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Bhandari V, Sivadasan A, Barnett-Tapia C, Katzberg H, Bril V. Using jitter analysis with concentric needle electrodes to assess disease status and treatment responses in myasthenia gravis. Clin Neurophysiol Pract 2024; 9:227-232. [PMID: 39224193 PMCID: PMC11366830 DOI: 10.1016/j.cnp.2024.06.004] [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: 10/25/2023] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 09/04/2024] Open
Abstract
Objective This study assesses the utility of jitter analysis with concentric needles to evaluate disease severity in myasthenia gravis (MG), correlate changes in jitter with clinical status as well as identify reasons for any discordance. Methods We performed a retrospective chart review of 82 MG patients and extracted data on demographics, MG subtype, antibody status, clinical scales, electrophysiology, and interventions at baseline and follow-up. Results Baseline MGII scores correlated with jitter (r = 0.25, p = 0.024) and abnormal pairs (r = 0.24, p = 0.03). After 28 months, MGII scores correlated with jitter (r = 0.31, p = 0.006), abnormal pairs (r = 0.29, p = 0.009), and pairs with blocks (r = 0.35, p = 0.001). Changes in MGII scores correlated with changes in jitter (r = 0.35, p = 0.002), abnormal pairs (r = 0.27, p = 0.014), and pairs with blocks (r = 0.36, p = 0.001). Conclusions Concentric needle jitter analysis may have the potential to evaluate baseline and sequential disease severity in MG. Significance This study highlights the potential for improved MG patient care through precise assessment and management using concentric needle jitter analysis to improve the accuracy of MG diagnosis and monitoring of disease activity.
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Affiliation(s)
- Vinaya Bhandari
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ajith Sivadasan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carolina Barnett-Tapia
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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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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Alcantara M, Barnett-Tapia C, Bril V, Mannan S, Shabanpour J, Riaz S, Ng E, Ryan C, Katzberg H. Office-based respiratory assessment in patients with generalized myasthenia gravis. Neuromuscul Disord 2024; 40:1-6. [PMID: 38776756 DOI: 10.1016/j.nmd.2024.05.005] [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: 01/18/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024]
Abstract
Patients with myasthenia gravis (MG) can present with respiratory dysfunction, ranging from exercise intolerance to overt respiratory failure, increased fatigue, or sleep-disordered breathing. To investigate the value of multiple respiratory tests in MG, we performed clinical and respiratory assessments in patients with mild to moderate generalized disease. One-hundred and thirty-six patients completed the myasthenia gravis quality-of-life score(MG-QOL-15), myasthenia gravis impairment index(MGII), Epworth sleepiness scale(ESS), University of California-San Diego Shortness of Breath Questionnaire(UCSD-SOB), Modified Medical Research Council Dyspnea Scales(MRC-DS), supine and upright forced vital capacity(FVC), maximal inspiratory pressures(MIPs) and sniff nasal inspiratory pressures(SNIP). Seventy-three (54 %) had respiratory and/or bulbar symptoms and 45 (33 %) had baseline abnormal FVC, with no significant postural changes (p = 0.89); 55 (40.4 %) had abnormal MIPs and 50 (37 %) had abnormal SNIPs. Overall, there were low scores on respiratory and disability scales. Females had increased odds of presenting with abnormal FVC (OR 2.89, p = 0.01) and MIPs (OR 2.48, p = 0.022). There were significant correlations between MIPs, FVC and SNIPs; between MGII/MG-QOL15 and UCSD-SOB/MRC-DS and between ESS and respiratory scales in the whole group. Our data suggests that office-based respiratory measurements are a useful screening method for stable MG patients, even when presenting with minimal respiratory symptoms and no significant disability.
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Affiliation(s)
- Monica Alcantara
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett-Tapia
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Shabber Mannan
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Jafar Shabanpour
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Riaz
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Eduardo Ng
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh Ryan
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Hans Katzberg
- Department of Medicine, Division of Neurology, Prosserman Family Neuromuscular clinic, University of Toronto, Toronto, Ontario, Canada.
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Meisel A, Saccà F, Spillane J, Vissing J. Expert consensus recommendations for improving and standardising the assessment of patients with generalised myasthenia gravis. Eur J Neurol 2024; 31:e16280. [PMID: 38523419 PMCID: PMC11236001 DOI: 10.1111/ene.16280] [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: 10/02/2023] [Revised: 01/26/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Regular and consistent disease assessment could provide a clearer picture of burden in generalised myasthenia gravis (gMG) and improve patient care; however, the use of assessment tools in practice lacks standardisation. This modified Delphi approach was taken to review current evidence on assessment tool use in gMG and develop expert-derived consensus recommendations for good practice. METHODS A European expert panel of 15 experienced gMG neurologists contributed to development of this consensus, four of whom formed a lead Sub-committee. The PICO (Population, Intervention, Control, Outcomes) framework was used to define six clinical questions on gMG assessment tools, a systematic literature review was conducted, and evidence-based statements were developed. According to a modified Delphi voting process, consensus was reached when ≥70% of the experts rated agreement with a statement as ≥8 on a scale of 1-10. RESULTS Eighteen expert- and evidence-based consensus statements based on six themes were developed. Key recommendations include: consistent use of the Myasthenia Gravis Activities of Daily Living score (MG-ADL) across clinical settings, followed by a simple question (e.g., Patient Acceptable Symptom State [PASS]) or scale to determine patient satisfaction in clinical practice; use of a Quantitative Myasthenia Gravis [QMG] or quality of life [QoL] assessment when the MG-ADL indicates disease worsening; and consideration of symptom state to determine the timing and frequency of recommended assessments. Expert panel consensus was reached on all 18 statements after two voting rounds. CONCLUSIONS This process provided evidence- and expert consensus-based recommendations for the use of objective and subjective assessment tools across gMG research and care to improve management and outcomes for patients.
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Affiliation(s)
- Andreas Meisel
- Department of Neurology with Experimental NeurologyNeuroscience Clinical Research CenterCharité Universitätsmedizin BerlinBerlinGermany
| | - Francesco Saccà
- GENESIS Department, Federico II University of NaplesNaplesItaly
| | - Jennifer Spillane
- National Hospital for Neurology and NeurosurgeryUCLH NHS Foundation TrustLondonUK
| | - John Vissing
- Copenhagen Neuromuscular CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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Regnault A, Habib AA, Creel K, Kaminski HJ, Morel T. Clinical meaningfulness and psychometric robustness of the MG Symptoms PRO scales in clinical trials in adults with myasthenia gravis. Front Neurol 2024; 15:1368525. [PMID: 38978809 PMCID: PMC11229520 DOI: 10.3389/fneur.2024.1368525] [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: 01/10/2024] [Accepted: 05/20/2024] [Indexed: 07/10/2024] Open
Abstract
Objectives The objective of this research was to generate psychometric evidence supporting the myasthenia gravis (MG) symptoms patient-reported outcome (PRO) scales as a fit-for-purpose measure of severity of core symptoms of MG and provide information allowing their meaningful interpretation using data from a phase 3 study in MG. Methods Data from the MycarinG study, a phase 3 study of rozanolixizumab in patients with generalized MG who experience moderate to severe symptoms (ClinicalTrials.gov Identifier: NCT03971422) were analyzed with both classical test theory (CTT) and Rasch measurement theory (RMT). Meaningful within-individual change and group-level meaningful change were estimated for three MG Symptoms PRO scales using anchor- and distribution-based methods. Anchor-based methods used patient global impression of severity (PGIS) and change (PGIC) in MG symptoms as anchors. Results Good measurement properties of the MG Symptoms PRO scales were shown in the sample of 200 participants: good to excellent reliability (test-retest and internal consistency reliability) and validity (associations between items and scores within the MG Symptoms PRO scales and between the MG Symptoms PRO scores and other clinical outcomes-MG ADL, QMG score, MGC score, and MGFA classes-were as expected); and the items showed good coverage of the continuum and fit to the Rasch model. Triangulation of the anchor- and distribution-based method results led to the definition of clinically meaningful within-patient improvement in scores for Muscle Weakness Fatigability (-16.67), Physical Fatigue (-20.00), and Bulbar Muscle Weakness (-20.00), with associated ranges. Benchmarks are also proposed for the interpretation of group-level results. Conclusion The strong psychometric performance of the MG Symptoms PRO scales and the information generated to guide its interpretation supports its use in clinical trials for demonstrating the clinical benefits of new treatments targeting core symptoms of MG (muscle weakness fatigability, physical fatigue, bulbar muscle weakness, respiratory muscle weakness, and ocular muscle weakness).
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Affiliation(s)
| | - Ali A Habib
- MDA ALS and Neuromuscular Center, Department of Neurology, University of California, Irvine, Orange, CA, United States
| | | | - Henry J Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
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Martinez‐Harms R, Barnett C, Alcantara M, Bril V. Clinical characteristics and treatment outcomes in patients with double-seronegative myasthenia gravis. Eur J Neurol 2024; 31:e16022. [PMID: 37531447 PMCID: PMC11235949 DOI: 10.1111/ene.16022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/07/2023] [Accepted: 07/30/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND AND PURPOSE Double-seronegative myasthenia gravis (dSNMG) is defined as myasthenia gravis (MG) without detectable or low affinity antibodies to acetylcholine receptor (AChR) and muscle-specific kinase (MuSK). There are limited data on detailed clinical features and outcomes after treatment in dSNMG patients. The aim was to describe the clinical characteristics and outcomes in dSNMG patients based on MG scales. METHODS A retrospective study was performed of patients diagnosed with MG who had negative AChR or MuSK antibodies and they were compared with an AChR-positive MG cohort. Correlations were made with data from the first and last clinic visits, between demographics, clinical characteristics, treatment and disease severity, based on the Myasthenia Gravis Foundation of America category, Myasthenia Gravis Impairment Index (MGII), Patient Acceptable Symptom State and simple single question (SSQ). RESULTS Eighty patients met the inclusion criteria for dSNMG. The baseline MGII and SSQ scores in the dSNMG cohort showed no significant differences from the AChR group (p = 0.94 and p = 0.46). The dSNMG cohort MGII and SSQ scores improved significantly at the last clinical evaluation (p = 0.001 and p = 0.047). The MGII improvement in the AChR cohort was significantly better (p = 0.003). CONCLUSIONS The initial severity of dSNMG based on clinical scores is similar to antibody-positive MG patients. There is significant clinical improvement in dSNMG patients after therapy, measured in the last clinical evaluation. This supports an immune pathophysiology of many dSNMG patients.
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Affiliation(s)
- Rodrigo Martinez‐Harms
- Ellen and Martin Prosserman Centre for Neuromuscular DiseasesToronto General HospitalTorontoOntarioCanada
- University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular DiseasesToronto General HospitalTorontoOntarioCanada
- University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Monica Alcantara
- Ellen and Martin Prosserman Centre for Neuromuscular DiseasesToronto General HospitalTorontoOntarioCanada
- University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular DiseasesToronto General HospitalTorontoOntarioCanada
- University Health NetworkUniversity of TorontoTorontoOntarioCanada
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Hartford CA, Sherman SA, Karantzoulis S, Guillemin I, Phinney MG, Kelly KL, Negron KE, Raja SM, Rofail D. Experience of Daily Life with Generalized Myasthenia Gravis: A Qualitative Investigation and Assessment of Instrument Content Validity. Neurol Ther 2023; 12:2079-2099. [PMID: 37747661 PMCID: PMC10630275 DOI: 10.1007/s40120-023-00544-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION Generalized myasthenia gravis (gMG) is a rare autoimmune disease. Symptoms of gMG are diverse, and understanding of their impact on patients is limited. This qualitative study aimed to provide an in-depth exploration of patients' daily experiences of gMG. METHODS Published qualitative studies were reviewed to identify the most important signs, symptoms, and functional impacts related to the patient experience in gMG. Semi-structured hybrid concept elicitation interviews (allowing spontaneous generation of disease concepts) and cognitive debriefing interviews (assessing the validity of existing disease assessments) were conducted with clinicians and adult patients with gMG. Signs, symptoms, and impacts were reviewed to understand which were most salient (i.e., reported by at least 50% of patients, with disturbance rating 5 or higher [10-point numeric scale]); concept saturation was also assessed. The disease conceptual model was updated. Existing clinical outcomes assessments (COAs) that capture how patients feel, function, and survive were assessed. RESULTS Interviews with patients (n = 24) identified seven new signs and symptoms and 37 new impacts compared with the literature. Concept saturation was reached. Signs and symptoms identified by patients as most important (salient) were shortness of breath, general fatigue, muscle weakness of arms, legs, and neck, dysphonia, dysarthria, trouble swallowing liquids, choking, and heat sensitivity. Patient-identified salient impacts were work life, depression, difficulty walking, grooming hair, showering, and brushing teeth, eating, personal relationships, family life, and participating in social activities. Clinicians considered ocular, respiratory, swallowing, speech/talking, and extremity function as key clinical manifestations of gMG. Patients and clinicians found clinical outcome assessments (COAs) to be conceptually relevant and comprehensive. CONCLUSION This research provides a holistic understanding of gMG signs, symptoms, and impacts experienced by patients, as observed by patients and clinicians. The conceptual model of gMG highlights the range of signs, symptoms, and impacts that adult patients with gMG experience in their everyday lives, emphasizing the humanistic impact and unmet needs.
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Affiliation(s)
| | - Steven A Sherman
- Regeneron Pharmaceuticals, Inc., 1 Rockwood Rd, Sleepy Hollow, NY, 10591, USA
| | | | | | | | | | | | | | - Diana Rofail
- Regeneron Pharmaceuticals, Inc., 1 Rockwood Rd, Sleepy Hollow, NY, 10591, USA
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Regnault A, Morel T, de la Loge C, Mazerolle F, Kaminski HJ, Habib AA. Measuring Overall Severity of Myasthenia Gravis (MG): Evidence for the Added Value of the MG Symptoms PRO. Neurol Ther 2023; 12:1573-1590. [PMID: 37166675 PMCID: PMC10444722 DOI: 10.1007/s40120-023-00464-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 03/14/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION Accurate measurement of myasthenia gravis (MG) severity is required for appropriate clinical monitoring of patients with MG and assessment of the benefit of new treatments in clinical trials. Our objective was to explore how MG severity can be measured and to determine how the newly developed MG Symptoms Patient-Reported Outcome (PRO) instrument complements the available measures of MG severity. METHODS The conceptual coverage of the Quantitative MG (QMG), MG Composite (MGC), MG-Activities of Daily Living (MG-ADL), and MG Symptoms PRO was scrutinized against core symptoms of MG: muscle weakness in three muscle groups (ocular, bulbar, and respiratory), muscle weakness fatigability, and physical fatigue. Post hoc analyses of the MG0002 study, a Phase 2a clinical trial of rozanolixizumab in adults with moderate to severe generalized MG, included correlation and Rasch model analyses. RESULTS The qualitative appraisal highlighted that only the MG Symptoms PRO captured physical fatigue. Data from 541 assessments (43 unique patients) were used for the analyses. Correlations ranged between 0.56 and 0.74 for the MG-ADL, QMG, MGC, and MG Symptoms PRO Muscle Weakness Fatigability score, and between 0.20 and 0.71 for the MG Symptoms PRO scores focusing on independent muscle groups. Analyses with the Rasch model estimated a meaningful continuum of severity of MG, including all items, except ocular muscles, from the four instruments. The QMG and MG Symptoms PRO had the broadest coverage of the MG severity continuum. Muscle fatigability and physical fatigue were more characteristic of low severity while bulbar weakness indicated more severe MG. CONCLUSION The severity of MG can be reflected in a meaningful continuum underpinned by the MG-specific outcome measures. Only ocular muscle manifestations were shown to reflect a possibly different facet of MG severity. With its modular nature and comprehensive content, the MG Symptoms PRO provides complementary information to the outcome measures widely used in MG. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03052751.
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Affiliation(s)
| | - Thomas Morel
- UCB Pharma SRL, Allée de la Recherche, 60, 1070 Brussels, Belgium
| | | | | | - Henry J. Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC USA
| | - Ali A. Habib
- Department of Neurology, University of California, Irvine, CA USA
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Guptill JT, Benatar M, Granit V, Habib AA, Howard JF, Barnett-Tapia C, Nowak RJ, Lee I, Ruzhansky K, Dimachkie MM, Cutter GR, Kaminski HJ. Addressing Outcome Measure Variability in Myasthenia Gravis Clinical Trials. Neurology 2023; 101:442-451. [PMID: 37076302 PMCID: PMC10491448 DOI: 10.1212/wnl.0000000000207278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/23/2023] [Indexed: 04/21/2023] Open
Abstract
An increasing number of clinical trials are enrolling patients with myasthenia gravis (MG). A lack of standardization in the performance of outcome measures leads to confusion among site research teams and is a source of variability in clinical trial data. MGNet, the NIH-supported Rare Disease Clinical Research Network for MG, views standardization of MG outcome measures as a critical need. To address this issue, a group of experts summarized key outcome measures used in MG clinical trials and a symposium was convened to address issues contributing to outcome measure variability. Consensus recommendations resulted in changes to outcome measure instructions and, in some cases, modifications to specific instruments. Recommended changes were posted for public commentary before finalization. Changes to the MG-Activities of Daily Living, MG-Quality of Life-15r, and MG-Impairment Index were limited to adding details to the administration instructions. Recommendations for proper positioning of participants and how to score items that could not be performed because of non-MG reasons were provided for the MG Composite. The Quantitative MG (QMG) score required the most attention, and changes were made both to the instructions and the performance of certain items resulting in the QMG-Revised. The Postintervention Status was believed to have a limited role in clinical trials, except for the concept of minimal manifestation status. As a next step, training materials and revised source documents, which will be freely available to study teams, will be created and posted on the MGNet website. Further studies are needed to validate changes made to the QMG-Revised.
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Affiliation(s)
- Jeffrey T Guptill
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC.
| | - Michael Benatar
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Volkan Granit
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ali A Habib
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - James F Howard
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Carolina Barnett-Tapia
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Richard J Nowak
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ikjae Lee
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Katherine Ruzhansky
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Mazen M Dimachkie
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Gary R Cutter
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Henry J Kaminski
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
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10
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Martinez-Harms R, Barnett C, Bril V. Time to achieve a patient acceptable symptom state in myasthenia gravis. Front Neurol 2023; 14:1187189. [PMID: 37396757 PMCID: PMC10313102 DOI: 10.3389/fneur.2023.1187189] [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: 03/15/2023] [Accepted: 05/25/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction The patient acceptable symptom state (PASS) is a reliable way to characterize a patient's satisfaction with their disease state in a "Yes"/"No" dichotomous manner. There is limited data on the time required to reach an acceptable state in Myasthenia Gravis (MG). We aimed to determine the time to reach a first PASS "Yes" response in patients at MG diagnosis and a PASS "No" status, and also to determine the influence of various factors on this time. Methods We performed a retrospective study of patients diagnosed with myasthenia gravis who had an initial PASS "No" response and defined the time to reach a first PASS "Yes" by Kaplan-Meier analysis. Correlations were made between demographics, clinical characteristics, treatment and disease severity, using the Myasthenia Gravis Impairment Index (MGII) and Simple Single Question (SSQ). Results In 86 patients meeting inclusion criteria, the median time to PASS "Yes" was 15 months (95% CI 11-18). Of 67 MG patients who achieved PASS "Yes," 61 (91%), achieved it by 25 months after diagnosis. Patients who required only prednisone therapy achieved PASS "Yes" in a shorter time with a median of 5.5 months (p = 0.01). Very-late-onset MG patients reached PASS "Yes" status in a shorter time (HR = 1.99, 95% CI 0.26-2.63; p = 0.001). Discussion Most patients reached PASS "Yes" by 25 months after diagnosis. MG patients who only required prednisone and those with very-late-onset MG reach PASS "Yes" in shorter intervals.
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Affiliation(s)
- Rodrigo Martinez-Harms
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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11
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Gilhus NE. Myasthenia gravis, respiratory function, and respiratory tract disease. J Neurol 2023:10.1007/s00415-023-11733-y. [PMID: 37101094 PMCID: PMC10132430 DOI: 10.1007/s00415-023-11733-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
Myasthenia gravis (MG) is characterized by muscle weakness caused by autoantibodies that bind to the postsynaptic membrane at the neuromuscular junction and impair acetylcholine receptor function. Weakness of respiratory muscles represents the most severe MG manifestation, and 10-15% of all patients experience an MG crisis with the need of mechanical ventilatory support at least once in their life. MG patients with respiratory muscle weakness need active immunosuppressive drug treatment long term, and they need regular specialist follow-up. Comorbidities affecting respiratory function need attention and optimal treatment. Respiratory tract infections can lead to MG exacerbations and precipitate an MG crisis. Intravenous immunoglobulin and plasma exchange are the core treatments for severe MG exacerbations. High-dose corticosteroids, complement inhibitors, and FcRn blockers represent fast-acting treatments that are effective in most MG patients. Neonatal myasthenia is a transient condition with muscle weakness in the newborn caused by mother's muscle antibodies. In rare cases, treatment of respiratory muscle weakness in the baby is required.
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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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12
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Abstract
Myasthenia gravis is an autoimmune disorder caused by antibodies against elements in the postsynaptic membrane at the neuromuscular junction, which leads to muscle weakness. Congenital myasthenic syndromes are rare and caused by mutations affecting pre- or postsynaptic function at the neuromuscular synapse and resulting in muscle weakness. MG has a prevalence of 150-250 and an annual incidence of 8-10 individuals per million. The majority has disease onset after age 50 years. Juvenile MG with onset in early childhood is more common in East Asia. MG is subgrouped according to type of pathogenic autoantibodies, age of onset, thymus pathology, and generalization of muscle weakness. More than 80% have antibodies against the acetylcholine receptor. The remaining have antibodies against MuSK, LRP4, or postsynaptic membrane antigens not yet identified. A thymoma is present in 10% of MG patients, and more than one-third of thymoma patients develop MG as a paraneoplastic condition. Immunosuppressive drug therapy, thymectomy, and symptomatic drug therapy with acetylcholine esterase inhibitors represent cornerstones in the treatment. The prognosis is good, with the majority of patients having mild or moderate symptoms only. Most congenital myasthenic syndromes are due to dysfunction in the postsynaptic membrane. Symptom debut is in early life. Symptomatic drug treatment has sometimes a positive effect.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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13
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Gilhus NE, Hovland SIB. User Involvement in Myasthenia Gravis Research. Front Neurol 2022; 13:839769. [PMID: 35720063 PMCID: PMC9202346 DOI: 10.3389/fneur.2022.839769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- *Correspondence: Nils Erik Gilhus
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14
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Alcantara M, Barnett C, Katzberg H, Bril V. An update on the use of immunoglobulins as treatment for myasthenia gravis. Expert Rev Clin Immunol 2022; 18:703-715. [PMID: 35639497 DOI: 10.1080/1744666x.2022.2084074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies. AREAS COVERED We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease. EXPERT OPINION The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient's status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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15
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Chiu EC, Lee YC, Lee SC, Hsueh IP. Reliability of the performance-based measure of executive functions in people with schizophrenia. BMC Psychiatry 2021; 21:553. [PMID: 34758768 PMCID: PMC8579687 DOI: 10.1186/s12888-021-03562-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 10/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Performance-based measure of Executive Functions (PEF) with four domains is designed to assess executive functions in people with schizophrenia. The purpose of this study was to examine the test-retest reliability of the PEF administered by the same rater (intra-rater agreement) and by different raters (inter-rater agreement) in people with schizophrenia and to estimate the values of minimal detectable change (MDC) and MDC%. METHODS Two convenience samples (each sample, n = 60) with schizophrenia were conducted two assessments (two weeks apart). The intraclass correlation coefficient (ICC) was analyzed to examine intra-rater and inter-rater agreements of the test-retest reliability of the PEF. The MDC was calculated through standard error of measurement. RESULTS For the intra-rater agreement study, the ICC values of the four domains were 0.88-0.92. The MDC (MDC%) of the four domains (volition, planning, purposive action, and perfromance effective) were 13.0 (13.0%), 12.2 (16.4%), 16.2 (16.2%), and 16.3 (18.8%), respectively. For the inter-rater agreement study, the ICC values of the four domains were 0.82-0.89. The MDC (MDC%) were 15.8 (15.8%), 17.4 (20.0%), 20.9 (20.9%), and 18.6 (18.6%) for the volition, planning, purposive action, and performance effective domains, respectively. CONCLUSIONS The PEF has good test-retest reliability, including intra-rater and inter-rater agreements, for people with schizophrenia. Clinicians and researchers can use the MDC values to verify whether an individual with schizophrenia shows any real change (improvement or deterioration) between repeated PEF assessments by the same or different raters.
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Affiliation(s)
- En-Chi Chiu
- grid.412146.40000 0004 0573 0416Department of Long-Term Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan ,Department of Occupational Therapy, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Ya-Chen Lee
- grid.252470.60000 0000 9263 9645Department of Occupational Therapy, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Shu-Chun Lee
- Department of Occupational Therapy, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan ,grid.411447.30000 0004 0637 1806Department of Occupational Therapy, I-Shou University, Kaohsiung, Taiwan ,grid.419832.50000 0001 2167 1370University of Taipei, Taipei, Taiwan
| | - I-Ping Hsueh
- School of Occupational Therapy, College of Medicine, National Taiwan University, No.17, Xuzhou Rd., Zhongzheng Dist, Taipei City, Taiwan. .,Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan.
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16
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Cleanthous S, Mork AC, Regnault A, Cano S, Kaminski HJ, Morel T. Development of the Myasthenia Gravis (MG) Symptoms PRO: a case study of a patient-centred outcome measure in rare disease. Orphanet J Rare Dis 2021; 16:457. [PMID: 34717694 PMCID: PMC8556940 DOI: 10.1186/s13023-021-02064-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease, characterised by fluctuating muscle weakness which makes it challenging to assess symptom severity. Mixed methods psychometrics (MMP), which combines evidence from qualitative research and modern psychometrics, is a versatile approach to the development of patient-centred outcome measures (PCOM) in the context of rare disease. Our objective was to develop the MG Symptom patient-reported outcome (PRO) to assess key aspects of MG severity from the patient perspective. METHODS We used MMP to develop a novel PRO instrument in a multi-step process. An initial conceptual model for MG patient experience was developed and expanded based on preliminary literature review and two waves of concept elicitation interviews with people with MG (Step 1). Based on this, the novel PRO instrument, the MG Symptoms PRO, was drafted. The draft instrument was refined by combining qualitative and quantitative data collected in a Phase 2 clinical study (Step 2). RESULTS Findings from the literature review and concept elicitation interviews (n = 96) indicated that patient experience in MG includes proximal muscle weakness symptoms related to several body parts, along with muscle weakness fatigability and general fatigue. Then, a set of 42 items across five scales (ocular-, bulbar-, and respiratory muscle weakness, physical fatigue, and muscle weakness fatigability) was developed. Qualitative evidence endorsed its relevance, clarity, and ease of completion; quantitative analysis with Rasch measurement theory methods demonstrated strong measurement properties, including good targeting and high reliability. Classical test theory analyses showed adequate reliability of the instrument and mild to moderate correlations with other widely used MG-specific outcome measures. CONCLUSIONS The MG Symptoms PRO has potential to be used both to measure treatment benefit in clinical trials and monitor symptom severity in clinical practice. Its component scales were purposefully designed to stand alone, enhancing interpretability of scores given the heterogeneity of MG, and enabling modular use. Compared with existing MG PROs, it contains more detailed assessments of muscle weakness and muscle weakness fatigability symptoms, which are of key importance to people with MG. The MMP approach used may serve as a case study for developing PCOMs across rare disease indications.
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Affiliation(s)
| | | | | | | | | | - Thomas Morel
- UCB S.A., Allée de la Recherche, 60, 1070, Brussels, Belgium.
- KU Leuven, Leuven, Belgium.
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Petersson M, Feresiadou A, Jons D, Ilinca A, Lundin F, Johansson R, Budzianowska A, Roos AK, Kågström V, Gunnarsson M, Sundström P, Piehl F, Brauner S. Patient-Reported Symptom Severity in a Nationwide Myasthenia Gravis Cohort: Cross-sectional Analysis of the Swedish GEMG Study. Neurology 2021; 97:e1382-e1391. [PMID: 34376512 PMCID: PMC8520390 DOI: 10.1212/wnl.0000000000012604] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/09/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To describe myasthenia gravis activities of daily living (MG-ADL) in relation to clinical characteristics in a large Swedish nationwide cohort. METHODS In a cross-sectional prevalence cohort study, the Genes and Environment in Myasthenia Gravis study, performed from November 2018 through August 2019, patients with myasthenia gravis (MG) were invited to submit an extensive 106-item life environment questionnaire, including the MG-ADL score. Patients were classified into early-onset MG (EOMG, <50 years), late-onset MG (LOMG, ≥50 years), or thymoma-associated MG (TAMG). Comparisons of disease-specific characteristics were made between subgroups, sexes, and different MG-ADL scores. RESULTS A total of 1,077 patients were included, yielding a 74% response rate: 505 (47%) were classified as EOMG, 520 (48%) LOMG, and 45 (4%) TAMG. Mean age at inclusion was 64.3 years (SD 15.7) and mean disease duration was 14.6 years (SD 14.0). Complete MG-ADL scores (n = 1,035) ranged from 0p to 18p, where 26% reported a score of 0p. Higher MG-ADL scores were associated with female sex, obesity, and diagnostic delay (odds ratio [OR] 1.62, 1.72, and 1.69; p adj = 0.017, 0.013, and 0.008) and inversely correlated with high educational attainment (OR 0.59; p adj = 0.02), but not with age at inclusion, disease subtype, or disease duration. Almost half of the population (47%) reported MG-ADL ≥3p, corresponding to an unsatisfactory symptom state. DISCUSSION In this nationwide study, comprising more than 40% of the prevalent MG population in Sweden, almost half of the patients reported current disease symptoms associated with an unsatisfactory symptom state, indicating the need for improved treatment options.
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Affiliation(s)
- Malin Petersson
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Amalia Feresiadou
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Jons
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Andreea Ilinca
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Lundin
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Rune Johansson
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Anna Budzianowska
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Karin Roos
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Viktor Kågström
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Martin Gunnarsson
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Peter Sundström
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden
| | - Susanna Brauner
- From the Department of Clinical Neuroscience (M.P., F.P., S.B.), Karolinska Institutet, Stockholm; Department of Neuroscience, Neurology (A.F.), Uppsala University; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology (D.J.), the Sahlgrenska Academy, University of Gothenburg; Department of Neurology (D.J.), Sahlgrenska University Hospital, Gothenburg; Department of Clinical Sciences Lund, Neurology (A.I.), Skåne University Hospital, Lund University, Malmö; Departments of Neurology (F.L.) and Biomedical and Clinical Sciences (F.L., A.B.), Division of Neurobiology, Linköping University; Department of Neurology and Rehabilitation (R.J.), Karlstad Central Hospital; Department of Internal Medicine in Jönköping (A.B.), Section of Neurology, Region Jönköping County; Department of Clinical Science, Neurosciences (A.-K.R.), Unit of Neurology, Umeå University, Östersund; Rehabilitation Clinic (V.K.), Sundsvall Hospital; Department of Neurology, Faculty of Medicine and Health (M.G.), Örebro University; Department of Clinical Science, Neurosciences (P.S.), Umeå University; and Department of Neurology (F.P., S.B.), Karolinska University Hospital, Stockholm, Sweden.
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Validation of the Italian version of the Myasthenia Gravis Impairment Index (MGII). Neurol Sci 2021; 43:2059-2064. [PMID: 34505205 PMCID: PMC8860822 DOI: 10.1007/s10072-021-05585-5] [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: 04/10/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022]
Abstract
Objective
To validate the Italian version of the Myasthenia Gravis Impairment Index (MGII). Introduction MGII is a recent promising measure developed for MG patient evaluation. It includes a clinical severity evaluation and a patient-reported questionnaire. It has been developed in English and has demonstrated feasibility, reliability, and construct validity. Recently, its Dutch translation has been validated. Methods MGII was translated to Italian with a multi-step forward process. We assessed correlations with the following scores: Istituto Nazionale Carlo Besta score for Myasthenia Gravis (INCB-MG), the MG Activities of Daily Living (MG-ADL), the Myasthenia Gravis Composite (MGC), the Quality of Life 15 for Myasthenia Gravis (QOL15-MG), and the Myasthenia Gravis Disability (MGDIS). We also assessed differences in MGII scores by disease severity with the ANOVA Kruskal–Wallis test. Results One hundred forty-one patients were enrolled. The mean MGII total score was 13.3 ± 11.9 (range 0–49), with a mean ocular subscore of 3.7 ± 4.7 and a mean MGII generalized subscore of 9.6 ± 9.0. As expected, the MGII had a good correlation with the other severity scores. The MGII had a lower floor effect (3.5%) than the other measures. Twenty-five patients were assessed in follow-up; as expected, the MGII change scores had moderate correlations with change in other MG severity measures and lower correlations with quality of life measures. Conclusions The MGII score was cross-culturally validated in an Italian cohort of MG patients. We confirmed its lower floor effect and the correlations with other MG measures including INCB-MG that was not evaluated in previous studies.
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Menon D, Alnajjar S, Barnett C, Vijayan J, Katzberg H, Fathi D, Alcantara M, Bril V. Telephone consultation for myasthenia gravis care during the COVID-19 pandemic: Assessment of a novel virtual myasthenia gravis index. Muscle Nerve 2021; 63:831-836. [PMID: 33792967 PMCID: PMC8251129 DOI: 10.1002/mus.27243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/22/2021] [Accepted: 03/28/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION/AIMS The aim of the study was to determine the association between the virtual Myasthenia Gravis Impairment Index (vMGII) with other patient-reported outcomes (PROs) of myasthenia gravis (MG) and its usefulness in telephone consultations with MG patients. METHODS This was a retrospective case series in which vMGII score along with virtual Single Simple Question (vSSQ), virtual Patient-Acceptable Symptom State PASS (vPASS) response, and patient disease status based on Myathenia Gravis Foundation of America postintervention status were collected during telephone consultation along with the MGII, SSQ, and PASS responses during the preceding in-person clinic visits. RESULTS In 214 patients, the mean difference of vMGII between the vPASS "Yes" and "No" groups was -14.2 ± 1.4 (95% confidence interval, -16.9 to -11.3; P < .001) with mean vMGII for vPASS "Yes" group being 6.4 ± 7.7 and vPASS "No" being 20.5 ± 11.5. A vMGII of 11.5 or higher predicted vPASS "yes" response with a sensitivity of 78.7% and specificity of 81.4%. A strong negative correlation was found between the vMGII and vSSQ (r = -.667; P < .001). The mean vMGII was 0.48 ± 1.42 for patients in remission, and 9.31 ± 10.93 for improved, 9.32 ± 8.79 for stable, and 22.58 ± 14.04 for worsened groups (P < .001). These associations were the same as those obtained during the preceding in-person clinic visit and the direction of change in MGII scores also indicated change in disease status. DISCUSSION vMGII is an effective measure to assess an MG patient's disease status in telephone consultations and relates well with other PRO measures. The vMGII remains reliable for assessing MG disease status even with removal of the physical examination component.
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Affiliation(s)
- Deepak Menon
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Sara Alnajjar
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Joy Vijayan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Davood Fathi
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health NetworkUniversity of TorontoTorontoOntarioCanada
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20
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Ke L, Li Q, Song J, Jiao W, Ji A, Chen T, Pan H, Song Y. The mitochondrial biogenesis signaling pathway is a potential therapeutic target for myasthenia gravis via energy metabolism (Review). Exp Ther Med 2021; 22:702. [PMID: 34007311 PMCID: PMC8120506 DOI: 10.3892/etm.2021.10134] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
Myasthenia gravis (MG) is an autoantibody-mediated autoimmune disease that is characterized by muscle weakness and fatigue. Traditional treatments for MG target the neuromuscular junction (NMJ) or the immune system. However, the efficacy of such treatments is limited, and novel therapeutic options for MG are urgently required. In the current review, a new therapeutic strategy is proposed based on the mitochondrial biogenesis and energy metabolism pathway, as stimulating mitochondrial biogenesis and the energy metabolism might alleviate myasthenia gravis. A number of cellular sensors of the energy metabolism were investigated, including AMP-activated protein kinase (AMPK) and sirtuin 1 (SIRT1). AMPK and SIRT1 are sensors that regulate cellular energy homeostasis and maintain energy metabolism by balancing anabolism and catabolism. Peroxisome proliferator-activated receptor γ coactivator 1α and its downstream transcription factors nuclear respiratory factors 1, nuclear respiratory factors 2, and transcription factor A are key sensors of mitochondrial biogenesis, which can restore mitochondrial DNA and produce new mitochondria. These processes help to control muscle contraction and relieve the symptoms of MG, including muscle weakness caused by dysfunctional NMJ transmission. Therefore, the present review provides evidence for the therapeutic potential of targeting mitochondrial biogenesis for the treatment of MG.
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Affiliation(s)
- Lingling Ke
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Qing Li
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Jingwei Song
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Wei Jiao
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Aidong Ji
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510006, P.R. China
| | - Tongkai Chen
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Clinical Pharmacology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Huafeng Pan
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
| | - Yafang Song
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China.,Institute of Pi-Wei, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, P.R. China
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21
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Menon D, Katzberg H, Barnett C, Pal P, Bezjak A, Keshavjee S, Bril V. Thymoma pathology and myasthenia gravis outcomes. Muscle Nerve 2021; 63:868-873. [PMID: 33675078 DOI: 10.1002/mus.27220] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/24/2021] [Accepted: 02/27/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION There is limited evidence regarding the impact of World Health Organization (WHO) subtype of thymoma on post-thymectomy outcome of thymoma-associated myasthenia gravis (TAMG). The objective was to determine if the pathological subtypes of thymoma were associated with post-thymectomy outcomes of myasthenia gravis (MG), in patients with TAMG. METHODS We performed a retrospective study of consecutive patients with TAMG who attended the neuromuscular clinic between January 2018 and December 2019 with a minimum follow-up of 1 y after thymectomy. Outcome measures were MG Impairment Index (MGII), single-simple question (SSQ), Myasthenia Gravis Foundation of America post-intervention status (MGFA PIS) and non-responder MG status at last assessment. RESULTS Ninety-five patients were included; mean age at onset was 48.1 ± 12.1 y; 54(56.8%) were females. Thirteen patients developed MG post-thymectomy. The most common thymoma was WHO type B2 in 39 (41.1%). Most patients (40, 42.1%) had Masaoka stage II thymoma. There was no association of thymoma subtypes or Masaoka stage of disease with age, gender, MG phenotype, serology, post-thymectomy onset, interval from onset to thymectomy, MGII, SSQ, MGFA PIS, or non-responder status. Associations were found between positive serology and lower MGII (11.1 ± 14.2 vs 23 ± 12.9, P = .050), thymic follicular hyperplasia (TFH) and higher SSQ (89.3 ± 11.7 vs 80.1 ± 20.2, P-.043), and lack of recurrence and higher SSQ (84.1 ± 18 vs 72.5 ± 20, P = .037). DISCUSSION The WHO pathological subtype of thymoma did not correlate with MG outcomes. However, positive acetylcholine antibody serology, presence of TFH, and non-recurrence of thymoma predict a favorable outcome.
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Affiliation(s)
- Deepak Menon
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Hans Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Prodipto Pal
- Department of Laboratory Medicine and Pathology, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Bezjak
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Kim P, Arnold M, Gunti J. Five-Month Trial of Whole-Food Plant-Based Diet in a Patient With Coexisting Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome. Am J Lifestyle Med 2021; 15:230-237. [PMID: 34025312 DOI: 10.1177/1559827621993748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Introduction: Nutritional intervention, such as a whole-food plant-based (WFPB) diet, is suggested to improve symptoms of autoimmune disorders. Its effects on neuromuscular junction (NMJ) diseases are less known. Case Description: A 56-year-old female with a combined myasthenia gravis and Lambert-Eaton myasthenic syndrome presented with persistent musculoskeletal weakness and pain, fatigue, and diminished concentration. Methods: A WFPB diet was implemented for 5 months in this case study. Functionality, biometrics, and quality of life were assessed at regular intervals via blood work, vital signs, and patient surveys. Results: After 10 weeks, 2 medications were de-prescribed due to improvement in blood glucose levels and blood pressure readings. Neuromuscular symptoms lessened as measured by the Myasthenia Gravis Illness Index. Weight loss of 18.7 pounds was achieved. No deterioration in physical activity was reported throughout the 5-month trial of WFPB diet. Discussion: Our results have implications that an individualized dietary strategy may be considered as one component of management of NMJ diseases. The effects of WFPB diet on NMJ diseases remain inconclusive.
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Affiliation(s)
- Peter Kim
- Genesis Quad Cities Family Medicine Residency Program, Genesis Health System, Davenport, Iowa
| | - Matthew Arnold
- Genesis Quad Cities Family Medicine Residency Program, Genesis Health System, Davenport, Iowa
| | - Jasmine Gunti
- Genesis Quad Cities Family Medicine Residency Program, Genesis Health System, Davenport, Iowa
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Gilhus NE. Physical training and exercise in myasthenia gravis. Neuromuscul Disord 2021; 31:169-173. [PMID: 33461846 DOI: 10.1016/j.nmd.2020.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/27/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Myasthenia gravis is characterized by muscle weakness and fatigue. As sustained muscle use increases the weakness, the value of physical training programs has previously been questioned. This is a review to clarify the safety and usefulness of systematic training in myasthenia gravis, based on a systematic search in available databases using the relevant key words. Ten intervention studies including 159 patients with generalized disease have been published regarding the effect of systematic physical training, three of them on respiratory muscles. Muscle strength improved, and in the majority of the studies also daily function and quality of life. The feeling of fatigue not directly related to actual muscle weakness was less influenced by physical training. Continuous training was necessary to maintain the improved function. Physical training and exercise are safe in myasthenia gravis. This can improve both muscle strength and daily function. Type and intensity of systematic training should be adapted in the individual patient. A minimum of 150 min of exercise per week is recommended for myasthenia gravis patients with mild and moderate disease.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Norway; Department of Neurology, Haukeland University Hospital, 5021 Bergen, Norway.
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24
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Tran C, Biswas A, Mendoza M, Katzberg H, Bril V, Barnett C. Performance of different criteria for refractory myasthenia gravis. Eur J Neurol 2020; 28:1375-1384. [PMID: 33306873 DOI: 10.1111/ene.14675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/03/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Defining refractory myasthenia gravis is important, as this can drive clinical decision making, for example, by escalating treatments in refractory individuals. There are several definitions of refractory myasthenia, and their performances have not been compared. Having valid and reliable criteria can help select patients in whom more aggressive treatments may be needed. METHODS We applied five different refractory myasthenia criteria (Drachman, Mantegazza, Suh, the International Consensus Guideline (ICG), and the randomised controlled trial of eculizumab in refractory, anti-acetylcholine receptor positive, generalised myasthenia gravis (REGAIN), to a cohort of 237 patients. We compared the proportion of refractory patients among different criteria and their scores on disease severity, fatigue, and quality-of-life (QoL) scales. We also assessed the agreement for each criterion between two trained assessors. RESULTS The Drachman, Mantegazza, and Suh criteria resulted in high proportions of refractory individuals (40.1%, 39.2%, and 38.8%, respectively), compared with the ICG and REGAIN criteria (9.7% and 3.0%, respectively). Refractory patients by the ICG and REGAIN criteria had worse disease severity, QoL, and fatigue scores, compared with patients classified as refractory by other criteria. All criteria had high agreement between raters (between 70% and 100%). CONCLUSIONS There is high variability in the proportion of refractory myasthenia gravis patients depending on the criteria used, with ICG and REGAIN criteria capturing patients with worse disease severity. This reflects conceptual differences as to what refractory means. Further multicenter studies are needed to determine appropriate criteria for refractory myasthenia gravis.
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Affiliation(s)
- Christopher Tran
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Aishani Biswas
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meg Mendoza
- Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
| | - Hans Katzberg
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ellen and Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Thomsen JLS, Andersen H. Outcome Measures in Clinical Trials of Patients With Myasthenia Gravis. Front Neurol 2020; 11:596382. [PMID: 33424747 PMCID: PMC7793650 DOI: 10.3389/fneur.2020.596382] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/06/2020] [Indexed: 01/02/2023] Open
Abstract
Myasthenia gravis (MG) is a heterogeneous disorder whose clinical presentation ranges from mild ocular deficits to severe widespread weakness. This variance poses a challenge when quantifying clinical deficits. Deficits and symptoms are quantified using standardized clinical scales and questionnaires which are often used as outcome measures. The past decades have seen the development of several validated outcome measures in MG, which are used in clinical trials to obtain regulatory approval. In recent years, emphasis has moved from objective assessments to patient-reported outcomes. Despite a growing body of literature on the validity of the MG-specific outcome measures, several unresolved factors remain. As several novel therapeutics are currently in clinical development, knowledge about capabilities and limitations of outcome measures is needed. In the present paper, we describe the most widely used clinical classifications and scales in MG. We highlight the choice of outcome measures in published and ongoing trials, and we denote whether trial efficacy was reached on these outcomes. We discuss advantages and limitations of the individual scales, and discuss some of the unresolved factors relating to outcome assessments in MG.
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Affiliation(s)
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Alcantara M, Sarpong E, Barnett C, Katzberg H, Bril V. Chronic immunoglobulin maintenance therapy in myasthenia gravis. Eur J Neurol 2020; 28:639-646. [PMID: 32964565 DOI: 10.1111/ene.14547] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Long-term treatment of myasthenia gravis (MG) includes symptomatic and course-modifying therapies that target the immune system. Recently, both intravenous immunoglobulin (IVIG) and subcutaneous immunoglobulin (SCIG) have emerged as viable options for chronic therapy, considering the favourable safety-efficacy profile and possible immunosuppressant sparing properties. The aim was to investigate the outcomes of the long-term care of generalized MG with immunoglobulin (Ig). METHODS This is a retrospective, repeated-measures design study. Charts of generalized MG patients, treated with IVIG/SCIG for at least 6 months, from January 2015 to January 2020, were analysed. The primary outcome was the mean change in Myasthenia Gravis Impairment Index (MGII) after treatment with Ig, comparing baseline to IVIG and SCIG treatment periods. Secondary outcomes included the changes in pyridostigmine, immunosuppressive medications and patient-reported outcome 'percentage of normal' (0%-100%). RESULTS Thirty-four patients were treated with chronic Ig therapy (30 IVIG/SCIG, three SCIG, one IVIG). The mean durations of IVIG and SCIG periods were 21.8 ± 19.4 (range 3-64) months and 19.5 ± 11.3 (range 5-45) months respectively. There was a significant reduction in MGII scores (27.7 ± 15.7 baseline; 22.0 ± 17.4 IVIG period; 19.5 ± 18.1 SCIG period; F = 17.9; d.f. = 1.7; P < 0.01), pyridostigmine and immunosuppressant use (P = 0.00). The outcome 'percentage of normal' had a significant positive association with both treatments (P = 0.00). CONCLUSION Our study results suggest that patients can be successfully transitioned to IVIG and from IVIG to SCIG in the chronic treatment of generalized MG with reductions in impairments and use of other medications and improvement in overall status with Ig therapy. Prospective, randomized studies are needed to clarify costs and comparative effectiveness.
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Affiliation(s)
- M Alcantara
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - E Sarpong
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - C Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - H Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - V Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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Mendoza M, Tran C, Bril V, Katzberg HD, Barnett C. Patient-acceptable symptom states in myasthenia gravis. Neurology 2020; 95:e1617-e1628. [DOI: 10.1212/wnl.0000000000010574] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/18/2020] [Indexed: 12/13/2022] Open
Abstract
ObjectivesTo estimate patient-acceptable symptom state (PASS) cut points for myasthenia gravis (MG) health scales.MethodsWe conducted an electronic survey that included the Myasthenia Gravis Impairment Index (MGII), EuroQol 5-Dimension (EQ5D), and a simple PASS question. PASS-anchored thresholds were estimated for the MGII questionnaire through receiver operating characteristic curves. We used the MGII PASS cut point in a validation cohort of 257 patients to estimate PASS thresholds for other clinically relevant health scales such as the Quantitative Myasthenia Gravis Scale (QMGS), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Composite (MGC), and Myasthenia Quality of Life (MG-QoL15).ResultsOne hundred twenty-four of ≈250 invited patients answered the electronic survey (49% response rate), and 80 considered their current symptom state acceptable (PASS-positive). They had lower MGII scores than PASS-negative patients (7.76 ± 9.37 vs 25.0 ± 13.7, p < 0.0001) and better EQ5D scores (0.86 ± 0.17 vs 0.69 ± 0.18, p < 0.0001). The MGII questionnaire threshold for PASS was ≤10 points. With the use of this threshold in an independent dataset of 257 patients, all patients in remission or minimal manifestation status were PASS-positive. In addition, some patients in Classes I, II, and IIIA also achieved PASS status. PASS thresholds for the QMGS, MG-ADL, MGC, and MG-QoL15 were ≤7, 2, 3, and 8 points, respectively.ConclusionsWe have estimated thresholds for commonly used myasthenia health scales reflecting patient-acceptable states in patients with MG. These thresholds indicate a global state of well being, rather than a change in scores, or being better. Therefore, PASS thresholds can be used as secondary endpoints for myasthenia research.
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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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Wong SH, Eggenberger E, Cornblath W, Xhepa A, Miranda E, Lee H, Burke A, Barnett C. Preliminary Findings of a Dedicated Ocular Myasthenia Gravis Rating Scale: The OMGRate. Neuroophthalmology 2020; 44:148-156. [PMID: 32395166 DOI: 10.1080/01658107.2019.1660686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 10/25/2022] Open
Abstract
There is a pressing need for a robust rating scale for ocular myasthenia gravis (OMG). Rating scales for myasthenia gravis (MG) research have a predominant focus on generalised disease. We present results of the first dedicated rating scale for OMG: the ocular myasthenia gravis rating scale (OMGRate). The OMGRate was developed through an international collaboration between neuromuscular and neuro-ophthalmology experts in OMG. It comprises two components: a physician- examination (OMGRate-e) and a patient questionnaire (OMGRate-q).. The OMGRate was prospectively validated in patients attending a neuro-ophthalmology clinic from April 2017 to October 2018. External validity and reliability of OMGRate were evaluated using validated MG rating scales: the Myasthenia Gravis Composite (MGC), the Myasthenia Gravis Quality of Life (MG-QOL), and the ocular component from the Myasthenia Gravis Impairment Index questionnaire (MGII). Two hundred and eleven assessments were completed in 104 patients (67 males, mean age 55 y, range 18-86 y). There was very good external validity of the OMGRate: good correlation between OMGRate-e and MGC (r = 0.64, 95% confidence intervals [CI] 0.54-0.74, p < .0001); excellent correlation between OMGRate-q and MGII (r = 0.85, 95% CI 0.78-0.91, p < .0001) and good correlation between OMGRate and MG-QOL (r = 0.68, 95% CI 0.60-0.77, p < .0001). A higher correlation of OMGRate and MG-QOL compared with MGC and MG-QOL (r = 0.47, 95% CI 0.34-0.59, p < .0001) suggests that OMGRate is better able to capture significant QOL information in patients with OMG. It had excellent reliability with an intraclass correlation coefficient of 0.83 (95% CI 0.67-0.92). Feedback from examiners and patients indicated that the OMGRate was easy to use. In conclusion, OMGRate is an easy-to-use, valid and reliable rating scale for monitoring the severity of OMG.
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Affiliation(s)
- Sui Hsien Wong
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Eric Eggenberger
- Department of Neuro-ophthalmology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Wayne Cornblath
- Department of Neuro-ophthalmology, University of Michigan, Ann Arbor, MI, USA
| | - Alba Xhepa
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Eduardo Miranda
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Helena Lee
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Ailbhe Burke
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, UK
| | - Carolina Barnett
- Department of Medicine, Neurology, University Health Network and University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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de Meel RHP, Barnett C, Bril V, Tannemaat MR, Verschuuren JJGM. Myasthenia Gravis Impairment Index: Sensitivity for Change in Generalized Muscle Weakness. J Neuromuscul Dis 2020; 7:297-300. [PMID: 32250313 PMCID: PMC7369124 DOI: 10.3233/jnd-200484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The recently developed Myasthenia Gravis Impairment Index (MGII) is a promising measure as it has less floor effects and a higher relative efficiency in its responsiveness to treatment effect compared to other MG measures. This study aimed at validating the MGII in a Dutch cohort of MG patients and analyzing the sensitivity of MGII compared to MG-ADL for changes in generalized weakness. METHODS We analyzed (generalized items of; -gen) MGII, quantitative myasthenia gravis (QMG), Myasthenia Gravis Activities of Daily Living (MG-ADL), EQ-5D visual analog, Myasthenia Gravis Composite (MGC) and ACTIVLIM (an ADL questionnaire focusing on generalized weakness) scores in a prospective cohort of 99 MG patients. We investigated correlations between MGII and other outcome measures. We used a generalized linear model to assess whether MGIIgen had an additional sensitivity on top of MG-ADLgen for changes (Δ) in QMGgen in individual patients. RESULTS MGII had a lower floor effect (4%) compared to QMG (6%), MG-ADL (11%) and MGC (16%). MGII correlated well with QMG (r = 0.68), MG-ADL (r = 0.83) and MGC (r = 0.74). As expected, the correlations with EQ visual analog and ACTIVLIM were lower (r = - 0.57 and - 0.48). ΔMGIIgen had an additional value on top of ΔMG-ADLgen in the prediction of ΔQMGgen (B = 0.54, p = 0.01). DISCUSSION The MGII score was cross-culturally validated in a Dutch cohort of MG patients. MGII had a higher sensitivity for generalized weakness than MG-ADL.
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Affiliation(s)
- Robert H P de Meel
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carolina Barnett
- Department of Medicine, Division of Neurology, University Health Network and University of Toronto, Toronto, Canada
| | - Vera Bril
- Department of Medicine, Division of Neurology, University Health Network and University of Toronto, Toronto, Canada.,Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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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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Baseline Decrement in Patients with Mild Myasthenia Gravis Predicts Immunomodulation Treatment. Can J Neurol Sci 2019; 46:762-766. [PMID: 31322098 DOI: 10.1017/cjn.2019.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
To explore whether higher degrees of electrophysiological abnormalities are associated with a more frequent exposure to a more aggressive treatment regimen, we performed a retrospective chart review of patients attending the neuromuscular clinic from June 2012 to December 2015 and included 87 patients. We compared treatment regimens during the follow-up period between patients with high and low jitter and decrement. Myasthenia gravis patients with high jitter or decrement at baseline were more frequently treated with intravenous immunoglobulins (IVIG) and/or plasma exchange (PLEX) during the follow-up period. In patients with mild disease, IVIG or PLEX treatment was associated with high decrement.
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Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against the acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or other AChR-related proteins in the postsynaptic muscle membrane. Localized or general muscle weakness is the predominant symptom and is induced by the antibodies. Patients are grouped according to the presence of antibodies, symptoms, age at onset and thymus pathology. Diagnosis is straightforward in most patients with typical symptoms and a positive antibody test, although a detailed clinical and neurophysiological examination is important in antibody-negative patients. MG therapy should be ambitious and aim for clinical remission or only mild symptoms with near-normal function and quality of life. Treatment should be based on MG subgroup and includes symptomatic treatment using acetylcholinesterase inhibitors, thymectomy and immunotherapy. Intravenous immunoglobulin and plasma exchange are fast-acting treatments used for disease exacerbations, and intensive care is necessary during exacerbations with respiratory failure. Comorbidity is frequent, particularly in elderly patients. Active physical training should be encouraged.
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Barnett C, Bril V, Bayoumi AM. EQ-5D-5L and SF-6D health utility index scores in patients with myasthenia gravis. Eur J Neurol 2018; 26:452-459. [PMID: 30315714 DOI: 10.1111/ene.13836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/08/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Health utilities are a preference-based method of valuing health states that are used in healthcare research, such as economic evaluations. There are limited health utility valuation data for patients with myasthenia gravis (MG). The aim of the study was to describe health utilities for patients with MG and different health states, using the EQ-5D-5L and SF-6D utility instruments, and to explore clinical and demographic determinants of utilities in this population. METHODS Patients completed the EQ-5D-5L and SF-6D. In addition, patients were assessed with the Myasthenia Gravis Foundation of America classification, Myasthenia Gravis Impairment Index and MG-QOL15 as disease-specific measures, and the Neuro-QoL Fatigue scale. We calculated mean utilities for each Myasthenia Gravis Foundation of America severity class. We built regression models for the EQ-5D-5L and SF-6D to determine the clinical and demographic factors that determine patients' valuation of their health state. RESULTS Among 254 patients, mean EQ-5D-5L health utilities were as follows: Remission, 0.94 ± 0.03; Minimal Manifestations, 0.92 ± 0.04; Class I, 0.89 ± 0.06; Class II, 0.78 ± 0.16; Class III, 0.58 ± 0.24 and Class IV, 0.61 ± 0.22. Mean SF-6D health utilities were as follows: Remission, 0.83 ± 0.07; Minimal Manifestations, 0.86 ± 0.14; Class I, 0.82 ± 0.14; Class II, 0.67 ± 0.12; Class III, 0.56 ± 0.11 and Class IV, 0.50 ± 0.10. The limb/axial scores were more highly correlated to health utilities than ocular or bulbar scores. CONCLUSIONS We present estimates of health utilities for patients with MG that can be used in cost-utility and decision analyses. Limb/axial symptoms had a higher impact on health utilities than ocular or bulbar symptoms, which might reflect the impact of mobility on health valuation.
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Affiliation(s)
- C Barnett
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - V Bril
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON
| | - A M Bayoumi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.,Division of General Internal Medicine, Department of Medicine, St, Michael's Hospital, Toronto, ON.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Dimachkie MM, Barohn RJ. Fifty Key Publications on Myasthenia Gravis and Related Disorders. Neurol Clin 2018; 36:xiii-xvii. [PMID: 29655457 DOI: 10.1016/j.ncl.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mazen M Dimachkie
- Professor & Director, Neuromuscular Division, Executive Vice Chairman & Vice Chairman for Research Programs Department of Neurology, Associate Director, Institute for Neurological Discoveries, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 2012, Kansas City, KS 66160, USA.
| | - Richard J Barohn
- Gertrude and Dewey Ziegler Professor of Neurology, University Distinguished Professor Vice Chancellor for Research, President of the Research Institute, Director, Frontiers: University of Kansas Clinical, & Translational Science Institute, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 2012, Kansas City, KS 66160, USA.
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36
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Tran C, Bril V, Katzberg HD, Barnett C. Fatigue is a relevant outcome in patients with myasthenia gravis. Muscle Nerve 2018; 58:197-203. [PMID: 29342314 DOI: 10.1002/mus.26069] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with myasthenia gravis often experience fatigue, but its effect on quality of life (QoL) is underestimated, and fatigue is rarely measured in clinical trials. METHODS Two hundred fifty-seven myasthenic patients completed the Neuro-QoL-Fatigue and measures of disease severity and QoL. We studied the relationship between fatigue and clinical and demographic variables. Finally, we studied the responsiveness of the Neuro-QoL-Fatigue in 95 patients receiving treatments for myasthenia and estimated the minimal important difference (MID). RESULTS Fatigue correlated with greater disease severity (r = 0.52-0.69, P < 0.0001) and worse QoL (r = 0.65-0.75, P < 0.0001). Patients in remission, with minimal manifestations, and pure ocular symptoms reported minimal fatigue. Regression modeling showed that, in addition to its relationship with disease severity, fatigue was worse in females, patients with generalized disease, and those with anxiety/depression. Fatigue improved after immunomodulation (P < 0.0001), and the MID was 5.3 points. DISCUSSION Fatigue in myasthenia correlates with disease severity, affects QoL, and can improve after treatment. Muscle Nerve 58: 197-203, 2018.
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Affiliation(s)
- Christopher Tran
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University Health Network and University of Toronto, 200 Elizabeth Street, 5EC Room 344, Toronto, Ontario, M5G 2C4, Canada
| | - Hans D Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University Health Network and University of Toronto, 200 Elizabeth Street, 5EC Room 344, Toronto, Ontario, M5G 2C4, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Neurology, Department of Medicine, University Health Network and University of Toronto, 200 Elizabeth Street, 5EC Room 344, Toronto, Ontario, M5G 2C4, Canada
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Barnett C, Bril V, Kapral M, Kulkarni AV, Davis AM. Myasthenia Gravis Impairment Index: Responsiveness, meaningful change, and relative efficiency. Neurology 2017; 89:2357-2364. [PMID: 29101274 PMCID: PMC5719924 DOI: 10.1212/wnl.0000000000004676] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/13/2017] [Indexed: 12/01/2022] Open
Abstract
Objective: To study responsiveness and meaningful change of the Myasthenia Gravis Impairment Index (MGII) and its relative efficiency compared to other measures. Methods: We enrolled 95 patients receiving prednisone, IV immunoglobulin (IVIg), or plasma exchange (PLEX) and 54 controls. Patients were assessed with the MGII and other measures—including the Quantitative Myasthenia Gravis Score, Myasthenia Gravis Composite, and Myasthenia Gravis Activities of Daily Living—at baseline and 3–4 weeks after treatment. Statistical markers of responsiveness included between-groups and within-group differences, and we estimated the relative efficiency of the MGII compared to other measures. Patient-meaningful change was assessed with an anchor-based method, using the patient's impression of change. We determined the minimal detectable change (MDC) and the minimal important difference (MID) at the group and individual level. Results: Treated patients had a higher change in MGII scores than controls (analysis of covariance p < 0.001). The ocular domain changed more with prednisone than with IVIg/PLEX (effect size 0.67 and 0.13, analysis of covariance p = 0.001). The generalized domain changed more with IVIg/PLEX than with prednisone (effect size 0.50 and 0.22, analysis of covariance p = 0.07). For the total MGII score, the individual MDC95 was 9.1 and the MID was 5.5 for individuals and 8.1 for groups. Relative efficiency ratios were >1 favoring the MGII. Conclusions: The MGII demonstrated responsiveness to prednisone, IVIg, and PLEX in patients with myasthenia. There is a differential response in ocular and generalized symptoms to type of therapy. The MGII has higher relative efficiency than comparison measures and is viable for use in clinical trials.
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Affiliation(s)
- Carolina Barnett
- From the Division of Neurology (C.B., V.B.), Department of Medicine (M.K.), University of Toronto and University Health Network; Institute of Health Policy, Management and Evaluation (M.K., A.V.K., A.M.D.), and Department of Physical Therapy and Rehabilitation Science Institute (A.M.D.), University of Toronto; Division of Neurosurgery (A.V.K.), Sick Kids Hospital; and Division of Health Care and Outcomes (A.M.D.), Krembil Research Institute, University Health Network, Toronto, Canada.
| | - Vera Bril
- From the Division of Neurology (C.B., V.B.), Department of Medicine (M.K.), University of Toronto and University Health Network; Institute of Health Policy, Management and Evaluation (M.K., A.V.K., A.M.D.), and Department of Physical Therapy and Rehabilitation Science Institute (A.M.D.), University of Toronto; Division of Neurosurgery (A.V.K.), Sick Kids Hospital; and Division of Health Care and Outcomes (A.M.D.), Krembil Research Institute, University Health Network, Toronto, Canada
| | - Moira Kapral
- From the Division of Neurology (C.B., V.B.), Department of Medicine (M.K.), University of Toronto and University Health Network; Institute of Health Policy, Management and Evaluation (M.K., A.V.K., A.M.D.), and Department of Physical Therapy and Rehabilitation Science Institute (A.M.D.), University of Toronto; Division of Neurosurgery (A.V.K.), Sick Kids Hospital; and Division of Health Care and Outcomes (A.M.D.), Krembil Research Institute, University Health Network, Toronto, Canada
| | - Abhaya V Kulkarni
- From the Division of Neurology (C.B., V.B.), Department of Medicine (M.K.), University of Toronto and University Health Network; Institute of Health Policy, Management and Evaluation (M.K., A.V.K., A.M.D.), and Department of Physical Therapy and Rehabilitation Science Institute (A.M.D.), University of Toronto; Division of Neurosurgery (A.V.K.), Sick Kids Hospital; and Division of Health Care and Outcomes (A.M.D.), Krembil Research Institute, University Health Network, Toronto, Canada
| | - Aileen M Davis
- From the Division of Neurology (C.B., V.B.), Department of Medicine (M.K.), University of Toronto and University Health Network; Institute of Health Policy, Management and Evaluation (M.K., A.V.K., A.M.D.), and Department of Physical Therapy and Rehabilitation Science Institute (A.M.D.), University of Toronto; Division of Neurosurgery (A.V.K.), Sick Kids Hospital; and Division of Health Care and Outcomes (A.M.D.), Krembil Research Institute, University Health Network, Toronto, Canada
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Abraham A, Kassardjian CD, Katzberg HD, Bril V, Breiner A. Selective or predominant triceps muscle weakness in African–American patients with myasthenia gravis. Neuromuscul Disord 2017; 27:646-649. [DOI: 10.1016/j.nmd.2017.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/06/2017] [Accepted: 04/18/2017] [Indexed: 12/17/2022]
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Abraham A, Breiner A, Barnett C, Katzberg HD, Bril V. The utility of a single simple question in the evaluation of patients with myasthenia gravis. Muscle Nerve 2017; 57:240-244. [DOI: 10.1002/mus.25720] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 05/29/2017] [Accepted: 06/04/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Alon Abraham
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network; University of Toronto, General Hospital; Room 5 EB 309, 200 Elizabeth Street, Toronto Ontario M5G 2C4 Canada
| | - Ari Breiner
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network; University of Toronto, General Hospital; Room 5 EB 309, 200 Elizabeth Street, Toronto Ontario M5G 2C4 Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network; University of Toronto, General Hospital; Room 5 EB 309, 200 Elizabeth Street, Toronto Ontario M5G 2C4 Canada
| | - Hans D. Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network; University of Toronto, General Hospital; Room 5 EB 309, 200 Elizabeth Street, Toronto Ontario M5G 2C4 Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network; University of Toronto, General Hospital; Room 5 EB 309, 200 Elizabeth Street, Toronto Ontario M5G 2C4 Canada
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Abraham A, Breiner A, Barnett C, Katzberg HD, Lovblom LE, Rt MN, Bril V. Electrophysiological testing is correlated with myasthenia gravis severity. Muscle Nerve 2017; 56:445-448. [PMID: 28029691 DOI: 10.1002/mus.25539] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/07/2016] [Accepted: 12/24/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Electrophysiological studies play an important role in the diagnosis of myasthenia gravis (MG). The objectives of this study was to explore the correlation of jitter and decrement with various clinical symptoms and signs and disease severity. METHODS We performed a retrospective chart review of 75 MG patients who attended the neuromuscular clinic from April 2013 to May 2014. We compared clinical characteristics between patients with high jitter (>100 µs) and decrement (>10%), and patients with lower values to explore the correlations and optimal thresholds of jitter and decrement for different clinical features. RESULTS High jitter and decrement values were associated with more severe disease, manifested by more frequent symptomatic bulbar and limb muscle weakness, more frequent ocular and limb muscle weakness on examination, higher quantitative MG score, and generalized disease. CONCLUSIONS The yield of the electrophysiological assessment in MG extends beyond disease diagnosis and correlates with disease severity and the presence of generalized disease. Muscle Nerve 56: 445-448, 2017.
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Affiliation(s)
- Alon Abraham
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Room 5 EB 309, Toronto, Ontario, Canada, M5G 2C4
| | - Ari Breiner
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Room 5 EB 309, Toronto, Ontario, Canada, M5G 2C4
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Room 5 EB 309, Toronto, Ontario, Canada, M5G 2C4
| | - Hans D Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Room 5 EB 309, Toronto, Ontario, Canada, M5G 2C4
| | - Leif E Lovblom
- Division of Endocrinology and Metabolism, Department of Medicine, Mount Sinai, Hospital and Lunenfeld Tanenbaum Research Institute, University of Toronto, Toronto, Canada
| | - Mylan Ngo Rt
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Room 5 EB 309, Toronto, Ontario, Canada, M5G 2C4
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, Room 5 EB 309, Toronto, Ontario, Canada, M5G 2C4
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What's in the Literature? J Clin Neuromuscul Dis 2017; 18:165-175. [PMID: 28221312 DOI: 10.1097/cnd.0000000000000168] [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]
Abstract
In this edition of this column, we review new studies concerning the pathophysiology, treatment, and outcomes of patients with necrotizing myopathy, genetic testing in congenital myopathies, and limb girdle muscular dystrophies, and the incidence of polyneuropathy in the myotonic dystrophies. Various studies in myasthenia gravis, including those concerning antibody testing, clinical features, and quality of life are also reviewed as are recent findings in congenital myasthenic syndromes. Finally, 2 studies concerning polyneuropathy are discussed, including one on the association of polyneuropathy in patients with the metabolic syndrome and one on laboratory testing in patients with otherwise idiopathic small fiber polyneuropathy.
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