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Li Y, Yang S, Dong X, Duan W, Jiang F, Chen K, Zhou Q, Cai H, Yang H. Diagnostic value of antibody concentration ratio for treatment-refractory myasthenia gravis. Neurol Sci 2024; 45:5033-5041. [PMID: 38780854 DOI: 10.1007/s10072-024-07601-w] [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: 02/29/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE This study aimed to assess the diagnostic potential of the Antibody concentration ratio in identifying treatment-refractory myasthenia gravis (MG). METHODS A retrospective analysis was conducted on 116 MG patients who underwent antibody detection at least twice between June 1, 2015, and June 1, 2023. Demographic and clinical characteristics were collated to ascertain their association with refractory MG. The Antibody Concentration Ratio was applied to determine treatment response, using the International Consensus Guidance criteria as the reference standard. The area under nonparametric receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy were calculated to assess the diagnostic efficacy of the Antibody concentration ratio following consecutive immunotherapy relative to initial antibody concentrations for refractory MG. RESULTS 19 out of 116 patients were unequivocally diagnosed with refractory MG. A significant correlation was found between the Antibody Concentration Ratio and refractory MG status in treatment-refractory and treatment-responsive patients. Subsequently, the AUC demonstrated the robust diagnostic capability of the Antibody concentration ratio for refractory MG, with an AUC of 0.8709 (95% CI: 0.7995-0.9422, p < 0.0001). The optimal cut-off value stood at 0.8903, exhibiting a sensitivity of 94.74% (95% CI: 75.36%-99.73%), a specificity of 68.04% (95% CI: 58.23%-76.48%), and accuracy of 72.41% (95% CI: 64.28%-80.54%). CONCLUSION Elevated Antibody Concentration Ratio is intrinsically linked with refractory MG and exhibits potential as an diagnostic biomarker for the condition.
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Affiliation(s)
- Yi Li
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Shumei Yang
- Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Xiaohua Dong
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Weiwei Duan
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Fei Jiang
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Kangzhi Chen
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Qian Zhou
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Haobin Cai
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China
| | - Huan Yang
- Department of Neurology, Research Center for Neuroimmune and Neuromuscular disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410000, Hunan, China.
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2
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Schroeter CB, Nelke C, Stascheit F, Huntemann N, Preusse C, Dobelmann V, Theissen L, Pawlitzki M, Räuber S, Willison A, Vogelsang A, Marina AD, Hartung HP, Melzer N, Konen FF, Skripuletz T, Hentschel A, König S, Schweizer M, Stühler K, Poschmann G, Roos A, Stenzel W, Meisel A, Meuth SG, Ruck T. Inter-alpha-trypsin inhibitor heavy chain H3 is a potential biomarker for disease activity in myasthenia gravis. Acta Neuropathol 2024; 147:102. [PMID: 38888758 PMCID: PMC11195637 DOI: 10.1007/s00401-024-02754-6] [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: 02/15/2024] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
Myasthenia gravis is a chronic antibody-mediated autoimmune disease disrupting neuromuscular synaptic transmission. Informative biomarkers remain an unmet need to stratify patients with active disease requiring intensified monitoring and therapy; their identification is the primary objective of this study. We applied mass spectrometry-based proteomic serum profiling for biomarker discovery. We studied an exploration and a prospective validation cohort consisting of 114 and 140 anti-acetylcholine receptor antibody (AChR-Ab)-positive myasthenia gravis patients, respectively. For downstream analysis, we applied a machine learning approach. Protein expression levels were confirmed by ELISA and compared to other myasthenic cohorts, in addition to myositis and neuropathy patients. Anti-AChR-Ab levels were determined by a radio receptor assay. Immunohistochemistry and immunofluorescence of intercostal muscle biopsies were employed for validation in addition to interactome studies of inter-alpha-trypsin inhibitor heavy chain H3 (ITIH3). Machine learning identified ITIH3 as potential serum biomarker reflective of disease activity. Serum levels correlated with disease activity scores in the exploration and validation cohort and were confirmed by ELISA. Lack of correlation between anti-AChR-Ab levels and clinical scores underlined the need for biomarkers. In a subgroup analysis, ITIH3 was indicative of treatment responses. Immunostaining of muscle specimens from these patients demonstrated ITIH3 localization at the neuromuscular endplates in myasthenia gravis but not in controls, thus providing a structural equivalent for our serological findings. Immunoprecipitation of ITIH3 and subsequent proteomics lead to identification of its interaction partners playing crucial roles in neuromuscular transmission. This study provides data on ITIH3 as a potential pathophysiological-relevant biomarker of disease activity in myasthenia gravis. Future studies are required to facilitate translation into clinical practice.
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Affiliation(s)
- Christina B Schroeter
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christopher Nelke
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Niklas Huntemann
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Corinna Preusse
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Vera Dobelmann
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Lukas Theissen
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Saskia Räuber
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alice Willison
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Anna Vogelsang
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Adela Della Marina
- Department of Neuropaediatrics, Neuromuscular Centre, Universitätsmedizin Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, 94 Mallett St, Sydney, Australia
- Department of Neurology, Palacky University Olomouc, Nová Ulice, 779 00, Olomouc, Czech Republic
| | - Nico Melzer
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Felix F Konen
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Andreas Hentschel
- Leibniz-Institut Für Analytische Wissenschaften - ISAS - E.V, 44227, Dortmund, Germany
| | - Simone König
- Core Unit Proteomics, Interdisciplinary Center for Clinical Research, Medical Faculty, University of Münster, 48149, Münster, Germany
| | - Michaela Schweizer
- Electron Microscopy Unit, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, 20251, Hamburg, Germany
| | - Kai Stühler
- Institute for Molecular Medicine, Proteome Research, University Hospital and Medical Faculty, Heinrich Heine University, 40225, Duesseldorf, Germany
- Molecular Proteomics Laboratory, Biological Medical Research Center, Heinrich Heine University, Universitätsstr 1, 40225, Duesseldorf, Germany
| | - Gereon Poschmann
- Institute for Molecular Medicine, Proteome Research, University Hospital and Medical Faculty, Heinrich Heine University, 40225, Duesseldorf, Germany
| | - Andreas Roos
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
- Department of Neuropaediatrics, Neuromuscular Centre, Universitätsmedizin Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité - Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.
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3
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Sun C, Ruan Z, Zhang Y, Guo R, Li H, Wang T, Gao T, Tang Y, Song N, Hao S, Huang X, Li S, Ning F, Su Y, Lu Q, Wang Q, Cao X, Li Z, Chang T. High indirect bilirubin levels as an independent predictor of postoperative myasthenic crisis: a single-center, retrospective study. Front Neurol 2024; 14:1336823. [PMID: 38283685 PMCID: PMC10811789 DOI: 10.3389/fneur.2023.1336823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Background Thymectomy is an efficient and standard treatment strategy for patients with myasthenia gravis (MG), postoperative myasthenic crisis (POMC) is the major complication related to thymectomy and has a strongly life-threatening effect. As a biomarker, whether the bilirubin level is a risk factor for MG progression remains unclear. This study aimed to investigate the association between the preoperative bilirubin level and postoperative myasthenic crisis (POMC). Methods We analyzed 375 patients with MG who underwent thymectomy at Tangdu Hospital between January 2012 and September 2021. The primary outcome measurement was POMC. The association between POMC and bilirubin level was analyzed by restricted cubic spline (RCS). Indirect bilirubin (IBIL) was divided into two subgroups based on the normal upper limit of IBIL, 14 μmol/L. Results Compared with non-POMC group, IBIL levels were significantly higher in patients with POMC. Elevated IBIL levels were closely associated with an increased risk of POMC (p for trend = 0.002). There was a dose-response curve relationship between IBIL levels and POMC incidence (p for non-linearity = 0.93). However, DBIL levels showed a U-shaped association with POMC incidence. High IBIL level (≥14 μmol/L) was an independent predictive factor for POMC [odds ratio = 3.47, 95% confidence interval (CI): 1.56-7.8, p = 0.002]. The addition of high IBIL levels improved the prediction model performance (net reclassification index = 0.186, 95% CI: 0.039-0.334; integrated discrimination improvement = 0.0345, 95% CI: 0.005-0.065). Conclusion High preoperative IBIL levels, especially those exceeding the normal upper limit, could independently predict the incidence of POMC.
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Affiliation(s)
- Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yu Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Huanhuan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Tantan Wang
- School of Pharmaceutical Sciences, Peking-Tsinghua Center for Life Sciences, Key Laboratory of Bioorganic Phosphorus Chemistry & Chemical Biology (Ministry of Education), Tsinghua University, Beijing, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Na Song
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Sijia Hao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoxi Huang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shuang Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Fan Ning
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yue Su
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qingqing Wang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiangqi Cao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
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4
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Diogenes L, Dellavance A, Baldo DC, Gozzi-Silva SC, Gomes K, Prado MS, Andrade LEC, Keppeke GD. Detection of Autoantibodies Against the Acetylcholine Receptor, Evaluation of Commercially Available Methodologies: Fixed Cell-Based Assay, Radioimmunoprecipitation Assay and Enzyme-Linked Immunosorbent Assay1. J Neuromuscul Dis 2024; 11:613-623. [PMID: 38578899 DOI: 10.3233/jnd-230210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Background/Objective Myasthenia Gravis (MG) is an autoimmune disorder characterized by pathogenic autoantibodies (AAbs) targeting nicotinic acetylcholine receptors (AChR), disrupting neuromuscular communication. RadioImmunoPrecipitation Assay (RIPA) is recommended to detect AChR AAbs, but its complexity and radioactive requirements limit widespread use. We compare non-RIPA anti-AChR immunoassays, including Cell-Based Assay (CBA) and two ELISA kits, against the gold standard RIPA. Methods/Results 145 samples were included with medical indication for anti-AChR testing. By the RIPA method, 63 were negative (RIPA-Neg < 0.02 nmol/L), 18 were classified as Borderline (≥0.02 -1 nmol/L), and 64 were positive (RIPA-Pos > 1 nmol/L). The competitive ELISA showed poor agreement with RIPA (Kappa = 0.216). The indirect ELISA demonstrated substantial agreement with RIPA (Kappa = 0.652), with ∼76% sensitivity and ∼94% specificity for MG diagnostic. The CBA, where fixed cells expressing clustered AChR were used as substrate, exhibited almost perfect agreement with RIPA (Kappa = 0.984), yielding ∼98% sensitivity and 96% specificity for MG. In addition, a semiquantitative analysis showed a strong correlation between CBA titration, indirect ELISA, and RIPA levels (r = 0.793 and r = 0.789, respectively). Conclusions The CBA displayed excellent analytical performance for MG diagnostic when compared to RIPA, making it a potential replacement for RIPA in clinical laboratories. Some solid-phase assays (such as the indirect ELISA applied here), as well as CBA titration, offer reliable options to estimate anti-AChR AAb levels after confirming positivity by the CBA.∥.
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Affiliation(s)
- Larissa Diogenes
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo, Brasil
| | - Alessandra Dellavance
- Divisão de Imunologia, Departamento de Pesquisa e Desenvolvimento, Laboratório Fleury, São Paulo, Brasil
| | - Danielle Cristiane Baldo
- Divisão de Imunologia, Departamento de Pesquisa e Desenvolvimento, Laboratório Fleury, São Paulo, Brasil
| | - Sarah Cristina Gozzi-Silva
- Divisão de Imunologia, Departamento de Pesquisa e Desenvolvimento, Laboratório Fleury, São Paulo, Brasil
| | - Kethellen Gomes
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo, Brasil
| | - Monica Simon Prado
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo, Brasil
| | - Luis Eduardo C Andrade
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo, Brasil
- Divisão de Imunologia, Departamento de Pesquisa e Desenvolvimento, Laboratório Fleury, São Paulo, Brasil
| | - Gerson Dierley Keppeke
- Disciplina de Reumatologia, Departamento de Medicina, Universidade Federal de São Paulo, Brasil
- Departamento de Ciencias Biom dicas, Facultad de Medicina, Universidad Católica del Norte, Coquimbo, Chile
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5
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Oeztuerk M, Henes A, Schroeter CB, Nelke C, Quint P, Theissen L, Meuth SG, Ruck T. Current Biomarker Strategies in Autoimmune Neuromuscular Diseases. Cells 2023; 12:2456. [PMID: 37887300 PMCID: PMC10605022 DOI: 10.3390/cells12202456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Inflammatory neuromuscular disorders encompass a diverse group of immune-mediated diseases with varying clinical manifestations and treatment responses. The identification of specific biomarkers has the potential to provide valuable insights into disease pathogenesis, aid in accurate diagnosis, predict disease course, and monitor treatment efficacy. However, the rarity and heterogeneity of these disorders pose significant challenges in the identification and implementation of reliable biomarkers. Here, we aim to provide a comprehensive review of biomarkers currently established in Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), myasthenia gravis (MG), and idiopathic inflammatory myopathy (IIM). It highlights the existing biomarkers in these disorders, including diagnostic, prognostic, predictive and monitoring biomarkers, while emphasizing the unmet need for additional specific biomarkers. The limitations and challenges associated with the current biomarkers are discussed, and the potential implications for disease management and personalized treatment strategies are explored. Collectively, biomarkers have the potential to improve the management of inflammatory neuromuscular disorders. However, novel strategies and further research are needed to establish clinically meaningful biomarkers.
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Affiliation(s)
| | | | | | | | | | | | | | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany; (M.O.); (A.H.); (P.Q.)
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6
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Rath J, Moser B, Zimprich F. Thymectomy in myasthenia gravis. Curr Opin Neurol 2023; 36:416-423. [PMID: 37639450 DOI: 10.1097/wco.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Thymectomy has long been used in the treatment of patients with myasthenia gravis and antibodies against the acetylcholine receptor. However, its effectiveness has only been proven a few years ago in a randomized controlled trial in patients under the age of 65. Here, we review the current literature focusing on patient subgroups, potential biomarkers for outcome prediction and the choice of surgical approach. RECENT FINDINGS Long-term follow-up studies after thymectomy confirmed that the benefits regarding clinical outcome parameters and a reduced need for immunosuppressive treatment persist. Nevertheless, a substantial proportion of patients in real-world cohorts do not reach complete stable remission after thymectomy indicating that the underlying autoimmune process is sustained in the periphery. Our understanding of the responsible mechanisms has improved with recent studies. Presently, outcome data after thymectomy in several patient subgroups, such as those aged over 50 years, those with juvenile onset or those with purely ocular symptoms are limited and have been the focus of recent research activities. Similarly, biomarkers guiding an appropriate patient selection for thymectomy are under investigation. A number of cohort studies demonstrated that minimal invasive surgical techniques such as extended robotic thymectomy lead to similar positive outcomes as a transsternal approach with potentially fewer short-term adverse effects. SUMMARY Thymectomy is an effective treatment option in adult patients with early onset acetylcholine-receptor positive myasthenia gravis but uncertainty remains with regard to certain patient subgroups.
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Affiliation(s)
| | - Bernhard Moser
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
- ESTS Thymic Working Group
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7
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Zhong H, Ruan Z, Yan C, Lv Z, Zheng X, Goh LY, Xi J, Song J, Luo L, Chu L, Tan S, Zhang C, Bu B, Da Y, Duan R, Yang H, Luo S, Chang T, Zhao C. Short-term outcome prediction for myasthenia gravis: an explainable machine learning model. Ther Adv Neurol Disord 2023; 16:17562864231154976. [PMID: 36860354 PMCID: PMC9969443 DOI: 10.1177/17562864231154976] [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: 05/17/2022] [Accepted: 01/15/2023] [Indexed: 02/26/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and fatigability. The fluctuating nature of the disease course impedes the clinical management. Objective The purpose of the study was to establish and validate a machine learning (ML)-based model for predicting the short-term clinical outcome in MG patients with different antibody types. Methods We studied 890 MG patients who had regular follow-ups at 11 tertiary centers in China from 1 January 2015 to 31 July 2021 (653 patients for derivation and 237 for validation). The short-term outcome was the modified post-intervention status (PIS) at a 6-month visit. A two-step variable screening was used to determine the factors for model construction and 14 ML algorithms were used for model optimisation. Results The derivation cohort included 653 patients from Huashan hospital [age 44.24 (17.22) years, female 57.6%, generalized MG 73.5%], and the validation cohort included 237 patients from 10 independent centers [age 44.24 (17.22) years, female 55.0%, generalized MG 81.2%]. The ML model identified patients who were improved with an area under the receiver operating characteristic curve (AUC) of 0.91 [0.89-0.93], 'Unchanged' 0.89 [0.87-0.91], and 'Worse' 0.89 [0.85-0.92] in the derivation cohort, whereas identified patients who were improved with an AUC of 0.84 [0.79-0.89], 'Unchanged' 0.74 [0.67-0.82], and 'Worse' 0.79 [0.70-0.88] in the validation cohort. Both datasets presented a good calibration ability by fitting the expectation slopes. The model is finally explained by 25 simple predictors and transferred to a feasible web tool for an initial assessment. Conclusion The explainable, ML-based predictive model can aid in forecasting the short-term outcome for MG with good accuracy in clinical practice.
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Affiliation(s)
| | | | | | - Zhiguo Lv
- Department of Neurology, The Affiliated
Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Xueying Zheng
- Department of Biostatistics, School of Public
Health and Key Laboratory of Public Health Safety, Fudan University,
Shanghai, China
| | - Li-Ying Goh
- Shanghai Medical College, Fudan University,
Shanghai, China
| | - Jianying Xi
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Jie Song
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital,
Wuhan, China
| | - Lan Chu
- Department of Neurology, The Affiliated
Hospital of Guizhou Medical University, Guiyang, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial
People’s Hospital, University of Electronic Science and Technology of China,
Chengdu, China
| | - Chao Zhang
- Department of Neurology and Tianjin
Neurological Institute, Tianjin Medical University General Hospital,
Tianjin, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital,
Capital Medical University, Beijing, China
| | - Ruisheng Duan
- Department of Neurology, The First Affiliated
Hospital of Shandong First Medical University, Jinan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital,
Central South University, Changsha, China
| | | | - Ting Chang
- Department of Neurology, Tangdu Hospital, The
Air Force Medical University, Xi’an 710000, China
| | - Chongbo Zhao
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China,National Center for Neurological Disorders,
Shanghai, China
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8
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Spagni G, Gastaldi M, Businaro P, Chemkhi Z, Carrozza C, Mascagna G, Falso S, Scaranzin S, Franciotta D, Evoli A, Damato V. Comparison of Fixed and Live Cell-Based Assay for the Detection of AChR and MuSK Antibodies in Myasthenia Gravis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/1/e200038. [PMID: 36270951 PMCID: PMC9621337 DOI: 10.1212/nxi.0000000000200038] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Live cell-based assay (CBA) can detect acetylcholine receptors (AChRs) or muscle-specific tyrosine kinase (MuSK) antibodies (Abs) in a proportion of patients with radioimmunoassay (RIA)-double seronegative myasthenia gravis (dSN-MG). A commercial fixed CBA for AChR and MuSK Abs has recently become available; however, comparative studies on fixed and live CBAs are lacking. In this study, we compared the performance of fixed and live CBAs in patients with RIA-dSN MG and assessed their sensitivity in RIA-positive MG samples and their specificity. METHODS AChR and MuSK Abs were tested in 292 serum samples from 2 Italian MG referral centers by live and fixed CBAs: 192 from patients with MG and 100 from controls. All samples had been previously assessed by RIA: 66 were AChR positive, 40 MuSK positive, and 86 dSN. All controls were negative. Two independent raters assessed the CBA results. Fixed and live CBAs were compared with the McNemar test; interrater and interlaboratory agreement were assessed with Cohen's kappa or interclass correlation coefficient (ICC), as appropriate. RESULTS In 86 RIA-dSN samples, fixed CBA detected Abs in 10 cases (11.6%, 95% CI 5.7-20.3), whereas live CBA detected Abs in 16 (18.6%, 95% CI 11.0-28.5) (p = 0.0143). Of these sera, those positive by fixed CBA were also positive by live CBA. In addition, live CBA could detect MuSK Abs in 4 and AChR Abs in 2 samples that were negative by fixed CBA, providing an 8% (95% CI 2.9-16.6) further increase in the Ab detection rate. These results were confirmed by flow cytometry. In the RIA-positive cohort, the sensitivity for AChR Abs was 98.5% (95% CI 91.9%-99.9%) for fixed CBA and 100% (95% CI 94.6-100) for live CBA (p = 0.1573). For both assays, the sensitivity for MuSK Abs was 100% (95% CI 91.2-100), and the specificity was 100% (95% CI 96.4-100). Interrater agreement was almost perfect for live and fixed CBAs (Cohen's kappa 0.972 and 0.978, respectively), alike interlaboratory agreement. Interrater agreement for the CBA score ranged from good to excellent (ICC: 0.832-0.973). DISCUSSION Fixed CBA represents a valuable alternative to RIA for AChR and MuSK Ab detection in patients with MG and could be considered as a first-step diagnostic test. Live CBA can be useful in the serologic evaluation of RIA- and fixed CBA-negative samples.
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Affiliation(s)
- Gregorio Spagni
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Matteo Gastaldi
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Pietro Businaro
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Zeineb Chemkhi
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Cinzia Carrozza
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Giovanni Mascagna
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Silvia Falso
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Silvia Scaranzin
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Diego Franciotta
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
| | - Amelia Evoli
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy.
| | - Valentina Damato
- From the Department of Neuroscience (G.S., Z.C., S.F., A.E., V.D.), Università Cattolica del Sacro Cuore; Fondazione Policlinico Universitario "A. Gemelli" IRCCS (G.S., A.E.), Rome; Neuroimmunology Laboratory (M.G., P.B., S.S.), IRCCS Mondino Foundation; Department of Brain and Behavioral Sciences (P.B.), University of Pavia, Italy; Chemistry, Biochemistry and Clinical Molecular Biology Unit (C.C., G.M.), Fondazione Policlinico "Gemelli," IRCCS, Rome; Autoimmunology Laboratory (D.F.), IRCCS Ospedale Policlinico San Martino, Genoa; and Department of Neurosciences, Drugs and Child Health (V.D.), University of Florence, Italy
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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10
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Kaminski HJ, Denk J. Corticosteroid Treatment-Resistance in Myasthenia Gravis. Front Neurol 2022; 13:886625. [PMID: 35547366 PMCID: PMC9083070 DOI: 10.3389/fneur.2022.886625] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/21/2022] [Indexed: 12/25/2022] Open
Abstract
Chronic, high-dose, oral prednisone has been the mainstay of myasthenia gravis treatment for decades and has proven to be highly beneficial in many, toxic in some way to all, and not effective in a significant minority. No patient characteristics or biomarkers are predictive of treatment response leading to many patients suffering adverse effects with no benefit. Presently, measurements of treatment response, whether taken from clinician or patient perspective, are appreciated to be limited by lack of good correlation, which then complicates correlation to biological measures. Treatment response may be limited because disease mechanisms are not influenced by corticosteroids, limits on dosage because of adverse effects, or individual differences in corticosteroids. This review evaluates potential mechanisms that underlie lack of response to glucocorticoids in patients with myasthenia gravis.
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Affiliation(s)
- Henry J Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
| | - Jordan Denk
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
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11
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THE ROLE OF ANTIBODIES TO ACETYLCHOLINE, MUSCLE-SPECIFIC KINASE, TITIN AND SOX1 RECEPTORS IN PREDICTING SEVERE MYASTHENIA GRAVIS. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-2-80-74-78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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12
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Vincent A. Using AChR antibody titres to predict treatment responses in myasthenia gravis. J Neurol Neurosurg Psychiatry 2021; 92:915. [PMID: 33963052 DOI: 10.1136/jnnp-2021-326480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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13
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Circulating Biomarkers in Neuromuscular Disorders: What Is Known, What Is New. Biomolecules 2021; 11:biom11081246. [PMID: 34439911 PMCID: PMC8393752 DOI: 10.3390/biom11081246] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 02/07/2023] Open
Abstract
The urgent need for new therapies for some devastating neuromuscular diseases (NMDs), such as Duchenne muscular dystrophy or amyotrophic lateral sclerosis, has led to an intense search for new potential biomarkers. Biomarkers can be classified based on their clinical value into different categories: diagnostic biomarkers confirm the presence of a specific disease, prognostic biomarkers provide information about disease course, and therapeutic biomarkers are designed to predict or measure treatment response. Circulating biomarkers, as opposed to instrumental/invasive ones (e.g., muscle MRI or nerve ultrasound, muscle or nerve biopsy), are generally easier to access and less “time-consuming”. In addition to well-known creatine kinase, other promising molecules seem to be candidate biomarkers to improve the diagnosis, prognosis and prediction of therapeutic response, such as antibodies, neurofilaments, and microRNAs. However, there are some criticalities that can complicate their application: variability during the day, stability, and reliable performance metrics (e.g., accuracy, precision and reproducibility) across laboratories. In the present review, we discuss the application of biochemical biomarkers (both validated and emerging) in the most common NMDs with a focus on their diagnostic, prognostic/predictive and therapeutic application, and finally, we address the critical issues in the introduction of new biomarkers.
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14
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Lee I, Sanders D. Rethinking the utility of acetylcholine receptor antibody titer as a pharmacodynamic biomarker for myasthenia gravis. Muscle Nerve 2021; 64:385-387. [PMID: 34287983 DOI: 10.1002/mus.27381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/09/2021] [Accepted: 07/18/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Ikjae Lee
- The Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Donald Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
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