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Morganroth J, Zuroff L, Guidon AC, Liu GT, Bird SJ, Singhal S, Wolfe GI, Hamedani AG. Trends and Disparities in the Utilization of Thymectomy for Myasthenia Gravis in the United States. Neurol Clin Pract 2024; 14:e200335. [PMID: 38919930 PMCID: PMC11194790 DOI: 10.1212/cpj.0000000000200335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Abstract
Background and Objectives In 2016, a randomized controlled trial demonstrated the clinical efficacy of trans-sternal thymectomy for patients with non-thymomatous myasthenia gravis (MG). Whether large-scale changes occurred in clinical practice after this trial is unknown. Methods We performed a retrospective longitudinal cross-sectional analysis using National Inpatient Sample (NIS) data from 2012 to 2019. Our study included hospitalized adults at least 18 years of age diagnosed with MG without an associated thymoma. We used joinpoint regression to analyze annual trends in thymectomy volume and surgical approach (minimally invasive vs trans-sternal) from 2012 to 2019. Using logistic regression models, we examined patient and hospital-level factors that may have influenced whether thymectomy was performed, such as age, sex, race, insurance payor, hospital size and teaching status, and Elixhauser Comorbidity Index. Sampling weights were applied to account for the complex survey design of NIS. Results The total number of thymectomy procedures increased by 69.8% per year (95% CI 40.1-105.8) between 2012 and 2019. Trans-sternal thymectomies increased by 62.8% per year (95% CI 35.8-95.2) and minimally invasive thymectomies by 83.7% per year (95% CI 38.1-144.3). Thymectomies were significantly more likely to occur in 2017-2019 compared with 2012-2016 (OR 1.93, 95% CI 1.62-2.31). In a multivariable regression model, several factors decreased the odds of patients with MG having a thymectomy: older age, Black race (OR 0.62, 95% CI 0.49-0.77), female (OR 0.73, 95% CI 0.63-0.86), and higher Elixhauser Comorbidity Index. Patients in medium (OR 1.82, 95% CI 1.30-2.55) or large (OR 2.81, 95% CI 2.07-3.82) size and urban teaching hospitals (OR 6.09, 95% CI 2.65-13.97) were more likely to undergo thymectomy. Discussion Thymectomy is being performed more frequently for non-thymomatous MG, especially after 2016 after publication of a positive phase III clinical trial. There are several disparities in thymectomy utilization that warrant further attention.
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Affiliation(s)
- Jennifer Morganroth
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Leah Zuroff
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amanda C Guidon
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Grant T Liu
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shawn J Bird
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sunil Singhal
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gil I Wolfe
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ali G Hamedani
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Chan F, Hardy TA, Malik S, Ramanathan S, Riminton DS, Reddel SW. Induction cyclophosphamide with maintenance immunosuppression in high-risk myasthenia gravis: long-term follow-up and safety profile. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333189. [PMID: 38964847 DOI: 10.1136/jnnp-2023-333189] [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: 12/11/2023] [Accepted: 04/10/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Patients with refractory or high-risk myasthenia gravis (MG) respond poorly to conventional immunosuppressive therapy, requiring rescue therapies and often experiencing treatment toxicity. Rescue and injectable therapies do not induce remission and require repetitive administration leading to significant constraints on patients and the healthcare system. This long-term follow-up study demonstrates cyclophosphamide as a rapidly effective and safe treatment in patients with refractory or high-risk MG. METHODS Retrospective cohort study of MG patients treated with cyclophosphamide between January 2000 and June 2022 conducted at a quaternary neuroimmunology clinic in New South Wales, Australia. RESULTS 31 patients were treated: mean age of 64 years; median follow-up 3.6 years (5 months to 11 years); 94% seropositive to acetylcholine receptor (AChR) antibodies and 45% had thymoma. A reduced intensity cyclophosphamide induction protocol followed by oral antiproliferative maintenance is described.Median myasthenia gravis composite scores reduced by >50% after the third cycle of cyclophosphamide. Complete cessation of prednisolone was possible in 11 patients while 20 remained on prednisolone with a median daily dose of 5 mg. Plasma exchange was ceased in 62% of patients and intravenous immunoglobulin ceased in 55%. Cyclophosphamide was generally well tolerated with mild cytopenias. There were no malignancies or cases of haemorrhagic cystitis. CONCLUSION We describe a large cohort of high-risk MG patients treated with cyclophosphamide in a retrospective single-clinic cohort. We suggest cyclophosphamide should be considered for rapid remission induction, corticosteroid reduction and long-term freedom from recurrent injectable therapies in selected patients, typically those with AChR antibodies.
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Affiliation(s)
- Fiona Chan
- Queen Elizabeth Hospital, Birmingham, UK
| | - Todd A Hardy
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
| | - Sameer Malik
- Department of Immunology, Concord Hospital, Concord, New South Wales, Australia
| | - Sudarshini Ramanathan
- Department of Neurology, Concord Hospital, Concord, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - D Sean Riminton
- Department of Immunology, Concord Hospital, Concord, New South Wales, Australia
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Saccà F, Salort‐Campana E, Jacob S, Cortés‐Vicente E, Schneider‐Gold C. Refocusing generalized myasthenia gravis: Patient burden, disease profiles, and the role of evolving therapy. Eur J Neurol 2024; 31:e16180. [PMID: 38117543 PMCID: PMC11236062 DOI: 10.1111/ene.16180] [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: 02/10/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) continues to present significant challenges for clinical management due to an unpredictable disease course, frequent disease fluctuations, and varying response to therapy. The recent availability of new pharmacologic therapies presents a valuable opportunity to reevaluate how this disease is classified, assessed, and managed and identify new ways to improve the clinical care of patients with gMG. METHODS Narrative review was made of publications identified via searches of PubMed and selected congresses (January 2000-September 2022). RESULTS New consensus definitions are required to ensure consistency, to better characterize patients, and to identify patients who will benefit from specific drugs and earlier use of these agents. There is a need for more frequent, standardized patient assessment to identify the cause of motor function deficits, provide a clearer picture of the disease burden and its impact on daily living and quality of life (QoL), and better support treatment decision-making. Novel approaches that target different components of the immune system will play a role in more precise treatment of patients with gMG, alongside the development of new algorithms to guide individualized patient management. CONCLUSIONS gMG has a physical, mental, and social impact, resulting in a considerable burden of disease and substantially decreased QoL, despite standard treatments. The availability of novel, targeted treatments that influence key pathological mediators of gMG, together with new biomarkers, offers the potential to optimize patient management and ultimately enables a greater number of patients to achieve minimal manifestation status and a reduced burden of disease.
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Affiliation(s)
- Francesco Saccà
- Department of Neuroscience, Reproductive Science and OdontostomatologyFederico II UniversityNaplesItaly
| | - Emmanuelle Salort‐Campana
- Reference Center of Neuromuscular Disorders and ALS, Timone University HospitalAssistance Publique–Hopitaux de MarseilleMarseilleFrance
| | - Saiju Jacob
- Institute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUK
| | - Elena Cortés‐Vicente
- Neuromuscular Diseases Unit, Department of NeurologyHospital de la Santa Creu i Sant Pau and Biomedical Research Institute Sant PauBarcelonaSpain
- Centro de Investigación Biomédica en Red de Enfermedades RarasInstituto de Salud Carlos IIIMadridSpain
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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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Sun C, Ren Z, Miao X, Zheng Y, Zhang J, Qi X, Liu J, Qiu F. Clinical characteristics of late-onset myasthenia gravis. Heliyon 2024; 10:e28893. [PMID: 38596135 PMCID: PMC11002262 DOI: 10.1016/j.heliyon.2024.e28893] [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: 11/11/2023] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
Objective Late-onset myasthenia gravis (LOMG) often has comorbidities, and its initial symptoms may be ignored or misdiagnosed as other diseases. There were few large surveys on LOMG. Our study aimed to summarize clinical characteristics of LOMG to improve the rate of correct MG diagnosis. Methods A retrospective cohort study included 240 LOMG patients with onset age ≥65 years old who were treated at PLA General Hospital from January 1, 2003 to January 1, 2023. Results The male to female ratio was 1:1.2 (P = 0.699). MGFA clinical classification: Class I 31.3%, Class IIa 12.9%, Class IIb 51.3%, Class IIIa 0.8%, Class IIIb 0.8%, Class IV 0.4%, Class V2.5%. The onset symptom was ptosis in 78.8% and diplopia was in 18.8%. Swallowing dysfunction in the stage of LOMG was in 41.7%. The incidence of thymoma in LOMG was 14.2%. 85.4% of patients antibodies against the muscle acetylcholine receptor (AChR) are detected. The overall incidence of supramaximal repetitive nerve stimulation (Jolly test) was 57.1%, among which the highest positive rate (50.7%) was in the facial nerve. Jolly test of Class IIb was tested in the highest positive rate and Class I was in the lowest one (χ2 = 7.023, P = 0.030). Conclusion There was no significant difference in the incidence of LOMG between males and females. The clinical manifestations were mainly Class I and Class II, and severe MG was rare. The most common onset symptom was ptosis. The incidence of LOMG with thymoma was low. Supramaximal repetitive nerve stimulation (Jolly test) of the facial nerve was the easiest to detect and Jolly test of Class IIb was tested in the highest positive rate and Class I was in the lowest one.
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Affiliation(s)
- Chenjing Sun
- Senior Department of Neurology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Zhuangzhuang Ren
- Navy Clinical College, the Fifth School of Clinical Medicine, Anhui Medical University, Hefei, 230032, Anhui Province, China
| | - Xiuling Miao
- Senior Department of Neurology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Yanxu Zheng
- Xiangya School of Medicine, Central South University, 87 Xiangya Road, Changsha, Hunan 410000, China
| | - Jun Zhang
- The Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Xiaokun Qi
- Senior Department of Neurology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Jianguo Liu
- Senior Department of Neurology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Feng Qiu
- Senior Department of Neurology, The First Medical Center of PLA General Hospital, Beijing, China
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Myllynen C, Sarkkinen J, Atula S, Tienari P, Kekäläinen E, Laakso SM. A skewed ratio of free light chains is more common in patients with late-onset than early-onset myasthenia gravis. Immunol Lett 2023; 260:S0165-2478(23)00113-X. [PMID: 37414259 DOI: 10.1016/j.imlet.2023.07.001] [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: 04/16/2023] [Revised: 06/25/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
Myasthenia gravis (MG) is an autoantibody-mediated neuromuscular disease with an unpredictable clinical course. Serum free light chains (FLCs) have risen as a promising biomarker for MG, but their role in different subtypes of MG and in predicting disease progression is still uncharted. We investigated plasma from 58 generalized MG patients during post-thymectomy follow-up to determine κ and λ FLC and κ/λ ratio. In a subcohort of 30 patients, we examined the expression of 92 proteins associated with immuno-oncology using Olink. We further studied the ability of FLCs or proteomic markers to differentiate disease severity. Patients with late-onset MG (LOMG) displayed significantly higher mean κ/λ ratio than patients with early-onset MG (P=0.004). Inducible T-cell co-stimulator ligand (ICOSLG), matrix metalloproteinase 7 (MMP7), hepatocyte growth factor (HGF), and arginase 1 (ARG1) were differentially expressed in MG patients compared to healthy controls. There were no significant associations between clinical outcomes and FLCs or the assayed proteins. In conclusion, an elevated κ/λ ratio suggests long-lasting aberrant clonal plasma cell function in LOMG. Immuno-oncology-related proteomic analysis showed alterations in immunoregulatory pathways. Our findings pinpoint the FLC ratio as a biomarker for LOMG and call for further investigation of the immunoregulatory pathways in MG.
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Affiliation(s)
- Chris Myllynen
- Department of Neurosciences, University of Helsinki, Helsinki, Finland.
| | - Joona Sarkkinen
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Sari Atula
- Department of Neurosciences, University of Helsinki, Helsinki, Finland; Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Pentti Tienari
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Eliisa Kekäläinen
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; HUS Diagnostic Center, HUSLAB Clinical Microbiology, Helsinki University Hospital, Helsinki, Finland
| | - Sini M Laakso
- Department of Neurosciences, University of Helsinki, Helsinki, Finland; Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
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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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