frequently women (p < 0.0001), younger at onset (p < 0.0001), and anti‐MuSK positive (p = 0.037). Moreover, they more frequently presented a generalized form of the disease, bulbar symptoms, and life‐threatening events (p < 0.0001; p = 0.018; and p = 0.002, respectively) than non‐drug‐refractory patients. Mean follow‐up was 9.8 years (SD 4.5). Twenty‐four (50%) refractory patients had side effects to one or more of the drugs. At the end of follow‐up, 42.9% of drug‐refractory patients (42.6% of anti‐AChR, 100% of anti‐MuSK, and 10% of seronegative patients) and 79.8% of non‐drug‐refractory patients (p < 0.0001) achieved remission or had minimal manifestations. Eighty percent of drug‐refractory‐seronegative patients did not respond to any drug tested. Interpretation In this study, 8.5% of MG patients were drug‐refractory. New more specific drugs are needed to treat drug‐refractory MG patients.
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Affiliation(s)
- Elena Cortés-Vicente
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Rodrigo Álvarez-Velasco
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Francesc Pla-Junca
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Ricard Rojas-Garcia
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Paradas
- Neurology Department, Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla, Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Teresa Sevilla
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain.,Neuromuscular Unit, Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Department of Medicine, Universitat de València, Valencia, Spain.,Biomedical Research Institute La Fe (IIS La Fe), Valencia, Spain
| | - Carlos Casasnovas
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain.,Unitat de Neuromuscular, Neurology Department, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Julio Pardo
- Neurology Department, Hospital Clínico, Santiago de Compostela, Spain
| | - Alba Ramos-Fransi
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Neuromuscular Diseases Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ana Lara Pelayo-Negro
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain.,Service of Neurology, University Hospital "Marqués de Valdecilla (IDIVAL)", University of Cantabria (UC), Santander, Spain
| | - Gerardo Gutiérrez-Gutiérrez
- Neuromuscular Diseases Unit, Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid, Spain
| | - Janina Turon-Sans
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Adolfo López de Munain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain.,Neurology Department, Donostia University Hospital, University of the Basque Country, Neurosciences Area, Biodonostia Research Institute, San Sebastián, Spain
| | - Antonio Guerrero-Sola
- Neuromuscular Diseases Unit, Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Ivonne Jericó
- Department of Neurology, Complejo Hospitalario de Navarra-IdisNA, Pamplona, Spain
| | | | - María Dolores Mendoza
- Department of Neurology, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Germán Morís
- Department of Neurology, Hospital Central de Asturias, Oviedo, Spain
| | - Beatriz Vélez-Gómez
- Neurology Department, Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla, Sevilla, Spain
| | | | - Elba Pascual-Goñi
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - David Reyes-Leiva
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Illa
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Eduard Gallardo
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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Huang Y, Tan Y, Shi J, Li K, Yan J, Guan Y. Patients With Myasthenia Gravis With Acute Onset of Dyspnea: Predictors of Progression to Myasthenic Crisis and Prognosis. Front Neurol 2021; 12:767961. [PMID: 34867753 PMCID: PMC8637205 DOI: 10.3389/fneur.2021.767961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Life-threatening myasthenic crisis (MC) occurs in 10–20% of the patients with myasthenia gravis (MG). It is important to identify the predictors of progression to MC and prognosis in the patients with MG with acute exacerbations. Objective: This study aimed to explore the predictors of progression to MC in the patients with MG with acute onset of dyspnea and their short-term and long-term prognosis. Methods: This study is a retrospective cohort study. We collected and analyzed data on all the patients with MG with acute dyspnea over a 10-year period in a single center using the univariate and multivariate analysis. Results: Eighty-six patients with MG were included. In their first acute dyspnea episodes, 36 (41.9%) episodes eventually progressed to MC. A multivariate analysis showed that the early-onset MG (adjusted OR: 3.079, 95% CI 1.052–9.012) and respiratory infection as a trigger (adjusted OR: 3.926, 95% CI 1.141–13.510) were independent risk factors for the progression to MC, while intravenous immunoglobulin (IVIg) treatment prior to the mechanical ventilation (adjusted OR: 0.253, 95% CI 0.087–0.732) was a protective factor. The prognosis did not significantly differ between the patients with and without MC during the MG course, with a total of 45 (52.3%) patients reaching post-intervention status better than minimal manifestations at the last follow-up. Conclusion: When treating the patients with MG with acute dyspnea, the clinicians should be aware of the risk factors of progression to MC, such as early-onset MG and respiratory infection. IVIg is an effective treatment. With proper immunosuppressive therapy, this group of patients had an overall good long-term prognosis.
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Affiliation(s)
- Yangyu Huang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Tan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiayu Shi
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Li
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingwen Yan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Predictors of outcome in patients with myasthenic crisis undergoing non-invasive mechanical ventilation: A retrospective 20 year longitudinal cohort study from a single Italian center. Neuromuscul Disord 2021; 31:1241-1250. [PMID: 34782245 DOI: 10.1016/j.nmd.2021.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/05/2021] [Accepted: 08/12/2021] [Indexed: 11/22/2022]
Abstract
About 20% of patients with myasthenia gravis (MG) may develop myasthenic crisis (MC) requiring ventilation, either invasive (MV) or non-invasive (NIV) and intensive unit care (ICU). NIV failure in patients with MC can occur up to 60% of cases admitted to ICU. Moreover it is not known the outcome of MC receiving NIV. Purpose of this study was to identify predictors of outcome in MC who underwent non-invasive ventilator support outside ICU setting. We enrolled 90 patients, 53 females and 37 males admitted to University Hospital of Modena (Italy) between January 2000 and September 2020. Median age at MC was 65 years. Thirty-four patients (37.8%) required MV. Thymectomy was performed in 45 cases, associated with thymoma in 55%, with hyperplastic thymus in 33%. First-line treatment was plasmaexchange (38.8%) or intravenous immunoglobulins (45.6%). Males exhibited higher risk of MV than females .Patients in MV were treated with plasmaexchange as first-line therapy . Our in-hospital mortality rate was low. Nine patients underwent tracheostomy which was significantly related to male gender. Comorbidities had significant effect on length of ICU .Our study confirms as predictors of prognosis in our patients male gender, older age at onset, infections as trigger, pneumonia.
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20
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Zhou Q, Zhou R, Yang H, Yang H. To Be or Not To Be Vaccinated: That Is a Question in Myasthenia Gravis. Front Immunol 2021; 12:733418. [PMID: 34603311 PMCID: PMC8485039 DOI: 10.3389/fimmu.2021.733418] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/01/2021] [Indexed: 01/04/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and abnormal fatigability due to the antibodies against postsynaptic receptors. Despite the individual discrepancy, patients with MG share common muscle weakness, autoimmune dysfunction, and immunosuppressive treatment, which predispose them to infections that can trigger or exacerbate MG. Vaccination, as a mainstay of prophylaxis, is a major management strategy. However, the past years have seen growth in vaccine hesitancy, owing to safety and efficacy concerns. Ironically, vaccines, serving as an essential and effective means of defense, may induce similar immune cross-reactivity to what they are meant to prevent. Herein, we outline the progress in vaccination, review the current status, and postulate the clinical association among MG, vaccination, and immunosuppression. We also address safety and efficacy concerns of vaccination in MG, in relation to COVID-19. Since only a handful of studies have reported vaccination in individuals with MG, we further review the current clinical studies and guidelines in rheumatic diseases. Overall, our reviews offer a reference to guide future vaccine clinical decision-making and improve the management of MG patients.
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Affiliation(s)
| | | | | | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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21
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Ipe TS, Davis AR, Raval JS. Therapeutic Plasma Exchange in Myasthenia Gravis: A Systematic Literature Review and Meta-Analysis of Comparative Evidence. Front Neurol 2021; 12:662856. [PMID: 34531809 PMCID: PMC8439193 DOI: 10.3389/fneur.2021.662856] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/12/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Patients with Myasthenia Gravis (MG) can be treated acutely with therapeutic plasma exchange (TPE) or intravenous immune globulin (IVIG). To date, there is no definitive understanding of which of the two treatments is more effective and safer. The purpose of this study was to systematically review the literature on the comparative efficacy and safety of TPE to other available treatments for MG. Methods: A systematic literature search for studies published between 1997 and 2017 was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using two database sources, MEDLINE (through the PubMed database) and Cochrane Library. Results: The search strategy resulted in 535 articles whose abstracts were reviewed. Among these, 165 full texts articles were reviewed for eligibility and 101 articles were excluded. Of the 165 articles, 64 articles were included for a systematic literature and 11 articles for a meta-analysis. Conclusions: This systematic literature review and meta-analysis of treatment options showed that there was a higher response rate with TPE than IVIG in acute MG patients and patients undergoing thymectomy. There was no difference in mortality between the two treatment options. Our findings highlight the need for additional randomized clinical trials in these patients with MG.
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Affiliation(s)
- Tina S. Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Adeola R. Davis
- Terumo Blood and Cell Technologies, Lakewood, CO, United States
| | - Jay S. Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM, United States
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22
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Berrih-Aknin S, Claeys KG, Law N, Mantegazza R, Murai H, Saccà F, Dewilde S, Janssen MF, Bagshaw E, Kousoulakou H, Larkin M, Beauchamp J, Leighton T, Paci S. Patient-reportedimpact of myasthenia gravis in the real world: protocol for a digital observational study (MyRealWorld MG). BMJ Open 2021; 11:e048198. [PMID: 34285010 PMCID: PMC8292816 DOI: 10.1136/bmjopen-2020-048198] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is a rare, chronic, autoimmune disease, mediated by immunoglobulin G antibodies, which causes debilitating muscle weakness. As with most rare diseases, there is little patient-reported data with which to understand and address patient needs. This study explores the impact of MG in the real world from the patient perspective. METHODS AND ANALYSIS This is a 2-year prospective, observational, digital, longitudinal study of adults with MG, resident in the following countries: the USA, Japan, Germany, France, the UK, Italy, Spain, Canada and Belgium. The planned sample size is 2000. Recruitment will be community based, via patient advocacy groups, social media and word of mouth. Participants will use a smartphone application (app) to check eligibility, provide consent and contribute data. Planned data entry is as follows: (1) personal profile on enrollment-covering demographics, MG characteristics and previous care; (2) monthly event tracker-current treatments, healthcare visits, treatment-related adverse events, productivity losses; (3) monthly selection of validated generic and disease-specific patient-reported outcomes instruments: EQ-5D-5L, Myasthenia Gravis Activities of Daily Living, Myasthenia Gravis Quality of Life 15-item revised scale, Hospital Anxiety and Depression Scale and Health Utilities Index III. Analyses are planned for when the study has been running in most countries for approximately 6, 12, 18 and 24 months. ETHICS AND DISSEMINATION The study protocol has been reviewed and granted ethics approval by Salus IRB for participants resident in the following countries: Germany, the UK and the US. Local ethics approval is being sought for the following study countries: Belgium, Canada, France, Italy, Japan and Spain. Study results will be communicated to the public and participants via conference presentations and journal publications, as well as regular email, social media and in-application communication. TRIAL REGISTRATION NUMBER NCT04176211.
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Affiliation(s)
- Sonia Berrih-Aknin
- INSERM, Institute of Myology, Center of Research in Myology, Sorbonne Université, Paris, France
| | - Kristl G Claeys
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Nancy Law
- Myasthenia Gravis Foundation of America Inc, Westborough, Massachusetts, USA
| | - Renato Mantegazza
- Fondazione IRCCS, Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
- Associazione Italiana Miastenia e Malattie Immunodegenerative, Milan, Italy
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - Francesco Saccà
- DNSRO Department, University of Naples Federico II, Naples, Italy
| | | | - Mathieu F Janssen
- Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, Netherlands
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23
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Ruiter AM, Strijbos E, de Meel RHP, Lipka AF, Raadsheer WF, Tannemaat MR, Verschuuren JJGM. Accuracy of patient-reported data for an online patient registry of autoimmune myasthenia gravis and Lambert-Eaton myasthenic syndrome. Neuromuscul Disord 2021; 31:622-632. [PMID: 34210541 DOI: 10.1016/j.nmd.2021.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022]
Abstract
Disorders of the neuromuscular junction (NMJ) comprise a spectrum of rare diseases causing muscle fatigability and weakness, leading to life-long effects on quality of life. We established the Dutch-Belgian registry for NMJ disorders, based on a unique combination of patient- and physician-reported information. Information on natural course, disease burden, prevalence of complications and comorbidity is collected through patient-reported standardized questionnaires and verified using medical documentation. Currently, the registry contains information of 565 Myasthenia Gravis (MG) patients and 38 Lambert-Eaton myasthenic syndrome (LEMS) patients, constituting approximately 25% (MG) and 80% (LEMS) of patients in the Netherlands. This is a very large registry, with the highest participation rate per capita. In addition to confirming many disease characteristics previously described in the literature, this registry provides several novel insights. The reported rate of potentially corticosteroid-related comorbidity, including hypertension, heart disease, osteoporosis and type 2 diabetes was high, emphasizing the need to commence corticosteroid-sparing immune suppressive treatment as soon as possible. The reported rate of other auto-immune diseases is far higher than previously expected: 27% of MG and 38% of LEMS patients, and a surprisingly high number of MG patients (47%) is unaware of their antibody status. In conclusion, this registry provides a valuable collection of information regarding MG and LEMS disease course. Continuous collection of annual follow-up data will provide further longitudinal insights in disease burden, course and treatment effect.
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Affiliation(s)
- Annabel M Ruiter
- Department of Neurology, Leiden University Medical Center, the Netherlands.
| | - Ellen Strijbos
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Robert H P de Meel
- Department of Neurology, Leiden University Medical Center, the Netherlands
| | - Alexander F Lipka
- Department of Neurology, Leiden University Medical Center, the Netherlands; Department of Neurology, Groene Hart Hospital, Gouda, the Netherlands
| | - Wouter F Raadsheer
- Department of Neurology, Leiden University Medical Center, the Netherlands
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24
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König N, Stetefeld HR, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Bösel J, Lee DH, Gerner ST, Huttner HB, Schneider H, Reichmann H, Fuhrer H, Berger B, Zinke J, Alberty A, Kleiter I, Schneider-Gold C, Roth C, Dunkel J, Steinbrecher A, Thieme A, Schlachetzki F, Linker RA, Angstwurm K, Meisel A, Neumann B. MuSK-antibodies are associated with worse outcome in myasthenic crisis requiring mechanical ventilation. J Neurol 2021; 268:4824-4833. [PMID: 33970337 PMCID: PMC8563593 DOI: 10.1007/s00415-021-10603-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 10/24/2022]
Abstract
Myasthenic crisis (MC) is a life-threatening condition for patients with myasthenia gravis (MG). Muscle-specific kinase-antibodies (MuSK-ABs) are detected in ~ 6% of MG, but data on outcome of MuSK-MCs are still lacking. We made a subgroup analysis of patients who presented with MC with either acetylcholine-receptor-antibody positive MG (AchR-MG) or MuSK-MG between 2006 and 2015 in a retrospective German multicenter study. We identified 19 MuSK-AB associated MCs in 15 patients and 161 MCs in 144 patients with AchR-ABs only. In contrast to patients with AchR-AB, MuSK-AB patients were more often female (p = 0.05, OR = 2.74) and classified as Myasthenia Gravis Foundation of America-class IV before crisis (p = 0.04, OR = 3.25). MuSK-AB patients suffer more often from multiple chronic disease (p = 0.016, OR = 4.87) and were treated more invasively in terms of plasma exchanging therapies (not significant). The number of days of mechanical ventilation (MV) (43.0 ± 53.1 vs. 17.4 ± 18; p < 0.0001), days on an intensive care unit (ICU) (45.3 ± 49.5 vs. 21.2 ± 19.7; p < 0.0001), and hospital-length of stay (LOS) (55.9 ± 47.6 vs. 28.8 ± 20.9 days; p < 0.0001) were significantly increased in MuSK-MC. Remarkable is that these changes were mainly due to patients with MusK-ABs only, whereas patients' outcome with both antibodies was similar to AchR-MCs. Furthermore, our data showed a shortened duration of MV after treatment with plasma exchanging therapies compared to treatment with intravenous immunoglobulin in MuSK-MCs. We conclude that MuSK-AB-status is associated with a longer need of MV, ICU-LOS, and hospital-LOS in MC, and therefore recommend early initiation of a disease-specific therapy.
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Affiliation(s)
- Nicole König
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universitaetsstraße 84, 93051, Regensburg, Germany
| | | | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany.,Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany.,Departments of Neurology and Experimental Neurology, Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - De-Hyung Lee
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universitaetsstraße 84, 93051, Regensburg, Germany.,Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Mönchengladbach, Germany
| | - Ingo Kleiter
- St. Josef-Hospital, Department of Neurology, Ruhr-University Bochum, Bochum, Germany.,Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen Für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany.,Department of Neurology, Phillips University of Marburg, Marburg, Germany
| | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | | | - Andrea Thieme
- Department of Neurology, Helios Klinikum Erfurt, Erfurt, Germany
| | - Felix Schlachetzki
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universitaetsstraße 84, 93051, Regensburg, Germany
| | - Ralf A Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universitaetsstraße 84, 93051, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universitaetsstraße 84, 93051, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany.,Departments of Neurology and Experimental Neurology, Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universitaetsstraße 84, 93051, Regensburg, Germany.
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25
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Solé G, Mathis S, Friedman D, Salort-Campana E, Tard C, Bouhour F, Magot A, Annane D, Clair B, Le Masson G, Soulages A, Duval F, Carla L, Violleau MH, Saulnier T, Segovia-Kueny S, Kern L, Antoine JC, Beaudonnet G, Audic F, Kremer L, Chanson JB, Nadaj-Pakleza A, Stojkovic T, Cintas P, Spinazzi M, Foubert-Samier A, Attarian S. Impact of Coronavirus Disease 2019 in a French Cohort of Myasthenia Gravis. Neurology 2021; 96:e2109-e2120. [PMID: 33568541 DOI: 10.1212/wnl.0000000000011669] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/22/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To describe the clinical characteristics and outcomes of coronavirus disease 2019 (COVID-19) among patients with myasthenia gravis (MG) and identify factors associated with COVID-19 severity in patients with MG. METHODS The CO-MY-COVID registry was a multicenter, retrospective, observational cohort study conducted in neuromuscular referral centers and general hospitals of the FILNEMUS (Filière Neuromusculaire) network (between March 1, 2020, and June 8, 2020), including patients with MG with a confirmed or highly suspected diagnosis of COVID-19. COVID-19 was diagnosed based on a PCR test from a nasopharyngeal swab or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serology, thoracic CT scan, or typical symptoms. The main outcome was COVID-19 severity based on location of treatment/management (home, hospitalized in a medical unit, or in an intensive care unit). We collected information on demographic variables, general history, and risk factors for severe COVID-19. Multivariate ordinal regression models were used to identify factors associated with severe COVID-19 outcomes. RESULTS Among 3,558 patients with MG registered in the French database for rare disorders, 34 (0.96%) had COVID-19. The mean age at COVID-19 onset was 55.0 ± 19.9 years (mean MG duration: 8.5 ± 8.5 years). By the end of the study period, 28 patients recovered from COVID-19, 1 remained affected, and 5 died. Only high Myasthenia Gravis Foundation of America (MGFA) class (≥IV) before COVID-19 was associated with severe COVID-19 (p = 0.004); factors that were not associated included sex, MG duration, and medium MGFA classes (≤IIIb). The type of MG treatment had no independent effect on COVID-19 severity. CONCLUSIONS This registry-based cohort study shows that COVID-19 had a limited effect on most patients, and immunosuppressive medications and corticosteroids used for MG management are not risk factors for poorer outcomes. However, the risk of severe COVID-19 is elevated in patients with high MGFA classes (odds ratio, 102.6 [4.4-2,371.9]). These results are important for establishing evidence-based guidelines for the management of patients with MG during the COVID-19 pandemic.
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Affiliation(s)
- Guilhem Solé
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France.
| | - Stéphane Mathis
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Diane Friedman
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Emmanuelle Salort-Campana
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Céline Tard
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Françoise Bouhour
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Armelle Magot
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Djillali Annane
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Bernard Clair
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Gwendal Le Masson
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Antoine Soulages
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Fanny Duval
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Louis Carla
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Marie-Hélène Violleau
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Tiphaine Saulnier
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Sandrine Segovia-Kueny
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Léa Kern
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Jean-Christophe Antoine
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Guillemette Beaudonnet
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Frédérique Audic
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Laurent Kremer
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Jean-Baptiste Chanson
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Aleksandra Nadaj-Pakleza
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Tanya Stojkovic
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Pascal Cintas
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Marco Spinazzi
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Alexandra Foubert-Samier
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
| | - Shahram Attarian
- From the Referral Center for Neuromuscular Diseases AOC (G.S., S.M., G.L.M., A.S., F.D., L.C., M.-H.V.) and ALS Center (S.M., G.L.M., A.S., L.C.), Nerve-Muscle Unit, University Hospitals of Bordeaux (Pellegrin Hospital), University of Bordeaux; Department of Intensive Care (D.F., D.A., B.C.), Raymond Poincare University Hospital, Garches; Referral Center for Neuromuscular Diseases and ALS (E.S.-C., S.A.) and Referral Center for Neuromuscular Diseases, Neuropediatric Unit (F.A.), Timone University Hospital, Aix-Marseille University, Marseille; Department of Neurology, Referral Center for Neuromuscular Diseases (C.T.), University Hospitals of Lille; ENMG Unit, Referral Center for Neuromuscular Diseases (F.B.), University Hospitals of Lyon (Neurologic Hospital Pierre Wertheimer); Referral Center for Neuromuscular Diseases (A.M.), University Hospitals of Nantes; Inserm, UMR1219 (T.S., A.F.-S.), Bordeaux Population Health Research Center, ISPED, University of Bordeaux; Neurodegenerative Diseases Institute, French Reference Centre for MSA (T.S., A.F.-S.), University Hospitals of Bordeaux; AFM-Téléthon (S.S.-K.), Evry; Department of Neurology (L.K.), General Hospital of Le Mans; Department of Neurology (J.-C.A.), University Hospital of Saint-Etienne; Clinical Neurophysiology and Epileptology Department (G.B.), University Hospital of Bicêtre, Le Kremlin-Bicêtre; Neurology Department (L.K., J.-B.C., A.N.-P.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," University Hospitals of Strasbourg; APHP (Pitié-Salpêtrière Hospital) (T.S.), Referral Center for Neuromuscular Diseases "Nord-Est-Ile de France," Sorbonne University, Paris; Referral Center for Neuromuscular Diseases, Department of Neurology (P.C.), University Hospitals of Toulouse (Purpan Hospital); and Referral Center for Neuromuscular Diseases, Department of Neurology (M.S.), University Hospital of Angers, France
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Verwijst J, Westerberg E, Punga AR. Cancer in myasthenia gravis subtypes in relation to immunosuppressive treatment and acetylcholine receptor antibodies: A Swedish nationwide register study. Eur J Neurol 2021; 28:1706-1715. [PMID: 33427389 DOI: 10.1111/ene.14730] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/07/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The potentially increased risk of extrathymic cancers in myasthenia gravis (MG) remains uncertain. We present the occurrence of extrathymic cancer diagnoses in different MG subgroups. METHODS We conducted a nationwide Swedish register-based cohort study, including patients who had their first MG diagnosis or first prescription of acetylcholine esterase inhibitors between the years 2006 and 2018. Timing and subtypes of cancer diagnosis in relation to MG as well as corticosteroid-sparing immunosuppressants (CSISs) were identified from national patient, cancer and drug registers. RESULTS In the study population of 2812 MG patients, 92 had juvenile MG (3%), 632 had early-onset MG (23%), 1968 had late-onset MG (LOMG; 70%) and 120 patients had thymoma-associated MG (TAMG; 4%). Extrathymic cancers were observed in 630 patients (22.4%). Skin cancer and cancer in the male genital organs were most common (N = 138, respectively), followed by cancers in the female genital organs (N = 103), digestive organs (N = 90) and breast (N = 80). Patients with TAMG (29.2%) and LOMG (28.4%) had the highest occurrence of extrathymic cancer. Cancer frequency was comparable between acetylcholine receptor antibody seropositive and seronegative patients. Two or more CSIS prescriptions significantly increased the frequency of cancer, especially cancers in the digestive organs (p = 0.0026), male genital organs (p = 0.0037) and skin (p < 0.0001). CONCLUSIONS Most extrathymic cancer types in MG were observed in TAMG and LOMG patients, and there was a clear correlation between CSIS exposure and cancer risk. This study sheds light on extrathymic cancers also in non-thymoma MG.
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Affiliation(s)
- Johanna Verwijst
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Elisabet Westerberg
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Anna Rostedt Punga
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
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Su S, Liu Q, Zhang X, Wen X, Lei L, Shen F, Fan Z, Duo J, Lu Y, Di L, Wang M, Chen H, Zhu W, Xu M, Wang S, Da Y. VNTR2/VNTR3 genotype in the FCGRT gene is associated with reduced effectiveness of intravenous immunoglobulin in patients with myasthenia gravis. Ther Adv Neurol Disord 2021; 14:1756286420986747. [PMID: 33552238 PMCID: PMC7844454 DOI: 10.1177/1756286420986747] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Intravenous immunoglobulin (IVIG) has been commonly used to treat myasthenia gravis exacerbation, but is still ineffective in nearly 30% of patients. A variable number of tandem repeat (VNTR) polymorphism in the FCGRT gene has been found to reduce the efficiency of IgG biologics. However, whether the polymorphism influences the efficacy of IVIG in generalized myasthenia gravis (MG) patients with exacerbations remains unknown. Methods: The distribution of VNTR genotypes was analyzed in 334 patients with MG. Varied VNTR alleles were determined by capillary electrophoresis and confirmed by Sanger sequencing. Information of endogenous IgG levels were collected in patients without previous immunotherapy (n = 26). Medical records of patients who received IVIG therapy were retrospectively analyzed for therapeutic outcomes of IVIG treatment (n = 61). Patients whose Activities of Daily Living scores decreased by 2 or more points on day 14 were considered responders to the treatment. Results: The VNTR3/3 and VNTR2/3 genotypes were detected in 96.7% (323/334) and 3.4% (11/334) patients, respectively. Patients with VNTR2/3 heterozygosity had lower endogenous IgG levels than those with VNTR3/3 homozygosity (9.81 ± 2.61 g/L versus 12.41 ± 2.45g/L, p = 0.016). The response rate of IVIG therapy was 78.7% (48/61). All responders and nine non-responders were VNTR3/3 homozygotes, whereas all the patients with VNTR2/3 genotypes were non-responders (n = 4). In patients who took IVIG treatments, endogenous IgG levels were significantly lower in non-responders compared with responders (12.93 ± 2.24 g/L versus 8.85 ± 2.69 g/L, p = 0.006), especially in VNTR2/3 heterozygotes (7.86 ± 1.78 g/L, p = 0.001). Conclusion: The VNTR2/3 genotype could influence endogenous IgG levels and serve as a predictive marker for poor responses to IVIG in MG patients.
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Affiliation(s)
- Shengyao Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qing Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Chang Chun Street, Beijing, China
| | - Xueping Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Chang Chun Street, Beijing, China
| | - Xinmei Wen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lin Lei
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Faxiu Shen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhirong Fan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianying Duo
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Lu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li Di
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hai Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenjia Zhu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Suobin Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Chang Chun Street, Beijing 100053, China
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Detection of Microbiota from Human Thymus of Myasthenia Gravis. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02202-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Angstwurm K, Vidal A, Stetefeld H, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Bösel J, Neumann U, Lee DH, Gerner ST, Huttner HB, Thieme A, Dunkel J, Roth C, Schneider H, Schimmel E, Reichmann H, Fuhrer H, Berger B, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schalke B, Steinbrecher A, Meisel A, Neumann B. Early Tracheostomy Is Associated With Shorter Ventilation Time and Duration of ICU Stay in Patients With Myasthenic Crisis-A Multicenter Analysis. J Intensive Care Med 2020; 37:32-40. [PMID: 33233998 DOI: 10.1177/0885066620967646] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Myasthenic crisis (MC) requiring mechanical ventilation (MV) is a rare and serious complication of myasthenia gravis. Here we analyzed the frequency of performed tracheostomies, risk factors correlating with a tracheostomy, as well as the impact of an early tracheostomy on ventilation time and ICU length of stay (LOS) in MC. METHODS Retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015 to assess demographic/diagnostic data, rates and timing of tracheostomy and outcome. RESULTS In 107 out of 215 MC (49.8%), a tracheostomy was performed. Patients without tracheostomy were more likely to have an early-onset myasthenia gravis (27 [25.2%] vs 12 [11.5%], p = 0.01). Patients receiving a tracheostomy, however, were more frequently suffering from multiple comorbidities (20 [18.7%] vs 9 [8.3%], p = 0.03) and also the ventilation time (34.4 days ± 27.7 versus 7.9 ± 7.8, p < 0.0001) and ICU-LOS (34.8 days ± 25.5 versus 12.1 ± 8.0, p < 0.0001) was significantly longer than in non-tracheostomized patients. Demographics and characteristics of the course of the disease up to the crisis were not significantly different between patients with an early (within 10 days) compared to a late tracheostomy. However, an early tracheostomy correlated with a shorter duration of MV at ICU (26.2 days ± 18.1 versus 42.0 ± 33.1, p = 0.006), and ICU-LOS (26.2 days ± 14.6 versus 42.3 ± 33.0, p = 0.003). CONCLUSION Half of the ventilated patients with MC required a tracheostomy. Poorer health condition before the crisis and late-onset MG were associated with a tracheostomy. An early tracheostomy (≤ day 10), however, was associated with a shorter duration of MV and ICU-LOS by 2 weeks.
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Affiliation(s)
- Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Amelie Vidal
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | | | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany.,Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin.,Departments of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin.,Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Ursula Neumann
- Department of Mathematics and Computer Science, Philipps-Universitaet Marburg, Marburg, Germany
| | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany.,Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Eik Schimmel
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, Staedtisches Klinikum Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Germany
| | - Benjamin Berger
- Department of Neurology, Medical Center-University of Freiburg, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.,Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Mönchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Berthold Schalke
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | | | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin.,Departments of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Bernhard Neumann
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
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Liu C, Li T, Wang Q, Xu A, Wu B. Post-traumatic stress disorder symptoms after respiratory insufficiency in patients with myasthenia gravis. PSYCHOL HEALTH MED 2020; 26:221-227. [PMID: 32877257 DOI: 10.1080/13548506.2020.1807577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
To explore posttraumatic stress disorder symptoms (PTSD) after respiratory insufficiency in patients with myasthenia gravis (MG). The investigation was made with 134 adult patients with MG, after respiratory insufficiency, between January 2012 and January 2016 and had a return visit after one year. 134 patients finished this study and 69 patients (51.5%) had PTSD. Anxiety (HADS-A ≥ 8, HADS: Hospital Anxiety and Depression Scale) (OR 2.585,95% CI 1.102-6.061, p = 0.029), and depression (HADS-D ≥ 8) (OR 3.200, 95% CI 1.395-7.342, p = 0.006) were associated with greater probabilities of screening positive for PTSD. Gender, age, intubation, yearly income, marriage, inability to work, number of respiratory insufficiency episodes, education level, Mini-mental state examination (MMSE) (>20), ICU stays, having insurance, and MG-activities of daily living (ADL) (<9) were not significant predictors for PTSD. One year after a respiratory insufficiency episode, patients with PTSD experienced worse anxiety (p = 0.035), depressive disorder (p < 0.001), and 36-Item Short-Form Health Survey (SF-36) showed physical functioning (p = 0.042), role-physical (p = 0.013), social functioning (p = 0.040), and emotional-role (p = 0.034). But there were no differences in ADL, bodily pain, general health and vitality. PTSD in patients with MG is common after a respiratory insufficiency episode; anxiety and depression were both associated with greater probabilities of screening positive for PTSD.
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Affiliation(s)
- Chanchan Liu
- Clinical Neuroscience Institute, Stroke Center & Department of Neurology, The First Affiliated Hospital, Jinan University , Guangzhou, China.,Department of Neurology, University of Chinese Academy of Sciences-Shenzhen Hospital , Shenzhen, Guangdong, China
| | - Ting Li
- Department of Emergency, University of Chinese Academy of Sciences-Shenzhen Hospital , Shenzhen, Guangdong, China
| | - Qingyong Wang
- Department of Neurology, University of Chinese Academy of Sciences-Shenzhen Hospital , Shenzhen, Guangdong, China
| | - Anding Xu
- Clinical Neuroscience Institute, Stroke Center & Department of Neurology, The First Affiliated Hospital, Jinan University , Guangzhou, China
| | - Benqing Wu
- Department of Neonatology, University of Chinese Academy of Sciences-Shenzhen Hospital , Shenzhen, Guangdong, China
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Bogdan A, Barnett C, Ali A, AlQwaifly M, Abraham A, Mannan S, Ng E, Bril V. Prospective study of stress, depression and personality in myasthenia gravis relapses. BMC Neurol 2020; 20:261. [PMID: 32600271 PMCID: PMC7322879 DOI: 10.1186/s12883-020-01802-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/21/2020] [Indexed: 11/25/2022] Open
Abstract
Background Psychopathology and personality traits may influence the course of autoimmune disorders. With this prospective longitudinal cohort study, we aimed to assess personality, stress and depression in myasthenia patients who relapse and those who remain stable or improve (non-relapsers). Method We collected data from 155 consecutive adult patients with confirmed MG attending the Neuromuscular Clinic, Toronto General Hospital, between March 2017 and July 2018, for this study. Patients were assessed at baseline and 6 months, or at the time of MG relapse. At both visits, the patients were assessed clinically and were asked to complete self-administered questionnaires for disease severity, chronic stress and depression. Personality type was assessed at baseline only. Relapsing patients were defined as those patients with MGII score increasing by more than 5.5 points from visit 1 to visit 2. Results Relapsers had higher baseline scores for depression (p = 0.01) and the change in disease severity correlated with the change in depression score (r = 0.2534, p = 0.0015, 95% CI: 0.098 0.3961). Higher levels of stress at baseline and neuroticism predicted higher relapse rates (p = 0.01 and p < .0001, respectively). In the linear regression model, with change of the MGII score as the dependent variable, change in depression scores (p = 0.0004) and age (p = 0.03) predicted change in disease severity. Conclusions Since emotional factors and personality type may influence MG, attention to these factors might improve care in MG patients.
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Affiliation(s)
- Anca Bogdan
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 5EC, Room 309 200 Elizabeth St, Toronto, ON, M5G 2G4, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 5EC, Room 309 200 Elizabeth St, Toronto, ON, M5G 2G4, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Abdulrahman Ali
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Alon Abraham
- Neuromuscular Diseases Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shabber Mannan
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 5EC, Room 309 200 Elizabeth St, Toronto, ON, M5G 2G4, Canada
| | - Eduardo Ng
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 5EC, Room 309 200 Elizabeth St, Toronto, ON, M5G 2G4, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, 5EC, Room 309 200 Elizabeth St, Toronto, ON, M5G 2G4, Canada. .,Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
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Cortés-Vicente E, Álvarez-Velasco R, Segovia S, Paradas C, Casasnovas C, Guerrero-Sola A, Pardo J, Ramos-Fransi A, Sevilla T, López de Munain A, Gómez MT, Jericó I, Gutiérrez-Gutiérrez G, Pelayo-Negro AL, Martín MA, Mendoza MD, Morís G, Rojas-Garcia R, Díaz-Manera J, Querol L, Gallardo E, Vélez B, Albertí MA, Galán L, García-Sobrino T, Martínez-Piñeiro A, Lozano-Veintimilla A, Fernández-Torrón R, Cano-Abascal Á, Illa I. Clinical and therapeutic features of myasthenia gravis in adults based on age at onset. Neurology 2020; 94:e1171-e1180. [PMID: 32071167 DOI: 10.1212/wnl.0000000000008903] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/25/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To describe the characteristics of patients with very-late-onset myasthenia gravis (MG). METHODS This observational cross-sectional multicenter study was based on information in the neurologist-driven Spanish Registry of Neuromuscular Diseases (NMD-ES). All patients were >18 years of age at onset of MG and onset occurred between 2000 and 2016 in all cases. Patients were classified into 3 age subgroups: early-onset MG (age at onset <50 years), late-onset MG (onset ≥50 and <65 years), and very-late-onset MG (onset ≥65 years). Demographic, immunologic, clinical, and therapeutic data were reviewed. RESULTS A total of 939 patients from 15 hospitals were included: 288 (30.7%) had early-onset MG, 227 (24.2%) late-onset MG, and 424 (45.2%) very-late-onset MG. The mean follow-up was 9.1 years (SD 4.3). Patients with late onset and very late onset were more frequently men (p < 0.0001). Compared to the early-onset and late-onset groups, in the very-late-onset group, the presence of anti-acetylcholine receptor (anti-AChR) antibodies (p < 0.0001) was higher and fewer patients had thymoma (p < 0.0001). Late-onset MG and very-late-onset MG groups more frequently had ocular MG, both at onset (<0.0001) and at maximal worsening (p = 0.001). Although the very-late-onset group presented more life-threatening events (Myasthenia Gravis Foundation of America IVB and V) at onset (p = 0.002), they required fewer drugs (p < 0.0001) and were less frequently drug-refractory (p < 0.0001). CONCLUSIONS Patients with MG are primarily ≥65 years of age with anti-AChR antibodies and no thymoma. Although patients with very-late-onset MG may present life-threatening events at onset, they achieve a good outcome with fewer immunosuppressants when diagnosed and treated properly.
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Affiliation(s)
- Elena Cortés-Vicente
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Rodrigo Álvarez-Velasco
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Sonia Segovia
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Carmen Paradas
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Carlos Casasnovas
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Antonio Guerrero-Sola
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Julio Pardo
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Alba Ramos-Fransi
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Teresa Sevilla
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Adolfo López de Munain
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Maria Teresa Gómez
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Ivonne Jericó
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Gerardo Gutiérrez-Gutiérrez
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Ana Lara Pelayo-Negro
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - María Asunción Martín
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - María Dolores Mendoza
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Germán Morís
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Ricard Rojas-Garcia
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Jordi Díaz-Manera
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Luis Querol
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Eduard Gallardo
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Beatriz Vélez
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - María Antonia Albertí
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Lucía Galán
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Tania García-Sobrino
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Alicia Martínez-Piñeiro
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Ana Lozano-Veintimilla
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Roberto Fernández-Torrón
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Ángel Cano-Abascal
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
| | - Isabel Illa
- From the Neuromuscular Diseases Unit, Department of Neurology (E.C.-V., R.Á.-V., R.R.-G., J.D.-M., L.Q., E.G., I.I.), Hospital de la Santa Creu i Sant Pau; Department of Medicine (E.C.-V., R.Á.-V., I.I.), Universitat Autònoma de Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) (E.C.-V., R.Á.-V., S.S., C.C., T.S., R.R.-G., J.D.-M., L.Q., E.G., I.I.) and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED) (C.P., A.L.d.M., A.L.P.-N.), Instituto de Salud Carlos III, Madrid; Neurology Department (C.P., B.V.), Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla; Unitat de Neuromuscular (C.C., M.A.A.), Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, l'Hospitalet de Llobregat, Barcelona; Neuromuscular Diseases Unit (A.-G.S., L.G.), Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid; Neurology Department (J.P., T.G.-S.), Hospital Clínico, Santiago de Compostela; Neuromuscular Diseases Unit (A.R.-F., A.M.-P.), Department of Neurology, Hospital Germans Trias i Pujol; Department of Medicine (A.R.-F.), Universitat Autònoma de Barcelona, Badalona; Neuromuscular Unit (T.S., A.L.-M.), Neurology Department, Hospital Universitari i Politècnic La Fe; Department of Medicine (T.S.), Universitat de València; Neurology Department (A.L.d.M., A.F.-T.), Donostia University Hospital; Neurosciences Area (A.L.d.M.), Biodonostia Research Institute, University of the Basque Country, San Sebastián; Neurology Department (M.T.G.), Hospital Universitario Reina Sofía, Córdoba; Department of Neurology (I.J.), Complejo Hospitalario de Navarra, Pamplona; Neuromuscular Diseases Unit (G.G.-G.), Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Madrid; Complejo asistencial hospitalario de Burgos (M.A.M.), Burgos; Hospital Universitario de Gran Canaria Doctor Negrín (M.D.M.), Las Palmas de Gran Canaria; Hospital Central de Asturias (G.M.), Oviedo; and Service of Neurology (A.L.P.-N., Á.C.-A.), University Hospital "Marqués de Valdecilla (IDIVAL)," University of Cantabria, Santander, Spain
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Tomschik M, Koneczny I, Schötta AM, Scharer S, Smajlhodzic M, Rosenegger PF, Blüthner M, Höftberger R, Zimprich F, Stanek G, Markowicz M. Severe Myasthenic Manifestation of Leptospirosis Associated with New Sequence Type of Leptospira interrogans. Emerg Infect Dis 2019; 25:968-971. [PMID: 31002066 PMCID: PMC6478190 DOI: 10.3201/eid2505.181591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report the rapid development of a myasthenic crisis as the first-time manifestation of myasthenia gravis. The symptoms developed in the course of acute leptospirosis associated with a new sequence type of Leptospira interrogans. Antibiotic treatment led to rapid amelioration of myasthenia.
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Neumann B, Angstwurm K, Mergenthaler P, Kohler S, Schönenberger S, Bösel J, Neumann U, Vidal A, Huttner HB, Gerner ST, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Schimmel E, Fuhrer H, Fahrendorf C, Alberty A, Zinke J, Meisel A, Dohmen C, Stetefeld HR. Myasthenic crisis demanding mechanical ventilation: A multicenter analysis of 250 cases. Neurology 2019; 94:e299-e313. [PMID: 31801833 DOI: 10.1212/wnl.0000000000008688] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/11/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To determine demographic characteristics, clinical features, treatment regimens, and outcome of myasthenic crisis (MC) requiring mechanical ventilation (MV). METHODS Analysis of patients who presented with MC between 2006 and 2015 in a German multicenter retrospective study. RESULTS We identified 250 cases in 12 participating centers. Median age at crisis was 72 years. Median duration of MV was 12 days. Prolonged ventilation (>15 days) depended on age (p = 0.0001), late-onset myasthenia gravis (MG), a high Myasthenia Gravis Foundation of America Class before crisis (p = 0.0001 for IVb, odds ratio [OR] = infinite), number of comorbidities (>3 comorbidities: p = 0.002, OR 2.99), pneumonia (p = 0.0001, OR 3.13), and resuscitation (p = 0.0008, OR 9.15). MV at discharge from hospital was necessary in 20.5% of survivors. Patients with early-onset MG (p = 0.0001, OR 0.21), thymus hyperplasia (p = 0.002, OR 0), and successful noninvasive ventilation trial were more likely to be ventilated for less than 15 days. Noninvasive ventilation in 92 cases was sufficient in 38%, which was accompanied by a significantly shorter duration of ventilation (p = 0.001) and intensive care unit (ICU) stay (p = 0.01). IV immunoglobulins, plasma exchange, and immunoadsorption were more likely to be combined sequentially if the duration of MV and the stay in an ICU extended (p = 0.0503, OR 2.05). Patients who received plasma exchange or immunoadsorption as first-line therapy needed invasive ventilation significantly less often (p = 0.003). In-hospital mortality was 12%, which was significantly associated with the number of comorbidities (>3) and complications such as acute respiratory distress syndrome and resuscitation. Main cause of death was multiorgan failure, mostly due to sepsis. CONCLUSION Mortality and duration of MC remained comparable to previous reports despite higher age and a high disease burden in our study. Prevention and treatment of complications and specialized neurointensive care are the cornerstones in order to improve outcome.
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Affiliation(s)
- Bernhard Neumann
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Klemens Angstwurm
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Philipp Mergenthaler
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Siegfried Kohler
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Silvia Schönenberger
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Julian Bösel
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Ursula Neumann
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Amelie Vidal
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Hagen B Huttner
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Stefan T Gerner
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Andrea Thieme
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Andreas Steinbrecher
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Juliane Dunkel
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Christian Roth
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Hauke Schneider
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Eik Schimmel
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Hannah Fuhrer
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Christine Fahrendorf
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Anke Alberty
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Jan Zinke
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Andreas Meisel
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Christian Dohmen
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany
| | - Henning R Stetefeld
- From the Department of Neurology (B.N., K.A., A.V.), University Medical Center Regensburg; NeuroCure Clinical Research Center (P.M., S.K., A.M.) and Departments of Neurology and Experimental Neurology (P.M., A.M.), Charité-Universitätsmedizin Berlin; Berlin Institute of Health (P.M., S.K., A.M.); Department of Neurology (S.S., J.B.), Heidelberg University Hospital; Department of Neurology (J.B.), Klinikum Kassel; Department of Mathematics and Computer Science (U.N.), Philipps-Universität Marburg; Department of Neurology (H.B.H., S.T.G.), University Hospital Erlangen; Department of Neurology (A.T., A.S.), HELIOS Klinikum Erfurt; Department of Neurology (J.D., C.R.), DRK-Kliniken Nordhessen, Kassel; Department of Neurology (H.S., E.S.), University Hospital, Technische Universität Dresden; Department of Neurology (H.S.), Klinikum Augsburg; Department of Neurology (E.S.), Städtisches Klinikum Dresden; Department of Neurology (H.F.), University of Freiburg; Department of Neurology (C.F.), St. Josef-Hospital, Ruhr-University Bochum; Department of Neurology (A.A.), Kliniken Maria Hilf GmbH Mönchengladbach; Hans Berger Department of Neurology (J.Z.), Jena University Hospital; Department of Neurology (C.D., H.R.S.), University of Cologne; and Department of Neurology (C.D.), LVR-Klinik Bonn, Germany.
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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]
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Barnett C, Herbelin L, Dimachkie MM, Barohn RJ. Measuring Clinical Treatment Response in Myasthenia Gravis. Neurol Clin 2019; 36:339-353. [PMID: 29655453 DOI: 10.1016/j.ncl.2018.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In this article we provide an overview of health-related outcome measurement-to better understand what different outcomes used in myasthenia actually measure-and to provide some guidance when choosing measures based on the clinical context and question. In myasthenia, the most commonly used outcome measures are aimed at assessing the signs and symptoms. In this review, we provide a summary of the most commonly used outcome measures. We discuss instruments that gauge disease overall health impact, such as on disability and quality of life. Finally, we discuss other relevant outcomes such as steroid-sparing effects and the role of surrogate markers.
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Affiliation(s)
- Carolina Barnett
- Neurology (Medicine), University of Toronto, University Health Network, Toronto, Ontario, Canada.
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
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Abstract
Introduction The overall prevalence of myasthenic crisis is quite low at 30/1 million inhabitants because myasthenia gravis is a rare disease per se. But it should be noted that 15–20% of patients with myasthenia gravis experience at least one crisis in their lives. Most often, the crisis occurs within the first 2 years of the disease or is even the first manifestation of a yet undiagnosed myasthenia gravis in up to 20%. Median duration of MC is about 2 weeks (median 12–14 days of ventilation) under sufficient treatment, but prolonged courses are not uncommon and often due to comorbidities and complications, so that about 20% are still mechanically ventilated after 1 month. The lifetime risk of recurrence of a crisis is approx. 30%. Data on mortality differ between about 2–5% to even more than 16%. Lethal outcomes are almost never caused by the crisis itself, but because comorbidities or complications eventually become limiting. Definition Myasthenic crisis (MC) is the life-threatening maximal manifestation of myasthenia gravis (MG) necessitating mechanical ventilation, supportive feeding and (neuro-)intensive care. Weakness may develop within minutes to days and encompass flaccid tetraparesis with immobility, severe dyspnea, respiratory insufficiency and aspiration. Globus events may be life threatening due to rapidly exhausting coughing and swallowing. First steps: immediate measures ● Check and secure vital functions Comments ● not applicable Conclusion The main symptom of (imminent) myasthenic crisis is the rapidly progressive weakness of the respiratory and bulbar muscles, which lead to a decompensation with aspiration and respiratory insufficiency. Clinical examination and clinical history should lead early to the diagnosis of MG with (impending) crisis. The detection of red flags and the dynamic deterioration of symptoms entail admission to the intensive care unit. Due to bulbar symptoms with aspiration and/or respiratory insufficency, early intubation to secure the airway is essential. Therapy includes symptomatic treatment with pyridostigmine or neostigmine and acute causal treatment by immunoadsorption/plasmapheresis or alternatively with immunoglobulins. If used early, intubation may still be prevented and clinical improvement can be achieved within a few days. At the same time, immunosuppression with corticosteroids and azathioprine should be initiated or optimized. For escalation rituximab is an option. The early diagnosis and consequent treatment of infections and other complications such as delirium influence the further course.
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Affiliation(s)
- Henning Stetefeld
- Department of Neurology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Michael Schroeter
- Department of Neurology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Alonso-Pérez J, Segovia S, Domínguez-González C, Olivé M, Mendoza Grimón MD, Fernández-Torrón R, López de Munain A, Muñoz-Blanco JL, Ramos-Fransi A, Almendrote M, Illa I, Díaz-Manera J. Spanish Pompe registry: Baseline characteristics of first 49 patients with adult onset of Pompe disease. Med Clin (Barc) 2019; 154:80-85. [PMID: 31253477 DOI: 10.1016/j.medcli.2019.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Pompe disease is a rare autosomal recessive disorder produced by a deficiency of acid maltase. This deficit produces an accumulation of glycogen in tissues. Clinically it is mainly characterized by limb girdle and respiratory muscle weakness. In 2013, we developed the Spanish Pompe Registry. The objective of this article was to analyse the characteristics of the first 49 patients and disclose the existence of this registry within the medical community. MATERIAL AND METHODS An observational retrospective study was undertaken. We analysed the 49 patients included in the Spanish Registry of Pompe Disease from May 2013 to October 2018. RESULTS Patients were visited at 7 different Spanish hospitals. Twenty-six patients were women and 23 were men. The average age at the time of the analysis was 47.2 years. Ten patients were asymptomatic. The mean age of onset of symptoms was 29, and low limb girdle weakness was the most frequent initial symptom. Of the patients, 49% had respiratory involvement, and 70.8% of them required non-invasive mechanical ventilation. The most common mutation found was IVS1-13T>G in 85.3% of the patients. All symptomatic patients received treatment with ERT. CONCLUSIONS This registry allows us to know the clinical and genetic characteristics of adult patients with Pompe disease in Spain. Moreover, it can be the basis for future studies of natural history to understand the impact of ERT in the course of the disease.
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Affiliation(s)
- Jorge Alonso-Pérez
- Unidad de Patología Neuromuscular, Departamento de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España
| | - Sonia Segovia
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER)
| | - Cristina Domínguez-González
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER); Unidad de Neuromuscular, Servicio de Neurología, Hospital Universitario 12 de Octubre, Instituto de investigación i+12, Madrid, España
| | - Montse Olivé
- Servicio de Anatomía Patológica (Neuropatología) y Unidad de Patología Neuromuscular, Hospital Universitari de Bellvitge, Barcelona, España
| | | | | | | | | | - Alba Ramos-Fransi
- Servicio de Neurología, Hospital Germans Trias i Pujol, Badalona, España
| | - Miriam Almendrote
- Servicio de Neurología, Hospital Germans Trias i Pujol, Badalona, España
| | - Isabel Illa
- Unidad de Patología Neuromuscular, Departamento de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER)
| | - Jordi Díaz-Manera
- Unidad de Patología Neuromuscular, Departamento de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, España; Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER).
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Al-bassam W, Kubicki M, Bailey M, Walker L, Young P, Pilcher DV, Bellomo R. Characteristics, incidence, and outcome of patients admitted to the intensive care unit with myasthenia gravis. J Crit Care 2018; 45:90-94. [DOI: 10.1016/j.jcrc.2018.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/11/2017] [Accepted: 01/03/2018] [Indexed: 01/09/2023]
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Pedersen EG, Hallas J, Pottegård A, Hald SM, Jensen PEH, Gaist D. Oral Immunosuppressive Treatment of Myasthenia Gravis in Denmark: A Nationwide Drug Utilization Study, 1996-2013. Basic Clin Pharmacol Toxicol 2018; 123:486-493. [PMID: 29732733 DOI: 10.1111/bcpt.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022]
Abstract
Although immunosuppressants in the treatment of myasthenia have been available for several decades, population-based studies describing drug utilization in myasthenia patients are scarce. We aimed in this study to describe the treatment of myasthenia in Denmark in more recent years with emphasis on use of oral immunosuppressant agents. We identified a nationwide cohort of incident myasthenia patients in Denmark from 1996 to 2013 and tracked their use of drugs over the entire period using data from nationwide registers. Patients with myasthenia were classified according to utilization of specific immunosuppressants (e.g. prednisolone) as 'never user' or 'ever user'. We used Kaplan-Meier (K-M) and proportion of patients covered (PPC) curves to describe treatment onset and termination. We identified 928 patients (52% female) with incident myasthenia in the study period. Overall, 638 (69%) were treated with prednisolone and 506 (55%) with azathioprine. Treatment with prednisolone and azathioprine within 2 years of myasthenia diagnosis was initiated in 462 (56%) and 366 (45%). Only one of four myasthenia patients (n = 231) did not receive oral immunosuppressive treatment at any time in the study period. Prednisolone was stopped in most patients, whereas treatment with azathioprine was often continued throughout follow-up. In conclusion, we found that treatment of myasthenia in Denmark in recent years corresponded well to the expected clinical course of myasthenia and that most patients underwent long-term immunosuppression.
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Affiliation(s)
- Emil Greve Pedersen
- Department of Neurology, Odense University Hospital & Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark (SDU), Odense, Denmark
| | - Jesper Hallas
- Department of Public Health, Clinical Pharmacology, SDU, Odense, Denmark
| | - Anton Pottegård
- Department of Public Health, Clinical Pharmacology, SDU, Odense, Denmark
| | - Stine Munk Hald
- Department of Neurology, Odense University Hospital & Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark (SDU), Odense, Denmark
| | - Poul Erik Hyldgaard Jensen
- Neuroimmunology Laboratory, DMSC, Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Gaist
- Department of Neurology, Odense University Hospital & Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark (SDU), Odense, Denmark
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Myasthenia Gravis Presentation After a Cervical Laminectomy With Fusion. Dimens Crit Care Nurs 2018; 35:190-4. [PMID: 27258955 DOI: 10.1097/dcc.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Myasthenia gravis is a chronic neuromuscular disorder that causes skeletal muscle weakness. Typically, myasthenia gravis affects the ocular, bulbar, neck, proximal limbs, and respiratory muscles. Although the presentation is typically observed with complaints of vision and bulbar symptoms such as diplopia, dystonia, and dysphagia, this article presents a case study of an elderly man with a history of increasing upper extremity weakness with complaints of worsening hand dexterity and intermittent episodes of expressive aphasia. After cervical laminectomy with fusion, this gentleman was admitted to the medical intensive care unit, in a complete myasthenic crisis.
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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]
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Efficacy and Safety of the TCM Qi-Supplementing Therapy in Patients with Myasthenia Gravis: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2017:6512572. [PMID: 29333187 PMCID: PMC5733197 DOI: 10.1155/2017/6512572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 07/27/2017] [Indexed: 11/22/2022]
Abstract
Background The Traditional Chinese Medicine (TCM) Qi-supplementing therapy has been used widely for treating myasthenia gravis (MG) in China. The purpose of this meta-analysis was to evaluate the efficacy and safety of Qi-supplementing therapy as an adjunctive therapy in MG patients. Methods Seven electronic databases were searched through June 2016. Randomized controlled trials (RCTs) evaluating the add-on effect of Qi-supplementing therapy in MG patients were included. The outcome measures were the total effective rate, relapse rate, and adverse events. Results Twenty-three RCTs involving 1,691 MG patients were included. The included studies were of low-to-moderate quality. Meta-analysis showed that Qi-supplementing therapy combined with Western medicine (WM) significantly improved the total response rate and reduced the relapse risk during 6–24 months of follow-up. Subgroup analysis showed that Qi-supplementing therapy only affected the total response rate within the first 6 months of treatment. Moreover, the rate of adverse events was lower with the addition of Qi-supplementing therapy to WM than with WM only. Conclusions Short-term Qi-supplementing therapy combined with WM appears to be superior to WM for improving the total response rate and reducing the relapse rate. However, more high-quality RCTs are warranted owing to methodological flaws of previous trials.
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Outcomes after major surgery in patients with myasthenia gravis: A nationwide matched cohort study. PLoS One 2017; 12:e0180433. [PMID: 28666024 PMCID: PMC5493398 DOI: 10.1371/journal.pone.0180433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/24/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To validate the comprehensive features of adverse outcomes after surgery for patients with myasthenia gravis. Methods Using reimbursement claims from Taiwan’s National Health Insurance Research Database, we analyzed 2290 patients who received major surgery between 2004 and 2010 and were diagnosed with myasthenia gravis preoperatively. Surgical patients without myasthenia gravis (n = 22,900) were randomly selected by matching procedure with propensity score for comparison. The adjusted odds ratios and 95% confidence intervals of postoperative adverse events associated with preoperative myasthenia gravis were calculated under the multiple logistic regressions. Results Compared with surgical patients without myasthenia gravis, surgical patients with myasthenia gravis had higher risks of postoperative pneumonia (OR = 2.09; 95% CI: 1.65–2.65), septicemia (OR = 1.31; 95% CI: 1.05–1.64), postoperative bleeding (OR = 1.71; 95% CI: 1.07–2.72), and overall complications (OR = 1.70; 95% CI: 1.44–2.00). The ORs of postoperative adverse events for patients with myasthenia gravis who had symptomatic therapy, chronic immunotherapy, and short-term immunotherapy were 1.76 (95% CI 1.50–2.08), 1.70 (95% CI 1.36–2.11), and 4.36 (95% CI 2.11–9.04), respectively. Conclusions Patients with myasthenia gravis had increased risks of postoperative adverse events, particularly those experiencing emergency care, hospitalization, and thymectomy for care of myasthenia gravis. Our findings suggest the urgency of revising protocols for perioperative care for these populations.
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Su Z, Wang B, Ni J, Hu Y, Weng Y, Zhang X. Comment on 'Myasthenia gravis: descriptive analysis of life-threatening events in a recent nationwide registry'. Eur J Neurol 2017; 24:e17. [PMID: 28211243 DOI: 10.1111/ene.13248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 01/04/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Z Su
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang
| | - B Wang
- Shanghai Children's Hospital, Shanghai JiaoTong University, Shanghai
| | - J Ni
- Department of Pathology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang
| | - Y Hu
- Department of Infection and Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Y Weng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang
| | - X Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang
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Affiliation(s)
- A H V Schapira
- Clinical Neurosciences, UCL Institute of Neurology, London, UK
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48
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Raggi A, Leonardi M, Schiavolin S, Antozzi C, Brenna G, Maggi L, Mantegazza R. Validation of the MG-DIS: a disability assessment for myasthenia gravis. J Neurol 2016; 263:871-882. [DOI: 10.1007/s00415-016-8072-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 01/22/2023]
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