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Hehir MK, Conaway M, St Sauveur AB, Feb K, Kolb NA, Waheed W, McNeish BL, Tweedy N, Burns TM. Measuring treatment adverse event burden in myasthenia gravis: Single-center prospective evaluation utilizing the Adverse Event Unit (AEU). Muscle Nerve 2024; 69:32-39. [PMID: 37676119 DOI: 10.1002/mus.27966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION/AIMS We developed a patient- and physician-weighted consensus unit called the adverse event unit (AEU) that quantifies and compares adverse event (AE) burden among any group of medications in neurological patients. In this study we evaluated preliminary validity and feasibility of measuring AE burden with the AEU in myasthenia gravis (MG). METHODS This is a single-center, prospective, 1-year, observational study of adult MG patients presenting for routine care between April 1, 2021 and March 31, 2022. The MG Activities of Daily Living (MG-ADL), the 15-item MG Quality of Life revised (MG-QOL15r), MG-Composite, and AEU scores were obtained at all visits. A priori primary feasibility metric was AEU completion rate equal to (within 3.8%, one-sided 95% confidence interval [CI]) or better than MG-ADL completion rate. Time to administer AEU and MG-ADL/MG-QOL15r, correlation between AEU total score and MG-QOL15r, and median AEU scores for each MG medication were evaluated. RESULTS Fifty-four patients completed 67 study visits; side effects were reported at 75% of the visits. The study met the primary feasibility endpoint; AEU and MG-ADL were recorded at all visits. Times to administer the AEU (median 5 minutes) and MG-ADL/MG-QOL15r were similar. We observed a weak correlation of 0.29 (95% CI 0.03 to 0.51, P = .032) between AEU and MG-QOL15r scores. Non-statistically significant differences in median AEU scores were observed among MG medications. DISCUSSION Our data demonstrate preliminary feasibility and validity of using the AEU to measure AE burden in MG. Future studies will compare AE burden among MG treatments and evaluate clinically meaningful AEU scores in MG.
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Affiliation(s)
- Michael K Hehir
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Mark Conaway
- Division of Translational Research and Applied Statistics, University of Virginia, Charlottesville, Virginia, USA
| | - Avery B St Sauveur
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Kendall Feb
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Noah A Kolb
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Waqar Waheed
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Brendan L McNeish
- Departments of Physical Medicine and Rehabilitation and Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicole Tweedy
- Mission Health Neurology, Asheville, North Carolina, USA
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
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Hehir MK, Conaway M, Clark EM, Aronzon DB, Kolb N, Kolb A, Ruzhansky K, Sadjadi R, De Sousa EA, Burns TM. The Adverse Event Unit (AEU): A novel metric to measure the burden of treatment adverse events. PLoS One 2022; 17:e0262109. [PMID: 35176061 PMCID: PMC8853570 DOI: 10.1371/journal.pone.0262109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 12/18/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To design a physician and patient derived tool, the Adverse Event Unit (AEU), akin to currency (e.g. U.S. Dollar), to improve AE burden measurement independent of any particular disease or medication class. Patients/Methods A Research Electronic Data Capture (REDCap) online survey was administered to United States physicians with board certification or board eligibility in general neurology, subspecialty neurology, primary care internal medicine or family medicine, subspecialty internal medicine, general pediatrics, and subspecialty pediatrics. Physicians assigned value to 73 AE categories chosen from the Common Terminology Criteria of Adverse Events (CTCAE) relevant to neurologic disorder treatments. An online forced choice survey was administered to non-physician, potential patients, through Amazon Mechanical Turk (MTurK) to weight the severity of the same AE categories. Physician and non-physician data was combined to assign value to the AEU. Surveys completed between 1/2017 and 3/2019. Results 363 physicians rated the 73 AE categories derived from CTCAE. 660 non-physicians completed forced choice experiments comparing AEs. The AEU provides 0–10, weighted values for the AE categories studied that differ from the ordinal 1–4 CTCAE scale. For example, CTCAE severe diabetes (category 4) is assigned an AEU score of 9. Although non-physician input changed physician assigned AEU values, there was general agreement among physicians and non-physicians about severity of AEs. Conclusion The AEU has promise to be a useful, practical tool to add precision to AE burden measurement in the clinic and in comparative efficacy research with neurology patients. AEU utility will be assessed in planned comparative efficacy clinical trials.
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Affiliation(s)
- Michael K. Hehir
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, Vermont, United States of America
- * E-mail:
| | - Mark Conaway
- University of Virginia, Charlottesville, Virginia, United States of America
| | - Eric M. Clark
- University of Vermont Complex Systems Center, Burlington, Vermont, United States of America
| | - Denise B. Aronzon
- Timberlane Pediatrics, South Burlington, Vermont, United States of America
| | - Noah Kolb
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, Vermont, United States of America
| | - Amanda Kolb
- Department of Family Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, United States of America
| | - Katherine Ruzhansky
- Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Reza Sadjadi
- Harvard Medical School Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Eduardo A. De Sousa
- Mercy Clinic Neurology, Neuroscience Institute of Oklahoma City, Oklahoma City, Oklahoma, United States of America
| | - Ted M. Burns
- University of Virginia, Charlottesville, Virginia, United States of America
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Nowak RJ, Coffey CS, Goldstein JM, Dimachkie MM, Benatar M, Kissel JT, Wolfe GI, Burns TM, Freimer ML, Nations S, Granit V, Smith AG, Richman DP, Ciafaloni E, Al-Lozi MT, Sams LA, Quan D, Ubogu E, Pearson B, Sharma A, Yankey JW, Uribe L, Shy M, Amato AA, Conwit R, O'Connor KC, Hafler DA, Cudkowicz ME, Barohn RJ. Phase 2 Trial of Rituximab in Acetylcholine Receptor Antibody-Positive Generalized Myasthenia Gravis: The BeatMG Study. Neurology 2022; 98:e376-e389. [PMID: 34857535 PMCID: PMC8793103 DOI: 10.1212/wnl.0000000000013121] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/19/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To determine whether rituximab is safe and potentially beneficial, warranting further investigation in an efficacy trial for acetylcholine receptor antibody-positive generalized MG (AChR-Ab+ gMG). METHODS The B-Cell Targeted Treatment in MG (BeatMG) study was a randomized, double-blind, placebo-controlled, multicenter phase-2 trial that utilized a futility design. Individuals 21-90 years of age, with AChR-Ab+ gMG (MG Foundation of America Class II-IV) and receiving prednisone ≥15 mg/day were eligible. The primary outcome was a measure of steroid-sparing effect, defined as the proportion achieving ≥75% reduction in mean daily prednisone dose in the 4-weeks prior to week 52 and with clinical improvement or no significant worsening as compared to the 4-week period prior to randomization. The co-primary outcome was safety. Secondary outcomes included MG-specific clinical assessments. Fifty-two individuals were randomized (1:1) to either a two-cycle rituximab/placebo regimen, with follow-up through 52-weeks. RESULTS Of the 52 participants included, mean (±SD) age at enrollment was 55.1 (±17.1) years; 23 (44.2%) were female, and 31 (59.6%) were MGFA Class II. The mean (±SD) baseline prednisone dose was 22.1 (±9.7) mg/day. The primary steroid-sparing outcome was achieved in 60% of those on rituximab vs. 56% on placebo. The study reached its futility endpoint (p=0.03) suggesting that the pre-defined clinically meaningful improvement of 30% due to rituximab over placebo was unlikely to be achieved in a subsequent, larger trial. No safety issues identified. CONCLUSIONS While rituximab was safe and well-tolerated, these results suggest that there is a low probability of observing the defined clinically meaningful steroid-sparing effect over a 12-month period in a phase-3 trial of mild-moderately symptomatic AChR-Ab+ gMG. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for mild-to-moderate AChR-Ab+ gMG, compared with placebo, rituximab is safe but unlikely to reduce steroid use by an absolute difference of at least 30% at 1 year. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02110706.
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Affiliation(s)
- Richard J Nowak
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Christopher S Coffey
- Clinical Trials Statistical & Data Management Center, University of Iowa, Iowa City, IA
| | | | - Mazen M Dimachkie
- Department of Neurology, Kansas University School of Medicine, Kansas City, KS
| | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - John T Kissel
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Gil I Wolfe
- Department of Neurology, University at Buffalo Jacobs School of Medicine & Biomedical Sciences, Buffalo, NY
| | - Ted M Burns
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, VA
| | - Miriam L Freimer
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Sharon Nations
- Department of Neurology, University of Texas Southwestern Medical School, Dallas, TX
| | - Volkan Granit
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - A Gordon Smith
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT
| | - David P Richman
- Department of Neurology, University of California Davis School of Medicine, Sacramento, CA
| | - Emma Ciafaloni
- Department of Neurology, University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Muhammad T Al-Lozi
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Laura Ann Sams
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Dianna Quan
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
| | - Eroboghene Ubogu
- Department of Neurology, The University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Brenda Pearson
- Clinical Trials Statistical & Data Management Center, University of Iowa, Iowa City, IA
| | - Aditi Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, CT
- Department of Neurology, University of Iowa, Iowa City, IA
| | - Jon W Yankey
- Clinical Trials Statistical & Data Management Center, University of Iowa, Iowa City, IA
| | - Liz Uribe
- Clinical Trials Statistical & Data Management Center, University of Iowa, Iowa City, IA
| | - Michael Shy
- Department of Neurology, University of Iowa, Carver College of Medicine, Iowa City, IA
| | - Anthony A Amato
- Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | - Robin Conwit
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Rockville, MD
| | - Kevin C O'Connor
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - David A Hafler
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | | | - Richard J Barohn
- Department of Neurology, Kansas University School of Medicine, Kansas City, KS
- Department of Neurology, University of Missouri, Columbia, MO
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Placek K, Benatar M, Wuu J, Rampersaud E, Hennessy L, Van Deerlin VM, Grossman M, Irwin DJ, Elman L, McCluskey L, Quinn C, Granit V, Statland JM, Burns TM, Ravits J, Swenson A, Katz J, Pioro EP, Jackson C, Caress J, So Y, Maiser S, Walk D, Lee EB, Trojanowski JQ, Cook P, Gee J, Sha J, Naj AC, Rademakers R, Chen W, Wu G, Paul Taylor J, McMillan CT. Machine learning suggests polygenic risk for cognitive dysfunction in amyotrophic lateral sclerosis. EMBO Mol Med 2021; 13:e12595. [PMID: 33270986 PMCID: PMC7799365 DOI: 10.15252/emmm.202012595] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 11/09/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a multi-system disease characterized primarily by progressive muscle weakness. Cognitive dysfunction is commonly observed in patients; however, factors influencing risk for cognitive dysfunction remain elusive. Using sparse canonical correlation analysis (sCCA), an unsupervised machine-learning technique, we observed that single nucleotide polymorphisms collectively associate with baseline cognitive performance in a large ALS patient cohort (N = 327) from the multicenter Clinical Research in ALS and Related Disorders for Therapeutic Development (CReATe) Consortium. We demonstrate that a polygenic risk score derived using sCCA relates to longitudinal cognitive decline in the same cohort and also to in vivo cortical thinning in the orbital frontal cortex, anterior cingulate cortex, lateral temporal cortex, premotor cortex, and hippocampus (N = 90) as well as post-mortem motor cortical neuronal loss (N = 87) in independent ALS cohorts from the University of Pennsylvania Integrated Neurodegenerative Disease Biobank. Our findings suggest that common genetic polymorphisms may exert a polygenic contribution to the risk of cortical disease vulnerability and cognitive dysfunction in ALS.
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Placek K, Benatar M, Wuu J, Rampersaud E, Hennessy L, Van Deerlin VM, Grossman M, Irwin DJ, Elman L, McCluskey L, Quinn C, Granit V, Statland JM, Burns TM, Ravits J, Swenson A, Katz J, Pioro EP, Jackson C, Caress J, So Y, Maiser S, Walk D, Lee EB, Trojanowski JQ, Cook P, Gee J, Sha J, Naj AC, Rademakers R, Chen W, Wu G, Paul Taylor J, McMillan CT. Machine learning suggests polygenic risk for cognitive dysfunction in amyotrophic lateral sclerosis. EMBO Mol Med 2021. [PMID: 33270986 PMCID: PMC7799365 DOI: 10.15252/emmm.202012595|] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a multi-system disease characterized primarily by progressive muscle weakness. Cognitive dysfunction is commonly observed in patients; however, factors influencing risk for cognitive dysfunction remain elusive. Using sparse canonical correlation analysis (sCCA), an unsupervised machine-learning technique, we observed that single nucleotide polymorphisms collectively associate with baseline cognitive performance in a large ALS patient cohort (N = 327) from the multicenter Clinical Research in ALS and Related Disorders for Therapeutic Development (CReATe) Consortium. We demonstrate that a polygenic risk score derived using sCCA relates to longitudinal cognitive decline in the same cohort and also to in vivo cortical thinning in the orbital frontal cortex, anterior cingulate cortex, lateral temporal cortex, premotor cortex, and hippocampus (N = 90) as well as post-mortem motor cortical neuronal loss (N = 87) in independent ALS cohorts from the University of Pennsylvania Integrated Neurodegenerative Disease Biobank. Our findings suggest that common genetic polymorphisms may exert a polygenic contribution to the risk of cortical disease vulnerability and cognitive dysfunction in ALS.
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Affiliation(s)
- Katerina Placek
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Michael Benatar
- Department of NeurologyLeonard M. Miller School of MedicineUniversity of MiamiMiamiFLUSA
| | - Joanne Wuu
- Department of NeurologyLeonard M. Miller School of MedicineUniversity of MiamiMiamiFLUSA
| | - Evadnie Rampersaud
- Center for Applied BioinformaticsSt. Jude Children’s Research HospitalMemphisTNUSA
| | - Laura Hennessy
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Vivianna M Van Deerlin
- Department of Pathology & Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Murray Grossman
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - David J Irwin
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Lauren Elman
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Leo McCluskey
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Colin Quinn
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Volkan Granit
- Department of NeurologyLeonard M. Miller School of MedicineUniversity of MiamiMiamiFLUSA
| | - Jeffrey M Statland
- Department of NeurologyUniversity of Kansas Medical CenterKansas CityKSUSA
| | - Ted M Burns
- Department of NeurologyUniversity of Virginia Health SystemCharlottesvilleVAUSA
| | - John Ravits
- Department of NeurosciencesUniversity of California San DiegoSan DiegoCAUSA
| | | | - Jon Katz
- Forbes Norris ALS CenterCalifornia Pacific Medical CenterSan FranciscoCAUSA
| | - Erik P Pioro
- Department of NeurologyCleveland ClinicClevelandOHUSA
| | - Carlayne Jackson
- Department of NeurologyUniversity of Texas Health Science CenterSan AntonioTXUSA
| | - James Caress
- Department of NeurologyWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Yuen So
- Department of NeurologyStanford University Medical CenterSan JoseCAUSA
| | - Samuel Maiser
- Department of NeurologyUniversity of Minnesota Medical CenterMinneapolisMNUSA
| | - David Walk
- Department of NeurologyUniversity of Minnesota Medical CenterMinneapolisMNUSA
| | - Edward B Lee
- Department of Pathology & Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - John Q Trojanowski
- Department of Pathology & Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Philip Cook
- Penn Image Computing Science Laboratory (PICSL)Department of RadiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - James Gee
- Penn Image Computing Science Laboratory (PICSL)Department of RadiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Jin Sha
- Department of Biostatistics, Epidemiology, and InformaticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA,Penn Neurodegeneration Genomics CenterDepartment of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Adam C Naj
- Department of Pathology & Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA,Department of Biostatistics, Epidemiology, and InformaticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA,Penn Neurodegeneration Genomics CenterDepartment of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | | | | | - Wenan Chen
- Center for Applied BioinformaticsSt. Jude Children’s Research HospitalMemphisTNUSA
| | - Gang Wu
- Center for Applied BioinformaticsSt. Jude Children’s Research HospitalMemphisTNUSA
| | - J Paul Taylor
- Center for Applied BioinformaticsSt. Jude Children’s Research HospitalMemphisTNUSA,The Howard Hughes Medical InstituteChevy ChaseMSUSA
| | - Corey T McMillan
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
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Burns TM, Crowell JL, Smith AG. A crisis in
US
drug pricing: Consequences for patients with neuromuscular diseases, physicians and society, part 1. Muscle Nerve 2020; 62:567-572. [DOI: 10.1002/mus.27015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Ted M. Burns
- Department of Neurology University of Virginia Charlottesville Virginia USA
| | - Jason L. Crowell
- Beth Israel Deaconess Medical Center Jerome H. Grossman M.D. Graduate Fellow, Harvard Kennedy School Boston Massachusetts USA
| | - A. Gordon Smith
- Department of Neurology Virginia Commonwealth University Richmond Virginia USA
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Crowell JL, Burns TM. Rising Drug Costs for Neurologic Diseases. Continuum (Minneap Minn) 2020; 26:1392-1406. [PMID: 33003008 DOI: 10.1212/con.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The cost of prescription drugs in the United States is rising like never before and has led to an inflection point where clinicians must consider the potential financial damage to the patient and to society related to the more expensive drugs available. Many of the highest-priced drugs are approved as orphan drugs, a legally defined status providing additional benefits to pharmaceutical companies that is intended to incentivize therapeutic development for rare diseases. The Orphan Drug Act has been a great success since it was enacted in 1983, resulting in the development of many innovative, life-changing, and even lifesaving drugs; however, high drug prices place patients at risk for personal bankruptcy, prescription abandonment, and higher rates of hospitalization. These negative consequences have become more widespread and severe because some companies exploit pricing via the market exclusivity granted to them under the provisions of the Orphan Drug Act. As more and more companies develop these drugs, the cost to society increases as does the capacity to tolerate unjustified prices. The societal effects of drug pricing must be considered through the prism of opportunity costs; that is, what benefit is lost by choosing to spend on one thing instead of another. Clinical- and economic-based analyses from independent groups such as the Institute for Clinical and Economic Review can help physicians understand the value of drugs (ie, the benefits relative to cost). When prescribing a high-priced medication, clinicians should discuss the drug's value and the associated opportunity cost with patients and have an open discussion about patients' ability to financially tolerate the treatment.
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Burns TM, Crowell JL, Smith AG. A crisis in US drug pricing: Consequences for patients with neuromuscular diseases, physicians, and society, part 2. Muscle Nerve 2020; 62:573-578. [PMID: 32725709 DOI: 10.1002/mus.27018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/08/2022]
Abstract
Escalating drug costs place patients at risk for financial toxicity and demand that physicians understand and act on the ethical and economic principles related to drug pricing. This manuscript reviews these principles and provides clinicians with a framework to think about the value of the drugs prescribed for patients with neuromuscular diseases. A key component of addressing the drug pricing crisis will be establishing a value based (benefit/cost) drug pricing framework. Determining the value of a drug is difficult and requires estimating the benefit and costs to patients and society while integrating indirect and contextual variables. Other considerations in drug pricing include "externality," the value to society derived from innovation. The Institute for Clinical and Economic Review (ICER) is a leading independent research organization providing clinicians with value-based price "benchmarks." All physicians must educate themselves in drug pricing principles and be prepared to have conversations regarding individual and societal value with the patients they serve.
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Affiliation(s)
- Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Jason L Crowell
- Beth Israel Deaconess Medical Center, Jerome H. Grossman M.D. Graduate Fellow, Harvard Kennedy School, Boston, MA, USA
| | - A Gordon Smith
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
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Benatar M, Zhang L, Wang L, Granit V, Statland J, Barohn R, Swenson A, Ravits J, Jackson C, Burns TM, Trivedi J, Pioro EP, Caress J, Katz J, McCauley JL, Rademakers R, Malaspina A, Ostrow LW, Wuu J. Validation of serum neurofilaments as prognostic and potential pharmacodynamic biomarkers for ALS. Neurology 2020; 95:e59-e69. [PMID: 32385188 DOI: 10.1212/wnl.0000000000009559] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 12/10/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To identify preferred neurofilament assays and clinically validate serum neurofilament light (NfL) and phosphorylated neurofilament heavy (pNfH) as prognostic and potential pharmacodynamic biomarkers relevant to amyotrophic lateral sclerosis (ALS) therapy development. METHODS In this prospective, multicenter, longitudinal observational study of patients with ALS (n = 229), primary lateral sclerosis (n = 20), and progressive muscular atrophy (n = 11), biological specimens were collected, processed, and stored according to strict standard operating procedures (SOPs). Neurofilament assays were performed in a blinded manner by independent contract research organizations. RESULTS For serum NfL and pNfH measured using the Simoa assay, there were no missing data (i.e., technical replicates below the lower limit of detection were not encountered). For the Iron Horse and Euroimmun pNfH assays, such missingness was encountered in ∼4% and ∼10% of serum samples, respectively. Mean coefficients of variation for NfL in serum and CSF were both ∼3%. Mean coefficients of variation for pNfH in serum and CSF were ∼4%-5% and ∼2%-3%, respectively, in all assays. Baseline serum NfL concentration, but not pNfH, predicted the future Revised ALS Functional Rating Scale (ALSFRS-R) slope and survival. Incorporation of baseline serum NfL into mixed effects models of ALSFRS-R slopes yields an estimated sample size saving of ∼8%. Depending on the method used to estimate effect size, use of serum NfL (and perhaps pNfH) as pharmacodynamic biomarkers, instead of the ALSFRS-R slope, yields significantly larger sample size savings. CONCLUSIONS Serum NfL may be considered a clinically validated prognostic biomarker for ALS. Serum NfL (and perhaps pNfH), quantified using the Simoa assay, has potential utility as a pharmacodynamic biomarker of treatment effect.
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Affiliation(s)
- Michael Benatar
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD.
| | - Lanyu Zhang
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Lily Wang
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Volkan Granit
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Jeffrey Statland
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Richard Barohn
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Andrea Swenson
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - John Ravits
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Carlayne Jackson
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Ted M Burns
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Jaya Trivedi
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Erik P Pioro
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - James Caress
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Jonathan Katz
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Jacob L McCauley
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Rosa Rademakers
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Andrea Malaspina
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
| | - Lyle W Ostrow
- From Miller School of Medicine (M.B., L.Z., L.W., V.G., J.W.), University of Miami, FL; Kansas University Medical Center (J.S., R.B.), Kansas City; University of Iowa (A.S.), Iowa City; University of California San Diego (J.R.); University of Texas Health Science Center San Antonio (C.J.); University of Virginia (T.M.B.), Charlottesville; UT Southwestern Medical Center (J.T.), Dallas, TX; Cleveland Clinic (E.P.P.), OH; Wake Forest School of Medicine (J.C.), Winston-Salem, NC; California Pacific Medical Center (J.K.), San Francisco; John P Hussman Institute for Human Genomics (J.L.M.), Miami; Mayo Clinic Jacksonville (R.R.), FL; Blizard Institute (A.M.), Queen Mary University of London, UK; and Johns Hopkins University (L.W.O.), Baltimore, MD
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Cutter G, Xin H, Aban I, Burns TM, Allman PH, Farzaneh-Far R, Duda PW, Kaminski HJ. Cross-sectional analysis of the Myasthenia Gravis Patient Registry: Disability and treatment. Muscle Nerve 2019; 60:707-715. [PMID: 31487038 PMCID: PMC6899582 DOI: 10.1002/mus.26695] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 08/05/2019] [Accepted: 08/30/2019] [Indexed: 12/11/2022]
Abstract
Introduction The Myasthenia Gravis Patient Registry (MGR) is a voluntary, patient‐submitted database dedicated to improve understanding of care/burden of myasthenia gravis (MG). Methods In this study we present analyses of baseline records through July 2017 (n = 1140) containing data on the MG—Activities of Daily Living (MG‐ADL) and the MG 15‐item Quality of Life (MG‐QOL15) instruments, two validated scales assessing quality of life in MG patients at sign‐up into the MGR. Results Most registrants reported moderate to severe impairment of health‐related quality of life, with a median MG‐ADL score of 6 and a median MG‐QOL15 score of 21. Seventy‐one percent of the patients had received pyridostigmine. Corticosteroids, mycophenolate mofetil, and azathioprine were the most common immunomodulators/immunosuppressants, with 85% of participants having ever using one of these agents. Forty‐seven registrants reported receiving intravenous immunoglobulin, and 30% received plasma exchange. Twelve percent reported other treatments, and 40% were unsure whether they received less common therapies. Forty percent had undergone thymectomy. Discussion The MGR data correlate well with other MG cohorts. Many MG patients remain negatively impacted despite treatment.
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Affiliation(s)
- Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Haichang Xin
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia
| | - Phillip H Allman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ramin Farzaneh-Far
- Department of Clinical Research, Ra Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Petra W Duda
- Department of Clinical Research, Ra Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington, DC
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Bjelica B, Peric S, Gwathmey K, Sadjadi R, Bozovic I, Burns TM, Basta I. Chronic Acquired Polyneuropathy Patient Reported Index (CAPPRI) in chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2019; 24:247-252. [DOI: 10.1111/jns.12329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/12/2019] [Accepted: 06/12/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Bogdan Bjelica
- Neurology Clinic, Clinical Center of Serbia, School of MedicineUniversity of Belgrade Belgrade Serbia
| | - Stojan Peric
- Neurology Clinic, Clinical Center of Serbia, School of MedicineUniversity of Belgrade Belgrade Serbia
| | - Kelly Gwathmey
- Department of NeurologyVirginia Commonwealth University Richmond Virginia
| | - Reza Sadjadi
- Harvard Medical SchoolMassachusetts General Hospital Boston Massachusetts
| | - Ivo Bozovic
- Neurology Clinic, Clinical Center of Serbia, School of MedicineUniversity of Belgrade Belgrade Serbia
| | - Ted M. Burns
- Department of NeurologyThe University of Virginia Charlottesville Virginia
| | - Ivana Basta
- Neurology Clinic, Clinical Center of Serbia, School of MedicineUniversity of Belgrade Belgrade Serbia
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12
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Howard JF, Bril V, Burns TM, Mantegazza R, Bilinska M, Szczudlik A, Beydoun S, Garrido FJRDR, Piehl F, Rottoli M, Van Damme P, Vu T, Evoli A, Freimer M, Mozaffar T, Ward ES, Dreier T, Ulrichts P, Verschueren K, Guglietta A, de Haard H, Leupin N, Verschuuren JJGM. Randomized phase 2 study of FcRn antagonist efgartigimod in generalized myasthenia gravis. Neurology 2019; 92:e2661-e2673. [PMID: 31118245 DOI: 10.1212/wnl.0000000000007600] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/31/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate safety and explore efficacy of efgartigimod (ARGX-113), an anti-neonatal Fc receptor immunoglobulin G1 Fc fragment, in patients with generalized myasthenia gravis (gMG) with a history of anti-acetylcholine receptor (AChR) autoantibodies, who were on stable standard-of-care myasthenia gravis (MG) treatment. METHODS A phase 2, exploratory, randomized, double-blind, placebo-controlled, 15-center study is described. Eligible patients were randomly assigned (1:1) to receive 4 doses over a 3-week period of either 10 mg/kg IV efgartigimod or matched placebo combined with their standard-of-care therapy. Primary endpoints were safety and tolerability. Secondary endpoints included efficacy (change from baseline to week 11 of Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Composite disease severity scores, and of the revised 15-item Myasthenia Gravis Quality of Life scale), pharmacokinetics, pharmacodynamics, and immunogenicity. RESULTS Of the 35 screened patients, 24 were enrolled and randomized: 12 received efgartigimod and 12 placebo. Efgartigimod was well-tolerated in all patients, with no serious or severe adverse events reported, no relevant changes in vital signs or ECG findings observed, and no difference in adverse events between efgartigimod and placebo treatment. All patients treated with efgartigimod showed a rapid decrease in total immunoglobulin G (IgG) and anti-AChR autoantibody levels, and assessment using all 4 efficacy scales consistently demonstrated that 75% showed a rapid and long-lasting disease improvement. CONCLUSIONS Efgartigimod was safe and well-tolerated. The correlation between reduction of levels of pathogenic IgG autoantibodies and disease improvement suggests that reducing pathogenic autoantibodies with efgartigimod may offer an innovative approach to treat MG. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that efgartigimod is safe and well-tolerated in patients with gMG.
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Affiliation(s)
- James F Howard
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Vera Bril
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Ted M Burns
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Renato Mantegazza
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Malgorzata Bilinska
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Andrzej Szczudlik
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Said Beydoun
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Francisco Javier Rodriguez De Rivera Garrido
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Fredrik Piehl
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Mariarosa Rottoli
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Philip Van Damme
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Tuan Vu
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Amelia Evoli
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Miriam Freimer
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Tahseen Mozaffar
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - E Sally Ward
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Torsten Dreier
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Peter Ulrichts
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Katrien Verschueren
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Antonio Guglietta
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Hans de Haard
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
| | - Nicolas Leupin
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands.
| | - Jan J G M Verschuuren
- From the Department of Neurology (J.F.H.), University of North Carolina, Chapel Hill; Krembil Neuroscience Centre (V.B.), University Health Network, Toronto, Canada; Department of Neurology (T.M.B.), University of Virginia, Charlottesville; Department of Neuroimmunology and Neuromuscular Diseases (R.M.), Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Department of Neurology (B.M.), Wroclaw Medical University; Department of Neurology (A.S.), Jagiellonian University Medical College, Cracow, Poland; Department of Neurology (S.B.), University of Southern California, Keck School of Medicine, Los Angeles County Medical Center; Department of Neurology (F.J.R.D.R.G.), La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Autonoma University of Madrid, Spain; Neuroimmunology Unit, Department Clinical Neuroscience (F.P.), Karolinska Institutet, Karolinska University Hospital (Solna), Stockholm, Sweden; USC Neurologia (M.R.), USS Malattie Autoimmuni-Centro Sclerosi Multipla, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; Neurology Department (P.V.D.), University Hospitals Leuven; Laboratory of Neurobiology (P.V.D.), Department of Neuroscience, KU Leuven and Center for Brain & Disease Research, VIB, Leuven, Belgium; Department of Neurology (T.V.), University of South Florida, Morsani College of Medicine, Tampa; Institute of Neurology (A.E.), Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Neurology Department (M.F.), The Ohio State University, Columbus; Department of Neurology (T.M.), University of California, Irvine; Department of Molecular and Cellular Medicine (E.S.W.), Texas A&M University Health Science Center, College Station; argenx BVBA (T.D., P.U., K.V., A.G., H.d.H., N.L.), Zwijnaarde, Belgium; and Department of Neurology (J.J.G.M.V.), Leiden University Medical Center (LUMC), the Netherlands
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Muppidi S, Utsugisawa K, Benatar M, Murai H, Barohn RJ, Illa I, Jacob S, Vissing J, Burns TM, Kissel JT, Nowak RJ, Andersen H, Casasnovas C, de Bleecker JL, Vu TH, Mantegazza R, O'Brien FL, Wang JJ, Fujita KP, Howard JF. Long-term safety and efficacy of eculizumab in generalized myasthenia gravis. Muscle Nerve 2019; 60:14-24. [PMID: 30767274 PMCID: PMC6619057 DOI: 10.1002/mus.26447] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2019] [Indexed: 01/16/2023]
Abstract
Introduction: Eculizumab is effective and well tolerated in patients with antiacetylcholine receptor antibody‐positive refractory generalized myasthenia gravis (gMG; REGAIN; NCT01997229). We report an interim analysis of an open‐label extension of REGAIN, evaluating eculizumab's long‐term safety and efficacy. Methods: Eculizumab (1,200 mg every 2 weeks for 22.7 months [median]) was administered to 117 patients. Results: The safety profile of eculizumab was consistent with REGAIN; no cases of meningococcal infection were reported during the interim analysis period. Myasthenia gravis exacerbation rate was reduced by 75% from the year before REGAIN (P < 0.0001). Improvements with eculizumab in activities of daily living, muscle strength, functional ability, and quality of life in REGAIN were maintained through 3 years; 56% of patients achieved minimal manifestations or pharmacological remission. Patients who had received placebo during REGAIN experienced rapid and sustained improvements during open‐label eculizumab (P < 0.0001). Discussion: These findings provide evidence for the long‐term safety and sustained efficacy of eculizumab for refractory gMG. Muscle Nerve 2019 See editorial on pages 7–9 in this issue.
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Affiliation(s)
- Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Isabel Illa
- Neurology Department, Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
| | - Saiju Jacob
- Queen Elizabeth Neuroscience Centre and Wellcome Trust Clinical Research Facility, University Hospital Birmingham, Birmingham, United Kingdom
| | - John Vissing
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ted M Burns
- Department of Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John T Kissel
- Department of Neurology, The Ohio State University, Columbus, Ohio, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Carlos Casasnovas
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain.,Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
| | - Jan L de Bleecker
- Neuromuscular Reference Centre, Ghent University Hospital, Ghent, Belgium
| | - Tuan H Vu
- Department of Neurology, University of South Florida, Tampa, Florida, USA
| | - Renato Mantegazza
- Foundation of the Carlo Besta Neurological Institute, IRCSS, Milan, Italy
| | | | | | | | - James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina, USA
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Clifford KM, Hobson-Webb LD, Benatar M, Burns TM, Barnett C, Silvestri NJ, Howard JF, Visser A, Crum BA, Nowak R, Beekman R, Kumar A, Ruzhansky K, Chen IHA, Pulley MT, Laboy SM, Fellman MA, Howard DB, Kolb NA, Greene SM, Pasnoor M, Dimachkie MM, Barohn RJ, Hehir MK. Thymectomy may not be associated with clinical improvement in MuSK myasthenia gravis. Muscle Nerve 2019; 59:404-410. [PMID: 30575980 DOI: 10.1002/mus.26404] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/24/2018] [Accepted: 12/16/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION A randomized trial demonstrated benefit from thymectomy in nonthymomatous acetylcholine receptor (AChR)-antibody positive myasthenia gravis (MG). Uncontrolled observational and histologic studies suggest thymectomy may not be efficacious in anti-muscle-specific kinase (MuSK)-MG. METHODS The therapeutic impact of thymectomy was evaluated from data collected for a multicenter, retrospective blinded review of rituximab in MuSK-MG. RESULTS Baseline characteristics were similar between thymectomy (n = 26) and nonthymectomy (n = 29) groups, including treatment with rituximab (42% vs. 45%). At last visit, 35% of thymectomy subjects reached the primary endpoint, a Myasthenia Gravis Foundation of America (MGFA) post-intervention status (PIS) score of minimal manifestations (MM) or better, compared with 55% of controls (P = 0.17). After controlling for age at onset of MG, rituximab, prednisone, and intravenous immunoglobulin/plasma exchange treatment, thymectomy was not associated with greater likelihood of favorable clinical outcome (odds ratio = 0.43, 95% confidence interval 0.12-1.53, P = 0.19). DISCUSSION Thymectomy was not associated with additional clinical improvement in this multicenter cohort of MuSK-MG patients. Muscle Nerve 59:404-410, 2019.
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Affiliation(s)
- Katherine M Clifford
- Larner College of Medicine, University of Vermont, 1 South Prospect Street, Burlington, Vermont 05401, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Benatar
- Department of Neurology, University of Miami Health System, Miami, Florida, USA
| | - Ted M Burns
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Carolina Barnett
- Department of Neurology, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Nicholas J Silvestri
- Department of Neurology, University at Buffalo Jacobs School of Medicine & Biomedical Sciences, Buffalo, New York, USA
| | - James F Howard
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Amy Visser
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard Nowak
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aditya Kumar
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Ruzhansky
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - I-Hweii Amy Chen
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael T Pulley
- Department of Neurology, University of Florida, Jacksonville, Florida, USA
| | - Shannon M Laboy
- Department of Neurology, University of Florida, Jacksonville, Florida, USA
| | - Melissa A Fellman
- Department of Neurology, University of Miami Health System, Miami, Florida, USA
| | - Diantha B Howard
- Larner College of Medicine, University of Vermont, 1 South Prospect Street, Burlington, Vermont 05401, USA
| | - Noah A Kolb
- Larner College of Medicine, University of Vermont, 1 South Prospect Street, Burlington, Vermont 05401, USA
| | - Shane M Greene
- Larner College of Medicine, University of Vermont, 1 South Prospect Street, Burlington, Vermont 05401, USA
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael K Hehir
- Larner College of Medicine, University of Vermont, 1 South Prospect Street, Burlington, Vermont 05401, USA
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Burns TM. Estimating and managing fatigue for our patients: Are we measuring up? Muscle Nerve 2018. [DOI: 10.1002/mus.26125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ted M. Burns
- University of Virginia, Department of NeurologyCharlottesville Virginia USA
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16
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Gwathmey KG, Sadjadi R, Horton WB, Conaway MR, Barnett-Tapia C, Bril V, Russell JW, Shaibani A, Mauermann ML, Hehir MK, Kolb N, Guptill J, Hobson-Webb L, Gable K, Raja S, Silvestri N, Wolfe GI, Smith AG, Malik R, Traub R, Joshi A, Elliott MP, Jones S, Burns TM. Validation of a simple disease-specific, quality-of-life measure for diabetic polyneuropathy: CAPPRI. Neurology 2018; 90:e2034-e2041. [PMID: 29728528 DOI: 10.1212/wnl.0000000000005643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/20/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We studied the performance of a 15-item, health-related quality-of-life polyneuropathy scale in the clinic setting in patients with diabetic distal sensorimotor polyneuropathy (DSPN). METHODS Patients with DSPN from 11 academic sites completed a total of 231 Chronic Acquired Polyneuropathy Patient-Reported Index (CAPPRI) scales during their clinic visits. Conventional and modern psychometric analyses were performed on the completed forms. RESULTS Conventional and modern analyses generally indicated excellent psychometric properties of the CAPPRI in patients with DSPN. For example, the CAPPRI demonstrated unidimensionality and performed like an interval-level scale. CONCLUSION Attributes of the CAPPRI for DSPN include ease of use and interpretation; unidimensionality, allowing scores to be summed; adequate coverage of disease severity; and the scale's ability to address relevant life domains. Furthermore, the CAPPRI is free and in the public domain. The CAPPRI may assist the clinician and patient with DSPN in estimating disease-specific quality of life, especially in terms of pain, sleep, psychological well-being, and everyday function. The CAPPRI may be most useful in the everyday clinical setting but merits further study in this setting, as well as the clinical trial setting.
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Affiliation(s)
- Kelly G Gwathmey
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Reza Sadjadi
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - William B Horton
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Mark R Conaway
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Carolina Barnett-Tapia
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Vera Bril
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - James W Russell
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Aziz Shaibani
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Michelle L Mauermann
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Michael K Hehir
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Noah Kolb
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Jeffrey Guptill
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Lisa Hobson-Webb
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Karissa Gable
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Shruti Raja
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Nicholas Silvestri
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Gil I Wolfe
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - A Gordon Smith
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Rabia Malik
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Rebecca Traub
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Amruta Joshi
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Matthew P Elliott
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Sarah Jones
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill
| | - Ted M Burns
- From the Departments of Neurology (K.G.G., A.J., M.P.E., S.J., T.M.B.), Internal Medicine (W.B.H.), and Public Health Sciences (M.R.C.), University of Virginia, Charlottesville; Massachusetts General Hospital/Harvard Medical School (R.S.), Boston, MA; Division of Neurology (C.B.-T., V.B.), Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Canada; Department of Neurology (J.W.R.), University of Maryland, Baltimore; Department of Neurology (A.S.), Baylor St. Luke's Medical Center, Houston, TX; Department of Neurology (M.L.M.), Mayo Clinic, Rochester, MN; Department of Neurology (M.K.H., N.K.), University of Vermont, Burlington; Department of Neurology (J.G., L.H.-W., K.G., S.R.), Duke University Medical Center, Durham, NC; Department of Neurology (N.S., G.I.W.), University at Buffalo, SUNY, Buffalo, NY; Department of Neurology (A.G.S.), Virginia Commonwealth University, Richmond; Department of Neurology (R.M.), Rush University Medical Center, Chicago, IL; and Department of Neurology (R.T.), University of North Carolina, Chapel Hill.
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Howard JF, Utsugisawa K, Benatar M, Murai H, Barohn RJ, Illa I, Jacob S, Vissing J, Burns TM, Kissel JT, Muppidi S, Nowak RJ, O'Brien F, Wang JJ, Mantegazza R. Safety and efficacy of eculizumab in anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis (REGAIN): a phase 3, randomised, double-blind, placebo-controlled, multicentre study. Lancet Neurol 2017; 16:976-986. [PMID: 29066163 DOI: 10.1016/s1474-4422(17)30369-1] [Citation(s) in RCA: 387] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Complement is likely to have a role in refractory generalised myasthenia gravis, but no approved therapies specifically target this system. Results from a phase 2 study suggested that eculizumab, a terminal complement inhibitor, produced clinically meaningful improvements in patients with anti-acetylcholine receptor antibody-positive refractory generalised myasthenia gravis. We further assessed the efficacy and safety of eculizumab in this patient population in a phase 3 trial. METHODS We did a phase 3, randomised, double-blind, placebo-controlled, multicentre study (REGAIN) in 76 hospitals and specialised clinics in 17 countries across North America, Latin America, Europe, and Asia. Eligible patients were aged at least 18 years, with a Myasthenia Gravis-Activities of Daily Living (MG-ADL) score of 6 or more, Myasthenia Gravis Foundation of America (MGFA) class II-IV disease, vaccination against Neisseria meningitides, and previous treatment with at least two immunosuppressive therapies or one immunosuppressive therapy and chronic intravenous immunoglobulin or plasma exchange for 12 months without symptom control. Patients with a history of thymoma or thymic neoplasms, thymectomy within 12 months before screening, or use of intravenous immunoglobulin or plasma exchange within 4 weeks before randomisation, or rituximab within 6 months before screening, were excluded. We randomly assigned participants (1:1) to either intravenous eculizumab or intravenous matched placebo for 26 weeks. Dosing for eculizumab was 900 mg on day 1 and at weeks 1, 2, and 3; 1200 mg at week 4; and 1200 mg given every second week thereafter as maintenance dosing. Randomisation was done centrally with an interactive voice or web-response system with patients stratified to one of four groups based on MGFA disease classification. Where possible, patients were maintained on existing myasthenia gravis therapies and rescue medication was allowed at the study physician's discretion. Patients, investigators, staff, and outcome assessors were masked to treatment assignment. The primary efficacy endpoint was the change from baseline to week 26 in MG-ADL total score measured by worst-rank ANCOVA. The efficacy population set was defined as all patients randomly assigned to treatment groups who received at least one dose of study drug, had a valid baseline MG-ADL assessment, and at least one post-baseline MG-ADL assessment. The safety analyses included all randomly assigned patients who received eculizumab or placebo. This trial is registered with ClinicalTrials.gov, number NCT01997229. FINDINGS Between April 30, 2014, and Feb 19, 2016, we randomly assigned and treated 125 patients, 62 with eculizumab and 63 with placebo. The primary analysis showed no significant difference between eculizumab and placebo (least-squares mean rank 56·6 [SEM 4·5] vs 68·3 [4·5]; rank-based treatment difference -11·7, 95% CI -24·3 to 0·96; p=0·0698). No deaths or cases of meningococcal infection occurred during the study. The most common adverse events in both groups were headache and upper respiratory tract infection (ten [16%] for both events in the eculizumab group and 12 [19%] for both in the placebo group). Myasthenia gravis exacerbations were reported by six (10%) patients in the eculizumab group and 15 (24%) in the placebo group. Six (10%) patients in the eculizumab group and 12 (19%) in the placebo group required rescue therapy. INTERPRETATION The change in the MG-ADL score was not statistically significant between eculizumab and placebo, as measured by the worst-rank analysis. Eculizumab was well tolerated. The use of a worst-rank analytical approach proved to be an important limitation of this study since the secondary and sensitivity analyses results were inconsistent with the primary endpoint result; further research into the role of complement is needed. FUNDING Alexion Pharmaceuticals.
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Affiliation(s)
- James F Howard
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, KA, USA
| | - Isabel Illa
- Neurology Department, Hospital Sant Pau, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Saiju Jacob
- Queen Elizabeth Neuroscience Centre, Wellcome Trust Clinical Research Facility, University Hospitals of Birmingham, Birmingham, UK
| | - John Vissing
- Rigshospitalet, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Ted M Burns
- Department of Neurology, University of Virginia Health System, Charlottesville, VA, USA
| | - John T Kissel
- Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard J Nowak
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Hehir MK, Hobson-Webb LD, Benatar M, Barnett C, Silvestri NJ, Howard JF, Howard D, Visser A, Crum BA, Nowak R, Beekman R, Kumar A, Ruzhansky K, Chen IHA, Pulley MT, LaBoy SM, Fellman MA, Greene SM, Pasnoor M, Burns TM. Rituximab as treatment for anti-MuSK myasthenia gravis: Multicenter blinded prospective review. Neurology 2017; 89:1069-1077. [PMID: 28801338 DOI: 10.1212/wnl.0000000000004341] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/22/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of rituximab in treatment of anti-muscle-specific kinase (MuSK) myasthenia gravis (MG). METHODS This was a multicenter, blinded, prospective review, comparing anti-MuSK-positive patients with MG treated with rituximab to those not treated with rituximab. The primary clinical endpoint was the Myasthenia Gravis Status and Treatment Intensity (MGSTI), a novel outcome that combines the Myasthenia Gravis Foundation of America (MGFA) postintervention status (PIS) and the number and dosages of other immunosuppressant therapies used. A priori, an MGSTI of level ≤2 was used to define a favorable outcome. Secondary outcomes included modified MGFA PIS of minimal manifestations or better, mean/median prednisone dose, and mean/median doses of other immunosuppressant drugs. RESULTS Seventy-seven of 119 patients with anti-MuSK MG evaluated between January 1, 2005, and January 1, 2015, at 10 neuromuscular centers were selected for analysis after review of limited clinical data by a blinded expert panel. An additional 22 patients were excluded due to insufficient follow-up. Baseline characteristics were similar between the rituximab-treated patients (n = 24) and the controls (n = 31). Median follow-up duration was >3.5 years. At last visit, 58% (14/24) of rituximab-treated patients reached the primary outcome compared to 16% (5/31) of controls (p = 0.002). Number needed to treat for the primary outcome is 2.4. At last visit, 29% of rituximab-treated patients were taking prednisone (mean dose 4.5 mg/day) compared to 74% of controls (mean dose 13 mg/day) (p = 0.001 and p = 0.005). CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with anti-MuSK MG, rituximab increased the probability of a favorable outcome.
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Affiliation(s)
- Michael K Hehir
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville.
| | - Lisa D Hobson-Webb
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Michael Benatar
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Carolina Barnett
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Nicholas J Silvestri
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - James F Howard
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Diantha Howard
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Amy Visser
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Brian A Crum
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Richard Nowak
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Rachel Beekman
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Aditya Kumar
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Katherine Ruzhansky
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - I-Hweii Amy Chen
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Michael T Pulley
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Shannon M LaBoy
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Melissa A Fellman
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Shane M Greene
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Mamatha Pasnoor
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
| | - Ted M Burns
- From the Larner College of Medicine at the University of Vermont (M.K.H., D.H., S.M.G.), Burlington; Duke University School of Medicine (L.D.H.-W.), Durham, NC; University of Miami Health System (M.B., M.A.F.), FL; University of Toronto School of Medicine (C.B.), Canada; SUNY Buffalo Jacobs School of Medicine (N.J.S.), NY; UNC School of Medicine (J.F.H.), Chapel Hill, NC; Mayo Clinic (A.V., B.A.C.), Rochester, MN; Yale School of Medicine (R.N., R.B., A.K.), New Haven, CT; Medical University of South Carolina (K.R., I.-H.A.C.), Columbia; University of Florida (M.T.P., S.M.L., Gainesville; University of Kansas Medical Center (M.P.), Kansas City; and University of Virginia School of Medicine (T.M.B.), Charlottesville
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Affiliation(s)
- Ted M Burns
- From the Department of Neurology, University of Virginia, Charlottesville.
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Ballow M, Conaway MR, Sriaroon P, Rachid RA, Seeborg FO, Duff CM, Bonilla FA, Younger MEM, Shapiro R, Burns TM. Construction and validation of a novel disease-specific quality-of-life instrument for patients with primary antibody deficiency disease (PADQOL-16). J Allergy Clin Immunol 2017; 139:2007-2010.e8. [PMID: 28065678 DOI: 10.1016/j.jaci.2016.11.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/16/2016] [Accepted: 11/08/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Mark Ballow
- Department of Pediatrics, Division of Allergy and Immunology, University of South Florida, Johns Hopkins All Children's Hospital, St Petersburg, Fla.
| | - Mark R Conaway
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Va
| | - Panida Sriaroon
- Department of Pediatrics, Division of Allergy and Immunology, University of South Florida, Johns Hopkins All Children's Hospital, St Petersburg, Fla
| | - Rima A Rachid
- Department of Pediatrics, Division of Immunology, Allergy and Rheumatology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Filiz O Seeborg
- Division of Allergy and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Carla M Duff
- Department of Pediatrics, Division of Allergy and Immunology, University of South Florida, Johns Hopkins All Children's Hospital, St Petersburg, Fla
| | - Francisco A Bonilla
- Department of Pediatrics, Division of Immunology, Allergy and Rheumatology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - M Elizabeth M Younger
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Johns Hopkins University, School of Medicine, Baltimore, Md
| | | | - Ted M Burns
- Department of Neurology, University of Virginia Health System, Charlottesville, Va
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Affiliation(s)
- Ted M. Burns
- Department of NeurologyUniversity of VirginiaCharlottesville Virginia USA
| | - Gordon A. Smith
- Department of NeurologyUniversity of UtahSalt Lake City Utah USA
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Burns TM, Sadjadi R, Utsugisawa K, Gwathmey KG, Joshi A, Jones S, Bril V, Barnett C, Guptill JT, Sanders DB, Hobson-Webb L, Juel VC, Massey J, Gable KL, Silvestri NJ, Wolfe G, Cutter G, Nagane Y, Murai H, Masuda M, Farrugia ME, Carmichael C, Birnbaum S, Hogrel JY, Nafissi S, Fatehi F, Ou C, Liu W, Conaway M. International clinimetric evaluation of the MG-QOL15, resulting in slight revision and subsequent validation of the MG-QOL15r. Muscle Nerve 2016; 54:1015-1022. [PMID: 27220659 DOI: 10.1002/mus.25198] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The MG-QOL15 is a validated, health-related quality of life (HRQOL) measure for myasthenia gravis (MG). Widespread use of the scale gave us the opportunity to further analyze its clinimetric properties. METHODS We first performed Rasch analysis on >1,300 15-item Myasthenia Gravis Quality of Life scale (MG-QOL15) completed surveys. Results were discussed during a conference call with specialists and biostatisticians. We decided to revise 3 items and prospectively evaluate the revised scale (MG-QOL15r) using either 3, 4, or 5 responses. Rasch analysis was then performed on >1,300 MG-QOL15r scales. RESULTS The MGQOL15r performed slightly better than the MG-QOL15. The 3-response option MG-QOL15r demonstrated better clinimetric properties than the 4- or 5-option scales. Relative distributions of item and person location estimates showed good coverage of disease severity. CONCLUSIONS The MG-QOL15r is now the preferred HRQOL instrument for MG because of improved clinimetrics and ease of use. This revision does not negate previous studies or interpretations of results using the MG-QOL15. Muscle Nerve 54: 1015-1022, 2016.
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Affiliation(s)
- Ted M Burns
- University of Virginia, Department of Neurology, Charlottesville, Virginia, 22908, USA
| | - Reza Sadjadi
- University of Rochester, Rochester, New York, USA
| | | | - Kelly G Gwathmey
- University of Virginia, Department of Neurology, Charlottesville, Virginia, 22908, USA
| | - Amruta Joshi
- University of Virginia, Department of Neurology, Charlottesville, Virginia, 22908, USA
| | - Sarah Jones
- University of Virginia, Department of Neurology, Charlottesville, Virginia, 22908, USA
| | - Vera Bril
- Toronto General Hospital, Toronto, Canada
| | | | | | | | | | - Vern C Juel
- Duke University, Durham, North Carolina, USA
| | | | | | | | - Gil Wolfe
- University at Buffalo, SUNY Buffalo, New York, USA
| | - Gary Cutter
- University of Alabama, Birmingham, Birmingham, Alabama, USA
| | | | - Hiroyuki Murai
- Neurological Institute, Kyushu University, Fukuoka, Japan
| | | | - Maria Elena Farrugia
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland
| | - Caroline Carmichael
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland
| | | | | | - Shahriar Nafissi
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Fatehi
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Changyi Ou
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, PRC, China
| | - Weibin Liu
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, PRC, China
| | - Mark Conaway
- University of Virginia, Department of Neurology, Charlottesville, Virginia, 22908, USA
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Burns TM. Using disease-specific, patient-reported measures in everyday clinic. Neurology 2016; 87:858-9. [DOI: 10.1212/wnl.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Pasnoor M, He J, Herbelin L, Burns TM, Nations S, Bril V, Wang AK, Elsheikh BH, Kissel JT, Saperstein D, Shaibani JA, Jackson C, Swenson A, Howard JF, Goyal N, David W, Wicklund M, Pulley M, Becker M, Mozaffar T, Benatar M, Pazcuzzi R, Simpson E, Rosenfeld J, Dimachkie MM, Statland JM, Barohn RJ. A randomized controlled trial of methotrexate for patients with generalized myasthenia gravis. Neurology 2016; 87:57-64. [PMID: 27306628 DOI: 10.1212/wnl.0000000000002795] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 03/17/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the steroid-sparing effect of methotrexate (MTX) in patients with symptomatic generalized myasthenia gravis (MG). METHODS We performed a 12-month multicenter, randomized, double-blind, placebo-controlled trial of MTX 20 mg orally every week vs placebo in 50 acetylcholine receptor antibody-positive patients with MG between April 2009 and August 2014. The primary outcome measure was the prednisone area under the dose-time curve (AUDTC) from months 4 to 12. Secondary outcome measures included 12-month changes of the Quantitative Myasthenia Gravis Score, the Myasthenia Gravis Composite Score, Manual Muscle Testing, the Myasthenia Gravis Quality of Life, and the Myasthenia Gravis Activities of Daily Living. RESULTS Fifty-eight patients were screened and 50 enrolled. MTX did not reduce the month 4-12 prednisone AUDTC when compared to placebo (difference MTX - placebo: -488.0 mg, 95% confidence interval -2,443.4 to 1,467.3, p = 0.26); however, the average daily prednisone dose decreased in both groups. MTX did not improve secondary measures of MG compared to placebo over 12 months. Eight participants withdrew during the course of the study (1 MTX, 7 placebo). There were no serious MTX-related adverse events. The most common adverse event was nonspecific pain (19%). CONCLUSIONS We found no steroid-sparing benefit of MTX in MG over 12 months of treatment, despite being well-tolerated. This study demonstrates the challenges of conducting clinical trials in MG, including difficulties with recruitment, participants improving on prednisone alone, and the need for a better understanding of outcome measure variability for future clinical trials. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with generalized MG MTX does not significantly reduce the prednisone AUDTC over 12 months of therapy.
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Affiliation(s)
- Mamatha Pasnoor
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA.
| | - Jianghua He
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Laura Herbelin
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Ted M Burns
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Sharon Nations
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Vera Bril
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Annabel K Wang
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Bakri H Elsheikh
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - John T Kissel
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - David Saperstein
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - J Aziz Shaibani
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Carlayne Jackson
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Andrea Swenson
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - James F Howard
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Namita Goyal
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - William David
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Matthew Wicklund
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Michael Pulley
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Mara Becker
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Tahseen Mozaffar
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Michael Benatar
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Robert Pazcuzzi
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Ericka Simpson
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Jeffrey Rosenfeld
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Mazen M Dimachkie
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Jeffrey M Statland
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
| | - Richard J Barohn
- From the Department of Biostatistics (J.H.), University of Kansas Medical Center (M.P., J.H., L.H., M.M.D., J.M.S., R.J.B.), Kansas City; University of Virginia (T.M.B.), Charlottesville; University of Texas Southwestern (S.N.), Dallas; University of Toronto (V.B.), Canada; University of California-Irvine (A.K.W., T.M.), Orange; Ohio State University (B.H.E., J.T.K.), Columbus; Phoenix Neurological Associates (D.S.), AZ; Nerve and Muscle Center of Texas (J.A.S.), Houston; University of Texas Health Science Center (C.J.), San Antonio; University of Iowa (A.S.), Iowa City; University of North Carolina (J.F.H.), Chapel Hill; Massachusetts General Hospital (N.G., W.D.), Boston; Penn State Hershey Medical Center (M.W.), Hershey, PA; University of Florida-Jacksonville (M.P.); Children's Mercy Hospital and Clinics (M. Becker), Kansas City, MO; University of Miami (M. Benatar), FL; Indiana University (R.P.), Indianapolis; Methodist Hospital System (E.S.), Houston, TX; and University of San Francisco (J.R.), CA
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Nagel MA, Burns TM, Gilden D. SUNCT headaches after ipsilateral ophthalmic-distribution zoster. J Neurol Sci 2016; 366:207-208. [PMID: 27288808 DOI: 10.1016/j.jns.2016.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/11/2016] [Accepted: 05/13/2016] [Indexed: 11/17/2022]
Abstract
Nine days after left ophthalmic-distribution zoster, a 47-year-old man developed SUNCT headaches (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing). In contrast to two prior cases of SUNCT that developed after varicella zoster virus (VZV) meningoencephalitis without rash, this case describes an association of SUNCT with overt zoster, thus adding to the spectrum of headache and facial pain syndromes caused by VZV reactivation.
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Affiliation(s)
- Maria A Nagel
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Don Gilden
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
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Gwathmey KG, Conaway MR, Sadjadi R, Joshi A, Barnett C, Bril V, Ng E, David W, Gable K, Guptill JT, Hobson-Webb LD, Dineen J, Hehir M, Brannagan TH, Byun E, Adler M, Burns TM. Construction and validation of the chronic acquired polyneuropathy patient-reported index (CAP-PRI): A disease-specific, health-related quality-of-life instrument. Muscle Nerve 2015; 54:9-17. [PMID: 26600438 DOI: 10.1002/mus.24985] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 10/27/2015] [Accepted: 11/19/2015] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Generic health-related quality-of-life (HRQOL) patient-reported outcome measures have been used in patients with chronic immune-mediated polyneuropathies. We have created a disease-specific HRQOL instrument. METHODS The chronic acquired polyneuropathy patient-reported index (CAP-PRI) was developed and validated in multiple steps. Items were initially generated through patient and specialist input. The performance of the preliminary 20 items was analyzed via a prospective, 5-center study involving chronic immune-mediated polyneuropathy patients. RESULTS Data analysis suggested modification to a 15-item scale with 3 response categories rather than 5. The final CAP-PRI was validated in another prospective, 5-center study. The CAP-PRI appeared to be a unidimensional outcome measure that fit the Rasch model in our multicenter cohort. It correlated appropriately with outcome measures commonly used in this patient population. CONCLUSIONS The CAP-PRI is a simple disease-specific HRQOL measure that appears to be useful for clinical care and possibly also for clinical trials. Muscle Nerve 54: 9-17, 2016.
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Affiliation(s)
- Kelly G Gwathmey
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, Virginia, 22908, USA
| | - Mark R Conaway
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Reza Sadjadi
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, Virginia, 22908, USA
| | - Amruta Joshi
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, Virginia, 22908, USA
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Ontario, Canada, USA
| | - Vera Bril
- Division of Neurology, Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Ontario, Canada, USA
| | - Eduardo Ng
- Division of Neurology, Department of Medicine, The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University of Toronto and University Health Network, Toronto, Ontario, Canada, USA
| | - William David
- Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Karissa Gable
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa D Hobson-Webb
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer Dineen
- Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Hehir
- Department of Neurology, University of Vermont, Burlington, Vermont, USA
| | | | - Esther Byun
- Department of Neurology, Jerry L. Pettis VA Medical Center, Loma Linda, California, USA
| | - Margaret Adler
- Department of Neurology, University of California, Los Angeles, California, USA
| | - Ted M Burns
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, Virginia, 22908, USA
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Burns TM, Smith GA, Allen JA, Amato AA, Arnold WD, Barohn R, Benatar M, Bird SJ, Bromberg M, Chahin N, Ciafaloni E, Cohen JA, Corse A, Crum BA, David WS, Dimberg E, Sousa EAD, Donofrio PD, Dyck PJB, Engel AG, Ensrud ER, Ferrante M, Freimer M, Gable KL, Gibson S, Gilchrist JM, Goldstein JM, Gooch CL, Goodman BP, Gorelov D, Gospe SM, Goyal NA, Guidon AC, Guptill JT, Gutmann L, Gutmann L, Gwathmey K, Harati Y, Harper CM, Hehir MK, Hobson-Webb LD, Howard JF, Jackson CE, Johnson N, Jones SM, Juel VC, Kaminski HJ, Karam C, Kennelly KD, Khella S, Khoury J, Kincaid JC, Kissel JT, Kolb N, Lacomis D, Ladha S, Larriviere D, Lewis RA, Li Y, Litchy WJ, Logigian E, Lou JS, MacGowen DJ, Maselli R, Massey JM, Mauermann ML, Mathews KD, Meriggioli MN, Miller RG, Moon JS, Mozaffar T, Nations SP, Nowak RJ, Ostrow LW, Pascuzzi RM, Peltier A, Ruzhansky K, Richman DP, Ross MA, Rubin DEVONI, Russell JA, Sachs GM, Salajegheh MK, Saperstein DS, Scelsa S, Selcen D, Shaibani A, Shieh PB, Silvestri NJ, Singleton JR, Smith BE, So YT, Solorzano G, Sorenson EJ, Srinivasen J, Tavee J, Tawil R, Thaisetthawatkul P, Thornton C, Trivedi J, Vernino S, Wang AK, Webb TA, Weiss MD, Windebank AJ, Wolfe GI. Editorial by concerned physicians: Unintended effect of the orphan drug act on the potential cost of 3,4-diaminopyridine. Muscle Nerve 2015; 53:165-8. [DOI: 10.1002/mus.25009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Sadjadi R, Reilly MM, Shy ME, Pareyson D, Laura M, Murphy S, Feely SME, Grider T, Bacon C, Piscosquito G, Calabrese D, Burns TM. Psychometrics evaluation of Charcot-Marie-Tooth Neuropathy Score (CMTNSv2) second version, using Rasch analysis. J Peripher Nerv Syst 2015; 19:192-6. [PMID: 25400013 DOI: 10.1111/jns.12084] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/21/2014] [Accepted: 06/04/2014] [Indexed: 11/28/2022]
Abstract
Charcot-Marie-Tooth Neuropathy Score second version (CMTNSv2) is a validated clinical outcome measure developed for use in clinical trials to monitor disease impairment and progression in affected CMT patients. Currently, all items of CMTNSv2 have identical contribution to the total score. We used Rasch analysis to further explore psychometric properties of CMTNSv2, and in particular, category response functioning, and their weight on the overall disease progression. Weighted category responses represent a more accurate estimate of actual values measuring disease severity and therefore could potentially be used in improving the current version.
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Affiliation(s)
- Reza Sadjadi
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
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Burns TM. The best of both worlds: Using patient-reported plus physician-scored measures during the evaluation of myasthenia gravis. Muscle Nerve 2015; 53:3-4. [DOI: 10.1002/mus.24953] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 10/16/2015] [Accepted: 10/21/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Ted M. Burns
- Department of Neurology; University of Virginia; Charlottesville Virginia
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Abstract
Myasthenia gravis is an autoimmune neuromuscular disease caused by antibodies directed against the postsynaptic muscle membrane. The clinical hallmark of the disease is fluctuating and fatigable weakness that affects the ocular muscles (resulting in diplopia and ptosis), the bulbar muscles (causing dysphagia, dysarthria, and dyspnea), and extremity muscles. The diagnosis is most often made with serological testing that identifies either acetylcholine receptor antibodies or muscle-specific tyrosine kinase antibodies. Electrodiagnostic testing has a role in supporting the diagnosis. There are many available treatments that result in improvement of function and quality of life. Treatment should be individualized after consideration of many factors, including disease distribution and severity, patient comorbidities, age, serological status, and what is known about the efficacy and safety of the various treatments.
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Affiliation(s)
- Kelly G Gwathmey
- Department of Neurology, University of Virginia, Charlottesville, Virginia
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia
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Mourão AM, Barbosa LSM, Comini-Frota ER, Freitas DDS, Gomez RS, Burns TM, Lemos SMA, Teixeira AL. Clinical profile of patients with myasthenia gravis followed at the University Hospital, Federal University of Minas Gerais. Rev Assoc Med Bras (1992) 2015; 61:156-60. [PMID: 26107366 DOI: 10.1590/1806-9282.61.02.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/21/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to determine the clinical profile of patients with myasthenia gravis (MG); followed at the Neuromuscular Diseases Clinic of the University Hospital, Federal University of Minas Gerais, Brazil, and to compare it with other Brazilian case series. METHODS sociodemographic and clinical data were collected from patients, and a systematic literature review performed, focusing on national studies on the clinical profile of MG patients. RESULTS sixty nine patients were enrolled in the study. Fifty five (91%) subjects were female and the mean age (SD) was 37.6 (± 11.4) years. The mean disease duration was 14.1 years. Regarding treatment, prednisone was the most used strategy (64%), followed by the use of azathioprine (43%). There was no difference between thymectomized (42) and non-thymectomized (27) patients regarding disease severity and medication use. CONCLUSION clinical and socio-demographic features of this MG sample from a University-based clinic resemble those reported in other Brazilian series and in the international literature.
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Affiliation(s)
| | | | | | - Denise da Silva Freitas
- Neurology Service, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Rodrigo Santiago Gomez
- Neurology Service, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Ted M Burns
- University of Virginia, Charlottesville, Virginia, USA
| | - Stela Maris Aguiar Lemos
- Department of Speech Pathology and Audiology, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
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Hobson-Webb LD, Hehir M, Crum B, Visser A, Sanders D, Burns TM. Can mycophenolate mofetil be tapered safely in myasthenia gravis? A retrospective, multicenter analysis. Muscle Nerve 2015; 52:211-5. [DOI: 10.1002/mus.24694] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/18/2015] [Accepted: 04/22/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Lisa D. Hobson-Webb
- Department of Neurology; Duke University Medical Center; DUMC 3403 Durham North Carolina 27710 USA
| | - Michael Hehir
- Department of Neurosciences; University of Vermont College of Medicine; Burlington Vermont USA
| | - Brian Crum
- Department of Neurology; Mayo Clinic; Rochester Minnesota USA
| | - Amy Visser
- Department of Neurology; Mayo Clinic; Rochester Minnesota USA
| | - Donald Sanders
- Department of Neurology; Duke University Medical Center; DUMC 3403 Durham North Carolina 27710 USA
| | - Ted M. Burns
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
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Burns TM, Sanders DB, Kaminski HJ, Wolfe GI, Narayanaswami P, Venitz J. Two steps forward, one step back: Mycophenolate mofetil treatment for myasthenia gravis in the united states. Muscle Nerve 2015; 51:635-7. [DOI: 10.1002/mus.24608] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/05/2015] [Accepted: 02/10/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Ted M. Burns
- University of Virginia; Department of Neurology; Charlottesville Virginia USA
| | | | | | - Gil I. Wolfe
- University of Buffalo; Dept of Neurology; Buffalo New York USA
| | - Pushpa Narayanaswami
- Beth Israel Deaconess Medical Center/Harvard Medical School; Boston Massachusetts USA
| | - Jurgen Venitz
- School of Pharmacy; Medical College of Virginia of Virginia Commonwealth; Richmond Virginia USA
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Affiliation(s)
- Sarah M. Jones
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
| | - Kelly G. Gwathmey
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
| | - Ted M. Burns
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
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Affiliation(s)
- A Gordon Smith
- From the University of Utah Health Care (A.G.S.), Salt Lake City; and University of Virginia (T.M.B.), Charlottesville.
| | - Ted M Burns
- From the University of Utah Health Care (A.G.S.), Salt Lake City; and University of Virginia (T.M.B.), Charlottesville
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Farrugia ME, Carmichael C, Cupka BJ, Warder J, Brennan KM, Burns TM. The modified rankin scale to assess disability in myasthenia gravis: Comparing with other tools. Muscle Nerve 2014; 50:501-7. [DOI: 10.1002/mus.24214] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 02/12/2014] [Accepted: 02/17/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Maria E. Farrugia
- Department of Neurology; Institute of Neurological Sciences, Southern General Hospital; 1345 Govan Road Glasgow G51 4TF UK
| | - Caroline Carmichael
- Department of Neurology; Institute of Neurological Sciences, Southern General Hospital; 1345 Govan Road Glasgow G51 4TF UK
| | - Bryan J. Cupka
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
| | - Judy Warder
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
| | - Kathryn M. Brennan
- Department of Neurology; Institute of Neurological Sciences, Southern General Hospital; 1345 Govan Road Glasgow G51 4TF UK
| | - Ted M. Burns
- Department of Neurology; University of Virginia; Charlottesville Virginia USA
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Sanders DB, Burns TM, Cutter GR, Massey JM, Juel VC, Hobson-Webb L. Does change in acetylcholine receptor antibody level correlate with clinical change in myasthenia gravis? Muscle Nerve 2014; 49:483-6. [DOI: 10.1002/mus.23944] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/24/2013] [Accepted: 06/25/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Donald B. Sanders
- Neuromuscular Division; Department of Neurology; Box 3403; Duke University Medical Center; Durham North Carolina 27710
| | - Ted M. Burns
- Department of Neurology; University of Virginia Medical School; Charlottesville Virginia USA
| | - Gary R. Cutter
- University of Alabama School of Public Health, Birmingham; Birmingham Alabama USA
| | - Janice M. Massey
- Neuromuscular Division; Department of Neurology; Box 3403; Duke University Medical Center; Durham North Carolina 27710
| | - Vern C. Juel
- Neuromuscular Division; Department of Neurology; Box 3403; Duke University Medical Center; Durham North Carolina 27710
| | - Lisa Hobson-Webb
- Neuromuscular Division; Department of Neurology; Box 3403; Duke University Medical Center; Durham North Carolina 27710
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Rutkove SB, Caress JB, Cartwright MS, Burns TM, Warder J, David WS, Goyal N, Maragakis NJ, Benatar M, Sharma KR, Narayanaswami P, Raynor EM, Watson ML, Shefner JM. Electrical impedance myography correlates with standard measures of ALS severity. Muscle Nerve 2013; 49:441-3. [PMID: 24273034 DOI: 10.1002/mus.24128] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/10/2013] [Accepted: 11/18/2013] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Electrical impedance myography (EIM) can be used to assess amyotrophic lateral sclerosis (ALS) progression. The relationship between EIM values and standard assessment measures, however, is unknown. METHODS EIM 50 kHz phase data from 60 subjects who participated in a longitudinal natural history study of ALS were correlated with handheld dynamometry (HHD), the ALS Functional Rating Scale-Revised (ALSFRS-R) score, and motor unit number estimation (MUNE). RESULTS Moderate strength correlations between EIM parameters and HHD were observed for both whole-body and individual upper and lower extremity values. Similarly, moderate strength correlations were observed between EIM and ALSFRS-R upper and lower extremity subscores, but not total ALSFRS-R scores. MUNE correlated significantly with single muscle EIM data but not with whole body or upper or lower extremity values. CONCLUSIONS These results support the concept that EIM can serve as a meaningful measure of disease severity in ALS.
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Affiliation(s)
- Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, TCC-810, Boston, Massachusetts, USA, 02215
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Mourao AM, Araujo CM, Barbosa LSM, Gomez RS, Burns TM, Lemos SMA, Teixeira AL. Brazilian cross-cultural translation and adaptation of the "Questionnaire of Life Quality Specific for Myasthenia Gravis - 15 items". Arq Neuro-Psiquiatr 2013; 71:955-8. [DOI: 10.1590/0004-282x20130180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 07/17/2013] [Indexed: 11/22/2022]
Abstract
Objective To translate and to perform the cross-cultural adaptation of the “Questionnaire of Life Quality Specific for Myasthenia Gravis - 15 items” (MG-QOL15). Method The original English version of the questionnaire was translated into Portuguese. This version was revised and translated back into English. Later, both English versions were compared and the divergences were corrected in the Portuguese text. At a second stage, ten patients with MG followed at the Neuromuscular Diseases Clinic from the University Hospital, Universidade Federal de Minas Gerais answered the questionnaire. The authors analyzed the difficulties and misunderstandings in the application of the questionnaire. Results The questions 8, 13 and 15 were considered difficult to understand and were modified in the final Portuguese version. Most patients (70%) had a total score above 25, and the statements 3, 8 and 9 showed the highest scores. Conclusion The Brazilian version of the questionnaire MG-QOL15 seems to be a promising tool for the assessment of Brazilian patients with MG.
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Burns TM. Myasthenia gravis and myasthenic disorders, 2nd edition. Muscle Nerve 2013. [DOI: 10.1002/mus.23928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
The myasthenia gravis composite (MGC) was constructed by selecting the best performing items from three commonly used, MG-specific scales. The response categories of the items were subsequently weighted for importance. The MGC, which takes less than five minutes to complete, is made up of three ocular, three bulbar, one respiratory, one neck, and two limb items. After its construction, the MGC was validated in an 11-center scale validity study. During the validation study, which included test-retest analysis, it was determined that a 3-point improvement in MGC score reliably indicates clinical improvement. A 3-point improvement in MGC also appears to be meaningful to the patient. Rasch analysis of the MGC confirmed that all 10 items belong and can be summed to provide a total score, and that the weights given to the response categories of the items are appropriate.
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Affiliation(s)
- Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, USA.
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Sanders DB, Benatar M, Burns TM, Cutter GR. Reply: To PMID 22581550. Muscle Nerve 2013; 47:145-6. [PMID: 23042161 DOI: 10.1002/mus.23668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 09/03/2012] [Accepted: 09/04/2012] [Indexed: 11/08/2022]
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Burns TM. More than meets the eye: the benefits of listening closely to what our patients with myasthenia gravis are telling us. Muscle Nerve 2012; 46:153-4. [PMID: 22806362 DOI: 10.1002/mus.23461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Rutkove SB, Caress JB, Cartwright MS, Burns TM, Warder J, David WS, Goyal N, Maragakis NJ, Clawson L, Benatar M, Usher S, Sharma KR, Gautam S, Narayanaswami P, Raynor EM, Watson ML, Shefner JM. Electrical impedance myography as a biomarker to assess ALS progression. ACTA ACUST UNITED AC 2012; 13:439-45. [PMID: 22670883 DOI: 10.3109/17482968.2012.688837] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Electrical impedance myography (EIM), a non-invasive, electrophysiological technique, has preliminarily shown value as an ALS biomarker. Here we perform a multicenter study to further assess EIM's potential for tracking ALS. ALS patients were enrolled across eight sites. Each subject underwent EIM, handheld dynamometry (HHD), and the ALS Functional Rating Scale-revised (ALSFRS-R) regularly. Techniques were compared by assessing the coefficient of variation (CoV) in the rate of decline and each technique's correlation to survival. Results showed that in the 60 patients followed for one year, EIM phase measured from the most rapidly progressing muscle in each patient had a CoV in the rate of decline of 0.62, compared to HHD (0.82) and the ALSFRS-R (0.74). Restricting the measurements to the first six months gave a CoV of 0.55 for EIM, 0.93 for HHD, and 0.84 for ALSFRS-R. For both time-periods, all three measures correlated with survival. Based on these data, a six-month clinical trial designed to detect a 20% treatment effect with 80% power using EIM would require only 95 patients/arm compared to the ALSFRS-R, which would require 220 subjects/arm. In conclusion, EIM can serve as a useful ALS biomarker that offers the prospect of greatly accelerating phase 2 clinical trials.
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Affiliation(s)
- Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Burns TM, Graham CD, Rose MR, Simmons Z. Quality of life and measures of quality of life in patients with neuromuscular disorders. Muscle Nerve 2012; 46:9-25. [PMID: 22644588 DOI: 10.1002/mus.23245] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2011] [Indexed: 12/12/2022]
Abstract
In this review we present an overview of quality of life (QOL) and QOL measures in neuromuscular disorders. We discuss the characteristics of QOL measures used in neuromuscular research, highlighting differences between generic versus disease-specific and global versus health-related QOL instruments. The phenomenon of response shift is reviewed. Commonly used QOL instruments are reviewed for amyotrophic lateral sclerosis, muscle diseases, myasthenia gravis, and polyneuropathy. We also review some of what is known about QOL for patients with these neuromuscular disorders.
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Affiliation(s)
- Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia 22908, USA.
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Sadjadi R, Conaway M, Cutter G, Sanders DB, Burns TM. Psychometric evaluation of the myasthenia gravis composite using rasch analysis. Muscle Nerve 2012; 45:820-5. [DOI: 10.1002/mus.23260] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Benatar M, Sanders DB, Burns TM, Cutter GR, Guptill JT, Baggi F, Kaminski HJ, Mantegazza R, Meriggioli MN, Quan J, Wolfe GI. Recommendations for myasthenia gravis clinical trials. Muscle Nerve 2012; 45:909-17. [DOI: 10.1002/mus.23330] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shefner JM, Watson ML, Simionescu L, Caress JB, Burns TM, Maragakis NJ, Benatar M, David WS, Sharma KR, Rutkove SB. Multipoint incremental motor unit number estimation as an outcome measure in ALS. Neurology 2011; 77:235-41. [PMID: 21676915 DOI: 10.1212/wnl.0b013e318225aabf] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Improved outcome measures are necessary to reduce sample size and increase power in amyotrophic lateral sclerosis (ALS) clinical trials. Motor unit number estimation (MUNE) is a potentially attractive tool. MUNE methods previously employed in multicenter trials exhibited excessive variability and were prone to artifact. OBJECTIVE To evaluate a modification of standard incremental MUNE in a multicenter natural history study of subjects with ALS. METHODS Fifty healthy subjects were evaluated twice and 71 subjects with ALS were studied repeatedly for up to 500 days. Side and nerve studied was based on clinical examination findings. Nerves were stimulated at 3 specified locations and 3 increments were obtained at each location. Average single motor unit action potential (SMUP) amplitude was calculated by adding the amplitude of the third increment at each location and dividing by 9; SMUP was divided into maximum CMAP amplitude to determine the MUNE. RESULTS Test-retest variability was 9% in normal subjects. Average MUNE for normal subjects was 225 (±87), and was 41.9 (±39) among subjects with ALS at baseline. Subjects with ALS showed clear decrements over time, with an overage rate of decline of approximately 9% per month. SMUP amplitude increased with time in a fashion consistent with the known pathophysiology of ALS. CONCLUSION Multipoint incremental MUNE has a number of attributes that make it attractive as an outcome measure in ALS and other diseases characterized by motor unit loss. It can be rapidly performed on any EMG machine and has repeatability and rates of decline that favorably compare to other previously described methods.
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Affiliation(s)
- J M Shefner
- Department of Neurology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
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