Quality of life and well-being of patients with myasthenia gravis

Case Report: Telitacicept in severe myasthenia gravis: a case study with multiple autoantibodies

Multi-antibody-positive myasthenia gravis (MG) presentations are relatively rare, often found in older patients, and generally predict a poor prognosis. We report a case of a female patient with generalized MG, testing positive for Titin antibodies (Titin-Ab), ryanodine receptor antibodies (RyR-Ab), and acetylcholine receptor antibodies (AChR-Ab), and resistant to acetylcholinesterase inhibitors. Following unsuccessful traditional therapies, she received Telitacicept, leading to significant improvements. This case underscores Telitacicept's potential efficacy for similar patients and offers insights into the clinical characteristics of multi-antibody MG.

Neuromuscular fatigue in autoimmune myasthenia gravis: A cross-sectional study

OBJECTIVES

To investigate the presence of increased neuromuscular fatigue (NMF) in individuals with myasthenia gravis (IwMG), compared to healthy controls. A secondary aim was to assess associations between NMF, strength and perceived health-related quality of life (HRQoL) and symptom severity in IwMG.

METHODS

In this cross-sectional study, we assessed NMF using classical myoelectrical indicators (root mean square: RMS, mean power frequency: MPF) obtained from surface electromyography (sEMG) during a sustained submaximal isometric contraction of the right Biceps Brachii and the right Vastus Lateralis and by evaluating the post-effort decline in peak torque following a fatiguing task consisting of a 40-second sustained isometric contraction. Relationships with MG-specific clinical scores (Myasthenia Muscle Score for symptom severity, MGQOL-15-F for HRQoL) were investigated.

RESULTS

Forty-one females with MG were compared to 18 control females of similar age. IwMG demonstrated reduced strength in both muscle groups, compared to control subjects. In both populations and both limbs, NMF was demonstrated by an increase in RMS and a decrease in MPF. However, IwMG did not demonstrate greater NMF based on these myoelectrical indicators nor based on post-effort peak torque decline.

DISCUSSION

Despite a decrease in baseline strength, IwMG did not display greater NMF in this specific experimental paradigm. This cohort consisted of individuals with mild-to-moderately severe MG which was well-controlled and stable. Further studies are warranted to identify simple and reliable methods to measure NMF in MG and to understand the relationship between NMF and perceived fatigue in activities of daily living for IwMG.

Association Between Myasthenia Gravis-Activities of Daily Living (MG-ADL) and EQ-5D-5L Utility Values: The Additional Effect of Efgartigimod on Utilities

INTRODUCTION

For patients with generalized myasthenia gravis (gMG), the association between symptom severity, often measured with the Myasthenia Gravis Activities of Daily Living (MG-ADL) instrument, and utility values is unknown.

METHODS

Data was analyzed from the phase 3 ADAPT trial, which included adult patients with gMG randomly assigned to treatment with efgartigimod + conventional therapy (EFG + CT) or placebo + CT (PBO + CT). MG-ADL total symptom scores and the EQ-5D-5L, a measure of health-related quality of life (HRQoL), were collected biweekly up to 26 weeks. Utility values were derived from the EQ-5D-5L data with the United Kingdom value set. Descriptive statistics were reported for MG-ADL and EQ-5D-5L at baseline and follow-up. A normal identity-link regression model estimated the association between utility and the eight MG-ADL items. A generalized estimating equations (GEE) model was estimated to predict utility based on the patient's MG-ADL score and treatment received.

RESULTS

A total of 167 patients (84 EFG + CT, 83 PBO + CT) contributed 167 baseline and 2867 follow-up measurements of MG-ADL and EQ-5D-5L. EFG + CT-treated patients experienced more improvements than PBO + CT-treated patients in most MG-ADL items and EQ-5D-5L dimensions, with the largest improvements observed in chewing, brushing teeth/combing hair, eyelid droop (MG-ADL); self-care, usual activities, mobility (EQ-5D-5L). The regression model indicated that individual MG-ADL items contributed differently to utility values, with the largest impact from brushing teeth/combing hair, rising from a chair, chewing, and breathing. The GEE model showed that each unit improvement in MG-ADL led to a statistically significant utility increase of 0.0233 (p < 0.001). In addition, a statistically significant improvement of 0.0598 (p = 0.0079) in utility was found for patients in the EFG + CT group compared to the PBO + CT group.

CONCLUSION

Among patients with gMG, improvements in MG-ADL were significantly associated with higher utility values. MG-ADL scores alone were not sufficient to capture the utility gained from efgartigimod therapy.

The effects of spinal stabilization exercises in patients with myasthenia gravis: a randomized crossover study

PURPOSE

The effects of spinal stabilization exercises (SSE) on fatigue, muscle strength, respiratory functions, functional capacity, and quality of life (QoL) in myasthenia gravis (MG) patients were investigated.

MATERIALS AND METHODS

This study which was designed a single-blinded, randomized crossover trial were included mild to moderate 10 MG patients, aged between 18 and 65. SSE and home program were applied to the patients for six weeks, four weeks between each exercise program. Fatigue assessed with Fatigue Severity Scale (FSS) and Visual Analog Fatigue Scale (VAFS). Muscle strengths were assessed with dynamometric measures. Respiratory Function Test, 6 Minute Walk Test (6MWT), Quantitative Myasthenia Gravis Score (QMGS), Myasthenia Gravis Quality of Life Scale-15 (MGQOL-15) were used.

RESULTS

All parameters were improved in SSE group, but not neck muscles strength, QMGS, and respiratory functions in home program group. FSS, VAFS, muscle strength, 6MWT, MGQOL-15 values were found significantly different in SSE group (p = .005 in all parameters).

CONCLUSIONS

SSE are safe and effective on fatigue, muscle strength, respiratory functions, functional capacity, and QoL for MG patients, so it may be suggested to include SSE in rehabilitation programs of MG patients.Implications For RehabilitationSpinal stabilization exercises are safe and effective for Myasthenia Gravis patients.Home exercise program which included breathing exercises and callisthenic exercises tailored to the patients' needs is safe and effective for Myasthenia Gravis patients.Rehabilitation programs of Myasthenia Gravis patients should include spinal stabilization exercises.

Fragmented care and missed opportunities: the experiences of adults with myasthenia gravis in accessing and receiving allied health care in Australia

PURPOSE

Although allied health services are important adjuncts to medical care for people with myasthenia gravis (MG), the underutilisation of these services is not well understood within the Australian context. It is critical to explore patients' perceptions to develop services that meet consumer needs. This study, therefore, sought to obtain insight into MG patients' perspectives and experiences, in addition to the outcomes, of accessing allied health services.

MATERIALS AND METHODS

Thirteen Australian adults with MG participated in semi-structured interviews. Qualitative analysis was conducted inductively using thematic content analysis.

RESULTS

Four themes were identified: (1) missed opportunities and unmet care needs were common, due to frequent patient-provider communication breakdowns and a lack of referral protocols, (2) personal factors - patient self-advocacy influenced their perceived need, with some lacking confidence to seek help, (3) perceived benefit and health provider capacities - most valued allied health despite differing perceptions of health professionals' attitudes, skills, and willingness to learn, and (4) a resultant fragmentation of care between services was universal.

CONCLUSIONS

Findings highlighted a need for clear referral pathways, coordinated multidisciplinary care, improved access to community-based services and education for allied health professionals about MG.Implications for rehabilitationAdults with myasthenia gravis (MG) report a lack of referral pathways to allied health services, leading to unmet needs and fragmented care.Although there is a perceived benefit to allied health care, experiences are impacted by health provider capacity and attitudes.There needs to be an overall shift towards multidisciplinary care for people with MG, and the development of clear referral pathways.Specific education about MG should be available for allied health professionals to improve their knowledge and skills in treating this population.

Burden of disease in myasthenia gravis: taking the patient's perspective

BACKGROUND

Myasthenia gravis (MG) leads to exertion-dependent muscle weakness, but also psychological and social well-being are limited. We aim to describe the burden of disease in MG including sociodemographic, economical, psychosocial as well as clinical aspects, to compare health-related quality of life (HRQoL) of patients with MG to the general population (genP) and to explore risk factors for a lower HRQoL.

METHODS

This case-control study was conducted with MG patients of the German Myasthenia Association. A questionnaire-based survey included sociodemographic and clinical data as well as standardized questionnaires, e.g. the Short Form Health (SF-36). HRQoL was compared to genP in a matched-pairs analysis. Participants of the German Health Interview and Examination Survey for Adults (DEGS1) served as control group.

RESULTS

In our study, 1660 MG patients participated and were compared to 2556 controls from the genP. Patients with MG showed lower levels of physical functioning (SF-36 mean 56.0, SD 30.3) compared to the genP (mean 81.8, SD 22.1, adjusted difference: 25, 95% CI 22-29) and lower mental health sub-score (SF-36 mean 67.3, SD 19.8, vs. 74.1, SD 16.7, adjusted difference: 5, 95% CI 2-8). Female gender, higher age, low income, partnership status, lower activities of daily life, symptoms of depression, anxiety and fatigue and self-perceived low social support were associated with a lower HRQoL in MG patients.

DISCUSSION

HRQoL is lower in patients with MG compared to genP. The burden of MG on patients includes economic and social aspects as well as their emotional well-being. New therapies must achieve improvements for patients in these areas.

TRIAL REGISTRATION INFORMATION

Clinicaltrials.gov, NCT03979521, submitted: June 7, 2019, first patient enrolled: May 1, 2019, https://clinicaltrials.gov/ct2/show/NCT03979521.

OUP accepted manuscript

Myasthenia gravis is an autoimmune disease affecting neuromuscular transmission and causing skeletal muscle weakness. Additionally, systemic inflammation, cognitive deficits and autonomic dysfunction have been described. However, little is known about myasthenia gravis-related reorganization of the brain. In this study, we thus investigated the structural and functional brain changes in myasthenia gravis patients. Eleven myasthenia gravis patients (age: 70.64 ± 9.27; 11 males) were compared to age-, sex- and education-matched healthy controls (age: 70.18 ± 8.98; 11 males). Most of the patients (n = 10, 0.91%) received cholinesterase inhibitors. Structural brain changes were determined by applying voxel-based morphometry using high-resolution T₁-weighted sequences. Functional brain changes were assessed with a neuropsychological test battery (including attention, memory and executive functions), a spatial orientation task and brain-derived neurotrophic factor blood levels. Myasthenia gravis patients showed significant grey matter volume reductions in the cingulate gyrus, in the inferior parietal lobe and in the fusiform gyrus. Furthermore, myasthenia gravis patients showed significantly lower performance in executive functions, working memory (Spatial Span, P = 0.034, d = 1.466), verbal episodic memory (P = 0.003, d = 1.468) and somatosensory-related spatial orientation (Triangle Completion Test, P = 0.003, d = 1.200). Additionally, serum brain-derived neurotrophic factor levels were significantly higher in myasthenia gravis patients (P = 0.001, d = 2.040). Our results indicate that myasthenia gravis is associated with structural and functional brain alterations. Especially the grey matter volume changes in the cingulate gyrus and the inferior parietal lobe could be associated with cognitive deficits in memory and executive functions. Furthermore, deficits in somatosensory-related spatial orientation could be associated with the lower volumes in the inferior parietal lobe. Future research is needed to replicate these findings independently in a larger sample and to investigate the underlying mechanisms in more detail.

Validation of Spanish version of 15-item myasthenia gravis quality-of-life questionnaire

OBJECTIVES

The aim of this study was to achieve the translation and cross-cultural adaptation of the MG-QOL15R questionnaire into Spanish and the analysis of its psychometric properties.

MATERIALS AND METHODS

We recruited patients with MG, ≥18 years old, whose mother tongue was Spanish. After the translation and cross-cultural adaptation of the MG-QOL15-R, the following tests were performed: internal consistency using the Cronbach-α coefficient and corrected item-total correlations; reproducibility with a test-retest analysis using intraclass correlation coefficients; and concurrent validity using Spearman's correlation coefficient of the Spanish language MG-QOL15R-S, Myasthenia Gravis Activity of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. As an approximation to construct validity, the nonparametric Mann-Whitney U test was performed between MG-QOL15R-S scores according to the Myasthenia Gravis Foundation of America classification.

RESULTS

A total of 83 MG patients were enrolled, mean age 48.19 ± 17.25 years; 58 (69.9%) were women. The mean MG-QOL15R-S score was 11.3 ± 7.1. Cronbach-α coefficient was 0.92. Item-total correlation ranged between 0.43 and 0.75. Intraclass correlation coefficient was 0.80. The Spearman correlation coefficient was 0.637 (p-value < .001) for MG-ADL and 0.487 (p-value < .001) for QMG. Mann-Whitney U tests of the mean MG-QOL15R-S scores were significantly different according to the clinical severity (p-value < .001).

CONCLUSIONS

The Spanish version of the MG-QOL15R is a valid and reliable instrument and potentially useful for measuring health-related quality of life in Spanish-speaking MG patients.

Application Prospect of Artificial Intelligence in Rehabilitation and Management of Myasthenia Gravis

Myasthenia gravis (MG) is a chronic autoimmune disease of the nervous system, which is still incurable. In recent years, with the progress of immunosuppressive and supportive treatment, the therapeutic effect of MG in the acute stage is satisfactory, and the mortality rate has been greatly reduced. However, there is still no consensus on how to conduct long-term management of stable MG, such as guiding patients to identify relapses, practice exercise, return to work and school, etc. In the international consensus guidance for management of myasthenia gravis published by the Myasthenia Gravis Foundation of America (MGFA) in 2020, for the first time, “the role of physical training/exercise in MG” was identified as the topic of discussion. Finally, due to a lack of high-quality evidence on physical training/exercise in patients with MG, the topic was excluded after the literature review. Therefore, this paper reviewed the current status of MG rehabilitation research and the difficulties faced by stable MG patients in self-management. It is suggested that we should take advantage of artificial intelligence (AI) and leverage it to develop the data-driven decision support platforms for MG management which can be used for adverse event monitoring, disease education, chronic management, and a wide variety of data collection and analysis.

Determinants of Quality of Life in Myasthenia Gravis Patients

Background: Although approximately half of myasthenia gravis (MG) patents achieve remission, for the remaining group MG is often a life-long disease. Better understanding of the determinants of Quality of Life (QoL) in MG is needed to optimize treatment goals in chronic cases.

Materials and Methods: We performed a single center cross-sectional study in 339 MG adult patients (64.9% women), with ocular or generalized disease. SF-36 and a structured questionnaire was administered, including information on previous and current MG severity, medications, comorbidities, education, occupation and BMI of the patient. Mean disease duration was 7.5 + 9.3 years. Current age was 51.6 + 18.3 years, 55% had Early-Onset (<50 years) MG.

Results: There were no statistically significant differences in mean SF-36 subscores between women and men. Worse MGFA class was related to lower QoL in physical (PCS) and mental (MCS) subscore (p = 0.000 for both). Patients with MGFA I-II class had significantly better QoL in physical and mental subscores than patients with more severe MG (p < 0.005). Late-onset MG patients had worse QoL than EOMG in physical score domain PCS (p = 0.049). Overweight and obese patients had lower PCS (p = 0.002) and MCS (p = 0.038) than patients with normal BMI. University education was related to statistically higher PCS (p = 0.015) and MCS (p = 0.006). QoL in currently employed was better in PCS and MCS (p = 0.000), with white collar workers reporting higher PCS (p = 0.049) than the remaining group. Patients living with family evaluated their MCS (p = 0.015) better than living alone. Moderate physical activity (twice a week) improved PCS (p = 0.045).

Conclusion: Our study confirmed that greater severity of symptoms, age, age of onset but also BMI, type of work, education status and physical activity affect QoL in MG.

Evidence-Based Practice in Rehabilitation of Myasthenia Gravis. A Systematic Review of the Literature

Myasthenia gravis is a rare neuromuscular disorder characterized by muscle weakness and fatigue. This review analyzes the most recent evidence regarding the effectiveness and safety of different rehabilitative approaches to the disease. The review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 365 articles were found in the main scientific databases. Applying the inclusion/exclusion criteria, 11 studies were admitted to the final phase of the review. Three different rehabilitative approaches were identified: physical training, respiratory training, and balance training. All rehabilitative modalities contributed to enhancing functional outcomes, reducing fatigue, and improving quality of life, but currently none can be recommended over another for the lack of cross-comparative studies. The included studies showed methodological quality from low to fair. Despite the range of rehabilitative interventions available, there is a lack of high-quality evidence. However, this review suggests that a multidisciplinary rehabilitation approach should be recommended to people with myasthenia gravis, and above all, for those with mild to moderate symptomatology.

The Impact of the Coronavirus Disease-2019 Pandemic on the Psychological Status and Quality of Life of Myasthenia Gravis Patients

Objectives:

The coronavirus disease 2019 (COVID-19) is the largest pandemic of our times. We wanted to investigate the impact of COVID-19 pandemic on the psychological status, quality of life (QoL) and quality of sleep (QoS) of myasthenia gravis (MG) patients.

Methods:

Data on the epidemiological and clinical characteristics of MG were collected. We used a self-designed questionnaire (consisting of 12 questions), a revised 15-item Myasthenia Gravis Quality of Life Questionnaire (MGQOL15r), a 36-item health survey of the Medical Outcomes Study Short Form (SF36), Pittsburgh sleep quality index (PSQI), Hamilton scales for the assessment of anxiety (HAM-A), and depression (HAMD) were used. We reassessed patients who were tested three years ago using the same questionnaires.

Results:

The study included 64 MG patients. We noticed a statistically significant difference between the results obtained three years ago and the results from April 2020 in PSQI scores (P < 0.01). MGQOL15r, SF36, and PSQI scores correlate with severe clinical manifestation, high scores on HAM-A and HAM-D (P < 0.01). Higher scores on HAM-D and fear that MG symptoms will be worse if the patient gets an upper respiratory infection were independent predictors of the lower SF36 scores. Regarding MGQOL15r-independent predictors of the higher score were higher scores on HAM-D.

Conclusions:

There is a significant impact of the COVID-19 epidemic on the psychological status and especially on the quality of sleep of MG patients. Healthcare organizations need to provide professional therapeutic advice and psychosocial support for this population of patients during the pandemic.

Understanding side effects of therapy for myasthenia gravis and their impact on daily life

Background

Myasthenia gravis is a chronic, autoimmune, neuromuscular junction disorder characterized by skeletal muscle weakness. Current therapies for myasthenia gravis are associated with significant side effects. The objective of this study was to characterize the side effects, and associated health-related quality of life and treatment impacts, of traditional myasthenia gravis treatments.

Methods

This study had two phases; a Phase 1 interview and a 2-part web-based survey in Phase 2 that included brainstorming (Step 1) and rating (Step 2) exercises using group concept mapping. In Phase 1, all 14 participants reported experiencing side effects from myasthenia gravis treatments which had significant impacts on daily life. In Phase 2, 246 participants contributed to Step 1; 158 returned for Step 2.

Results

The brainstorming exercise produced 874 statements about side effects and their impact, which were reduced to 35 side effects and 23 impact-on-daily life statements. When rating these statements on severity, frequency, and tolerability, blood clots, infections/decreased immunity, weight gain, and diarrhea were the least tolerable and most severely rated. The most frequent and severe impacts were sleep interference and reduced physical and social activities.

Conclusions

Based on these findings, there appears to be a need for better and more tolerable treatments for myasthenia gravis patients.

Long-term follow-up, quality of life, and survival of patients with Lambert-Eaton myasthenic syndrome

Objective

To study survival and to characterize long-term functional impairments and health-related quality of life (HRQOL) of patients with Lambert-Eaton myasthenic syndrome (LEMS).

Methods

In this observational study, survival of patients with LEMS, separately for nontumor (NT) and small cell lung cancer (SCLC), was compared to that of the Dutch general population and patients with SCLC. Disease course in patients with LEMS was recorded retrospectively. Several scales for functional impairments and health-related quality of life were assessed.

Results

We included 150 patients with LEMS. Survival was similar to that of the general population in 65 patients with NT-LEMS. Tumor survival was significantly longer in 81 patients with SCLC-LEMS compared to patients with non-LEMS SCLC (overall median survival 17 vs 7.0 months, p < 0.0001). At diagnosis, 39 (62%) of 63 patients with complete follow-up data were independent for activities of daily living, improving to 85% at the 1-year follow-up. The physical HRQOL composite score (55.9) was significantly lower than in the general population (76.3, p < 0.0001) and comparable to that of patients with myasthenia gravis (60.5). The mental HRQOL composite score was 71.8 in patients with LEMS, comparable to that of the general population (77.9, p = 0.19) and patients with myasthenia gravis (70.3).

Conclusions

This study shows that patients with NT-LEMS have normal survival. Patients with SCLC-LEMS have an improved tumor survival, even after correction for tumor stage. A majority of patients with LEMS report a stable disease course and remain or become independent for self-care after treatment.

Quality of life in refractory generalized myasthenia gravis: A rapid review of the literature

Generalized myasthenia gravis (GMG) is a neuromuscular transmission disorder that creates a fluctuating weakness of the voluntary muscles. This study is aimed at understanding the effect that refractory GMG has on the quality of life of patients who suffer from it, and the effect of eculizumab on it. A systematic literature search was conducted in MEDLINE (Ovid), EMBASE and the Cochrane Database of Systematic Reviews (Ovid). Eligibility criteria were verified via the title and summary and afterward through the full text. The risk of bias of the included randomized clinical trials was evaluated and the data were synthesized in a descriptive manner. Nine studies were identified that evaluated the quality of life of patients with GMG. Regarding the effect of eculizumab, two studies were identified. The quality of life in patients with GMG is lower compared to ocular myasthenia gravis (MG) and MG in remission, especially in the domains of physical function, physical role, bodily pain, vitality, and social function. Patients treated with eculizumab had a better perception of their quality of life compared to those who received placebo. GMG affects the quality of life more than other types of MG. This outcome is of great importance for the choice of therapeutic options in patients with refractory GMG. Eculizumab generates improvements in the perception of patients' quality of life compared to placebo, making it a relevant therapeutic option in the management of refractory GMG.

Risk of Depressive Disorders Following Myasthenia Gravis: A Nationwide Population-Based Retrospective Cohort Study

The chronic autoimmune disease myasthenia gravis (MG) is characterized by fluctuating muscle weakness, which can lead to a large amount of stress in the patient. The current investigation plans to assess the risk of depressive disorders in MG patients. A retrospective cohort study of patients ageing 20 years and older and also newly diagnosed with MG between January 1, 2000, and December 31, 2008, was conducted from the National Health Insurance Research Database (NHIRD) in Taiwan. Observations of all 349 MG patients and 1,396 control individuals were made until a diagnosis of a depressive disorder by a psychiatrist, until death, or until December 31, 2013. A range of comorbidities were found, such as coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia, with cerebrovascular disease being reported more frequently in MG patients in comparison with control subjects. After adjustment of patients' sex, age, urbanization, comorbidities, and monthly income, results indicated that MG individuals are 1.94 times more at risk (95% confidence interval [CI], 1.15-3.27, P = 0.014) of developing depressive disorders than are controls. This showed an increased risk in the development of depressive disorders in people with MG. Thus, depressive symptoms in MG patients should be regularly assessed.

Marathons and myasthenia gravis: a case report

Background

The cardinal symptoms of auto-immune myasthenia gravis are fatigue and weakness. Endurance events such as marathon running would seem incompatible with this chronic disease. Many patients stop sport altogether. There is limited literature of patients with auto-immune myasthenia gravis undergoing regular endurance exercise.

Case presentation

We report the case of a 36-year-old female who began long-distance running whilst experiencing initial symptoms of myasthenia gravis. She was diagnosed with auto-immune myasthenia gravis and whilst advised to stop all sport, her way of fighting and living with this chronic and unpredictable disease was to continue running to maintain a healthy body and mind. Despite suffering from ocular, bulbar and localized limb fatigability, she managed to complete multiple marathons and achieve disease stability with cholinesterase inhibitors.

Conclusions

Marathon and half-marathon running lead to distinct changes in mediators of inflammation in an exercise-dose-dependent manner. Despite symptoms of weakness and fatigue in certain muscles in myasthenia gravis, physical exertion remains possible and may not worsen symptoms as demonstrated in this case and recent studies. The immunomodulatory role of exercise could be considered in this case however this hypothesis remains to be confirmed in future studies with quantitative data.

Quality of life in patients with MuSK positive myasthenia gravis

It is believed that myasthenia gravis (MG) with antibodies to muscle-specific tyrosine kinase (MuSK) is the most severe form of the disease, especially in the first years of the disease. The aim of our study was to investigate quality of life (QoL) in a population of patients with MuSK MG compared to those with MG who have antibodies to acetylcholine receptor (AChR) in their sera. The study group consisted of 35 MuSK MG patients (28 females and 7 males), while the control group included 38 AChR MG patients matched for gender, age, and duration of the disease. SF-36 questionnaire was used to evaluate the health-related QoL. Following scales were also used: Hamilton's scales for depression and anxiety, the Multidimensional Scale of Perceived Social Support, and the Acceptance of Illness Scale. Physical domain scores of QoL were similarly affected in both MuSK and AChR groups, while mental domain and total SF-36 scores were even better in MuSK MG patients. Social support was better in the MuSK group (77.3 ± 9.3 vs. 70.6 ± 14.1, p < 0.05). SF-36 total score correlated with depression (rho = 0.54, p < 0.01), anxiety (rho = 0.49, p < 0.01), and MSPSS (rho = - 0.35, p < 0.05), and depression was an independent predictor of worse QoL. Besides therapy of weakness, psychiatric treatment and different forms of psychosocial condition should be part of regular therapeutic protocols for MG. Adequate team work of health professionals and family can provide a healthy mental environment in which a MuSK MG patient would feel more comfortable in spite of the disease.

Translation, cross-cultural adaptation, and validation of the chinese version of the 15-item myasthenia gravis quality of life questionnaire

INTRODUCTION

We sought to translate, cross-culturally adapt, and evaluate the internal consistency and validity of the Chinese version of the 15-Item Myasthenia Gravis Quality of Life (MG-QOL15).

METHODS

Translation and cross-cultural adaptation of the MG-QOL15 were performed. We used Cronbach's α to test internal consistency, one-way analysis of variance to test construct validity, and Pearson or Spearman correlations to test discriminant and concurrent validity.

RESULTS

We enrolled 168 outpatients. Internal consistency was excellent (Cronbach's α = 0.928). The MG-QOL15 discriminated MG severity as stratified by the MG Composite (MGC; P < 0.001) and Osserman class (P = 0.01). Concurrent validity was low to moderate with the subscales of the 36-item Short Form (-0.31 to ∼-0.59), MGC (r = 0.46), and Myasthenia Gravis Activities of Daily Living profile (r = 0.54).

DISCUSSION

The Chinese MG-QOL15 showed comparable construct, discriminant and concurrent validity, and internal consistency with to the original version. Muscle Nerve 59:95-99, 2019.

Is there any relationship between quality of life and polysomnographically detected sleep parameters/disorders in stable myasthenia gravis?

It is known that quality of life in myasthenia gravis is positively correlated with subjective sleep quality, still no data is available regarding the relationship between QOL and polysomnographically detected sleep parameters and disorders. In this study, we tried to highlighten this relationship, by performing polysomnography. Sleep-related complaints were evaluated in face-to-face interviews with 19 clinically stable MG patients and 26 healthy controls. During the interviews questionnaires assessing sleep quality, excessive daytime sleepiness, fatigue, depression, anxiety, and Turkish version of the MG-QOL 15-item scale [(MG-QOL15(T)] were administered and then an overnight polysomnography was performed. Sleep disorders, especially obstructive sleep apnea and fatigue were higher, whereas subjective sleep duration was significantly lower, in patients than controls. Excessive daytime sleepiness and poor sleep quality were not different between patients and controls. Other than percentage of sleep stage III, which was negatively correlated with MG-QOL15(T) scores, neither other sleep parameters nor sleep disorders were correlated with MG-QOL15(T) scores. MG composite, subjective sleep duration, fatigue severity and Hamilton depression rating scale scores were found to be positively correlated with MG-QOL15(T) scores. It was shown that decreasing disease severity and enhancing psychological well-being will improve patients' quality of life. We recommend that our findings should be repeated in a large prospective cohort of MG patients.

Muscle strength and psychiatric symptoms influence health-related quality of life in patients with myasthenia gravis

Myasthenia gravis (MG) is a neuromuscular autoimmune disease characterized by skeletal muscle weakness which can impact motor function and, furthermore, produce negative impact on the health-related quality of life (HRQOL).

OBJECTIVE

To evaluate the predictors for HRQOL in patients with MG.

METHODS

Eighty patients were evaluated with the MG Foundation of America classification and the MG Composite scale. HRQOL was estimated by the MGQOL15, while anxious and depressive symptoms were evaluated with the Hospital Anxiety and Depression Scale (HAD).

RESULTS

The mean age of patients was 41.9 years with mean illness duration of 13.5 years. Almost half of the patients (43.75%) had significant anxiety and more than a quarter (27.50%) had depressive symptoms. Factors that influenced the HRQOL in MG were skeletal muscle weakness and anxiety and depressive symptoms (p < .001 in logistic regression model).

CONCLUSION

Anxiety and depressive symptoms, besides motor symptoms, influence HRQOL in MG. Mental health must be a clinical focus in addition to the treatment of somatic symptoms during the course of MG.

The benefits and tolerance of exercise in myasthenia gravis (MGEX): study protocol for a randomised controlled trial

Background

Research exploring the effects of physical exercise in auto-immune myasthenia gravis (MG) is scarce. The few existing studies present methodological shortcomings limiting the conclusions and generalisability of results. It is hypothesised that exercise could have positive physical, psychological as well as immunomodulatory effects and may be a beneficial addition to current pharmacological management of this chronic disease. The aim of this study is to evaluate the benefits on perceived quality of life (QOL) and physical fitness of a home-based physical exercise program compared to usual care, for patients with stabilised, generalised auto-immune MG.

Methods

MGEX is a multi-centre, interventional, randomised, single-blind, two-arm parallel group, controlled trial. Forty-two patients will be recruited, aged 18–70 years. Following a three-month observation period, patients will be randomised into a control or experimental group. The experimental group will undertake a 40-min home-based physical exercise program using a rowing machine, three times a week for three months, as an add-on to usual care. The control group will receive usual care with no additional treatment. All patients will be followed up for a further three months. The primary outcome is the mean change in MGQOL-15-F score between three and six months (i.e. pre-intervention and immediately post-intervention periods). The MGQOL-15-F is an MG-specific patient-reported QOL questionnaire. Secondary outcomes include the evaluation of deficits and functional limitations via MG-specific clinical scores (Myasthenia Muscle Score and MG-Activities of Daily Living scale), muscle force and fatigue, respiratory function, free-living physical activity as well as evaluations of anxiety, depression, self-esteem and overall QOL with the WHO-QOL BREF questionnaire. Exercise workload will be assessed as well as multiple safety measures (ECG, biological markers, medication type and dosage and any disease exacerbation or crisis).

Discussion

This is the largest randomised controlled trial to date evaluating the benefits and tolerance of physical exercise in this patient population. The comprehensive evaluations using standardised outcome measures should provide much awaited information for both patients and the scientific community. This study is ongoing.

Trial registration

ClinicalTrials.gov, NCT02066519. Registered on 13 January 2014.

Electronic supplementary material

The online version of this article (10.1186/s13063-017-2433-2) contains supplementary material, which is available to authorized users.

Cognitive fatigue in patients with myasthenia gravis

INTRODUCTION

Cognitive fatigue has frequently been reported in myasthenia gravis (MG). However, objective assessment of cognitive fatigability has never been evaluated.

METHODS

Thirty-three MG patients with stable generalized disease and 17 healthy controls underwent a test battery including repeated testing of attention and concentration (d2-R) and Paced Auditory Serial Addition Test. Fatigability was based on calculation of linear trend (LT) reflecting dynamic performance within subsequent constant time intervals. Additionally, fatigue questionnaires were used.

RESULTS

MG patients showed a negative LT in second d2-R testing, indicating cognitive fatigability. This finding significantly differed from stable cognitive performance in controls (P < 0.05). Results of Paced Auditory Serial Addition Test testing did not differ between groups. Self-assessed fatigue was significantly higher in MG patients compared with controls (P < 0.001), but did not correlate with LT.

CONCLUSIONS

LT quantifies cognitive fatigability as an objective measurement of performance decline in MG patients. Self-assessed cognitive fatigue is not correlated with objective findings. Muscle Nerve 56: 449-457, 2017.

Social disadvantages associated with myasthenia gravis and its treatment: a multicentre cross-sectional study

OBJECTIVES

To clarify the social disadvantages associated with myasthenia gravis (MG) and examine associations with its disease and treatment.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

We evaluated 917 consecutive cases of established MG seen at 13 neurological centres in Japan over a short duration.

OUTCOME MEASURES

All patients completed a questionnaire on social disadvantages resulting from MG and its treatment and a 15-item MG-specific quality of life scale at study entry. Clinical severity at the worst condition was graded according to the MG Foundation of America classification, and that at the current condition was determined according to the quantitative MG score and MG composite. Maximum dose and duration of dose ≥20 mg/day of oral prednisolone during the disease course were obtained from the patients' medical records. Achievement of the treatment target (minimal manifestation status with prednisolone at ≤5 mg/day) was determined at 1, 2 and 4 years after starting treatment and at study entry.

RESULTS

We found that 27.2% of the patients had experienced unemployment, 4.1% had been unwillingly transferred and 35.9% had experienced a decrease in income, 47.1% of whom reported that the decrease was ≥50% of their previous total income. In addition, 49.0% of the patients reported feeling reduced social positivity. Factors promoting social disadvantages were severity of illness, dose and duration of prednisolone, long-term treatment, and a depressive state and change in appearance after treatment with oral steroids. Early achievement of the treatment target was a major inhibiting factor.

CONCLUSIONS

Patients with MG often experience unemployment, unwilling job transfers and a decrease in income. In addition, many patients report feeling reduced social positivity. To inhibit the social disadvantages associated with MG and its treatment, greater focus needs to be placed on helping patients with MG resume a normal lifestyle as soon as possible by achieving the treatment target.

Labour market participation and sick leave among patients diagnosed with myasthenia gravis in Denmark 1997-2011: a Danish nationwide cohort study

Background

To examine labour market participation and long-term sick leave following a diagnosis with myasthenia gravis (MG) compared with the general Danish population and for specific subgroups of MG patients.

Methods

A nationwide matched cohort study from 1997 to 2011 using data from population-based medical and social registries. The study includes 330 MG patients aged 18 to 65 years old identified from hospital diagnoses and dispensed prescriptions, and twenty references from the Danish population matching each MG patient on age, gender, and profession. Main outcome measures are labour market participation (yes/no) and long-term sick leave ≥9 weeks (yes/no) with follow-up at 1- and 2 years after the time of MG diagnosis or match. Based on complete person-level information on all public transfer payments in Denmark, persons having no labour market participation are defined as individuals receiving social benefits for severely reduced workability, flexijob, and disability pension.

Results

MG is consistently associated with higher odds of having no labour market participation and long-term sick leave compared with the general Danish population (no labour market participation & ≥9 weeks sick leave at 2-year follow-up, adjusted OR (95% CI): 5.76 (4.13 to 8.04) & 8.60 (6.60 to 11.23)). Among MG patients, females and patients treated with both acetylcholinesterase inhibitors and immunosuppression have higher odds of lost labour market participation and long-term sick leave.

Conclusions

This study suggests that MG patients have almost 6 times higher odds of no labour market participation and almost 9 times higher odds of long-term sick leave 2 years after diagnosis compared with the general Danish population. In particular female MG patients and patients treated with both acetylcholinesterase and immunosuppression have high odds of a negative labour market outcome. Future research should focus on predictors in workplace and labour market policy of labour market participation among MG patients.

Determinants of quality of life in Brazilian patients with myasthenia gravis

OBJECTIVES

The aims of the current study were 1) to evaluate the reliability and validity of the Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale and 2) to investigate the quality of life of Brazilian patients with myasthenia gravis and its determinants.

METHODS

This cross-sectional study included 69 patients with myasthenia gravis who underwent neurological evaluation and completed questionnaires regarding quality of life (the 36-item Short Form of the Medical Outcomes Study and the 15-item Myasthenia Gravis Quality of Life Scale), anxiety and depressive symptoms.

RESULTS

The Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale showed high internal consistency and good concurrent validity with the 36-item Short Form of the Medical Outcomes Study and its subscales. Determinants of quality of life in Brazilian patients with myasthenia gravis included the current status of myasthenia gravis as assessed by the Myasthenia Gravis Composite, the current prednisone dose and the levels of anxiety and depression.

CONCLUSION

The Brazilian version of the 15-item Myasthenia Gravis Quality of Life Scale is a valid instrument. Symptom severity, prednisone dosage and anxiety and depression levels impact the quality of life of patients with myasthenia gravis.

An up-date on health-related quality of life in myasthenia gravis -results from population based cohorts

Abstract

Current available therapies control Myasthenia gravis (MG) reasonably well, but Health Related Quality of life (HRQOL) remains lower than expected. The aim was provide insights in how HRQOL in MG stands across borders and time, compare the scores to general population controls and other chronic disorders and assess the impact of potential predictors for quality of life such as a) clinical characteristics b) antibodies c) thymoma and d) treatment in a population-based cohort.

Methods

We designed a population-based cross-sectional study including 858 patients, 373 from Norway and 485 from the Netherlands. The Short Form Health Survey 36 (SF-36) and a cross-cultural validated questionnaire were used. Data were in addition compared to the general population, other chronic diseases and previous studies.

Results

Mean physical composite score was 59.4 and mental composite score 69.0 with no differences between the countries. The mean HRQOL score was lower in patients with bulbar and generalized symptoms (p < 0.001) compared to sex and age adjusted healthy controls, but not in patients with ocular symptoms or patients in remission. Multivariate analysis revealed that female gender, generalized symptoms and use of secondary immunosuppressive drugs at the time of testing were risk factors for reduced HRQOL.

Conclusions

Remission and absence of generalized symptoms were favorable factors for HRQOL in MG patients. Historically, the HRQOL levels have not changed since 2001 and no new clinical predictors could be detected in this exhaustive population-based study. Further studies should explore the impact of non clinical factors like ethnic variations, socio-economic and hormonal factors on HRQOL.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-015-0298-1) contains supplementary material, which is available to authorized users.

Quality of life in 188 patients with myasthenia gravis in China

Myasthenia gravis (MG) is a kind of chronic autoimmune disease which can weaken patients' motor function and, furthermore, produce negative impact on the health-related quality of life (HRQoL). The primary purpose of this research was to evaluate factors that might affect the HRQoL of MG patients. A cross-sectional clinical research was carried out including 188 successive patients with MG. Myasthenia Gravis Foundation of America (MGFA) classification and Quantitative Myasthenia Gravis (QMG) score were applied to assess the severity of the disease. The Medical Outcome Survey 36-Item Short-Form Health Survey (SF-36) was used to estimate the HRQoL. Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS) were utilized to measure the depression and anxiety symptom. Factors may influence the HRQoL of MG patients include age, educational level, occupation, the situation of the thymus, the type of MG and generalized myasthenia gravis (GMG), the severity of the disease and the psychological disorder. Higher QMG and HARS scores were two significant factors that can prognosticate lower Physical Composite Score (PCS) and Mental Composite Score (MCS), while older age was just a significant factor which has prognostic value for lower PCS. The results of this research may have a potential guiding significance for the clinical treatment strategy and improve the quality of life in patients with MG consequently. In addition to the treatment of physical symptoms, the psychological symptoms such as anxiety and depression should be concerned as well.

Clinical features and impact of myasthenia gravis disease in Australian patients

We performed a community-based survey of 165 Australian patients with a physician-confirmed diagnosis of myasthenia gravis (MG). MG is an autoimmune disease of the neuromuscular junction causing fatiguable muscle weakness. Patients with early onset MG (<40 years of age) were more frequently female (22 males, 60 females) whereas patients with late onset MG (>40 years of age) were more frequently male (50 males, 28 females; p < 0.001). Triggering and exacerbating factors included physical and emotional stress, infections, surgery or trauma, seasonal changes and medications. The co-occurrence of other immune-related diseases was reported by 54% of patients. The median MG quality of life (QOL) score was 92 (range: 24-186). The factor most strongly associated with poor QOL was depression. Only 40.6% of patients were working at the time of the survey and of these, almost half had required sick leave due to MG in the past 12 months. A further 39.4% had stopped work due to MG and 19.4% having to change occupation. Full-time or part-time care was required by 29% of patients and government financial support was received by 52.7%.

Surgical treatment for medically refractory myasthenic blepharoptosis

PURPOSE

Currently, only a few reports have recommended surgery as a suitable treatment for blepharoptosis associated with myasthenia gravis. The present study aims to introduce our surgical criteria, surgical options, outcomes, and precautions for medically refractory myasthenic blepharoptosis.

PATIENTS AND METHODS

Eight patients who failed to respond to at least 2 years of medical treatment and who underwent blepharoptosis surgery, from January 2008 to December 2011, were enrolled in this study. Medical records, photographs, and questionnaire results regarding postoperative status were evaluated. Of the eleven procedures performed, four involved frontal suspension, four involved external levator advancement, one involved nonincisional transconjunctival levator advancement, and two involved subbrow blepharoplasty with orbicularis oculi muscle tucking. The margin reflex distance improved postoperatively in seven patients.

RESULTS

Seven patients had very minimal scarring, and one had minimal scarring. Five patients showed no eyelid asymmetry, one had subtle asymmetry, and two had obvious asymmetry. Seven patients were very satisfied, and one patient was satisfied with the overall result. Postoperative complications included mild lid lag with incomplete eyelid closure, prolonged scar redness, and worsened heterophoria. No patient experienced postoperative exposure keratitis or recurrent blepharoptosis during the study period.

CONCLUSION

Our results indicate that blepharoptosis surgery is effective for patients with myasthenia gravis, especially those with residual blepharoptosis despite multiple sessions of medical treatments. We recommend that neurologists and surgeons collaborate more systematically and discuss comprehensive treatment plans to increase the quality of life for patients with myasthenia gravis.

Effects of balance strategy training in myasthenia gravis: a case study series

INTRODUCTION

Studies of exercise in patients with myasthenia gravis (MG) are sparse. Balance strategy training (BST) multimodal exercise has proven efficacy in adults for enhancing balance and functional mobility. This prospective study aims to determine if BST improves functional ability and balance in people with MG.

METHODS

Seven individuals with MG participated in a 16-session workstation intervention. Repeated measures (pre/post-intervention and 4-week follow-up) consisting of quantitative myasthenia gravis score (QMG), 6-minute walk test (6MWT), timed up and go (TUG) with dual task (TUG(manual) and TUG(cognitive)), and standing stability on foam with eyes closed (foamEC) were assessed.

RESULTS

Most measurements showed sustained improvement at follow-up. QMG, TUG(cognitive), and foam EC achieved clinically significant improvements (>15%). No adverse effects were reported.

CONCLUSIONS

BST was effective in improving balance and QMG scores in subjects with MG. A multimodal BST approach is thus suggested to target different aspects of balance and functional mobility.

Prognostic factors and health-related quality of life in ocular Myasthenia Gravis (OMG)

We evaluate the factors predictive of prognosis in 91 Caucasian patients affected by ocular myasthenia gravis (OMG), followed at our Institution during an observational time, ranging from 12 to 240 months. The Myasthenia Gravis Foundation of America (MGFA) clinical classification was used to grade the disease severity. We considered as outcome measures the variation in two subscores, ocular (O-QMG) and nonocular (NO-QMG); the last one reflected bulbar, neck, extremity functions. None of the independent variables evaluated for association with the outcome, as age of onset, type of therapy, length of interval between first and last examinations, and presence of antibodies to acetylcholine receptors (AChR-Abs) significantly affected the evolution of O-QMG and of NO-QMG. Health-related quality of life (HRQol) was assessed in 63 patients. Variations of diplopia or ptosis did not affect significantly physical (PCS) or mental composite subscores (MCS) of the Short-Form Health Survey (SF-36). Human leukocyte antigen (HLA) genotyping was studied to explore whether HLA class I and II allelic distribution differed among MG patients and controls. None of the studied HLA alleles significantly differed between OMG patients and controls. Similarly, none of the alleles with frequencies higher than 15% either in OMG patients or in controls was significantly associated, after Bonferroni correction, with the presence or absence of anti-AChR-Abs in serum.

Development of the MG-DIS: an ICF-based disability assessment instrument for myasthenia gravis

PURPOSE

To develop a preliminary version of a disease-specific, patient-reported disability assessment instrument for myasthenia gravis (MG) based on the International Classification of Functioning, Disability and Health (ICF): the MG-DIS.

METHODS

Five consecutive steps were taken: literature review and selection of outcome measures; linking of measures' concepts to ICF categories and selection of those reported by 30% of the instruments; comparison of linking results with a previous selection of MG-relevant ICF categories; patient interview; development of questions based on retained ICF categories.

RESULTS

Thirty-one papers containing 21 different outcome measures were found: 13 ICF categories were linked to them. Fifty-five items were retained after the comparison with the list of MG-specific categories, and were used for patient interview. Thirteen interviews were conducted before saturation of data was reached and the final list was composed of 42 categories: based upon them, 44 questions were developed.

CONCLUSIONS

The preliminary version of the MG-DIS contains more information than each single MG-specific tool, in particular, for the component of environmental factors. Further research is needed to test its psychometric properties.

IMPLICATIONS FOR REHABILITATION

It is important that patient-reported outcome is incorporated in MG patient's assessment. MG features can be evaluated with ICF-based methods. An MG-specific patient-reported disability assessment instrument can be used to monitor changes of functioning in patients on MG-specific treatments, and can be used in clinical trials as outcome measure.

Quality of life and measures of quality of life in patients with neuromuscular disorders

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.

Evaluation of a scale of patient-reported outcomes for the assessment of myasthenia gravis patients in China

OBJECTIVE

To evaluate a scale of patient-reported outcomes for the assessment of myasthenia gravis patients (MG-PRO) in China.

METHODS

A total of 100 MG patients were interviewed for the field testing. Another 56 MG patients were selected and assessed with the MG-PRO scale before treatment and at 1, 2 and 4 weeks after treatment. The classical test theory and item response theory (IRT) were used to assess the psychometric characteristics of the MG-PRO scale.

RESULTS

The MG-PRO scale included 4 dimensions: physical, psychological, social environment, and treatment. Confirmatory factor analysis showed that each dimension was consistent with the theoretical construct. The scores of the physical and psychological dimensions increased significantly at 1 week after treatment (P<0.05). All the dimension scores and the MG-PRO score increased significantly at 2 and 4 weeks after treatment (P<0.05). IRT showed that person separation indices were greater than 0.8, most of the item fit residual statistics were within ± 2.5, and no item had uniform or non-uniform differential item functioning (DIF) between gender and age (<40, [Symbol: see text]40).

CONCLUSIONS

The MG-PRO scale is valid for measuring the quality of life (QOL) of MG patients, with good reliability, validity, responsiveness, and good psychometric characteristics from IRT. It can be applied to evaluate the QOL of MG patients and to assess treatment effects in clinical trials.

Psychiatric disorders in myasthenia gravis

OBJECTIVE: To investigate the prevalence of psychiatric disorders in patients with myasthenia gravis (MG). METHOD: Forty-one patients with MG answered to a structured psychiatric interview (MINI-Plus). RESULTS: Eleven (26.1%) patients were diagnosed with a depressive disorder and 19 (46.3%) were diagnosed with an anxiety disorder. Patients with dysthymia were older (p=0.029) and had longer disease duration (p=0.006). Patients with social phobia also had longer disease duration (p=0.039). CONCLUSION: Psychiatric disorders in MG are common, especially depressive and anxiety disorders.