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Torri F, Mancuso M, Siciliano G, Ricci G. Beyond Motor Neurons in Spinal Muscular Atrophy: A Focus on Neuromuscular Junction. Int J Mol Sci 2024; 25:7311. [PMID: 39000416 PMCID: PMC11242411 DOI: 10.3390/ijms25137311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/29/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
5q-Spinal muscular atrophy (5q-SMA) is one of the most common neuromuscular diseases due to homozygous mutations in the SMN1 gene. This leads to a loss of function of the SMN1 gene, which in the end determines lower motor neuron degeneration. Since the generation of the first mouse models of SMA neuropathology, a complex degenerative involvement of the neuromuscular junction and peripheral axons of motor nerves, alongside lower motor neurons, has been described. The involvement of the neuromuscular junction in determining disease symptoms offers a possible parallel therapeutic target. This narrative review aims at providing an overview of the current knowledge about the pathogenesis and significance of neuromuscular junction dysfunction in SMA, circulating biomarkers, outcome measures and available or developing therapeutic approaches.
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Affiliation(s)
- Francesca Torri
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giulia Ricci
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Remijn-Nelissen L, Tannemaat MR, Ruiter AM, Campman YJM, Verschuuren JJGM. Efgartigimod in refractory autoimmune myasthenia gravis. Muscle Nerve 2024. [PMID: 38899431 DOI: 10.1002/mus.28184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 05/27/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION/AIMS Efgartigimod, a neonatal Fc-receptor inhibitor, has recently been approved as treatment for myasthenia gravis (MG). In this retrospective cohort study, we aimed to systematically assess short- and long-term effectiveness of efgartigimod in patients with refractory MG. METHODS Sixteen patients with refractory autoimmune acetylcholine receptor MG were treated with efgartigimod. Data were collected from January 2021 to March 2023 on Myasthenia Gravis Activities of Daily Living (MG-ADL), Quantitative Myasthenia Gravis score (QMG), Myasthenia Gravis Composite score (MGC) and the 15-item revised version of the Myasthenia Gravis Quality of Life questionnaire (MG-QoL15r). RESULTS A favorable outcome was seen in 56% of patients at the last measurement. Out of 16 patients, 50% were an MG-ADL responder after the first treatment cycle. After 4 weeks, a clinically meaningful improvement compared to baseline was seen on the MG-ADL, QMG, and MGC. There was a statistically significant improvement on the MGQoL15r from baseline to week 4. The improvement was maintained until the last measurement for the MGC and the MGQoL15r. At the last visit, all patients had discontinued 4-weekly dosages, shifting to administration frequencies of 1, 2, or 3 weeks. Drug doses could be decreased for prednisolone (n = 7), azathioprine (n = 2), and intravenous immunoglobulin (n = 9). Frequency of plasma exchange was decreased in nine patients. DISCUSSION In patients with refractory MG, efgartigimod was effective for at least half of all patients. Patients required more frequent dosing compared to the ADAPT phase 3 trial. In 80% of the patients concurrent medication could be reduced or discontinued.
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Affiliation(s)
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annabel M Ruiter
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvonne J M Campman
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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Gilhus NE, Andersen H, Andersen LK, Boldingh M, Laakso S, Leopoldsdottir MO, Madsen S, Piehl F, Popperud TH, Punga AR, Schirakow L, Vissing J. Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment. Eur J Neurol 2024; 31:e16229. [PMID: 38321574 DOI: 10.1111/ene.16229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Linda Kahr Andersen
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marion Boldingh
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Sini Laakso
- Department of Neurology, Brain Center, Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | | | - Sidsel Madsen
- The National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Rostedt Punga
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
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Peng S, Meng L, Fang R, Shen Q, Tian Y, Xiong A, Li S, Yang Y, Chang W, Ni J, Zhu W. Current state of research on exercise for the treatment of myasthenia gravis: A scoping review. Complement Ther Med 2024; 81:103033. [PMID: 38458542 DOI: 10.1016/j.ctim.2024.103033] [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: 10/31/2023] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVE To provide a comprehensive overview of existing evidence, research gaps, and future research priorities concerning the treatment of myasthenia gravis (MG) using exercise therapies. METHOD Clinical studies on exercise treatment for MG were searched in nine databases to conduct a scoping review. Two independent researchers screened the literature and comprehensively analyzed the characteristics and limitations of the included articles. RESULTS A total of 5725 studies were retrieved, of which 24 were included. The included studies were conducted in 16 different countries/regions and 456 patients were enrolled. Study designs included both interventional and observational studies. Exercise interventions included aerobic exercise, resistance exercise, balance training, and stretch training, and are typically administered in conjunction with medication, usual care, or some other interventions. The intensity, frequency, and duration of exercise interventions varied hugely among studies. Six-minute walk test, adverse events, muscle strength, MG quality of life-15 scale, forced vital capacity, quantitative MG scale, and MG activities of daily living scale were the most frequently used outcomes. All studies reported results in favor of the efficacy and safety of exercise in MG, and exercise-related adverse events were reported in two studies. CONCLUSION This scoping review provides an overview of the evidence concerning exercise treatment for MG. Key gaps in evidence include a limited number of participants, complex interventions, variability in outcome selection, and insufficient reporting in publications. The promotion of exercise treatment for MG still encounters several obstacles. A larger population, rigorous study design and conduction, standardized interventions and outcomes, and standardized reporting are essential.
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Affiliation(s)
- Siyang Peng
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Linghao Meng
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruiying Fang
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiqi Shen
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yukun Tian
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anni Xiong
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shaohong Li
- Treatment Center of Traditional Chinese Medicine, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Yajing Yang
- Department of Traditional Chinese Medicine, Yuyuantan Community Health Center, Beijing, China
| | - Weiqian Chang
- Department of Acupuncture, Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine Ji'nan Hospital (Ji'nan Hospital of Traditional Chinese Medicine), Shandong, China
| | - Jinxia Ni
- Department of Acupuncture, Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Wenzeng Zhu
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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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:e16280. [PMID: 38523419 DOI: 10.1111/ene.16280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 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 Neurology, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Francesco Saccà
- GENESIS Department, Federico II University of Naples, Naples, Italy
| | - Jennifer Spillane
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, UK
| | - John Vissing
- Copenhagen Neuromuscular Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Bril V, Howard JF, Karam C, De Bleecker JL, Murai H, Utsugisawa K, Ulrichts P, Brauer E, Zhao S, Mantegazza R, Vu T. Effect of efgartigimod on muscle group subdomains in participants with generalized myasthenia gravis: post hoc analyses of the phase 3 pivotal ADAPT study. Eur J Neurol 2024; 31:e16098. [PMID: 37843174 DOI: 10.1111/ene.16098] [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: 07/14/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) is a rare, chronic, neuromuscular autoimmune disease mediated by pathogenic immunoglobulin G (IgG) autoantibodies. Patients with gMG experience debilitating muscle weakness, resulting in impaired mobility, speech, swallowing, vision and respiratory function. Efgartigimod is a human IgG1 antibody Fc fragment engineered for increased binding affinity to neonatal Fc receptor. The neonatal Fc receptor blockade by efgartigimod competitively inhibits endogenous IgG binding, leading to decreased IgG recycling and increased degradation resulting in lower IgG concentration. METHODS The safety and efficacy of efgartigimod were evaluated in the ADAPT study. Key efficacy outcome measures included Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Efgartigimod demonstrated significant improvement in both the MG-ADL and QMG scores. This post hoc analysis aimed to determine whether all subdomains of MG-ADL and QMG improved with efgartigimod treatment. Individual items of MG-ADL and QMG were grouped into four subdomains: bulbar, ocular, limb/gross motor and respiratory. Change from baseline over 10 weeks in each subdomain was calculated for each group. RESULTS Greater improvements from baseline were seen across MG-ADL subdomains in participants treated with efgartigimod compared with placebo. These improvements were typically observed 1 to 2 weeks after the first infusion and correlated with reductions in IgG. Similar results were observed across most QMG subdomains. CONCLUSIONS These post hoc analyses of MG-ADL and QMG subdomain data from ADAPT suggest that efgartigimod is beneficial in improving muscle function and strength across all muscle groups, leading to the observed efficacy in participants with gMG.
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Affiliation(s)
- Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - James F Howard
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Pennsylvania, Philadelphia, USA
| | | | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Tokyo, Japan
| | | | | | | | | | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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Sikorski P, Li Y, Cheema M, Wolfe GI, Kusner LL, Aban I, Kaminski HJ. Serum metabolomics of treatment response in myasthenia gravis. PLoS One 2023; 18:e0287654. [PMID: 37816000 PMCID: PMC10564178 DOI: 10.1371/journal.pone.0287654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/09/2023] [Indexed: 10/12/2023] Open
Abstract
OBJECTIVE High-dose prednisone use, lasting several months or longer, is the primary initial therapy for myasthenia gravis (MG). Upwards of a third of patients do not respond to treatment. Currently no biomarkers can predict clinical responsiveness to corticosteroid treatment. We conducted a discovery-based study to identify treatment responsive biomarkers in MG using sera obtained at study entry to the thymectomy clinical trial (MGTX), an NIH-sponsored randomized, controlled study of thymectomy plus prednisone versus prednisone alone. METHODS We applied ultra-performance liquid chromatography coupled with electro-spray quadrupole time of flight mass spectrometry to obtain comparative serum metabolomic and lipidomic profiles at study entry to correlate with treatment response at 6 months. Treatment response was assessed using validated outcome measures of minimal manifestation status (MMS), MG-Activities of Daily Living (MG-ADL), Quantitative MG (QMG) score, or a strictly defined composite measure of response. RESULTS Increased serum levels of phospholipids were associated with treatment response as assessed by QMG, MMS, and the Responders classification, but all measures showed limited overlap in metabolomic profiles, in particular the MG-ADL. A panel including histidine, free fatty acid (13:0), γ-cholestenol and guanosine was highly predictive of the strictly defined treatment response measure. The AUC in Responders' prediction for these markers was 0.90 irrespective of gender, age, thymectomy or baseline prednisone use. Pathway analysis suggests that xenobiotic metabolism could play a major role in treatment resistance. There was no association with outcome and gender, age, thymectomy or baseline prednisone use. INTERPRETATION We have defined a metabolomic and lipidomic profile that can now undergo validation as a treatment predictive marker for MG patients undergoing corticosteroid therapy. Metabolomic profiles of outcome measures had limited overlap consistent with their assessing distinct aspects of treatment response and supporting unique biological underpinning for each outcome measure. Interindividual variation in prednisone metabolism may be a determinate of how well patients respond to treatment.
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Affiliation(s)
- Patricia Sikorski
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, United States of America
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, United States of America
| | - Yaoxiang Li
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States of America
| | - Mehar Cheema
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, United States of America
| | - Gil I. Wolfe
- Department of Neurology, University at Buffalo/SUNY, Buffalo, New York, United States of America
| | - Linda L. Kusner
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, United States of America
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Henry J. Kaminski
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, United States of America
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Dewilde S, Phillips G, Paci S, De Ruyck F, Tollenaar NH, Janssen MF. People Diagnosed with Myasthenia Gravis have Lower health-related quality of life and Need More Medical and Caregiver Help in Comparison to the General Population: Analysis of Two Observational Studies. Adv Ther 2023; 40:4377-4394. [PMID: 37490259 PMCID: PMC10499690 DOI: 10.1007/s12325-023-02604-z] [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: 03/29/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is a neuromuscular disease causing extreme muscular fatigue, triggering problems with vision, swallowing, speech, mobility, dexterity, and breathing. This analysis intended to estimate the health-related quality-of-life impact, the medical burden, and the need for caregiver help of people diagnosed with MG. METHODS MyRealWorld-MG (MRW) is an observational study among adults diagnosed with MG in 9 countries. The General Population Norms (POPUP) observational study enrolled representative members of the general population in 8 countries. In both digital studies, respondents entered personal characteristics and provided data on medical conditions, EQ-5D-5L, HUI3, MG-Activities of Daily Living (MG-ADL), sick leave, caregiver help, and medical care utilization. RESULTS In MRW (n = 1859), 58.4% of respondents had moderate-to-severe MG. Average utility values were lower in MRW versus POPUP (0.739 vs. 0.843 for EQ-5D-5L; 0.493 vs. 0.746 for HUI3), and declined with more severe disease (0.872, 0.707, 0.511 EQ-5D-5L utilities and 0.695, 0.443, 0.168 HUI3 utilities for mild, moderate, and severe MG, respectively). Taking sick leave in the past month was 2.6 times more frequent among people diagnosed with MG compared to the general population (34.4% vs. 13.2%) and four times more people diagnosed with MG reported needing help from a caregiver (34.8% vs. 8.3%). Use of medical care was twice as likely in MRW in comparison with POPUP (51.9% vs. 24.6%). CONCLUSION This direct comparison of people diagnosed with MG and the general population using two large international studies revealed significant negative impact of MG. Results were consistent across all outcomes, in all countries.
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Affiliation(s)
- S Dewilde
- Services in Health Economics (SHE), Rue JG Eggerickx 36, 1150, Brussels, Belgium.
| | | | - S Paci
- Argenx BV, Ghent, Belgium
| | | | - N H Tollenaar
- Services in Health Economics (SHE), Rue JG Eggerickx 36, 1150, Brussels, Belgium
| | - M F Janssen
- Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
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Lesport Q, Joerger G, Kaminski HJ, Girma H, McNett S, Abu-Rub M, Garbey M. Eye Segmentation Method for Telehealth: Application to the Myasthenia Gravis Physical Examination. SENSORS (BASEL, SWITZERLAND) 2023; 23:7744. [PMID: 37765800 PMCID: PMC10536520 DOI: 10.3390/s23187744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
Due to the precautions put in place during the COVID-19 pandemic, utilization of telemedicine has increased quickly for patient care and clinical trials. Unfortunately, teleconsultation is closer to a video conference than a medical consultation, with the current solutions setting the patient and doctor into an evaluation that relies entirely on a two-dimensional view of each other. We are developing a patented telehealth platform that assists with diagnostic testing of ocular manifestations of myasthenia gravis. We present a hybrid algorithm combining deep learning with computer vision to give quantitative metrics of ptosis and ocular muscle fatigue leading to eyelid droop and diplopia. The method works both on a fixed image and frame by frame of the video in real-time, allowing capture of dynamic muscular weakness during the examination. We then use signal processing and filtering to derive robust metrics of ptosis and l ocular misalignment. In our construction, we have prioritized the robustness of the method versus accuracy obtained in controlled conditions in order to provide a method that can operate in standard telehealth conditions. The approach is general and can be applied to many disorders of ocular motility and ptosis.
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Affiliation(s)
- Quentin Lesport
- Department of Surgery, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
| | | | - Henry J. Kaminski
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Helen Girma
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Sienna McNett
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Mohammad Abu-Rub
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Marc Garbey
- Department of Surgery, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
- Care Constitution Corp., Newark, DE 19702, USA;
- LaSIE, UMR CNRS 7356, Université de la Rochelle, 17000 La Rochelle, France
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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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11
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Zhong H, Huan X, Zhao R, Su M, Yan C, Song J, Xi J, Zhao C, Luo F, Luo S. Peripheral immune landscape for hypercytokinemia in myasthenic crisis utilizing single-cell transcriptomics. J Transl Med 2023; 21:564. [PMID: 37620910 PMCID: PMC10464341 DOI: 10.1186/s12967-023-04421-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is the most prevalent autoimmune disorder affecting the neuromuscular junction. A rapid deterioration in respiratory muscle can lead to a myasthenic crisis (MC), which represents a life-threatening condition with high mortality in MG. Multiple CD4+ T subsets and hypercytokinemia have been identified in the peripheral pro-inflammatory milieu during the crisis. However, the pathogenesis is complicated due to the many types of cells involved, leaving the underlying mechanism largely unexplored. METHODS We conducted single-cell transcriptomic and immune repertoire sequencing on 33,577 peripheral blood mononuclear cells (PBMCs) from two acetylcholine receptor antibody-positive (AChR +) MG patients during MC and again three months post-MC. We followed the Scanpy workflow for quality control, dimension reduction, and clustering of the single-cell data. Subsequently, we annotated high-resolution cell types utilizing transfer-learning models derived from publicly available single-cell immune datasets. RNA velocity calculations from unspliced and spliced mRNAs were applied to infer cellular state progression. We analyzed cell communication and MG-relevant cytokines and chemokines to identify potential inflammation initiators. RESULTS We identified a unique subset of monocytes, termed monocytes 3 (FCGR3B+ monocytes), which exhibited significant differential expression of pro-inflammatory signaling pathways during and after the crisis. In line with the activated innate immune state indicated by MC, a high neutrophil-lymphocyte ratio (NLR) was confirmed in an additional 22 AChR + MC patients in subsequent hemogram analysis and was associated with MG-relevant clinical scores. Furthermore, oligoclonal expansions were identified in age-associated B cells exhibiting high autoimmune activity, and in CD4+ and CD8+ T cells demonstrating persistent T exhaustion. CONCLUSIONS In summary, our integrated analysis of single-cell transcriptomics and TCR/BCR sequencing has underscored the role of innate immune activation which is associated with hypercytokinemia in MC. The identification of a specific monocyte cluster that dominates the peripheral immune profile may provide some hints into the etiology and pathology of MC. However, future functional studies are required to explore causality.
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Affiliation(s)
- Huahua Zhong
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Xiao Huan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Rui Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Manqiqige Su
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chong Yan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chongbo Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Feifei Luo
- Department of Digestive Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China.
| | - Sushan Luo
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China.
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12
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Dewilde S, Janssen MF, Tollenaar NH, Vanoli F, Frangiamore R, Phillips G, Paci S, Mantegazza R, Meisel A, Stascheit F. Concordance between patient- and physician-reported Myasthenia Gravis Activities of Daily Living (MG-ADL) scores. Muscle Nerve 2023. [PMID: 37144893 DOI: 10.1002/mus.27837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION/AIMS Myasthenia gravis (MG) is a neuromuscular disease characterized by abnormal skeletal muscle fatiguability. The MG Activities of Daily Living (MG-ADL) scale assesses eight symptoms and is often used as primary endpoint in MG clinical trials where it is completed by neurologists. However, in observational studies, patients frequently complete the MG-ADL scale independently of their neurologist. In this study we aimed to assess the concordance between self- and physician-reported MG-ADL scores. METHODS An international observational study was conducted among adult patients with MG scheduled for a routine visit or who entered the hospital via emergency services. Consenting patients and physicians completed the MG-ADL. Concordance between assessments was calculated using Gwet's agreement coefficient (Gwet's AC) for the MG-ADL individual items and the intraclass correlation coefficient (ICC) for the MG-ADL total score. RESULTS Data were collected from 137 patients (63% female; mean age, 57.7 years). Physicians assessed the patient's symptoms as slightly more severe (8.1 vs 7.5 MG-ADL total score, respectively), corresponding to a difference of 0.6 on a range from 0 to 24. The ICC for the MG-ADL total score between the patient and the physician assessment was 0.94 (95% confidence interval, 0.89 to 0.95), showing excellent concordance. Gwet's AC showed substantial to almost perfect agreement for all items, except eyelid droop, for which the agreement was moderate. DISCUSSION Our results demonstrate that patients and neurologists have a concordant assessment of the patient's MG symptoms when using the MG-ADL scale. This evidence supports patient self-administration of the MG-ADL in clinical practice and research.
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Affiliation(s)
| | - M F Janssen
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Fiammetta Vanoli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milan, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | - Glenn Phillips
- Health Economics & Outcomes Research, argenx BV, Boston, Massachusetts, USA
| | - Sandra Paci
- Health Economics & Outcomes Research, argenx BV, Boston, Massachusetts, USA
| | | | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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13
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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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14
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Saccà F, Barnett C, Vu T, Peric S, Phillips GA, Zhao S, Qi CZ, Gelinas D, Chiroli S, Verschuuren JJGM. Efgartigimod improved health-related quality of life in generalized myasthenia gravis: results from a randomized, double-blind, placebo-controlled, phase 3 study (ADAPT). J Neurol 2023; 270:2096-2105. [PMID: 36598575 PMCID: PMC10025199 DOI: 10.1007/s00415-022-11517-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/26/2022] [Accepted: 12/03/2022] [Indexed: 01/05/2023]
Abstract
There are substantial disease and health-related quality-of-life (HRQoL) burdens for many patients with myasthenia gravis (MG), especially for those whose disease symptoms are not well controlled. HRQoL measures such as the Myasthenia Gravis Quality of Life 15-item revised (MG-QOL15r) and EuroQoL 5-Dimensions 5-Levels (EQ-5D-5L) are vital for evaluating the clinical benefit of therapeutic interventions in patients with MG, as they assess the burden of disease and the effectiveness of treatment, as perceived by patients. The phase 3 ADAPT study (NCT03669588) demonstrated that efgartigimod-a novel neonatal Fc receptor inhibitor-was well tolerated and that acetylcholine receptor antibody-positive (AChR-Ab+) participants who received efgartigimod had statistically significant improvements in MG-specific clinical scale scores. The ancillary data reported here, which cover an additional treatment cycle, show that these participants had similar significant improvements in HRQoL measures, the MG-QOL15r and EQ-5D-5L utility and visual analog scales, and that these improvements were maintained in the second treatment cycle. Positive effects on HRQoL were rapid, seen as early as the first week of treatment in both treatment cycles, and maintained for up to 4 weeks in the follow-up-only portion of treatment cycles. The pattern of improvements in HRQoL paralleled changes in immunoglobulin G level, and correlational analyses show that improvements were consistent across HRQoL measures and with clinical efficacy measures in the ADAPT study. The substantial and durable improvements in HRQoL end points in this study demonstrate the broader benefit of treatment with efgartigimod beyond relief of immediate signs and symptoms of gMG.
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Affiliation(s)
| | - Carolina Barnett
- Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital/UHN, Toronto, ON, Canada
| | - Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Stojan Peric
- University of Belgrade-Faculty of Medicine, University Clinical Center of Serbia-Neurology Clinic, Belgrade, Serbia
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15
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Dewilde S, Qi CZ, Phillips G, Iannazzo S, Janssen MF. Association Between Myasthenia Gravis-Activities of Daily Living (MG-ADL) and EQ-5D-5L Utility Values: The Additional Effect of Efgartigimod on Utilities. Adv Ther 2023; 40:1818-1829. [PMID: 36867327 PMCID: PMC10070298 DOI: 10.1007/s12325-023-02437-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/17/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION For patients with generalized myasthenia gravis (gMG), the association between symptom severity, often measured with the Myasthenia Gravis Activities of Daily Living (MG-ADL) instrument, and utility values is unknown. METHODS Data was analyzed from the phase 3 ADAPT trial, which included adult patients with gMG randomly assigned to treatment with efgartigimod + conventional therapy (EFG + CT) or placebo + CT (PBO + CT). MG-ADL total symptom scores and the EQ-5D-5L, a measure of health-related quality of life (HRQoL), were collected biweekly up to 26 weeks. Utility values were derived from the EQ-5D-5L data with the United Kingdom value set. Descriptive statistics were reported for MG-ADL and EQ-5D-5L at baseline and follow-up. A normal identity-link regression model estimated the association between utility and the eight MG-ADL items. A generalized estimating equations (GEE) model was estimated to predict utility based on the patient's MG-ADL score and treatment received. RESULTS A total of 167 patients (84 EFG + CT, 83 PBO + CT) contributed 167 baseline and 2867 follow-up measurements of MG-ADL and EQ-5D-5L. EFG + CT-treated patients experienced more improvements than PBO + CT-treated patients in most MG-ADL items and EQ-5D-5L dimensions, with the largest improvements observed in chewing, brushing teeth/combing hair, eyelid droop (MG-ADL); self-care, usual activities, mobility (EQ-5D-5L). The regression model indicated that individual MG-ADL items contributed differently to utility values, with the largest impact from brushing teeth/combing hair, rising from a chair, chewing, and breathing. The GEE model showed that each unit improvement in MG-ADL led to a statistically significant utility increase of 0.0233 (p < 0.001). In addition, a statistically significant improvement of 0.0598 (p = 0.0079) in utility was found for patients in the EFG + CT group compared to the PBO + CT group. CONCLUSION Among patients with gMG, improvements in MG-ADL were significantly associated with higher utility values. MG-ADL scores alone were not sufficient to capture the utility gained from efgartigimod therapy.
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16
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Zhong H, Ruan Z, Yan C, Lv Z, Zheng X, Goh LY, Xi J, Song J, Luo L, Chu L, Tan S, Zhang C, Bu B, Da Y, Duan R, Yang H, Luo S, Chang T, Zhao C. Short-term outcome prediction for myasthenia gravis: an explainable machine learning model. Ther Adv Neurol Disord 2023; 16:17562864231154976. [PMID: 36860354 PMCID: PMC9969443 DOI: 10.1177/17562864231154976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 01/15/2023] [Indexed: 02/26/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and fatigability. The fluctuating nature of the disease course impedes the clinical management. Objective The purpose of the study was to establish and validate a machine learning (ML)-based model for predicting the short-term clinical outcome in MG patients with different antibody types. Methods We studied 890 MG patients who had regular follow-ups at 11 tertiary centers in China from 1 January 2015 to 31 July 2021 (653 patients for derivation and 237 for validation). The short-term outcome was the modified post-intervention status (PIS) at a 6-month visit. A two-step variable screening was used to determine the factors for model construction and 14 ML algorithms were used for model optimisation. Results The derivation cohort included 653 patients from Huashan hospital [age 44.24 (17.22) years, female 57.6%, generalized MG 73.5%], and the validation cohort included 237 patients from 10 independent centers [age 44.24 (17.22) years, female 55.0%, generalized MG 81.2%]. The ML model identified patients who were improved with an area under the receiver operating characteristic curve (AUC) of 0.91 [0.89-0.93], 'Unchanged' 0.89 [0.87-0.91], and 'Worse' 0.89 [0.85-0.92] in the derivation cohort, whereas identified patients who were improved with an AUC of 0.84 [0.79-0.89], 'Unchanged' 0.74 [0.67-0.82], and 'Worse' 0.79 [0.70-0.88] in the validation cohort. Both datasets presented a good calibration ability by fitting the expectation slopes. The model is finally explained by 25 simple predictors and transferred to a feasible web tool for an initial assessment. Conclusion The explainable, ML-based predictive model can aid in forecasting the short-term outcome for MG with good accuracy in clinical practice.
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Affiliation(s)
| | | | | | - Zhiguo Lv
- Department of Neurology, The Affiliated
Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Xueying Zheng
- Department of Biostatistics, School of Public
Health and Key Laboratory of Public Health Safety, Fudan University,
Shanghai, China
| | - Li-Ying Goh
- Shanghai Medical College, Fudan University,
Shanghai, China
| | - Jianying Xi
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Jie Song
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital,
Wuhan, China
| | - Lan Chu
- Department of Neurology, The Affiliated
Hospital of Guizhou Medical University, Guiyang, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial
People’s Hospital, University of Electronic Science and Technology of China,
Chengdu, China
| | - Chao Zhang
- Department of Neurology and Tianjin
Neurological Institute, Tianjin Medical University General Hospital,
Tianjin, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital,
Capital Medical University, Beijing, China
| | - Ruisheng Duan
- Department of Neurology, The First Affiliated
Hospital of Shandong First Medical University, Jinan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital,
Central South University, Changsha, China
| | | | - Ting Chang
- Department of Neurology, Tangdu Hospital, The
Air Force Medical University, Xi’an 710000, China
| | - Chongbo Zhao
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China,National Center for Neurological Disorders,
Shanghai, China
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17
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Dewilde S, Philips G, Paci S, Beauchamp J, Chiroli S, Quinn C, Day L, Larkin M, Palace J, Berrih-Aknin S, Claeys KG, Muppidi S, Mantegazza R, Saccà F, Meisel A, Bassez G, Murai H, Janssen MF. Patient-reported burden of myasthenia gravis: baseline results of the international prospective, observational, longitudinal real-world digital study MyRealWorld-MG. BMJ Open 2023; 13:e066445. [PMID: 36720569 PMCID: PMC9890761 DOI: 10.1136/bmjopen-2022-066445] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Myasthenia gravis (MG) is a rare, chronic, autoimmune neuromuscular disease which can affect functional and mental aspects of health and health-related quality of life (HRQoL). This study aims to obtain detailed knowledge of the impact of MG on HRQoL in a broad population from the perspective of the patient. DESIGN Prospective, observational, digital, longitudinal real-world study. SETTING Adult patients with MG from seven countries (USA, Japan, Germany, UK, Italy, Spain and Canada) downloaded a mobile application onto their phones and entered data about themselves and their MG. OUTCOME MEASURES Data was collected using the following general and disease-specific patient-reported outcome measurements: EuroQol 5 Domains Health-Related Quality of Life Questionnaire (EQ-5D-5L), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Quality of Life 15-item revised scale (MG-QoL-15r), Hospital Anxiety and Depression Scale (HADS) and Health Utilities Index III (HUI3). Patients were categorised by their self-assessed Myasthenia Gravis Foundation of America (MGFA) class (I-V). RESULTS Baseline results of 841 participants (mean age 47 years, 70% women) are reported . The distribution across the MGFA classes was: 13.9%, 31.0%, 38.1%, 15.5% and 1.6% for classes I-V. The MGFA class was a strong predictor of all aspects of HRQoL, measured with disease-specific and with generic instruments. The domains in which patients with MG most frequently mentioned problems were usual activities, anxiety and depression, tiredness, breathing and vision. The mean total MG-ADL Score was positively associated with increasing MGFA classes: 2.7, 4.4, 6.3 and 8.4 for MGFA classes I-IV. Mean baseline EQ-5D-5L utility was also associated with MGFA classes and was 0.817, 0.766, 0.648 and 0.530 for MGFA class I-IV. CONCLUSIONS MG has a large impact on key aspects of health and HRQoL. The impact of this disease increases substantially with increasing disease severity.
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Affiliation(s)
| | | | - Sandra Paci
- Market Access & Patient Advocacy, argenx, Ghent, Belgium
| | - Jon Beauchamp
- Market Access & Patient Advocacy, argenx, Ghent, Belgium
| | | | | | | | | | | | - Sonia Berrih-Aknin
- INSERM, Institute of Myology, Center of Research in Myology, Sorbonne Université, Paris, France
| | - Kristl G Claeys
- Department of Neurology, KU Leuven University Hospitals, Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University, Stanford, California, USA
| | - Renato Mantegazza
- Fondazione IRCCS, Istituto Nazionale Neurologico Carlo Besta, Milano, Italy
- Associazione Italiana Miastenia e Malattie Immunodegenerative, Milan, Italy
| | - Francesco Saccà
- DNSRO Department, University of Naples Federico II, Napoli, Italy
| | - Andreas Meisel
- Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Guillaume Bassez
- Neuromuscular Diseases Reference Center, Pitié-Salpêtrière University Hospital, Paris, France
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - M F Janssen
- Department of Medical Psychology and Psychotherapy, Erasmus University Rotterdam, Rotterdam, The Netherlands
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18
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Aktoz G, Boz C, Zengin S, Okumus AC, Horozoglu H, Kara F, Oral E, Ozmenoglu M. Clinical course and outcome of Covid-19 in patients with myasthenia gravis. Neurol Res 2023; 45:583-589. [PMID: 36681934 DOI: 10.1080/01616412.2023.2167536] [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: 01/23/2023]
Abstract
OBJECTIVES To analyze the prognosis and outcomes of COVID-19 in patients with MG and to determine factors associated with COVID-19 severity in patients with MG. METHODS Information concerning COVID-19 occurrence in patients with MG was collected in this single-center observational study. Univariate and multivariate analyses were used to identify factors associated with severe Covid-19. RESULTS Two hundred seventy-five of the 386 records of MG were included in this study. Eighty-two (29.8%) patients had concurrent COVID-19 . The patients' mean age was 50.3 ± 1.6 years, and the mean duration of MG was 6.7 ± 5.4 years. MG was diagnosed after COVID-19 in five cases. Covid-19 was mild in 45 patients (54.9%), moderate in 23 (28.1%), and severe in 14 (17.07%), while mortality occurred in four of the severe cases (4.9%). Three of the exitus patients were receiving rituximab therapy. Pre-Covid MG Activity of Daily Living (MG-ADL) severity scores were significantly high in severe cases. A history of myasthenic crisis was also higher in severe cases. Similarly, univariate and multivariate analyses revealed an association between severe COVID-19 and myasthenic crisis history and high pre-Covid MG-ADL. The type of MG treatment had no independent effect on COVID-19 severity. CONCLUSION The vast majority of the MG patients made a good recovery from Covid-19. The risk of severe COVID-19 is high in patients with high MG-ADL severity scores and a history of myasthenic crisis.
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Affiliation(s)
- Gonulden Aktoz
- Faculty of Health Sciences, Infectious Disease and Clinical Microbiology, Avrasya University, Trabzon, Turkey
| | - Cavit Boz
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Serap Zengin
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | | | - Hilal Horozoglu
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Fatma Kara
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Ebru Oral
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
| | - Mehmet Ozmenoglu
- Department of Neurology, Karadeniz Technical University, Trabzon, Turkey
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19
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Kaminski HJ, Denk J. Corticosteroid Treatment-Resistance in Myasthenia Gravis. Front Neurol 2022; 13:886625. [PMID: 35547366 PMCID: PMC9083070 DOI: 10.3389/fneur.2022.886625] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/21/2022] [Indexed: 12/25/2022] Open
Abstract
Chronic, high-dose, oral prednisone has been the mainstay of myasthenia gravis treatment for decades and has proven to be highly beneficial in many, toxic in some way to all, and not effective in a significant minority. No patient characteristics or biomarkers are predictive of treatment response leading to many patients suffering adverse effects with no benefit. Presently, measurements of treatment response, whether taken from clinician or patient perspective, are appreciated to be limited by lack of good correlation, which then complicates correlation to biological measures. Treatment response may be limited because disease mechanisms are not influenced by corticosteroids, limits on dosage because of adverse effects, or individual differences in corticosteroids. This review evaluates potential mechanisms that underlie lack of response to glucocorticoids in patients with myasthenia gravis.
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Affiliation(s)
- Henry J Kaminski
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
| | - Jordan Denk
- Department of Neurology and Rehabilitation Medicine, George Washington University, Washington, DC, United States
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20
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Nelke C, Schroeter CB, Stascheit F, Pawlitzki M, Regner-Nelke L, Huntemann N, Arat E, Öztürk M, Melzer N, Mergenthaler P, Gassa A, Stetefeld H, Schroeter M, Berger B, Totzeck A, Hagenacker T, Schreiber S, Vielhaber S, Hartung HP, Meisel A, Wiendl H, Meuth SG, Ruck T. Eculizumab versus rituximab in generalised myasthenia gravis. J Neurol Neurosurg Psychiatry 2022; 93:548-554. [PMID: 35246490 PMCID: PMC9016243 DOI: 10.1136/jnnp-2021-328665] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/22/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Myasthenia gravis (MG) is the most common autoimmune disorder affecting the neuromuscular junction. However, evidence shaping treatment decisions, particularly for treatment-refractory cases, is sparse. Both rituximab and eculizumab may be considered as therapeutic options for refractory MG after insufficient symptom control by standard immunosuppressive therapies. METHODS In this retrospective observational study, we included 57 rituximab-treated and 20 eculizumab-treated patients with MG to compare the efficacy of treatment agents in generalised, therapy-refractory anti-acetylcholine receptor antibody (anti-AChR-ab)-mediated MG with an observation period of 24 months. Change in the quantitative myasthenia gravis (QMG) score was defined as the primary outcome parameter. Differences between groups were determined in an optimal full propensity score matching model. RESULTS Both groups were comparable in terms of clinical and demographic characteristics. Eculizumab was associated with a better outcome compared with rituximab, as measured by the change of the QMG score at 12 and 24 months of treatment. Minimal manifestation of disease was more frequently achieved in eculizumab-treated patients than rituximab-treated patients at 12 and 24 months after baseline. However, the risk of myasthenic crisis (MC) was not ameliorated in either group. INTERPRETATION This retrospective, observational study provides the first real-world evidence supporting the use of eculizumab for the treatment of refractory, anti-AChR-ab positive MG. Nonetheless, the risk of MC remained high and prompts the need for intensified monitoring and further research effort aimed at this vulnerable patient cohort.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | | | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc Pawlitzki
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany.,Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Liesa Regner-Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Niklas Huntemann
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Ercan Arat
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Menekse Öztürk
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Nico Melzer
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Philipp Mergenthaler
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Asmae Gassa
- Department of Cardiothoracic Surgery, University Hospital Cologne, Koln, Germany
| | - Henning Stetefeld
- Departement of Neurology, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | | | - Benjamin Berger
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Freiburg, Germany
| | - Andreas Totzeck
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefan Vielhaber
- Otto von Guericke Universität Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology - Inflammatory Disorders of the Nervous System and Neurooncology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
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21
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Beretta F, Huang YF, Punga AR. Towards Personalized Medicine in Myasthenia Gravis: Role of Circulating microRNAs miR-30e-5p, miR-150-5p and miR-21-5p. Cells 2022; 11:cells11040740. [PMID: 35203389 PMCID: PMC8870722 DOI: 10.3390/cells11040740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disease characterized by fatigable skeletal muscle weakness with a fluctuating unpredictable course. One main concern in MG is the lack of objective biomarkers to guide individualized treatment decisions. Specific circulating serum microRNAs (miRNAs) miR-30e-5p, miR-150-5p and miR-21-5p levels have been shown to correlate with clinical course in specific MG patient subgroups. The aim of our study was to better characterize these miRNAs, regardless of the MG subgroup, at an early stage from diagnosis and determine their sensitivity and specificity for MG diagnosis, as well as their predictive power for disease relapse. Serum levels of these miRNAs in 27 newly diagnosed MG patients were compared with 245 healthy individuals and 20 patients with non-MG neuroimmune diseases. Levels of miR-30e-5p and miR-150-5p significantly differed between MG patients and healthy controls; however, no difference was seen compared with patients affected by other neuroimmune diseases. High levels of miR-30e-5p predicted MG relapse (p = 0.049) with a hazard ratio of 2.81. In summary, miR-150-5p is highly sensitive but has low specificity for MG, while miR-30e-5p has the greatest potential as a predictive biomarker for the disease course in MG, regardless of subgroup.
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Affiliation(s)
- Francesca Beretta
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy;
| | - Yu-Fang Huang
- Department of Medical Sciences, Clinical Neurophysiology, Uppsala University, 75185 Uppsala, Sweden;
| | - Anna Rostedt Punga
- Department of Medical Sciences, Clinical Neurophysiology, Uppsala University, 75185 Uppsala, Sweden;
- Correspondence:
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22
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Punga AR, Maddison P, Heckmann JM, Guptill JT, Evoli A. Epidemiology, diagnostics, and biomarkers of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:176-188. [DOI: 10.1016/s1474-4422(21)00297-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/18/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022]
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23
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Thomsen JLS, Vinge L, Harbo T, Andersen H. A population-based follow-up study of maximal muscle strength and mobility in patients with myasthenia gravis. Neuromuscul Disord 2022; 32:305-312. [DOI: 10.1016/j.nmd.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 01/23/2022] [Accepted: 02/15/2022] [Indexed: 10/19/2022]
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24
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Faghani S, Okhvat AA, Karimi N, Moassefi M, Maroufi SF, Nafissi S, Fatehi F. Validation of myasthenia gravis activity of daily living questionnaire: Persian version. CURRENT JOURNAL OF NEUROLOGY 2022; 21:35-39. [PMID: 38011442 PMCID: PMC9527858 DOI: 10.18502/cjn.v21i1.9360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/21/2021] [Indexed: 11/24/2022]
Abstract
Background: The 8-item myasthenia gravis activity of daily living (MG-ADL) questionnaire is a valid and reliable instrument for evaluating myasthenia gravis (MG)-associated disability. This study aims to assess its validity and reliability in the Iranian population. Methods: A total number of 58 patients with MG were qualified for the examination. All 58 patients completed the Persian translation of 15-item Myasthenia Gravis Quality of Life (MG-QOL15) and MG-ADL questionnaires initially, and 30 filled out the MG-ADL questionnaire 2 to 4 weeks after the initial visit. Pearson correlation coefficient of questionnaires, internal consistency using Cronbach's alpha (α), and test-retest repeatability of the questionnaire were evaluated. Results: The Pearson correlation coefficient of Persian versions of MG-QOL and MG-ADL was 0.93 (P < 0.01). The Persian MG-ADL showed satisfactory internal consistency (Cronbach's α = 0.89) and test-retest reliability (r = 0.99, P < 0.01). Conclusion: The Persian MG-ADL is a valid and reliable questionnaire for the determination of activities of daily life in Iranian patients with MG.
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Affiliation(s)
- Shahriar Faghani
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Asghar Okhvat
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Karimi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Immunogenetics Research Center, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mana Moassefi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shahriar Nafissi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Fatehi
- Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Neuromuscular Research Center, Tehran University of Medical Sciences, Tehran, Iran
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25
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Bonanno S, Zanin R, Bello L, Tramacere I, Bozzoni V, Caumo L, Ferraro M, Bortolani S, Sorarù G, Silvestrini M, Vacchiano V, Turri M, Tanel R, Liguori R, Coccia M, Mantegazza RE, Mongini T, Pegoraro E, Maggi L. Quality of life assessment in adult spinal muscular atrophy patients treated with nusinersen. J Neurol 2022; 269:3264-3275. [PMID: 34978620 DOI: 10.1007/s00415-021-10954-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To retrospectively evaluate quality of life (QoL) in a large multicenter cohort of adult patients affected by spinal muscular atrophy (SMA) during nusinersen treatment. METHODS We included adult (≥ 18 years) patients clinically and genetically defined as SMA2, SMA3 and SMA4, who started nusinersen treatment in adulthood. QoL was rated by the Individualized Neuromuscular Quality of Life (INQoL) questionnaire. Concurrent motor function evaluation included the Hammersmith Functional Motor Scale Expanded (HFMSE), the Revised Upper Limb Module (RULM), the 6 min walking test (6MWT). RESULTS 189 completed questionnaires were collected during a 14 months' treatment period. 78 patients were included (7 SMA2 and 69 SMA3 and 2 SMA4) with mean disease duration at first nusinersen administration of 33.2 years (± 12.5 years). All the scores for each INQoL domain (weakness, fatigue, activities, independence, social relationship, emotions, body images) and the derived QoL total score, significantly improved during the observation period, except the muscle locking and pain items. Exploratory analyses suggested that emotions and social relationships were more relevant issues for females compared to males. Social relationships were affected also by a longer disease duration (> 30 years). In SMA3 non-walker patients, activities ameliorate better compared to walkers. The HFMSE and RULM significantly improved from baseline; however, no associations with QoL total score and weakness, activities or independence were demonstrated. CONCLUSION In our cohort, adult SMA patients showed a global improvement at the INQoL assessment over 14 months of nusinersen treatment. QoL assessment is relevant to SMA multidisciplinary evaluation.
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Affiliation(s)
- Silvia Bonanno
- Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, via Celoria 11, 20133, Milan, Italy
| | - Riccardo Zanin
- Developmental Neurology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Luca Bello
- Department of Neuroscience, Myology Institute, University of Padova, Padua, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Virginia Bozzoni
- Department of Neuroscience, Myology Institute, University of Padova, Padua, Italy
| | - Luca Caumo
- Department of Neuroscience, Myology Institute, University of Padova, Padua, Italy
| | - Manfredi Ferraro
- Department of Neurosciences Rita Levi Montalcini, Neuromuscular Center, University of Torino, Turin, Italy
| | - Sara Bortolani
- Department of Neurosciences Rita Levi Montalcini, Neuromuscular Center, University of Torino, Turin, Italy
| | - Gianni Sorarù
- Department of Neuroscience, Myology Institute, University of Padova, Padua, Italy
| | - Mauro Silvestrini
- Department of Neurological Sciences, Ospedali Riuniti di Ancona, Ancona, Italy.,Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Veria Vacchiano
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Mara Turri
- Department of Neurology/Stroke Unit, San Maurizio Hospital, Bolzano, Italy
| | | | - Rocco Liguori
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Michela Coccia
- Department of Neurological Sciences, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Renato Emilio Mantegazza
- Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, via Celoria 11, 20133, Milan, Italy
| | - Tiziana Mongini
- Department of Neurosciences Rita Levi Montalcini, Neuromuscular Center, University of Torino, Turin, Italy
| | - Elena Pegoraro
- Department of Neuroscience, Myology Institute, University of Padova, Padua, Italy
| | - Lorenzo Maggi
- Neuroimmunology and Neuromuscular Disease Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, via Celoria 11, 20133, Milan, Italy.
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26
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Pascuzzi RM, Bodkin CL. Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome: New Developments in Diagnosis and Treatment. Neuropsychiatr Dis Treat 2022; 18:3001-3022. [PMID: 36578903 PMCID: PMC9792103 DOI: 10.2147/ndt.s296714] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
"Myasthenia Gravis is, like it or not, the neurologist's disease!" (Thomas Richards Johns II, MD Seminars in Neurology 1982). The most common disorders in clinical practice involving defective neuromuscular transmission are myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS). The hallmark of weakness related to malfunction of the neuromuscular junction (NMJ) is variability in severity of symptoms from minute to minute and hour to hour. Fatigable weakness and fluctuation in symptoms are common in patients whether the etiology is autoimmune, paraneoplastic, genetic, or toxic. Autoimmune MG is the most common disorder of neuromuscular transmission affecting adults with an estimated prevalence of 1 in 10,000. While LEMS is comparatively rare, the unique clinical presentation, the association with cancer, and evolving treatment strategies require the neurologist to be familiar with its presentation, diagnosis, and management. In this paper we provide a summary of the meaningful recent clinical developments in the diagnosis and treatment of both MG and LEMS.
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Affiliation(s)
- Robert M Pascuzzi
- Indiana University School of Medicine, Indiana University Health, Indianapolis, IN, USA
| | - Cynthia L Bodkin
- Indiana University School of Medicine, Indiana University Health, Indianapolis, IN, USA
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27
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Marcuse F, Brandts L, Moens D, Damoiseaux J, Hochstenbag M, Hoeijmakers JGJ, Maessen JG, De Baets M. The association between anti-acetylcholine receptor antibody level and clinical improvement in myasthenia gravis. Eur J Neurol 2021; 29:1187-1197. [PMID: 34967067 PMCID: PMC9303954 DOI: 10.1111/ene.15238] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anti-AChR-antibodies in the serum are detected in most patients with generalized myasthenia gravis (MG) and used as a diagnostic tool. The aim of this study was to analyse a possible association between anti-AChR-antibody serum levels and clinical improvement of MG. METHODS The Maastricht University Medical Center is a centre of expertise for the treatment of MG. Between 1997 till 2020, more than 4.000 anti-AChR-antibodies were measured for clinical care using quantitative radioimmunoassay (RIA) technique. These results, in combination with the clinical status obtained from the patients' electronic patient files, were retrospectively analysed by a single blinded clinician. Symptoms of MG were classified by the Myasthenia Gravis Foundation of America (MGFA). RESULTS In total, 90 anti-AChR-antibody positive MG-patients with 837 blood samples were included. Median follow-up time was 72 months. The majority of the included patients were female (61.1%), on immunosuppressive drug therapy (88.9%), and did undergo a thymectomy (54.4%). Multilevel logistic regression analysis showed a significantly inverse association between change in anti-AChR-antibody level and the odds of MGFA improvement (per 10 percent decrease of anti-AChR-antibody level OR: 1.21, CI: 1.12-1.31, p <0.001). CONCLUSIONS A change in anti-AChR-antibody serum level is associated with the clinical status in patients with MG. Analyses of anti-AChR-antibody are not only useful for diagnostics but also in follow-up of adult symptomatic patients with MG. The use of repetitive anti-AChR-antibody serum levels might be valuable as a long-term monitor for clinical improvement in patients with MG, however, further research is required for specific recommendations.
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Affiliation(s)
- Florit Marcuse
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Pulmonology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Daan Moens
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Monique Hochstenbag
- Department of Pulmonology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Janneke G J Hoeijmakers
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Neurology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marc De Baets
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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28
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Pharmacological Management of Myasthenia Gravis: A Century of Expert Opinions in Cecil Textbook of Medicine. Am J Ther 2021; 28:e631-e637. [PMID: 34757964 DOI: 10.1097/mjt.0000000000001454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Advances in drug therapy for myasthenia gravis have had a significant impact on the quality of life and work potential of a substantial majority of affected persons and has contributed to a remarkable decrease in the frequency and severity of complications, hospitalizations, and mortality. STUDY QUESTION What are the milestones of the changes in the expert approach to the pharmacological management of myasthenia in the past century? STUDY DESIGN To determine the changes in the experts' approach to the management of myasthenia gravis, as presented in a widely used textbook in the United States. DATA SOURCES The chapters presenting the management of myasthenia gravis in the 26 editions of Cecil Textbook of Medicine published from 1927 to 2020. RESULTS Adequate feeding, absolute rest in bed, and "tonics" were the only interventions recommended for the care of patients with myasthenia gravis in 1927. Ephedrine and glycine were used in the early 1930s. Treatment with the anticholinesterases physostigmine and neostigmine was recommended in 1937, 3 years after Mary Walker discovered it in the United Kingdom. Immunosuppressant pharmacological interventions with prednisone and azathioprine have been considered the standard since 1975, and intravenous immune globulin was added to usual care in 1996. The newer immunosuppressant drugs mycophenolate, cyclosporine, and tacrolimus have expanded the arsenal since 2008, and the monoclonal antibodies rituximab and eculizumab have been mentioned in the textbooks published in 2012-2020. The first randomized clinical trial of drug therapy for myasthenia gravis was published in 1987. CONCLUSIONS The pharmacological management of myasthenia gravis was revolutionized by the epiphany of an astute clinician in the 1930s. Immunosuppressant treatment was a logical step once the autoimmune nature of the condition was established. The major therapeutic advances highlight the values of empiricism and persistent attention to detail in treating relatively rare chronic disorders.
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29
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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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30
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Menon D, Urra Pincheira A, Bril V. Emerging drugs for the treatment of myasthenia gravis. Expert Opin Emerg Drugs 2021; 26:259-270. [PMID: 34228579 DOI: 10.1080/14728214.2021.1952982] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Advances in understanding the immune pathomechanisms in myasthenia gravis (MG) allow for the development of novel targeted immune therapies. By working at specific points in the immunopathogenesis, these agents have the potential to provide rapid and efficacious responses compared to conventional immunosuppressive therapy (IST), addressing unmet needs and consequently are a research priority.Areas covered: This paper reviews the advances in MG treatment modalities with their scientific rationale. A search of clinicaltrials.gov and a literature search of PubMed from January 2015 to the end of June 2021 was done using the search terms: MG, treatment, immune targets to obtain information on recent developments of complement inhibitors, FcRn receptor inhibitors, direct and indirect B cell inhibitors, CAR and CAAR- T cell therapy, and hematopoietic stem cell transplantation. Specific agents in various phases of clinical development, evidence from ongoing trials and potential roadblocks are examined.Expert opinion: Despite several promising novel agents, existing data as to the timing of initiation and duration of treatment, long-term safety profile and utility in certain patient subsets are limited and require further research. Despite these considerations, the future of MG treatment is transitioning from broad-spectrum IST toward precise, target-driven and personalized immunotherapy.
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Affiliation(s)
- Deepak Menon
- Department of Medicine, Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Alejandra Urra Pincheira
- Department of Medicine, Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Department of Medicine, Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
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31
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Youn BY, Ko Y, Moon S, Lee J, Ko SG, Kim JY. Digital Biomarkers for Neuromuscular Disorders: A Systematic Scoping Review. Diagnostics (Basel) 2021; 11:diagnostics11071275. [PMID: 34359358 PMCID: PMC8307187 DOI: 10.3390/diagnostics11071275] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Abstract
Biomarkers play a vital role in clinical care. They enable early diagnosis and treatment by identifying a patient's condition and disease course and act as an outcome measure that accurately evaluates the efficacy of a new treatment or drug. Due to the rapid development of digital technologies, digital biomarkers are expected to grow tremendously. In the era of change, this scoping review was conducted to see which digital biomarkers are progressing in neuromuscular disorders, a diverse and broad-range disease group among the neurological diseases, to discover available evidence for their feasibility and reliability. Thus, a total of 10 studies were examined: 9 observational studies and 1 animal study. Of the observational studies, studies were conducted with amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy (SMA) patients. Non-peer reviewed poster presentations were not considered, as the articles may lead to erroneous results. The only animal study included in the present review investigated the mice model of ALS for detecting rest disturbances using a non-invasive digital biomarker.
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Affiliation(s)
- Bo-Young Youn
- Department of Global Public Health and Korean Medicine Management, Graduate School, Kyung Hee University, Seoul 02447, Korea; (B.-Y.Y.); (S.M.)
| | - Youme Ko
- Department of Preventive Medicine, Kyung Hee University, Seoul 02447, Korea; (Y.K.); (S.-G.K.)
| | - Seunghwan Moon
- Department of Global Public Health and Korean Medicine Management, Graduate School, Kyung Hee University, Seoul 02447, Korea; (B.-Y.Y.); (S.M.)
| | - Jinhee Lee
- Department of Korean Medicine, Graduate School, Kyung Hee University, Seoul 02447, Korea;
| | - Seung-Gyu Ko
- Department of Preventive Medicine, Kyung Hee University, Seoul 02447, Korea; (Y.K.); (S.-G.K.)
| | - Jee-Young Kim
- Department of Neurology, Cheongna Best Rehabilitation Hospital, Incheon 22883, Korea
- Correspondence:
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32
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Development of a Computerized Adaptive Test for Quantifying Chinese Medicine Syndrome of Myasthenia Gravis on Basis of Multidimensional Item Response Theory. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021. [PMID: 34122609 DOI: 10.1155/2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Making comprehensive management of myasthenia gravis (MG) is a challenge in clinical practice due to heterogeneity and multiple comorbidities among patients. AIM To develop an end-to-end instrument for individualized assessment of MG in the perspective of Chinese medicine (TCM) with the application of multidisciplinary quantification approaches. METHODS A self-administrated questionnaire was developed integrating typical symptoms of MG and spleen-kidney deficiency syndrome on basis of the conceptual framework of TCM. With data collected in a multicenter cross-sectional study, confirmatory factor analysis together with multidimensional item response theory (MIRT) was used for evaluating the psychometric property of the questionnaire. A computerized adaptive test was developed based on the MIRT model, and scores of syndrome factors were calculated in simulation. A logistics regression model was also estimated for evaluating the consistency between the quantitative result and the clinical diagnosis of syndrome from clinical practitioners. RESULT With 337 patients enrolled and assessed, the 14-item questionnaire was evaluated to be with adequate validity and reliability (Cronbach's alpha indices = 0.87, AIC = 195.827, BIC = 348.631, CFI = 0.921, RMR = 0.006, GFI = 0.954, RMSEA = 0.048, and χ2/df = 1.782). With adequate factor loadings of symptoms on related syndrome factor, the instrument was evaluated with preliminary interpretation and was suitable for evaluating patients with moderate severity of the spleen and kidney deficiency syndrome. CONCLUSION Setting typical symptoms of MG together with systemic discomforts in a computerized adaptive test on the basis of MIRT, this study proposed an innovative research paradigm for quantifying individual condition in the perspective of TCM with application of interdisciplinary approaches.
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33
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Thomsen JLS, Vinge L, Harbo T, Andersen H. Gender differences in clinical outcomes in myasthenia gravis: A prospective cohort study. Muscle Nerve 2021; 64:538-544. [PMID: 34036597 DOI: 10.1002/mus.27331] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION/AIMS It is uncertain whether clinical outcomes differ between male and female patients with myasthenia gravis (MG) while receiving standard clinical care. METHODS In a prospective cohort study of 107 patients with MG receiving standard of care from 2012 to 2019, the Quantitative MG (QMG), the MG Composite (MGC), the MG Activities of Daily Living (MG-ADL), and the MG Quality of Life 15-Items (QOL15) were determined. Clinical outcomes were analyzed in relation to gender. RESULTS Mean follow-up time was 4.8 (±0.4) y, and 70 patients completed all follow-up assessments. Patients improved on all clinical scores: QMG -1.8 (P < .001), MGC -1.5 (P < .001), MG-ADL -1.3 (P < .001), and QOL15 -3.0 (P < .001). Females improved less than males on the QMG (P = .01), MGC (P < .001), MG-ADL (P = .006), and QOL15 (P < .001) independent of potential confounders. Males had moderate to strong correlations between changes in all clinical scales (r range 0.52 to 0.73), whereas females had weak correlations between changes in the QMG and MG-ADL (r = 0.13), the QMG and QOL15 (r = 0.27), the MGC and MG-ADL (r = 0.21), the MGC and QOL15 (r = 0.00), and the MG-ADL and QOL15 (r = 0.31). DISCUSSION Females improved less compared to males on objective and patient-reported outcomes. Moreover, females improved more on objective measures than on patient-reported outcomes. These gender differences should receive attention in clinical care and in the design of future trials.
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Affiliation(s)
- Jan L S Thomsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Lotte Vinge
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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34
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Development of a Computerized Adaptive Test for Quantifying Chinese Medicine Syndrome of Myasthenia Gravis on Basis of Multidimensional Item Response Theory. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:9915503. [PMID: 34122609 PMCID: PMC8166489 DOI: 10.1155/2021/9915503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/29/2021] [Accepted: 04/03/2021] [Indexed: 11/30/2022]
Abstract
Background Making comprehensive management of myasthenia gravis (MG) is a challenge in clinical practice due to heterogeneity and multiple comorbidities among patients. Aim To develop an end-to-end instrument for individualized assessment of MG in the perspective of Chinese medicine (TCM) with the application of multidisciplinary quantification approaches. Methods A self-administrated questionnaire was developed integrating typical symptoms of MG and spleen-kidney deficiency syndrome on basis of the conceptual framework of TCM. With data collected in a multicenter cross-sectional study, confirmatory factor analysis together with multidimensional item response theory (MIRT) was used for evaluating the psychometric property of the questionnaire. A computerized adaptive test was developed based on the MIRT model, and scores of syndrome factors were calculated in simulation. A logistics regression model was also estimated for evaluating the consistency between the quantitative result and the clinical diagnosis of syndrome from clinical practitioners. Result With 337 patients enrolled and assessed, the 14-item questionnaire was evaluated to be with adequate validity and reliability (Cronbach's alpha indices = 0.87, AIC = 195.827, BIC = 348.631, CFI = 0.921, RMR = 0.006, GFI = 0.954, RMSEA = 0.048, and χ2/df = 1.782). With adequate factor loadings of symptoms on related syndrome factor, the instrument was evaluated with preliminary interpretation and was suitable for evaluating patients with moderate severity of the spleen and kidney deficiency syndrome. Conclusion Setting typical symptoms of MG together with systemic discomforts in a computerized adaptive test on the basis of MIRT, this study proposed an innovative research paradigm for quantifying individual condition in the perspective of TCM with application of interdisciplinary approaches.
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