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Schirinzi E, Bochicchio MA, Lochmüller H, Vissing J, Jordie-Diaz-Manerae, Evangelista T, Plançon JP, Fanucci L, Marini M, Tonacci A, Mancuso M, Segovia-Kueny S, Toscano A, Angelini C, Schoser B, Sacconi S, Siciliano G. E-Health & Innovation to Overcome Barriers in Neuromuscular Diseases. Report from the 3rd eNMD Congress: Pisa, Italy, 29-30 October 2021. J Neuromuscul Dis 2024:JND230091. [PMID: 38728200 DOI: 10.3233/jnd-230091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Neuromuscular diseases (NMDs), in their phenotypic heterogeneity, share quite invariably common issues that involve several clinical and socio-economical aspects, needing a deep critical analysis to develop better management strategies. From diagnosis to treatment and follow-up, the development of technological solutions can improve the detection of several critical aspects related to the diseases, addressing both the met and unmet needs of clinicians and patients. Among several aspects of the digital transformation of health and care, this congress expands what has been learned from previous congresses editions on applicability and usefulness of technological solutions in NMDs. In particular the focus on new solutions for remote monitoring provide valuable insights to increase disease-specific knowledge and trigger prompt decision-making. In doing that, several perspectives from different areas of expertise were shared and discussed, pointing out strengths and weaknesses on the current state of the art on topic, suggesting new research lines to advance technology in this specific clinical field.
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Affiliation(s)
- Erika Schirinzi
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy
| | | | - Hanns Lochmüller
- Department of Medicine, Children's Hospital of Eastern Ontario Research Institute, Division of Neurology, The Ottawa Hospital, and Brain and Mind Research Institute, University of Ottawa, Ottawa, Canada
| | - John Vissing
- Copenhagen Neuromuscular Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jordie-Diaz-Manerae
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Neurology Department, Neuromuscular Disorders Unit, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain
| | - Teresinha Evangelista
- AP-HP, H. Pitié-Salpêtrière, Institut de Myologie, Unité de Morphologie Neuromusculaire, Paris, France
- AP-HP, H. Pitié-Salpêtrière, Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Paris, France
- Sorbonne Université, INSERM, Institut de Myologie, Centre de Recherche en Myologie, France
| | - Jean-Philippe Plançon
- European Patient Organisation for Dysimmune and Inflammatory Neuropathies (EPODIN) and EURO-NMD Educational board, Paris, France
| | - Luca Fanucci
- Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Marco Marini
- Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Alessandro Tonacci
- Institute of Clinical Physiology, National Research Council - CNR, Pisa, Italy
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy
| | | | - Antonio Toscano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Corrado Angelini
- Department Neurosciences, Padova University School of Medicine, Padova, Italy
| | - Benedikt Schoser
- Department of Neurology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sabrina Sacconi
- Peripheral Nervous System and Muscle Department, Université Cúte d'Azur (UCA), Centre Hospitalier Universitaire de Nice, Rare Neuromuscular Disease Reference Center, ERN-Euro-NMD, Nice, France
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy
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Meisel A, Saccà F, Spillane J, Vissing J. Expert consensus recommendations for improving and standardising the assessment of patients with generalised myasthenia gravis. Eur J Neurol 2024:e16280. [PMID: 38523419 DOI: 10.1111/ene.16280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/26/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Regular and consistent disease assessment could provide a clearer picture of burden in generalised myasthenia gravis (gMG) and improve patient care; however, the use of assessment tools in practice lacks standardisation. This modified Delphi approach was taken to review current evidence on assessment tool use in gMG and develop expert-derived consensus recommendations for good practice. METHODS A European expert panel of 15 experienced gMG neurologists contributed to development of this consensus, four of whom formed a lead Sub-committee. The PICO (Population, Intervention, Control, Outcomes) framework was used to define six clinical questions on gMG assessment tools, a systematic literature review was conducted, and evidence-based statements were developed. According to a modified Delphi voting process, consensus was reached when ≥70% of the experts rated agreement with a statement as ≥8 on a scale of 1-10. RESULTS Eighteen expert- and evidence-based consensus statements based on six themes were developed. Key recommendations include: consistent use of the Myasthenia Gravis Activities of Daily Living score (MG-ADL) across clinical settings, followed by a simple question (e.g., Patient Acceptable Symptom State [PASS]) or scale to determine patient satisfaction in clinical practice; use of a Quantitative Myasthenia Gravis [QMG] or quality of life [QoL] assessment when the MG-ADL indicates disease worsening; and consideration of symptom state to determine the timing and frequency of recommended assessments. Expert panel consensus was reached on all 18 statements after two voting rounds. CONCLUSIONS This process provided evidence- and expert consensus-based recommendations for the use of objective and subjective assessment tools across gMG research and care to improve management and outcomes for patients.
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Affiliation(s)
- Andreas Meisel
- Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Francesco Saccà
- GENESIS Department, Federico II University of Naples, Naples, Italy
| | - Jennifer Spillane
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, UK
| | - John Vissing
- Copenhagen Neuromuscular Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Delmondes GMB, Couto NFS, Correia Junior MGA, Bonifácio ABDS, Freitas Dias RD, Bezerra J, Santos MADM, Gomes de Barros MV, Costa EC, Correia Junior MADV. Single breath counting technique to assess pulmonary function: a systematic review and meta-analysis. J Breath Res 2023; 18:014001. [PMID: 37875103 DOI: 10.1088/1752-7163/ad0647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/24/2023] [Indexed: 10/26/2023]
Abstract
Pulmonary function is usually assessed by measuring Vital Capacity (VC) using equipment such as a spirometer or ventilometer, but these are not always available to the population, as they are relatively expensive tests, difficult to transport and require trained professionals. However, the single breath counting technique (SBCT) appears as a possible alternative to respiratory function tests, to help in the pathophysiological understanding of lung diseases. The objective is to verify the applicability of the SBCT as a parameter for evaluating VC. This is a systematic review registered in the International Prospective Register of Systematic Reviews (CRD42023383706) and used for PubMed®, Scientific Electronic Library Online, LILACS, EMBASE, and Web of Science databases of articles published until January 2023. Methodological quality regarding the risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 and National Institutes of Health tools. Eleven of a total of 574 studies were included, of these, nine showed a correlation between VC and SBCT (weak in healthy, moderate in neuromuscular and strong in hospitalized patients). One study of hospitalized patients accurately identified a count value of 21 for a VC of 20 ml kg-1(Sensitivity = 94% and Specificity = 77%), and another estimated a count lower than 41 for a VC below 80% of predicted in patients with neuromuscular dystrophy (Sensitivity = 89% and Specificity = 62%), and another showed good intra and inter-examiner reproducibility in young, adult, and elderly populations. A meta-analysis of three studies showed a moderate correlation in subjects with neuromuscular diseases (r= 0.62, 95% CI = 0.52-0.71,p< 0.01). A high risk of bias was identified regarding the justification of the sample size and blinding of the evaluators. SBCT has been presented as an alternative to assess VC in the absence of specific equipment. There is a clear relationship between SBCT and VC, especially in neuromuscular and hospitalized individuals. New validation studies conducted with greater control of potential bias risks are necessary.
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Affiliation(s)
| | - Nathália Ferreira Santos Couto
- Universidade de Pernambuco-UPE/Universidade Federal da Paraíba-UFPB, Associate Graduate Program in Physical Education, Recife, Pernambuco, Brazil
| | | | | | | | - Jorge Bezerra
- Universidade de Pernambuco-UPE, Graduate Program in Hebiatrics, Recife, Pernambuco, Brazil
- Universidade de Pernambuco-UPE/Universidade Federal da Paraíba-UFPB, Associate Graduate Program in Physical Education, Recife, Pernambuco, Brazil
| | - Marcos André de Moura Santos
- Universidade de Pernambuco-UPE, Graduate Program in Hebiatrics, Recife, Pernambuco, Brazil
- Universidade de Pernambuco-UPE/Universidade Federal da Paraíba-UFPB, Associate Graduate Program in Physical Education, Recife, Pernambuco, Brazil
| | - Mauro Virgílio Gomes de Barros
- Universidade de Pernambuco-UPE, Graduate Program in Hebiatrics, Recife, Pernambuco, Brazil
- Universidade de Pernambuco-UPE/Universidade Federal da Paraíba-UFPB, Associate Graduate Program in Physical Education, Recife, Pernambuco, Brazil
| | - Emília Chagas Costa
- Centro Acadêmico de Vitória da Universidade Federal de Pernambuco, Vitoria de Santo Antao, Pernambuco, Brazil
| | - Marco Aurélio de Valois Correia Junior
- Universidade de Pernambuco-UPE, Graduate Program in Hebiatrics, Recife, Pernambuco, Brazil
- Universidade de Pernambuco-UPE/Universidade Federal da Paraíba-UFPB, Associate Graduate Program in Physical Education, Recife, Pernambuco, Brazil
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Lesport Q, Joerger G, Kaminski HJ, Girma H, McNett S, Abu-Rub M, Garbey M. Eye Segmentation Method for Telehealth: Application to the Myasthenia Gravis Physical Examination. SENSORS (BASEL, SWITZERLAND) 2023; 23:7744. [PMID: 37765800 PMCID: PMC10536520 DOI: 10.3390/s23187744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
Due to the precautions put in place during the COVID-19 pandemic, utilization of telemedicine has increased quickly for patient care and clinical trials. Unfortunately, teleconsultation is closer to a video conference than a medical consultation, with the current solutions setting the patient and doctor into an evaluation that relies entirely on a two-dimensional view of each other. We are developing a patented telehealth platform that assists with diagnostic testing of ocular manifestations of myasthenia gravis. We present a hybrid algorithm combining deep learning with computer vision to give quantitative metrics of ptosis and ocular muscle fatigue leading to eyelid droop and diplopia. The method works both on a fixed image and frame by frame of the video in real-time, allowing capture of dynamic muscular weakness during the examination. We then use signal processing and filtering to derive robust metrics of ptosis and l ocular misalignment. In our construction, we have prioritized the robustness of the method versus accuracy obtained in controlled conditions in order to provide a method that can operate in standard telehealth conditions. The approach is general and can be applied to many disorders of ocular motility and ptosis.
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Affiliation(s)
- Quentin Lesport
- Department of Surgery, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
| | | | - Henry J. Kaminski
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Helen Girma
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Sienna McNett
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Mohammad Abu-Rub
- Department of Neurology & Rehabilitation Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA; (H.J.K.); (H.G.); (S.M.); (M.A.-R.)
| | - Marc Garbey
- Department of Surgery, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
- Care Constitution Corp., Newark, DE 19702, USA;
- LaSIE, UMR CNRS 7356, Université de la Rochelle, 17000 La Rochelle, France
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Bouvier L, Green JR, Tapia CB, Tilton-Bolowsky V, Maffei MF, Fless Z, Seaver K, Huynh A, Gutz SE, Martino R, Abrahao A, Berry J, Zinman L, Yunusova Y. Amyotrophic Lateral Sclerosis-Bulbar Dysfunction Index-Remote: Test-Retest and Interrater Reliability of Candidate Items. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1884-1900. [PMID: 37494887 PMCID: PMC10561957 DOI: 10.1044/2023_ajslp-22-00177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/27/2022] [Accepted: 06/05/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE The primary aim of this study was to establish the reliability of candidate items as a step in the development of the Amyotrophic Lateral Sclerosis-Bulbar Dysfunction Index-Remote (ALS-BDI-Remote), a novel tool being developed for the detection and monitoring of bulbar signs and symptoms in remote settings. METHOD The set of candidate items included 40 items covering three domains: cranial nerve examination, auditory-perceptual evaluation, and functional assessment. Forty-eight participants diagnosed with ALS and exhibiting a range of bulbar disease severity were included. Data collection for each participant took place on Zoom over three sessions. During Session 1, the participants were instructed to adjust their Zoom settings and to optimize their recording environment (e.g., lighting, background noise). Their cognition and eating were screened to determine their ability to follow instructions and their eligibility to perform the swallowing and chewing tasks. During Session 2, two speech-language pathologists (SLPs) administered the tool consecutively to determine the items' interrater reliability. During Session 3, one of the SLPs readministered the tool within 2 weeks of Session 1 to assess test-retest reliability. The reliability of each item was estimated using weighted kappa and the percentage of agreement. To be considered reliable, the items had to reach a threshold of 0.5 weighted kappa or 80% percentage agreement (if skewed distribution of the scores) for both interrater and test-retest reliability. RESULTS In total, 33 of the 40 candidate items reached the reliability cutoff for both reliability analyses. All assessment domains included reliable items. Items requiring very good visualization of structures or movements were generally less reliable. CONCLUSIONS This study resulted in the selection of reliable items to be included in the next version of the ALS-BDI-Remote, which will undergo psychometric evaluation (reliability, validity, and responsiveness analyses). Additionally, the results contributed to our understanding of the remote administration of SLP assessments for telehealth applications.
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Affiliation(s)
- Liziane Bouvier
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- KITE—University Health Network, Toronto, Ontario, Canada
| | - Jordan R. Green
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
- Speech and Hearing Biosciences and Technology, Harvard University, Boston, MA
| | - Carolina Barnett Tapia
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Victoria Tilton-Bolowsky
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
| | - Marc F. Maffei
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
| | - Zuzana Fless
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Katie Seaver
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
| | - Anna Huynh
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- KITE—University Health Network, Toronto, Ontario, Canada
| | - Sarah E. Gutz
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
- Speech and Hearing Biosciences and Technology, Harvard University, Boston, MA
| | - Rosemary Martino
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Ontario, Canada
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Agessandro Abrahao
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - James Berry
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston
| | - Lorne Zinman
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yana Yunusova
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Speech-Language Pathology, Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- KITE—University Health Network, Toronto, Ontario, Canada
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Garbey M, Joerger G, Lesport Q, Girma H, McNett S, Abu-Rub M, Kaminski H. A Digital Telehealth System to Compute the Myasthenia Gravis Core Examination Metrics. JMIR NEUROTECHNOLOGY 2023; 2:e43387. [PMID: 37435094 PMCID: PMC10334459 DOI: 10.2196/43387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
Background Telemedicine practice for neurological diseases has grown significantly during the COVID-19 pandemic.Telemedicine offers an opportunity to assess digitalization of examinations and enhances access to modern computer vision and artificial intelligence processing to annotate and quantify examinations in a consistent and reproducible manner. The Myasthenia Gravis Core Examination (MG-CE) has been recommended for the telemedicine evaluation of patients with myasthenia gravis. Objective We aimed to assess the ability to take accurate and robust measurements during the examination, which would allow improvement in workflow efficiency by making the data acquisition and analytics fully automatic and thereby limit the potential for observation bias. Methods We used Zoom (Zoom Video Communications) videos of patients with myasthenia gravis undergoing the MG-CE. The core examination tests required 2 broad categories of processing. First, computer vision algorithms were used to analyze videos with a focus on eye or body motions. Second, for the assessment of examinations involving vocalization, a different category of signal processing methods was required. In this way, we provide an algorithm toolbox to assist clinicians with the MG-CE. We used a data set of 6 patients recorded during 2 sessions. Results Digitalization and control of quality of the core examination are advantageous and let the medical examiner concentrate on the patient instead of managing the logistics of the test. This approach showed the possibility of standardized data acquisition during telehealth sessions and provided real-time feedback on the quality of the metrics the medical doctor is assessing. Overall, our new telehealth platform showed submillimeter accuracy for ptosis and eye motion. In addition, the method showed good results in monitoring muscle weakness, demonstrating that continuous analysis is likely superior to pre-exercise and post-exercise subjective assessment. Conclusions We demonstrated the ability to objectively quantitate the MG-CE. Our results indicate that the MG-CE should be revisited to consider some of the new metrics that our algorithm identified. We provide a proof of concept involving the MG-CE, but the method and tools developed can be applied to many neurological disorders and have great potential to improve clinical care.
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Affiliation(s)
- Marc Garbey
- Department of Surgery, School of Medicine & Health Sciences, George Washington University, Washington, DC, United States
- ORintelligence LLC, Houston, TX, United States
- Laboratoire des Sciences de l’Ingénieur pour l’Environnement (LaSIE UMR-CNRS 7356), University of La Rochelle, La Rochelle, France
- Care Constitution Corporation, Washington, DC, United States
| | - Guillaume Joerger
- ORintelligence LLC, Houston, TX, United States
- Care Constitution Corporation, Washington, DC, United States
| | - Quentin Lesport
- Department of Surgery, School of Medicine & Health Sciences, George Washington University, Washington, DC, United States
- Laboratoire des Sciences de l’Ingénieur pour l’Environnement (LaSIE UMR-CNRS 7356), University of La Rochelle, La Rochelle, France
- Care Constitution Corporation, Washington, DC, United States
| | - Helen Girma
- Department of Neurology & Rehabilitation Medicine, School of Medicine & Health Sciences, George Washington University, Washington, DC, United States
| | - Sienna McNett
- Department of Neurology & Rehabilitation Medicine, School of Medicine & Health Sciences, George Washington University, Washington, DC, United States
| | - Mohammad Abu-Rub
- Department of Neurology & Rehabilitation Medicine, School of Medicine & Health Sciences, George Washington University, Washington, DC, United States
| | - Henry Kaminski
- Department of Neurology & Rehabilitation Medicine, School of Medicine & Health Sciences, George Washington University, Washington, DC, United States
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De León AM, Aban I, McPherson T, Granit V, Benatar M, Cutter G, Lee I. Impact of the COVID-19 pandemic on patients with myasthenia gravis: A survey of the Myasthenia Gravis Foundation of America MG patient registry. Muscle Nerve 2023; 67:25-32. [PMID: 36324261 PMCID: PMC9877793 DOI: 10.1002/mus.27743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Factors associated with coronavirus disease 2019 (COVID-19) infection among the myasthenia gravis (MG) population are incompletely understood. This study aimed to characterize the behavior of MG patients during the pandemic and to examine risk factors associated with COVID-19 infection. METHODS A "COVID-19 Survey" was sent to MG Patient Registry participants in the summer of 2020 (CSS20) and winter of 2021 (CWS21). Survey results were summarized descriptively. Demographics, disease characteristics, medication use, and survey results were compared between those reporting COVID-19 diagnosis (COVID), COVID-19 like symptoms without diagnosis (COVID-Like), and asymptomatic participants. RESULTS A total of 454 and 665 participants completed the CSS20 and CWS21 surveys respectively; 326 participants completed both. Most continued follow-up visits and MG treatments. The frequency of COVID-like symptoms was similar between CSS20 and CWS21, while COVID-19 exposure (6% vs. 27%), COVID-19 testing among symptomatic individuals (35% vs. 78%), and COVID-19 diagnosis (0.2% vs. 6%) were higher in the CWS21. Cough, fever, fatigue, myalgia, anosmia/ageusia, and hospital and intensive care unit (ICU) admissions were more frequent in the COVID compared to the COVID-Like group. COVID-19 exposure (odds ratio [OR] 7.88), number of people in the household (OR 1.31), and report of MG exacerbation before the pandemic (OR 2.6) were independently associated with COVID-19 infection. DISCUSSION COVID-19 affected MG patients increasingly through the early pandemic. While face-to-face contact with a COVID-19 infected individual was an obvious risk factor, MG patients who had more people in the household and unstable disease were at elevated risk for COVID-19 infection.
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Affiliation(s)
| | - Inmaculada Aban
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Tarrant McPherson
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Volkan Granit
- Department of NeurologyUniversity of MiamiMiamiFloridaUSA
| | | | - Gary Cutter
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Ikjae Lee
- Department of NeurologyColumbia UniversityNew YorkNew YorkUSA
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Stein M, Hoffmann S, Gerischer L, Stascheit F, Legg D, Meisel A, Lehnerer S. Myasthenia gravis - a retrospective analysis of e-mail inquiries made to a patient organisation and specialized center to uncover unmet needs from patients and caregivers. BMC Neurol 2022; 22:455. [PMID: 36476357 PMCID: PMC9727989 DOI: 10.1186/s12883-022-02981-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Myasthenia Gravis requires expert treatment from specialized neurologists. In Germany, this treatment is mainly provided by 18 Integrated Myasthenia Centers (iMZ) accredited by the German Myasthenia Gravis Association (DMG). The DMG is a large and well-organized patient organisation that is regarded as a trusted source for disease-specific information. The aim of this study was to analyse the type of requests that each of these institutions receives in order to identify any potential unmet needs regarding the availability of advice for patients and caregivers. This data can then be used in further research to tailor modern digital communication tools to the specific needs of MG patients. METHODS Counselling requests sent via e-mail to both institutions were extracted for defined examination periods and divided into a period 'before COVID-19 pandemic' (01.07.2019-31.12.2019) and 'during COVID-19 pandemic' (01.07.2020-31.12.2020). Requests were then analysed using four main categories: medical requests, organisational issues, COVID-19 and social legislation inquiries. RESULTS One thousand seven hundred eleven requests for advice were addressed to DMG and iMZ Charité. Most inquiries directed to the DMG (47%; n = 750) were related to medical issues, most frequently to side effects of medications (n = 325; 20%) and questions about treatment (n = 263; 16%), followed by inquiries regarding organisational issues (26%; n = 412). About half of the inquiries (n = 69; 58%) to the iMZ Charité were related to medical issues and almost one in three inquiries concerned organisational issues (n = 37; 30%). About one in ten inquiries concerned socio-legal matters (iMZ: n = 7; 6% and DMG: n = 177; 11%). During the pandemic, COVID-19 related issues accounted for 8% (n = 6) of inquiries at iMZ, and 16% (n = 253) at DMG. CONCLUSIONS MG sufferers have a high demand for timely advice. In the current setting, they address their requests to both iMZs and the DMG via e-mail. Our findings confirm that the DMG is highly trusted by patients and caregivers and is used to obtain second opinions. A relevant proportion of requests to the iMZ could be answered more effectively through standardized responses or improved process management. The implementation of modern digital solutions, including telemedicine, for communication between patient and specialist should be evaluated in further research.
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Affiliation(s)
- Maike Stein
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany. .,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany. .,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - David Legg
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany
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9
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Hehir MK, Li Y. Diagnosis and Management of Myasthenia Gravis. Continuum (Minneap Minn) 2022; 28:1615-1642. [PMID: 36537972 DOI: 10.1212/con.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW This article reviews updated diagnostic procedures and currently available treatment modalities for myasthenia gravis (MG). RECENT FINDINGS Patients with MG can be classified based on antibody status and their clinical presentation; treatment responses may differ based on disease subtypes. Improved diagnostic methods and recognition of new antigenic targets such as lipoprotein-related protein 4 have led to improved diagnostic efficiencies. Corticosteroids remain the first-line immunotherapy, but there is a trend toward minimizing their use at high doses and for long durations. Oral immunosuppressants such as mycophenolate mofetil, azathioprine, and tacrolimus remain useful. An international, multicenter randomized trial comparing thymectomy plus prednisone with prednisone alone demonstrated that thymectomy improves clinical outcomes in selected patients with nonthymomatous MG. Eculizumab, efgartigimod, and ravulizumab have recently been approved by the US Food and Drug Administration (FDA) for adult patients with generalized MG who are acetylcholine receptor-antibody positive. These drugs take advantage of novel mechanisms of action and expand treatment options for patients with MG. Data on rituximab suggest that it can be a good option, especially for patients with MG who are positive for antibodies against muscle-specific tyrosine kinase (MuSK). The number of clinical trials and drugs in development for MG is steadily increasing. SUMMARY The diagnosis of MG can generally be made from the patient's history, a neurologic examination, and laboratory and electrodiagnostic testing. Carefully selected treatment improves outcomes in MG. Additional treatment options for MG will likely be available in the near future.
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10
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Bhadola S, Tang C, Marks A, Kaku MC, Zhou L, Siao P, Vincent Lau K. Disparate healthcare access and telehealth-based hybrid consultations during the COVID-19 pandemic. Work 2022; 73:377-382. [DOI: 10.3233/wor-211463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND: The coronavirus disease-2019 pandemic led to rapid expansion of telehealth services. This was speculated to improve healthcare access among underserved populations, including individuals unable to take time off work or arrange transportation. OBJECTIVE: We completed a quality improvement project to evaluate the feasibility of hybrid consultations that combined televisits and abbreviated in-person visits for neuromuscular referrals. METHODS: Using a censoring date of August 5, 2021, we reviewed all outpatient neuromuscular consultations from August 5, 2020 to February 5, 2021. For both hybrid and traditional in-person consultations, we reviewed no-show rates, completion rates of ordered diagnostic workup, and billing codes. For hybrid consultations only, we also reviewed intervals between initial televisit and subsequent examination and rates of video-enhanced versus audio-only televisits. RESULTS: During the study period, we completed 153 hybrid and 59 in-person new-patient consultations (no-show rates 9% and 27% respectively.) For hybrid consultations, 77% and 73% of laboratory and imaging studies were completed respectively, compared to 89% and 91% for in-person consultations. For hybrid visits, average RVUs (a marker for reimbursement) per consultation depended on whether audio-only televisits were billed as telephone calls or E/M visits per insurance payer rules, while video-enhanced televisits were uniformly billed as E/M visits. This resulted in average RVUs between 2.09 and 2.26, compared to 2.30 for in-person consultations. CONCLUSIONS: Telehealth-based hybrid neuromuscular consultations are feasible with minor caveats. However, the future of telehealth may be restricted by decreasing reimbursement rates particularly for audio-only televisits, limiting its potential to improve healthcare access.
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Affiliation(s)
- Shivkumar Bhadola
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Connie Tang
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ariel Marks
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Michelle C. Kaku
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Lan Zhou
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Peter Siao
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - K.H. Vincent Lau
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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11
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Development and validation of the Myasthenia Gravis TeleScore (MGTS). Neurol Sci 2022; 43:4503-4509. [PMID: 35226211 PMCID: PMC8883006 DOI: 10.1007/s10072-022-05918-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/20/2022] [Indexed: 10/28/2022]
Abstract
Abstract
Objective
The aim of our study was to validate the Myasthenia Gravis TeleScore (MGTS), a scale for the evaluation of MG patients in telemedicine.
Introduction
COVID-19 pandemic has boosted telemedicine in clinical practice. It could be crucial in the care of neurological patients with chronic disease. However, there is a lack of validated disease-specific tools to evaluate MG patients in telemedicine.
Methods
The MGTS included ten items divided in four districts: ocular, generalized muscular strength, bulbar, and respiratory. Patients were assessed with two different scales: the MGTS and the INCB-MG chosen as a reference from which MGTS was partially derived. Visit in presence with INCB-MG and televisit with MGTS were performed consecutively. Televisit was conducted by another neurologist between two rooms. A blind method was adopted. The strength of correlation was determined by the correlation coefficient (r); analysis of covariance (ANOVA—Kruskal–Wallis test) was used to compare subgroups. Significance was set to p < 0.05.
Results
One hundred thirty-one patients were included in the study, 71 females and 60 males. The Spearman correlation coefficient between the INCB-MG scale and the MGTS was 0.825 (p < 0.001), indicating a very strong correlation between them. Different items showed different correlations from low to high (0.32 to 0.80). As expected, correlation was lower between items with different evaluation modality (anamnestic vs clinical).
Discussion
The MGTS demonstrated a good correlation with INCB-MG, reliability and construct validity.
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12
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Hafeez K, Kushlaf H, Al-Sultani H, Joseph AC, Zaeem Z, Siddiqi Z, Laboy S, Pulley M, Habib AA, Robbins NM, Zadeh S, Hafeez MU, Hussain Y, Melendez-Zaidi A, Kassardjian C, Johnson K, Leonhard H, Biliciler S, Patino Murillas JE, Shaibani AI. Patient preference for virtual versus in-person visits in neuromuscular clinical practice. Muscle Nerve 2022; 66:142-147. [PMID: 35596667 PMCID: PMC9540760 DOI: 10.1002/mus.27641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 11/11/2022]
Abstract
Introduction/Aims It is unknown if patients with neuromuscular diseases prefer in‐person or virtual telemedicine visits. We studied patient opinions and preference on virtual versus in‐person visits, and the factors influencing such preferences. Methods Telephone surveys, consisting of 11 questions, of patients from 10 neuromuscular centers were completed. Results Five hundred and twenty surveys were completed. Twenty‐six percent of respondents preferred virtual visits, while 50% preferred in‐person visits. Sixty‐four percent reported physical interaction as “very important.” For receiving a new diagnosis, 55% preferred in‐person vs 35% reporting no preference. Forty percent were concerned about a lack of physical examination vs 20% who were concerned about evaluating vital signs. Eighty four percent reported virtual visits were sufficiently private. Sixty eight percent did not consider expenses a factor in their preference. Although 92% were comfortable with virtual communication technology, 55% preferred video communications, and 19% preferred phone calls. Visit preference was not significantly associated with gender, diagnosis, disease severity, or symptom management. Patients who were concerned about a lack of physical exam or assessment of vitals had significantly higher odds of selecting in‐person visits than no preference. Discussion Although neither technology, privacy, nor finance burdened patients in our study, more patients preferred in‐person visits than virtual visits and 40% were concerned about a lack of physical examination. Interactions that occur with in‐person encounters had high importance for patients, reflecting differences in the perception of the patient‐physician relationship between virtual and in‐person visits.
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Affiliation(s)
- Komal Hafeez
- Baylor College of Medicine, Houston, TX, Nerve and Muscle Center of Texas, Houston, Texas, USA
| | | | - Husam Al-Sultani
- Baylor College of Medicine, Houston, TX, Nerve and Muscle Center of Texas, Houston, Texas, USA
| | | | - Zoya Zaeem
- University of Alberta, Canada, University of Alberta, Alberta, Canada
| | - Zaeem Siddiqi
- University of Alberta, Canada, University of Alberta, Alberta, Canada
| | | | | | - Ali A Habib
- University of California, Irvine, California, USA
| | | | - Sean Zadeh
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Muhammad Ubaid Hafeez
- Baylor College of Medicine, Houston, TX, Nerve and Muscle Center of Texas, Houston, Texas, USA
| | | | | | | | | | | | - Suur Biliciler
- UT Health Science Center at Houston, Houston, Texas, USA
| | | | - Aziz I Shaibani
- Baylor College of Medicine, Houston, TX, Nerve and Muscle Center of Texas, Houston, Texas, USA
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13
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Saadi A, Mendizabal A, Mejia NI. Teleneurology and Health Disparities. Semin Neurol 2022; 42:60-66. [PMID: 35576930 DOI: 10.1055/s-0041-1742194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The disparate access to, and use of, telemedicine reflects those of in-person health. These disparities are perpetuated as a result of individual, social, and structural factors like low digital literacy, unequal availability of broadband services, and systemic racism. This review focuses on extant literature on disparities in teleneurology, including racial or ethnic disparities, language inequities, and the global context. Understanding social and structural barriers to equitable access to quality teleneurology is critical to addressing and preventing health disparities, ensuring effective and equitable neurological care for all patients.
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Affiliation(s)
- Altaf Saadi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Adys Mendizabal
- Department of Neurology, University of California Los Angeles, Los Angeles, California
| | - Nicte I Mejia
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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14
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A Comprehensive Review of Neuromuscular Manifestations of COVID-19 and Management of Pre-Existing Neuromuscular Disorders in Children. J Clin Med 2022; 11:jcm11040934. [PMID: 35207206 PMCID: PMC8876161 DOI: 10.3390/jcm11040934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Since the emergence of SARS-CoV-2, several studies have been published describing neuromuscular manifestations of the disease, as well as management of pre-existing pediatric neuromuscular disorders during the COVID-19 pandemic. These disorders include muscular dystrophies, myasthenic syndromes, peripheral nerve disorders, and spinal muscular atrophy. Such patients are a vulnerable population due to frequent complications such as scoliosis, cardiomyopathy, and restrictive lung disease that put them at risk of severe complications of COVID-19. In this review, neuromuscular manifestations of COVID-19 in children and the management of pre-existing pediatric neuromuscular disorders during the COVID-19 pandemic are discussed. We also review strategies to alleviate pandemic-associated disruptions in clinical care and research, including the emerging role of telemedicine and telerehabilitation to address the continued special needs of these patients.
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15
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Gutierrez G, Girma H, Kuhnell P, Macaluso M, Kaminski HJ. Impact of the Covid-19 epidemic on a US sample of patients with myasthenia gravis. THERAPEUTIC ADVANCES IN RARE DISEASE 2022; 3:26330040221082673. [PMID: 37125217 PMCID: PMC10032427 DOI: 10.1177/26330040221082673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/04/2022] [Indexed: 05/02/2023]
Abstract
Introduction The Covid-19 pandemic has devastated the world and demonstrated the inadequacy of health care in the United States. To assess its impact, the Rare Disease Clinical Research Network conducted a survey to assess the pandemic on the rare disease community of patients, including those with myasthenia gravis (MG). Methods A cross-sectional survey was designed to target people or their care givers who live in the United States, have a rare disease, and are under 90 years of age. Respondents logged onto a dedicated web page and completed the survey online, which requested demographic, disease-specific, drug treatment, and symptom information as well as assessment of Covid-19 impact on them. The survey was open from May 2020 to December 2020. Results Five hundred ninety-four with self-reported myasthenia gravis completed the survey, which was the largest number of respondents. Sixty percent of respondents were women with a mean age of 60 years. Eighty-nine percent identified as White. Respondents did not appreciate a worsening of symptoms after the pandemic. Only 7 respondents reported the diagnosis of Covid-19 but 11% indicated they had difficulty accessing care at the time of the survey. Discussion and Conclusion Patients with MG complained of worse access to medical care during the early months of the pandemic, including challenges in diagnosis of suspected Covid-19 infection. A major limitation of the survey is its inability to access minority populations. Nevertheless, the results of the Rare Disease Clinical Research Network (RCDRN) survey of patients with MG provide clear evidence that the pandemic has demonstrated the deficiencies in US healthcare.
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Affiliation(s)
| | | | - Pierce Kuhnell
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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16
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Myasthenia gravis and telemedicine: a lesson from COVID-19 pandemic. Neurol Sci 2021; 42:4889-4892. [PMID: 34436726 PMCID: PMC8390022 DOI: 10.1007/s10072-021-05566-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/12/2021] [Indexed: 01/09/2023]
Abstract
COVID-19 pandemic has induced an urgent reorganization of the healthcare system to ensure continuity of care for patients affected by chronic neurological diseases including myasthenia gravis (MG). Due to the fluctuating nature of the disease, early detection of disease worsening, adverse events, and possibly life-threatening complications is mandatory. This work analyzes the main unresolved issues in the management of the myasthenic patient, the possibilities offered so far by digital technologies, and proposes an online evaluation protocol based on 4 simple tests to improve MG management. Telemedicine and Digital Technology might help neurologists in the clinical decision-making process of MG management, avoiding unnecessary in presence consultations and allowing a rational use of the time and space reduced by the pandemic.
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