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Alcantara M, Mannan S, de la Cruz J, Bril V. Value of multi-modality small fiber assessments in a genotypically diverse cohort of transthyretin-related amyloidosis in the early stages of disease. Med Clin (Barc) 2024:S0025-7753(24)00159-3. [PMID: 38616431 DOI: 10.1016/j.medcli.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Transthyretin-related amyloidosis (ATTRv) is a progressive multisystem disorder, predominantly involving the peripheral nerve system (PNS) and heart. Quantification of small fiber damage may help guide treatment decisions, as amyloid deposits frequently affect those fibers early in disease course. Corneal confocal microscopy (CCM) is a promising method to monitor patients with ATTRv, due to similarities between corneal nerves and PNS, as the cornea is innervated by Aδ and C fibers. METHODS We compared CCM measures from ATTRv patients to a group of healthy individuals, matched by age and gender. We then investigated the correlations between small fiber tests (SFT): CCM, LDI-Flare and CDT, COMPASS-31 and disability scales (RODS and ONLS) in patients. RESULTS Of 20 patients (6 with V30M), mean age 50.3±15.3Y, 7 female (35%), six (30%) had polyneuropathy and 10 (50%) carpal tunnel syndrome. CDT was abnormal in 9 and LDI-flare in 6 patients. CCM was abnormal in 19 tested patients and significantly reduced when compared to controls (CNFL: 6.31±0.31 vs. 15.21±1.02mm/mm2, p<0.001). Mean COMPASS-31-scores were 22.27±22.84; RODS and ONLS were 38.15±12.33 and 2.05±2.3, with no significant differences between sub-group scores. Disease duration was significantly correlated with ONLS (0.43, p=0.05) and RODS (0.46, p=0.03). There were no significant correlations between measures of disability and SFT. CONCLUSIONS In a diverse cohort of ATTRv patients, CCM was the most frequent abnormal measurement. CCM can be a useful test to triage patients in the early disease stages and with few or equivocal symptoms.
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Affiliation(s)
- Monica Alcantara
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Shabber Mannan
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - James de la Cruz
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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Hébert J, De Santis RJ, Daniyal L, Mannan S, Ng E, Thain E, Sanabria-Salas MC, Kim RH, Bril V, Reid AY. Epilepsy in neurofibromatosis type 1: Prevalence, phenotype, and genotype in adults. Epilepsy Res 2024; 202:107336. [PMID: 38471245 DOI: 10.1016/j.eplepsyres.2024.107336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Studies have shown an increased risk of epilepsy in patients with neurofibromatosis type 1 (NF1). However, most reports focus on the pediatric population. In this study, we describe the trajectory of patients with NF1 and epilepsy beyond childhood. METHODS Patients with NF1 ≥18 years-old consecutively seen at a multidisciplinary neurofibromatosis clinic during a four-year period were prospectively enrolled and offered routine EEG, MRI, and genetic testing. The lifelong and point prevalence of epilepsy in patients with NF1 were calculated. Demographic, genetic, radiological, and clinical features found to be statistically associated with having received a diagnosis of epilepsy were incorporated into a logistic regression model. RESULTS Among 113 patients with NF1 included in this study (median age at study inclusion: 33 years), the lifelong prevalence of epilepsy was 11% (CI95%=6-18%) and point prevalence 7% (CI95%= 3-13%). Most patients (73%) were diagnosed with epilepsy before the age of 18 and achieved seizure-freedom by adulthood. At study inclusion, three-quarters of patients with a diagnosis of epilepsy had been seizure-free for more than one year and a third had resolved epilepsy. A routine EEG with epileptiform discharges had a sensitivity of 25% (CI95%=3-65) and specificity of 99% (CI95%=93-100) for identifying adult patients with NF1 and unresolved epilepsy. A history of epilepsy was associated with having a low-grade glioma (OR: 38.2; CI95%=2.2-674.7; p<0.01), learning disability (OR: 5.7; CI95%=1.0-31.5; p<0.05), and no plexiform neurofibroma (OR: 0.05; CI95%=0.0-0.8; p=0.04). No single mutation type was associated with the development of epilepsy. CONCLUSIONS In patients with NF1, although resolution of epilepsy over time was observed in many cases, the prevalence of epilepsy was higher among adults with NF1 than that reported in the general population. Epileptogenesis in NF1 likely requires the combination of multiple genetic and environmental factors and suggests involvement of a network that spreads beyond the borders of a well-defined parenchymal lesion.
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Affiliation(s)
- Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada; Comprehensive Epilepsy Center, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Lubna Daniyal
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, Toronto, ON, Canada
| | - Shabber Mannan
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, Toronto, ON, Canada
| | - Eduardo Ng
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, Toronto, ON, Canada
| | - Emily Thain
- Bhalwani Familial Cancer Clinic, University Health Network, Toronto, ON, Canada; Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | | | - Raymond H Kim
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, Toronto, ON, Canada; Bhalwani Familial Cancer Clinic, University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada; Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Vera Bril
- Division of Neurology, University of Toronto, Toronto, ON, Canada; Elisabeth Raab Neurofibromatosis Clinic, University Health Network, Toronto, ON, Canada
| | - Aylin Y Reid
- Division of Neurology, University of Toronto, Toronto, ON, Canada; Krembil Brain Institute, University Health Network, Toronto, ON, Canada.
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Martinez-Harms R, Barnett C, Alcantara M, Bril V. Reply to letter in response to Rethinking the diagnosis of double-seronegative myasthenia gravis. Eur J Neurol 2024; 31:e16152. [PMID: 37991152 DOI: 10.1111/ene.16152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Rodrigo Martinez-Harms
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
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Lanctôt SO, Lovblom LE, Lewis EJH, Morris M, Cardinez N, Scarr D, Bakhsh A, Abuabat MI, Lovshin JA, Lytvyn Y, Boulet G, Bussières A, Brent MH, Paul N, Bril V, Cherney DZI, Perkins BA. Fasted C-Peptide Distribution and Associated Clinical Factors in Adults With Longstanding Type 1 Diabetes: Analysis of the Canadian Study of Longevity in Type 1 Diabetes. Can J Diabetes 2024; 48:89-96. [PMID: 37944665 DOI: 10.1016/j.jcjd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 08/01/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Although insulin production is reportedly retained in many people with longstanding type 1 diabetes (T1D), the magnitude and relevance of connecting peptide (C-peptide) production are uncertain. In this study, we aimed to define fasted C-peptide distributions and associated clinical factors. METHODS In a cross-sectional analysis of the Canadian Study of Longevity, fasted serum and urinary C-peptide was measured in 74 patients with longstanding T1D (duration ≥50 years) and 75 age- and sex-matched controls. Extensive phenotyping for complications was performed and patient-reported variables were included. C-peptide distributions were analyzed, and multivariable logistic regression was used to assess the variable association in participants with T1D. RESULTS The 74 participants with T1D had a mean age of 66±8 years, a disease duration of 54 (interquartile range 52 to 58) years, and a glycated hemoglobin (A1C) of 7.4%±0.8% (56.8±9.15 mmol/mol). The 75 controls had a mean age of 65±8 years and an A1C of 5.7%±0.4% (38.4±4.05 mmol/mol). Participants with T1D had lower fasted serum C-peptide than controls (0.013±0.022 vs 1.595±1.099 nmol/L, p<0.001). Of the participants with T1D, C-peptide was detectable in 30 of 73 (41%) serum samples, 32 of 74 (43%) urine samples, and 48 of 74 (65%) for either serum or urine. The variables independently associated with detectable serum or urinary C-peptide were lower total daily insulin requirement (odds ratio 2.351 [for 1 lower unit/kg], p=0.013) and lower hypoglycemia worry score (odds ratio 1.059 [for 1 point lower on the worry subscore of the Hypoglycemia Fear Survey], p=0.030). CONCLUSIONS Although detectable C-peptide in longstanding diabetes was common, the magnitude of concentration was extremely low when compared with age- and sex-matched controls. Despite minimal detectability, its presence is validated by lower insulin requirements and strongly associated with lower hypoglycemia worry.
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Affiliation(s)
- Sebastien O Lanctôt
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Evan J H Lewis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Michelle Morris
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Nancy Cardinez
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Abdulmohsen Bakhsh
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada; Kidney & Pancreas Health Centre, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Mohammad I Abuabat
- Internal Medicine and Critical Care Department, King Abdullah bin Abdulaziz University Hospital, Princess Norah University, Riyadh, Saudi Arabia
| | - Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geneviève Boulet
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
| | - Alexandra Bussières
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Michael H Brent
- Faculty of Medicine, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Alcantara M, Bril V. Intra-familial variability of oculoleptomeningeal amyloidosis due to the ATTR I107M (c.381T > G) mutation: diagnostic challenges of a rare phenotype. Amyloid 2024; 31:70-72. [PMID: 37755317 DOI: 10.1080/13506129.2023.2260537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Monica Alcantara
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada
| | - Vera Bril
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada
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Antozzi C, Guptill J, Bril V, Gamez J, Meuth SG, Nowak RJ, Quan D, Sevilla T, Jouvin MH, Jin J, Karcher K, Ramchandren S, Sun H, Ling L, Zhu Y, Arroyo S. Safety and Efficacy of Nipocalimab in Patients With Generalized Myasthenia Gravis: Results From the Randomized Phase 2 Vivacity-MG Study. Neurology 2024; 102:e207937. [PMID: 38165333 PMCID: PMC10962909 DOI: 10.1212/wnl.0000000000207937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To evaluate in a phase 2 study the safety and efficacy of IV nipocalimab, a fully human, antineonatal Fc receptor monoclonal antibody, in patients with generalized myasthenia gravis (gMG). METHODS Patients with gMG with inadequate response to stable standard-of-care (SOC) therapy were randomized 1:1:1:1:1 to receive either IV placebo every 2 weeks (Q2W) or one of 4 IV nipocalimab treatments: 5 mg/kg once every 4 weeks (Q4W), 30 mg/kg Q4W, 60 mg/kg Q2W each for 8 weeks, or a 60 mg/kg single dose, in addition to their background SOC therapy. Infusions (placebo or nipocalimab) were Q2W in all groups to maintain blinding. The primary safety endpoint was incidence of treatment-emergent adverse events (TEAEs), including serious adverse events and adverse events of special interest. The primary efficacy endpoint was change from baseline to day 57 in Myasthenia Gravis-Activities of Daily Living (MG-ADL) total scores. Dose response of change at day 57 was analyzed with a linear trend test over the placebo, nipocalimab 5 mg/kg Q4W, nipocalimab 30 mg/kg Q4W, and nipocalimab 60 mg/kg Q2W groups. RESULTS Sixty-eight patients (nipocalimab: n = 54; placebo, n = 14) were randomized; 64 patients (94.1%) were positive for antiacetylcholine receptor autoantibodies, and 4 patients (6%) were positive for antimuscle-specific tyrosine kinase autoantibodies. Fifty-seven patients (83.8%) completed treatment through day 57. The combined nipocalimab group compared with the placebo group demonstrated similar incidences of TEAEs (83.3% vs 78.6%, respectively) and infections (33.3% vs 21.4%, respectively). No deaths or discontinuations due to TEAEs and no TEAEs of special interest (grade ≥3 infection or hypoalbuminemia) were observed with nipocalimab treatment. A statistically significant dose response was observed for change from baseline in MG-ADL at day 57 (p = 0.031, test of linear trend). DISCUSSION Nipocalimab was generally safe, well-tolerated, and showed evidence of dose-dependent reduction in MG-ADL scores at day 57 in this phase 2 study. These results support further evaluation of nipocalimab for the treatment of gMG. TRIAL REGISTRATION INFORMATION Clinical Trials Registration: NCT03772587; first submitted December 10, 2018; EudraCT Number: 2018-002247-28; first submitted November 30, 2018; date of first patient dosed April 10, 2019. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with gMG, nipocalimab was well-tolerated, and it did not significantly improve MG-ADL at any individual dose but demonstrated a significant dose response for improved MG-ADL across doses.
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Affiliation(s)
- Carlo Antozzi
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Jeffrey Guptill
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Vera Bril
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Josep Gamez
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Sven G Meuth
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Richard J Nowak
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Dianna Quan
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Teresa Sevilla
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Marie-Helene Jouvin
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Jim Jin
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Keith Karcher
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Sindhu Ramchandren
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Hong Sun
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Leona Ling
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Yaowei Zhu
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Santiago Arroyo
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
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Howard JF, Bril V, Vu T, Karam C, Peric S, De Bleecker JL, Murai H, Meisel A, Beydoun SR, Pasnoor M, Guglietta A, Van Hoorick B, Steeland S, T’joen C, Utsugisawa K, Verschuuren J, Mantegazza R. Long-term safety, tolerability, and efficacy of efgartigimod (ADAPT+): interim results from a phase 3 open-label extension study in participants with generalized myasthenia gravis. Front Neurol 2024; 14:1284444. [PMID: 38318236 PMCID: PMC10842202 DOI: 10.3389/fneur.2023.1284444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/27/2023] [Indexed: 02/07/2024] Open
Abstract
Objective ADAPT+ assessed the long-term safety, tolerability, and efficacy of efgartigimod in adult participants with generalized myasthenia gravis (gMG). Methods ADAPT+ was an open-label, single-arm, multicenter, up to 3-year extension of the pivotal phase 3 ADAPT study. Efgartigimod was administered in treatment cycles of 4 intravenous infusions (one 10 mg/kg infusion per week). Initiation of subsequent treatment cycles was individualized based on clinical evaluation. Safety endpoints included incidence and severity of adverse events. Efficacy endpoints assessed disease severity using Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Results As of January 2022, 151 participants had rolled over to ADAPT+ and 145 had received ≥1 dose of efgartigimod, of whom, 111 (76.6%) were AChR-Ab+ and 34 (23.4%) were AChR-Ab-. Mean study duration (treatment plus follow-up) was 548 days, and participants received up to 17 treatment cycles, corresponding to 217.6 participant-years of exposure. In the overall population, 123 (84.8%) participants reported ≥1 treatment-emergent adverse event; most frequent were headache (36 [24.8%]), COVID-19 (22 [15.2%]), and nasopharyngitis (20 [13.8%]). Clinically meaningful improvement (CMI) in mean MG-ADL and QMG scores was seen as early as 1 week following the first infusion across multiple cycles in AChR-Ab+ and AChR-Ab- participants. Maximal MG-ADL and QMG improvements aligned with onset and magnitude of total IgG and AChR-Ab reductions. For AChR-Ab+ participants at any time point in each of the first 10 treatment cycles, more than 90% had a maximum reduction of ≥2 points (CMI) in MG-ADL total score; across the 7 cycles in which QMG was measured, 69.4% to 91.3% of participants demonstrated a maximum reduction of ≥3 points (CMI) in QMG total score. Many participants demonstrated improvements well beyond CMI thresholds. In AChR-Ab+ participants with ≥1 year of combined follow-up between ADAPT and ADAPT+, mean number of annualized cycles was 4.7 per year (median [range] 5.0 [0.5-7.6]). Conclusion Results of ADAPT+ corroborate the substantial clinical improvements seen with efgartigimod in ADAPT and support its long-term safety, tolerability, and efficacy, as well as an individualized dosing regimen for treatment of gMG. Clinical trial registration https://classic.clinicaltrials.gov/ct2/show/NCT03770403, NCT03770403.
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Affiliation(s)
- James F. Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Stojan Peric
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jan L. De Bleecker
- Department of Neurology and Neuromuscular Reference Center, Ghent University Hospital, Ghent, Belgium
| | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Andreas Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Said R. Beydoun
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
| | | | | | | | | | | | - Jan Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Carlo Besta, Milan, Italy
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8
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Martinez-Harms R, Barnett C, Alcantara M, Bril V. Clinical characteristics and treatment outcomes in patients with double-seronegative myasthenia gravis. Eur J Neurol 2024; 31:e16022. [PMID: 37531447 DOI: 10.1111/ene.16022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/07/2023] [Accepted: 07/30/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND AND PURPOSE Double-seronegative myasthenia gravis (dSNMG) is defined as myasthenia gravis (MG) without detectable or low affinity antibodies to acetylcholine receptor (AChR) and muscle-specific kinase (MuSK). There are limited data on detailed clinical features and outcomes after treatment in dSNMG patients. The aim was to describe the clinical characteristics and outcomes in dSNMG patients based on MG scales. METHODS A retrospective study was performed of patients diagnosed with MG who had negative AChR or MuSK antibodies and they were compared with an AChR-positive MG cohort. Correlations were made with data from the first and last clinic visits, between demographics, clinical characteristics, treatment and disease severity, based on the Myasthenia Gravis Foundation of America category, Myasthenia Gravis Impairment Index (MGII), Patient Acceptable Symptom State and simple single question (SSQ). RESULTS Eighty patients met the inclusion criteria for dSNMG. The baseline MGII and SSQ scores in the dSNMG cohort showed no significant differences from the AChR group (p = 0.94 and p = 0.46). The dSNMG cohort MGII and SSQ scores improved significantly at the last clinical evaluation (p = 0.001 and p = 0.047). The MGII improvement in the AChR cohort was significantly better (p = 0.003). CONCLUSIONS The initial severity of dSNMG based on clinical scores is similar to antibody-positive MG patients. There is significant clinical improvement in dSNMG patients after therapy, measured in the last clinical evaluation. This supports an immune pathophysiology of many dSNMG patients.
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Affiliation(s)
- Rodrigo Martinez-Harms
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Monica Alcantara
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
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9
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Bril V, Howard JF, Karam C, De Bleecker JL, Murai H, Utsugisawa K, Ulrichts P, Brauer E, Zhao S, Mantegazza R, Vu T. Effect of efgartigimod on muscle group subdomains in participants with generalized myasthenia gravis: post hoc analyses of the phase 3 pivotal ADAPT study. Eur J Neurol 2024; 31:e16098. [PMID: 37843174 DOI: 10.1111/ene.16098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) is a rare, chronic, neuromuscular autoimmune disease mediated by pathogenic immunoglobulin G (IgG) autoantibodies. Patients with gMG experience debilitating muscle weakness, resulting in impaired mobility, speech, swallowing, vision and respiratory function. Efgartigimod is a human IgG1 antibody Fc fragment engineered for increased binding affinity to neonatal Fc receptor. The neonatal Fc receptor blockade by efgartigimod competitively inhibits endogenous IgG binding, leading to decreased IgG recycling and increased degradation resulting in lower IgG concentration. METHODS The safety and efficacy of efgartigimod were evaluated in the ADAPT study. Key efficacy outcome measures included Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Efgartigimod demonstrated significant improvement in both the MG-ADL and QMG scores. This post hoc analysis aimed to determine whether all subdomains of MG-ADL and QMG improved with efgartigimod treatment. Individual items of MG-ADL and QMG were grouped into four subdomains: bulbar, ocular, limb/gross motor and respiratory. Change from baseline over 10 weeks in each subdomain was calculated for each group. RESULTS Greater improvements from baseline were seen across MG-ADL subdomains in participants treated with efgartigimod compared with placebo. These improvements were typically observed 1 to 2 weeks after the first infusion and correlated with reductions in IgG. Similar results were observed across most QMG subdomains. CONCLUSIONS These post hoc analyses of MG-ADL and QMG subdomain data from ADAPT suggest that efgartigimod is beneficial in improving muscle function and strength across all muscle groups, leading to the observed efficacy in participants with gMG.
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Affiliation(s)
- Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - James F Howard
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Pennsylvania, Philadelphia, USA
| | | | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Tokyo, Japan
| | | | | | | | | | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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10
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Nowak RJ, Breiner A, Bril V, Allen JA, Khan S, Levine T, Jacobs DH, Sahagian G, Siddiqi ZA, Xu J, Macias WL, Benatar M. Subcutaneous batoclimab in generalized myasthenia gravis: Results from a Phase 2a trial with an open-label extension. Ann Clin Transl Neurol 2024; 11:194-206. [PMID: 38062618 PMCID: PMC10791011 DOI: 10.1002/acn3.51946] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/29/2023] [Accepted: 10/26/2023] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVES To assess the safety, tolerability, and key pharmacodynamic effects of subcutaneous batoclimab, a fully human anti-neonatal Fc receptor monoclonal antibody, in patients with generalized myasthenia gravis and anti-acetylcholine receptor antibodies. METHODS A Phase 2a, proof-of-concept, randomized, double-blind, placebo-controlled trial is described. Eligible patients were randomized (1:1:1) to receive once-weekly subcutaneous injections of batoclimab 340 mg, batoclimab 680 mg, or matching placebo for 6 weeks. Subsequently, all patients could enter an open-label extension study where they received batoclimab 340 mg once every 2 weeks for 6 weeks. Primary endpoints were safety, tolerability, and change from baseline in total immunoglobulin G, immunoglobulin G subclasses, and anti-acetylcholine receptor antibodies at 6 weeks post-baseline. Secondary endpoints included changes from baseline to 6 weeks post-baseline for Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, Myasthenia Gravis Composite, and revised 15-item Myasthenia Gravis Quality of Life scores. RESULTS Seventeen patients were randomized to batoclimab 680 mg (n = 6), batoclimab 340 mg (n = 5), or placebo (n = 6). Batoclimab was associated with significantly greater reductions in total immunoglobulin G and anti-acetylcholine receptor antibodies from baseline to 6 weeks post-baseline than placebo. Reductions in immunoglobulin G subclasses were generally consistent with total immunoglobulin G. While clinical measures showed directionally favorable improvements over time, the study was not powered to draw conclusions about therapeutic efficacy. No safety issues were identified. INTERPRETATION The safety profile, pharmacodynamics, and preliminary clinical benefits observed in this study support further investigation of subcutaneous batoclimab injections as a potential patient-administered therapy for seropositive generalized myasthenia gravis.
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Affiliation(s)
- Richard J. Nowak
- Department of NeurologyYale University School of MedicineNew HavenConnecticutUSA
| | - Ari Breiner
- Division of Neurology, Department of MedicineThe Ottawa Hospital and Ottawa Research Institute, University of OttawaOttawaOntarioCanada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular DiseasesUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Jeffrey A. Allen
- Department of NeurologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Shaida Khan
- Department of NeurologyUT Southwestern Medical CenterDallasTexasUSA
| | - Todd Levine
- HonorHealth Neurology dba Phoenix Neurological AssociatesPhoenixArizonaUSA
| | - Daniel H. Jacobs
- College of MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Gregory Sahagian
- The Neurology Center of Southern CaliforniaCarlsbadCaliforniaUSA
| | - Zaeem A. Siddiqi
- Division of Neurology, Department of MedicineUniversity of Alberta HospitalEdmontonAlbertaCanada
| | - Jing Xu
- Immunovant Inc.New YorkNew YorkUSA
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11
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Mendoza M, Tran C, Bril V, Katzberg HD, Barnett-Tapia C. Symptom and Treatment Satisfaction in Members of the US and Canadian GBS/CIDP Foundations with a Diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy. Adv Ther 2023; 40:5188-5203. [PMID: 37751023 DOI: 10.1007/s12325-023-02661-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/21/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Current guidelines for defining good outcomes in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) are predominately defined by experts. At present, we do not have a patient-anchored definition of what constitutes a "good" outcome. Our study aimed to assess the symptom burden of people living with CIDP, as well as satisfaction with treatments and clinical outcomes. METHODS We conducted an online-survey in CIDP patients registered with the US and Canadian GBS/CIDP foundations. Respondents answered general demographic and clinical questions, as well as satisfaction with current symptom burden and treatments, plus validated outcome measures. RESULTS A total of 318 individuals with self-reported CIDP completed the online survey, of whom 128 (40%) considered their current disease burden as satisfactory while 190 (60%) did not. Of 305 patients who answered the treatment satisfaction question, 222(74%) were satisfied with their treatments. Patients who were satisfied with their current symptoms had, on average, better scores in quality of life and disease severity scales, although regression modeling showed that only ability to walk, stable symptoms, and health utility scores were associated with symptom satisfaction. Treatment satisfaction was associated with stable symptoms, use of IVIG, and use of one versus no medication. CONCLUSIONS A high proportion of members of the US and Canadian GBS/CIDP Foundations reporting a diagnosis of CIDP were unsatisfied with current symptoms, despite a high level of overall satisfaction with treatments. There is an unmet need for improving long-term outcomes in people with a diagnosis of CIDP, and for studying patient-centered long-term treatment goals.
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Affiliation(s)
- Meg Mendoza
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada
| | - Christopher Tran
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Vera Bril
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Hans D Katzberg
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Carolina Barnett-Tapia
- Toronto General Hospital, Ellen and Martin Prosserman Centre for Neuromuscular Disease, 200 Elizabeth Street 5ECW-334, Toronto, ON, M5G2C4, Canada.
- Division of Neurology, University Health Network and University of Toronto, Toronto, ON, Canada.
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12
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Idiaquez JF, Martinez R, Barnett-Tapia C, Perkins BA, Bril V. Reliability of confocal corneal microscopy for measurement of dendritic cell density in suspected small fiber neuropathy. Muscle Nerve 2023; 68:460-463. [PMID: 37534704 DOI: 10.1002/mus.27948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION/AIMS Dendritic cells (DCs) and their contacts with corneal nerves are described in animal models of nerve damage. Dendritic cell density (DCD) is a potential marker of immune activity in suspected small-fiber neuropathy (SFN). Here, we aim to evaluate the intra- and inter-rater reliability of DCD measurements in suspected SFN. METHODS This retrospective study collected DCD from confocal microscopy images from the corneal sub-basal epithelium of the eye from 48 patients (mean age 49.6 ± 12.1 y, 61% female). Two examiners, each blinded to the other's examinations and measurements, assessed DCD to evaluate inter-rater reliability. For intra-rater reliability, the first examiner performed a second measurement after 14 days. DCs were classified into two cell morphological subtypes: mature and immature. RESULTS Test-retest reliability for total DCD showed excellent agreement, with an intraclass correlation coefficient of 0.96 and inter-rater reliability intraclass correlation coefficient of 0.77. The immature cell subtype showed excellent intra-rater reliability but lower inter-rater reliability. DISCUSSION We found that DCD measurements in the corneal sub-basal epithelium are sufficiently reliable for consideration in clinical studies of patients with suspected SFN.
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Affiliation(s)
- Juan Francisco Idiaquez
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Martinez
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett-Tapia
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, University of Toronto, and the Leadership Sinai Centre for Diabetes, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Alnajjar SA, Fathihelabad D, Abraham A, Daniyal L, Lovblom LE, Bril V. Systematic Comparison of Muscle Ultrasound Thickness in Polyneuropathies and Other Neuromuscular Diseases. Neurol Ther 2023; 12:1623-1630. [PMID: 37338783 PMCID: PMC10444740 DOI: 10.1007/s40120-023-00485-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/18/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND We have aimed to assess whether muscle thickness ultrasound (US) shows differences between patients with chronic inflammatory demyelinating polyneuropathy (CIDP), chronic axonal polyneuropathy (CAP), and other neuromuscular (NM) diseases compared to controls and to each other. METHODS We performed a cross-sectional study from September 2021 to June 2022. All subjects underwent quantitative sonographic evaluation of muscle thickness in eight relaxed muscles and four contracted muscles. Differences were assessed using multivariable linear regression, correcting for age and body mass index (BMI). RESULTS The study cohort consisted of 65 healthy controls, and 95 patients: 31 with CIDP, 34 with CAP, and 30 with other NM diseases. Both relaxed and contracted muscle thickness in all patient groups were lower than in the healthy controls, after controlling for age and body mass index (BMI). Regression confirmed that the differences persisted between patient groups and healthy controls. Differences between patient groups were not apparent. CONCLUSION The current study shows that muscle ultrasound thickness is not specific in NM disorders, but shows a global reduction in thickness compared with healthy controls after corrections for age and BMI.
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Affiliation(s)
- Sara A Alnajjar
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, Toronto, Canada
- University of Toronto, Toronto, Canada
- King Abdulaziz Hospital, Ministry of National Guard Health Affair, Al Ahsa, Saudi Arabia
| | - Davood Fathihelabad
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Alon Abraham
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lubna Daniyal
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, Toronto, Canada
- University of Toronto, Toronto, Canada
| | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, Toronto, Canada.
- University of Toronto, Toronto, Canada.
- 5EC-309, Toronto General Hospital, 200 Elizabeth St., Toronto, ON, Canada.
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14
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Abraham A, Fainmesser Y, Drory VE, Bril V. Quantitative sonographic assessment of muscle thickness and fasciculations distribution is a sensitive tool for neuromuscular disorders. PLoS One 2023; 18:e0292123. [PMID: 37768998 PMCID: PMC10538738 DOI: 10.1371/journal.pone.0292123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Loss of muscle thickness can be demonstrated in a wide spectrum of neuromuscular disorders, while fasciculations are more frequent in amyotrophic lateral sclerosis (ALS). In the current study, we aimed to determine the sensitivity and specificity of quantitative sonographic assessment of muscle thickness and the presence of fasciculations for diagnosing various neuromuscular disorders. METHODS The thickness and the presence of fasciculations in eight muscles were determined by sonography in patients with myopathy (22), polyneuropathy (36), ALS (91), and spinal muscular atrophy (SMA) (31) and compared to normative values determined in 65 heathy control subjects. RESULTS Reduced muscle thickness in at least one relaxed muscle showed 92-100% sensitivity for diagnosing a neuromuscular disease, with a specificity of 85% for differentiating patients from heathy controls (AUC = 0.90). Subtracting distal from proximal muscle thickness may differentiate between myopathy and polyneuropathy. Fasciculations in ≥1 proximal muscle showed good diagnostic accuracy (AUC = 0.87) for diagnosing ALS. DISCUSSION Sonographic assessment of muscle thickness is a sensitive tool for diagnosing a wide spectrum of neuromuscular diseases, and may facilitate diagnosis even in patients with normal strength on neurological examination, while the presence of fasciculations in proximal muscles may facilitate ALS diagnosis.
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Affiliation(s)
- Alon Abraham
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaara Fainmesser
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Vivian E. Drory
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
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15
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Avidan R, Fainmesser Y, Drory VE, Bril V, Abraham A. The Sensitivity of Quantitative Sonographic Assessment of Muscle Thickness for Amyotrophic Lateral Sclerosis Diagnosis. J Clin Neurophysiol 2023; 40:529-534. [PMID: 35066529 DOI: 10.1097/wnp.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE In the current proof-of-concept study, we aimed to examine the sensitivities and specificities of previously reported normal values for muscle ultrasound thickness in amyotrophic lateral sclerosis. METHODS Muscle ultrasound was performed in 65 healthy control subjects and 91 amyotrophic lateral sclerosis patients using a standardized assessment of eight relaxed muscles and four contracted muscles. Normal values for muscle thickness were determined as values above the 5th percentile stratified by age and gender using the weighted average method. Sensitivity for amyotrophic lateral sclerosis diagnosis was determined for muscles with and without the addition of muscle contraction. RESULTS Amyotrophic lateral sclerosis patients showed reduced muscle sum thickness both in relaxed and in contracted states compared with control subjects. Muscle ultrasound of muscles with and without contraction showed excellent diagnostic accuracy for differentiating amyotrophic lateral sclerosis patients from control subjects (area under curve = 0.96, sensitivity: 93%-95%, specificity: 84-87). Muscle ultrasound sensitivity was lower within 6 months of symptom onset (83%) compared with longer disease duration (>92%). CONCLUSIONS Quantitative sonographic assessment of muscle thickness can be complementary in the diagnosis of amyotrophic lateral sclerosis with excellent accuracy for differentiating patients from healthy subjects, and might be useful in other neuromuscular disorders, although additional studies are required.
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Affiliation(s)
| | - Yaara Fainmesser
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Vivian E Drory
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alon Abraham
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
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16
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Bril V, Hadden RDM, Brannagan TH, Bar M, Chroni E, Rejdak K, Rivero A, Andersen H, Latov N, Levine T, Pasnoor M, Sacconi S, Souayah N, Anderson-Smits C, Duff K, Greco E, Hasan S, Li Z, Yel L, Ay H. Hyaluronidase-facilitated subcutaneous immunoglobulin 10% as maintenance therapy for chronic inflammatory demyelinating polyradiculoneuropathy: The ADVANCE-CIDP 1 randomized controlled trial. J Peripher Nerv Syst 2023; 28:436-449. [PMID: 37314318 DOI: 10.1111/jns.12573] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND AIMS ADVANCE-CIDP 1 evaluated facilitated subcutaneous immunoglobulin (fSCIG; human immunoglobulin G 10% with recombinant human hyaluronidase) efficacy and safety in preventing chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) relapse. METHODS ADVANCE-CIDP 1 was a phase 3, double-blind, placebo-controlled trial conducted at 54 sites in 21 countries. Eligible adults had definite or probable CIDP and adjusted Inflammatory Neuropathy Cause and Treatment (INCAT) disability scores of 0-7 (inclusive), and received stable intravenous immunoglobulin (IVIG) for ≥12 weeks before screening. After stopping IVIG, patients were randomized 1:1 to fSCIG 10% or placebo for 6 months or until relapse/discontinuation. fSCIG 10% was administered at the same dose (or matching placebo volume) and interval as pre-randomization IVIG. The primary outcome was patient proportion experiencing CIDP relapse (≥1-point increase in adjusted INCAT score from pre-subcutaneous treatment baseline) in the modified intention-to-treat population. Secondary outcomes included time to relapse and safety endpoints. RESULTS Overall, 132 patients (mean age 54.4 years, 56.1% male) received fSCIG 10% (n = 62) or placebo (n = 70). CIDP relapse was reduced with fSCIG 10% versus placebo (n = 6 [9.7%; 95% confidence interval 4.5%, 19.6%] vs n = 22 [31.4%; 21.8%, 43.0%], respectively; absolute difference: -21.8% [-34.5%, -7.9%], p = .0045). Relapse probability was higher with placebo versus fSCIG 10% over time (p = .002). Adverse events (AEs) were more frequent with fSCIG 10% (79.0% of patients) than placebo (57.1%), but severe (1.6% vs 8.6%) and serious AEs (3.2% vs 7.1%) were less common. INTERPRETATION fSCIG 10% more effectively prevented CIDP relapse than placebo, supporting its potential use as maintenance CIDP treatment.
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Affiliation(s)
- Vera Bril
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Thomas H Brannagan
- Neurological Institute, Columbia University, New York City, New York, USA
| | - Michal Bar
- University Hospital and Faculty of Medicine, Ostrava, Czechia
| | | | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Alberto Rivero
- Institute for Neurological Research (FLENI), Buenos Aires, Argentina
| | | | - Norman Latov
- Weill Cornell Medicine, New York City, New York, USA
| | | | - Mamatha Pasnoor
- The University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Nizar Souayah
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Kim Duff
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Erin Greco
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Shabbir Hasan
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Zhaoyang Li
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Leman Yel
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Hakan Ay
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
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17
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Bhandari V, Kim R, Faghfoury H, Silver J, Chan RH, Ding Q, Schwartz MLB, Bril V. Congenital Myopathy Due to Pathogenic Missense Variant in the MYBPC1 Gene. Can J Neurol Sci 2023:1-3. [PMID: 37577974 DOI: 10.1017/cjn.2023.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Affiliation(s)
- Vinaya Bhandari
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Raymond Kim
- Division of Clinical and Metabolic Genetics, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Hanna Faghfoury
- Division of Clinical and Metabolic Genetics, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Josh Silver
- Department of Molecular Genetics, University of Toronto & Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Raymond H Chan
- University health Network, University of Toronto, Toronto, ON, Canada
| | - Qiliang Ding
- Ted Rogers Centre for Heart Research, Cardiac Genome Clinic, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Marci L B Schwartz
- Ted Rogers Centre for Heart Research, Cardiac Genome Clinic, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
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18
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Bhandari V, Bril V. FcRN receptor antagonists in the management of myasthenia gravis. Front Neurol 2023; 14:1229112. [PMID: 37602255 PMCID: PMC10439012 DOI: 10.3389/fneur.2023.1229112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder characterized by autoantibodies specifically directed against proteins located within the postsynaptic membrane of the neuromuscular junction. These pathogenic autoantibodies can be reduced by therapies such as plasma exchange, IVIG infusions and other immunosuppressive agents. However, there are significant side effects associated with most of these therapies. Since there is a better understanding of the molecular structure and the biological properties of the neonatal Fc receptors (FcRn), it possesses an attractive profile in treating myasthenia gravis. FcRn receptors prevent the catabolism of IgG by impeding their lysosomal degradation and facilitating their extracellular release at physiological pH, consequently extending the IgG half-life. Thus, the catabolism of IgG can be enhanced by blocking the FcRn, leading to outcomes similar to those achieved through plasma exchange with no significant safety concerns. The available studies suggest that FcRn holds promise as a versatile therapeutic intervention, capable of delivering beneficial outcomes in patients with distinct characteristics and varying degrees of MG severity. Efgartigimod is already approved for the treatment of generalized MG, rozanolixizumab is under review by health authorities, and phase 3 trials of nipocalimab and batoclimab are underway. Here, we will review the available data on FcRn therapeutic agents in the management of MG.
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Affiliation(s)
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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19
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Matic A, Alfaidi N, Bril V. An evaluation of rozanolixizumab-noli for the treatment of anti-AChR and anti-MuSK antibody-positive generalized myasthenia gravis. Expert Opin Biol Ther 2023; 23:1163-1171. [PMID: 38099334 DOI: 10.1080/14712598.2023.2296126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an auto-immune disease characterized by fluctuating symptoms of muscle weakness and fatigue. Corticosteroids and corticosteroid-sparing broad-spectrum immunosuppression play a great role in the treatment of myasthenia gravis. However, debilitating side effects and long time to treatment effect highlight the need for development of novel target-specific medications. Rozanolixizumab is a highly specific neonatal Fc receptor (FcRn) inhibitor that acts on immunoglobulin G (IgG) homeostasis. Results from the MycarinG Phase III randomized controlled trial demonstrated significant efficacy of rozanolixizumab in generalized MG in terms of primary outcome and all secondary endpoints, tolerability, and safety compared to placebo. AREAS COVERED We included different trials on myasthenia gravis and rozanolixizumab which include Phase II (NCT03052751) and Phase III MycarinG (NCT03971422) studies. EXPERT OPINION Clinical trials have demonstrated that rozanolixizumab has strong efficacy with a 78% reduction in pathogenic IgG like plasma exchange (PLEX) and has therapeutic benefits comparable with PLEX and IVIG. It has less treatment adverse events and is easily accessible through subcutaneous infusion. The safety and effectiveness of rozanolixizumab need to be assessed further in the real-world context in post-marketing studies. If current trial information holds true, rozanolixizumab may become a medication of choice for MG in succeeding years.
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Affiliation(s)
- Alexandria Matic
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nouf Alfaidi
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
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20
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Martinez-Harms R, Barnett C, Bril V. Time to achieve a patient acceptable symptom state in myasthenia gravis. Front Neurol 2023; 14:1187189. [PMID: 37396757 PMCID: PMC10313102 DOI: 10.3389/fneur.2023.1187189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/25/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction The patient acceptable symptom state (PASS) is a reliable way to characterize a patient's satisfaction with their disease state in a "Yes"/"No" dichotomous manner. There is limited data on the time required to reach an acceptable state in Myasthenia Gravis (MG). We aimed to determine the time to reach a first PASS "Yes" response in patients at MG diagnosis and a PASS "No" status, and also to determine the influence of various factors on this time. Methods We performed a retrospective study of patients diagnosed with myasthenia gravis who had an initial PASS "No" response and defined the time to reach a first PASS "Yes" by Kaplan-Meier analysis. Correlations were made between demographics, clinical characteristics, treatment and disease severity, using the Myasthenia Gravis Impairment Index (MGII) and Simple Single Question (SSQ). Results In 86 patients meeting inclusion criteria, the median time to PASS "Yes" was 15 months (95% CI 11-18). Of 67 MG patients who achieved PASS "Yes," 61 (91%), achieved it by 25 months after diagnosis. Patients who required only prednisone therapy achieved PASS "Yes" in a shorter time with a median of 5.5 months (p = 0.01). Very-late-onset MG patients reached PASS "Yes" status in a shorter time (HR = 1.99, 95% CI 0.26-2.63; p = 0.001). Discussion Most patients reached PASS "Yes" by 25 months after diagnosis. MG patients who only required prednisone and those with very-late-onset MG reach PASS "Yes" in shorter intervals.
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Affiliation(s)
- Rodrigo Martinez-Harms
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, Toronto, ON, Canada
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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21
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Idiaquez JF, Alcantara M, Bril V. Optimal cut-off value of the Modified Toronto Clinical Neuropathy Score in the diagnosis of polyneuropathy. Eur J Neurol 2023. [PMID: 37203998 DOI: 10.1111/ene.15870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The modified Toronto Clinical Neuropathy Score (mTCNS) is a valid and reliable scale for the diagnosis and staging of diabetic sensorimotor polyneuropathy (DSP). OBJECTIVE To determine the optimal diagnostic cut-off value of the mTCNS in diverse polyneuropathies. METHODS Demographics and mTCNS values were retrospectively extracted from an electronic database of 190 patients with polyneuropathy (PNP) and 20 normal controls. Sensitivity, specificity, and likelihood ratios and the area under the receiver operating characteristics (ROC) curve were determined for each diagnosis and different cut-off values of the mTCNS. Patients had clinical, electrophysiological, and functional assessments of their PNP. RESULTS 43% of PNP was related to diabetes or impaired glucose tolerance. mTCNS was significantly higher in patients with PNP than in those without (15.27±8 vs 0.79±1.4, P = 0.001). The cut-off value for diagnosing PNP was ≥3 (sensitivity 98.4%, specificity 85.7%, positive likelihood ratio 6.88). The area under the ROC curve is 0.987. CONCLUSION A value of 3 or more on the mTCNS is recommended for the diagnosis of PNP.
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Affiliation(s)
- Juan Francisco Idiaquez
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Monica Alcantara
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
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22
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Menon D, Alnajjar S, Katzberg H, Barnett C, Bril V. The demographic and clinical determinants of the quality-of-life (QOL) in adults with inherited and acquired myopathies. Eur J Neurol 2023. [PMID: 37159489 DOI: 10.1111/ene.15854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/11/2023] [Accepted: 05/04/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Measuring health-related quality of life (HR-QOL) is vital for understanding the disease impact, but the complex relationship between clinical parameters and QOL remains unclear. The objective was to determine the demographic and clinical factors that influence the QOL in adults with inherited and acquired myopathies. METHODS The study was of cross-sectional design. Detailed demographic and clinical details were collected. Patients answered Neuro-QOLTM and Patient Reported Outcomes Measurement Information System (PROMIS®) short-form questionnaires. RESULTS Data was collected from 100 consecutive in-person patient visits. Mean age of the cohort was 49.5±20.1 (18-85) years and the majority were males; 53 (53%). Bivariate analysis between the various demographic and clinical features with the QOL scales revealed SSQ, hand grip strength, MRC sum score, female gender, and age to be non-uniformly associated with the QOL scales. There was no difference between inherited and acquired myopathies for any of the QOL scores except poorer lower limb function domain in inherited myopathies (36.7±7.3 vs 40.9±11.2, p 0.049). Linear regression models revealed lower SSQ, lower hand grip strength and lower MRC sum score to independently predict poor QOL. CONCLUSION Hand grip strength and SSQ serve as novel predictors of QOL in myopathies. Handgrip strength has a significant impact on physical, mental and social domains and deserves special attention with respect to rehabilitation. SSQ correlates well with QOL and can be employed as a quick and global assessment of a patient's well-being. Differences in QOL scores between patients with inherited and acquired myopathies were minimal.
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Affiliation(s)
- Deepak Menon
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
- National Institute of Mental Health and Neuro Sciences. Bangalore, India
| | - Sara Alnajjar
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
- King Abdulaziz Hospital, Ministry of National Guard Health Affairs, Al Ahsa, Saudi Arabia
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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23
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Bril V, Drużdż A, Grosskreutz J, Habib AA, Mantegazza R, Sacconi S, Utsugisawa K, Vissing J, Vu T, Boehnlein M, Bozorg A, Gayfieva M, Greve B, Woltering F, Kaminski HJ. Safety and efficacy of rozanolixizumab in patients with generalised myasthenia gravis (MycarinG): a randomised, double-blind, placebo-controlled, adaptive phase 3 study. Lancet Neurol 2023; 22:383-394. [PMID: 37059507 DOI: 10.1016/s1474-4422(23)00077-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Generalised myasthenia gravis is a chronic, unpredictable, and debilitating autoimmune disease. New treatments for this disease are needed because conventional therapies have limitations, such as side-effects (eg, increased infection risk) or inadequate control of symptoms. Rozanolixizumab is a neonatal Fc receptor blocker that might provide a novel therapeutic option for myasthenia gravis. We aimed to assess the safety and efficacy of rozanolixizumab for generalised myasthenia gravis. METHODS MycarinG is a randomised, double-blind, placebo-controlled, adaptive phase 3 study done at 81 outpatient centres and hospitals in Asia, Europe, and North America. We enrolled patients (aged ≥18 years) with acetylcholine receptor (AChR) or muscle-specific kinase (MuSK) autoantibody-positive generalised myasthenia gravis (Myasthenia Gravis Foundation of America class II-IVa), a Myasthenia Gravis Activities of Daily Living (MG-ADL) score of at least 3 (non-ocular symptoms), and a quantitative myasthenia gravis score of at least 11. Patients were randomly assigned (1:1:1) to receive subcutaneous infusions once a week for 6 weeks of either rozanolixizumab 7 mg/kg, rozanolixizumab 10 mg/kg, or placebo. Randomisation was stratified by AChR and MuSK autoantibody status. Investigators, patients, and people assessing outcomes were masked to random assignments. The primary efficacy endpoint was change from baseline to day 43 in MG-ADL score, assessed in the intention-to-treat population. Treatment-emergent adverse events (TEAEs) were assessed in all randomly assigned patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT03971422) and EudraCT (2019-000968-18); an open-label extension study has been completed (NCT04124965; EudraCT 2019-000969-21) and another is underway (NCT04650854; EudraCT 2020-003230-20). FINDINGS Between June 3, 2019, and June 30, 2021, 300 patients were assessed for eligibility, of whom 200 were enrolled. 66 (33%) were randomly assigned to rozanolixizumab 7 mg/kg, 67 (34%) to rozanolixizumab 10 mg/kg, and 67 (34%) to placebo. Reductions in MG-ADL score from baseline to day 43 were greater in the rozanolixizumab 7 mg/kg group (least-squares mean change -3·37 [SE 0·49]) and in the rozanolixizumab 10 mg/kg group (-3·40 [0·49]) than with placebo (-0·78 [0·49]; for 7 mg/kg, least-squares mean difference -2·59 [95% CI -4·09 to -1·25], p<0·0001; for 10 mg/kg, -2·62 [-3·99 to -1·16], p<0·0001). TEAEs were experienced by 52 (81%) of 64 patients treated with rozanolixizumab 7 mg/kg, 57 (83%) of 69 treated with rozanolixizumab 10 mg/kg, and 45 (67%) of 67 treated with placebo. The most frequent TEAEs were headache (29 [45%] patients in the rozanolixizumab 7 mg/kg group, 26 [38%] in the rozanolixizumab 10 mg/kg group, and 13 [19%] in the placebo group), diarrhoea (16 [25%], 11 [16%], and nine [13%]), and pyrexia (eight [13%], 14 [20%], and one [1%]). Five (8%) patients in the rozanolixizumab 7 mg/kg group, seven (10%) in the rozanolixizumab 10 mg/kg group, and six (9%) in the placebo group had a serious TEAE. No deaths occurred. INTERPRETATION Rozanolixizumab showed clinically meaningful improvements in patient-reported and investigator-assessed outcomes in patients with generalised myasthenia gravis, for both 7 mg/kg and 10 mg/kg doses. Both doses were generally well tolerated. These findings support the mechanism of action of neonatal Fc receptor inhibition in generalised myasthenia gravis. Rozanolixizumab represents a potential additional treatment option for patients with generalised myasthenia gravis. FUNDING UCB Pharma.
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Affiliation(s)
- Vera Bril
- University Health Network, Toronto, ON, Canada.
| | - Artur Drużdż
- Department of Neurology, Municipal Hospital, Poznań, Poland
| | - Julian Grosskreutz
- Precision Neurology, Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Ali A Habib
- MDA ALS and Neuromuscular Center, University of California, Irvine, CA, USA
| | - Renato Mantegazza
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Neurologico Carlo Besta, Milan, Italy
| | - Sabrina Sacconi
- Université Côte d'Azur, Peripheral Nervous System and Muscle Department, Pasteur 2 Hospital, Centre Hospitalier Universitaire de Nice, Nice, France
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Sivadasan A, Bril V. Clinical efficacy and safety of efgartigimod for treatment of myasthenia gravis. Immunotherapy 2023; 15:553-563. [PMID: 37013835 DOI: 10.2217/imt-2022-0298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Treatment of acute exacerbations and refractory myasthenia gravis (MG) remains challenging despite advances in immunotherapy. Frequent use of plasmapheresis and immunoglobulins are associated with adverse events and strain on resources. The neonatal Fc receptor (FcRn) facilitates IgG recycling and FcRn antagonism enhances the degradation of IgG pathogenic autoantibodies without compromising adaptive and innate immunity. Efgartigimod, an FcRN antagonist, has been shown in well-designed clinical trials to improve clinical status and reduce autoantibody levels without significant safety concerns. Efgartigimod has received approvals for use in the United States, Japan and Europe. It is plausible that efgartigimod is effective across different subgroups and varied spectrums of MG severity. Novel strategies involving FcRn modulation and long-term follow-up studies will help provide further insights and expand the therapeutic repertoire.
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Affiliation(s)
- Ajith Sivadasan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Networkand University of Toronto, 5EC-309, TGH, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Networkand University of Toronto, 5EC-309, TGH, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
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Abstract
Importance There are limited data regarding COVID-19 outcomes and vaccine uptake and safety among people with myasthenia gravis (MG). Objective To investigate COVID-19-related outcomes and vaccine uptake among a population-based sample of adults with MG. Design, Setting, and Participants This population-based, matched cohort study in Ontario, Canada, used administrative health data from January 15, 2020, and August 31, 2021. Adults with MG were identified using a validated algorithm. Each patient was matched by age, sex, and geographic area of residence to 5 controls from the general population and from a cohort of individuals with rheumatoid arthritis (RA). Exposure Patients with MG and matched controls. Main Outcomes and Measures Main outcomes were COVID-19 infection and related hospitalizations, intensive care unit admissions, and 30-day mortality among patients with MG vs controls. Secondary outcomes were uptake of COVID-19 vaccination among patients with MG vs controls. Results Among 11 365 233 eligible Ontario residents, 4411 patients with MG (mean [SD] age, 67.7 [15.6] years; 2274 women [51.6%]) were matched to 22 055 general population controls (mean [SD] age, 67.7 [15.6] years; 11 370 women [51.6%]) and 22 055 controls with RA (mean [SD] age, 67.7 [15.6] years; 11 370 women [51.6%]). In the matched cohort, 38 861 of 44 110 individuals (88.1%) were urban residents; in the MG cohort, 3901 (88.4%) were urban residents. Between January 15, 2020, and May 17, 2021, 164 patients with MG (3.7%), 669 general population controls (3.0%), and 668 controls with RA (3.0%) contracted COVID-19. Compared with general population controls and controls with RA, patients with MG had higher rates of COVID-19-associated emergency department visits (36.6% [60 of 164] vs 24.4% [163 of 669] vs 29.9% [200 of 668]), hospital admissions (30.5% [50 of 164] vs 15.1% [101 of 669] vs 20.7% [138 of 668]), and 30-day mortality (14.6% [24 of 164] vs 8.5% [57 of 669] vs 9.9% [66 of 668]). By August 2021, 3540 patients with MG (80.3%) vs 17 913 general population controls (81.2%) had received 2 COVID-19 vaccine doses, and 137 (3.1%) vs 628 (2.8%), respectively had received 1 dose. Of 3461 first vaccine doses for patients with MG, fewer than 6 individuals were hospitalized for MG worsening within 30 days of vaccination. Vaccinated patients with MG had a lower risk than unvaccinated patients with MG of contracting COVID-19 (hazard ratio, 0.43; 95% CI, 0.30-0.60). Conclusions and Relevance This study suggests that adults with MG who contracted COVID-19 had a higher risk of hospitalization and death compared with matched controls. Vaccine uptake was high, with negligible risk of severe MG exacerbations after vaccination, as well as evidence of effectiveness. The findings support public health policies prioritizing people with MG for vaccination and new COVID-19 therapeutics.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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26
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Jimenez-Zepeda V, Bril V, Lemieux-Blanchard E, Royal V, McCurdy A, Schwartz D, Davis MK. A Comprehensive Multidisciplinary Diagnostic Algorithm for the Early and Efficient Detection of Amyloidosis. Clin Lymphoma Myeloma Leuk 2023; 23:194-202. [PMID: 36653205 DOI: 10.1016/j.clml.2022.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
Amyloidosis is a rare protein misfolding disease caused by the accumulation of amyloid fibrils in various tissues and organs. There are different subtypes of amyloidosis, with light chain (AL) amyloidosis being the most common. Amyloidosis is notoriously difficult to diagnose because it is clinically heterogeneous, no single test is diagnostic for the disease, and diagnosis typically involves multiple specialists. Here, we propose an integrated, multidisciplinary algorithm for efficiently diagnosing amyloidosis. Drawing on research from several medical disciplines, we have combined clinical decisions and best practices into a comprehensive algorithm to facilitate the early detection of amyloidosis. Currently, many patients are diagnosed more than 6 months after symptom onset, yet early diagnosis is the major predictor of survival. Our algorithm aims to shorten the time to diagnosis with efficient sequencing of tests and minimizing uninformative investigations. We also recommend typing and staging of confirmed amyloidosis to guide treatment. By reducing time to diagnosis, our algorithm could lead to earlier and more targeted treatment, ultimately improving prognosis and survival.
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Affiliation(s)
- Victor Jimenez-Zepeda
- Department of Hematology, University of Calgary and Arnie Charbonneau Cancer Institute, Calgary, Alberta, Canada.
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toranto, Ontario, Canada
| | - Emilie Lemieux-Blanchard
- Department of Hematology, Service d'hématologie-oncologie du Centre hospitalier de l'Université de Montréal and Centre de recherche du CHUM, Montreal, Quebec, Canada
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montreal, Montreal, Quebec, Canada
| | - Arleigh McCurdy
- Division of Hematology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Schwartz
- Faculty of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margot K Davis
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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27
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Bril V, Szczudlik A, Vaitkus A, Rozsa C, Kostera-Pruszczyk A, Hon P, Bednarik J, Tyblova M, Köhler W, Toomsoo T, Nowak RJ, Mozaffar T, Freimer ML, Nicolle MW, Magnus T, Pulley MT, Rivner M, Dimachkie MM, Distad BJ, Pascuzzi RM, Babiar D, Lin J, Querolt Coll M, Griffin R, Mondou E. Randomized Double-Blind Placebo-Controlled Trial of the Corticosteroid-Sparing Effects of Immunoglobulin in Myasthenia Gravis. Neurology 2023; 100:e671-e682. [PMID: 36270895 PMCID: PMC9969924 DOI: 10.1212/wnl.0000000000201501] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction at the neuromuscular junction. Treatment frequently includes corticosteroids (CSs) and IV immunoglobulin (IVIG). This study was conducted to determine whether immune globulin (human), 10% caprylate/chromatography purified (IGIV-C) could facilitate CS dose reduction in CS-dependent patients with MG. METHODS In this randomized double-blind placebo-controlled trial, CS-dependent patients with MG (Myasthenia Gravis Foundation of America Class II-Iva; AChR+) received a loading dose of 2 g/kg IGIV-C over 2 days (maximum 80 g/d) or placebo at week 0 (baseline). Maintenance doses (1 g/kg IGIV-C or placebo) were administered every 3 weeks through week 36. Tapering of CS was initiated at week 9 and continued through week 36 unless the patient worsened (quantitative MG score ≥4 points from baseline). CS doses were increased (based on the current CS dose) in patients who worsened. Patients were withdrawn if worsening failed to improve within 6 weeks or if a second CS increase was required. The primary efficacy end point (at week 39) was a ≥50% reduction in CS dose. Secondary and safety end points were assessed throughout the study and follow-up (weeks 42 and 45). The study results and full protocol are available at clinicaltrials.gov/ct2/show/NCT02473965. RESULTS The primary end point (≥50% reduction in CS dose) showed no significant difference between the IGIV-C treatment (60.0% of patients) and placebo (63.3%). There were no significant differences for secondary end points. Safety data indicated that IGIV-C was well tolerated. DISCUSSION In this study, IGIV-C was not more effective than placebo in reducing daily CS dose. These results suggest that the effects of IGIV-C and CS are not synergistic and may be mechanistically different. TRIAL REGISTRATION INFORMATION The trial was registered on clinicaltrialsregister.eu (EudraCT #: 2013-005099-17) and clinicaltrials.gov (identifier NCT02473965). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that IVIG infusions in adult patients with MG do not increase the percentage of patients achieving a ≥50% reduction in corticosteroid dose compared with placebo.
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Affiliation(s)
- Vera Bril
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain.
| | - Andrzej Szczudlik
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Antanas Vaitkus
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Csilla Rozsa
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Anna Kostera-Pruszczyk
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Petr Hon
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Josef Bednarik
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michaela Tyblova
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Wolfgang Köhler
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Toomas Toomsoo
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Richard J Nowak
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Tahseen Mozaffar
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Miriam L Freimer
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael W Nicolle
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Tim Magnus
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael T Pulley
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Michael Rivner
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Mazen M Dimachkie
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - B Jane Distad
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Robert M Pascuzzi
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Donna Babiar
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Jiang Lin
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Montse Querolt Coll
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Rhonda Griffin
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
| | - Elsa Mondou
- From the Toronto General Hospital (V.B.), Toronto, Ontario, Canada; Centrum Neurologii Klinicznej (A.S.), Krakow, Poland; Department of Neurology (A.V.), Kaunas Clinics, Hospital of Lithuanian University of Health Sciences, Lithuania; Jahn Ferenc Del-pesti Korhaz es Rendelointezet Neurologiai Osztaly (C.R.), Budapest, Hungary; Department of Neurology (A.K.-P.), Medical University of Warsaw, Poland, ERN EURO NMD; Fakultni Nemocnice Ostrava (P.H.), Neurologicka Klinika, Ostrava-Poruba, Czech Republic; Department of Neurology (J.B.), Masaryk University, University Hospital Brno and Faculty of Medicine, Czech Republic; Vseobecna Fakultni Nemocnice v Praze (M.T.), Neurologicka Klinika, Centrum Myasthenia Gravis, Praha, Czech Republic; FKH Hubertusburg (W.K.), Klinik Fuer Neurologie und Neurologische, Intensivmedizin, Wermsdorf, Germany; East Tallinn Central Hospital (T.T.), Estonia; Department of Neurology (R.J.N.), Yale University School of Medicine, New Haven, CT; University of California (Tahseen Mozaffar), Irvine, Orange; Department of Neurology (M.L.F.), The Ohio State University, Columbus; London Health Sciences Centre (M.W.N.), Western University, Ontario, Canada; Universitaetsklinikum Hamburg Eppendorf (Tim Magnus), Klinik und Poliklinik Fuer Neurologie, Neurologische Studienzentrale, Hamburg, Germany; University of Florida Health Science Center (M.T.P.), Jacksonville, FL; Neurology/EMG Laboratory (M.R.), Augusta University, GA; The University of Kansas Medical Center (M.M.D.); University of Washington (B.J.D.), Seattle; Indiana School of Medicine (R.M.P.), Indianapolis; Grifols Bioscience Research Group (D.B., J.L., R.G., E.M.), Research Triangle Park, NC; and Grifols Bioscience Research Group (M.Q.C.), Sant Cugat, Spain
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Pasnoor M, Bril V, Levine T, Trivedi J, Silvestri NJ, Phadnis M, Katzberg HD, Saperstein DS, Wolfe GI, Herbelin L, Higgs K, Heim AJ, Statland JM, Barohn RJ, Dimachkie MM. Phase 2 trial in acetylcholine receptor antibody-positive myasthenia gravis of transition from intravenous to subcutaneous immunoglobulin: The MGSCIg study. Eur J Neurol 2023; 30:1417-1424. [PMID: 36779862 DOI: 10.1111/ene.15745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND PURPOSE Data on maintenance therapy with subcutaneous immunoglobulin (SCIg) in myasthenia gravis (MG) are limited. We report on transitioning acetylcholine receptor (AChR) antibody-positive (Ab+) MG patients on stable intravenous immunoglobulin (IVIg) regimens as part of routine clinical care to SCIg 1:1.2. METHODS This multicenter North American open-label prospective investigator-initiated study had two components: the IVIg Stabilization Period (ISP) enrolling patients already on IVIg as part of routine clinical care (Weeks -10 to -1), followed by transition of stable MG subjects to SCIg in the Experimental Treatment Period (ETP; Weeks 0 to 12). We hypothesized that >65% of patients entering the ETP would have a stable Quantitative Myasthenia Gravis (QMG) score from Week 0 to Week 12. Secondary outcome measures included other efficacy measures, safety, tolerability, IgG levels, and treatment satisfaction. RESULTS We recruited 23 patients in the ISP, and 22 entered the ETP. A total of 12 subjects (54.5%) were female, and 18 (81.8%) were White, with mean age 51.4 ± 17 years. We obtained Week 12 ETP QMG data on 19 of 22; one subject withdrew from ETP owing to clinical deterioration, and two subjects withdrew due to dislike of needles. On primary analysis, 19 of 22 participants (86.4%, 95% confidence interval = 0.72-1.00) were treatment successes using last observation carried forward (p = 0.018). Secondary efficacy measures supported MG stability. SCIg was safe and well tolerated, and IgG levels were stable. Treatment satisfaction was comparable between ISP and ETP. CONCLUSIONS MG patients on IVIg as part of their routine clinical care remained stable on monthly IVIg dosage, and most maintained similar disease stability on SCIg.
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Affiliation(s)
- Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Vera Bril
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Todd Levine
- HonorHealth Neurology, Phoenix, Arizona, USA
| | - Jaya Trivedi
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Milind Phadnis
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Hans D Katzberg
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Gil I Wolfe
- Department of Neurology, University at Buffalo, Buffalo, New York, USA
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kiley Higgs
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew J Heim
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Howard J, Bril V, Vu T, Karam C, Peric S, De Bleecker J, Murai H, Meisel A, Beydoun S, Pasnoor M, Guglietta A, Ulrichts P, T'joen C, Brauer E, Utsugisawa K, Verschuuren J, Mantegazza R. Long-term Safety and Efficacy of Efgartigimod in Patients With Generalized Myasthenia Gravis: Interim Results of the ADAPT+ Study. Neurology 2022. [DOI: 10.1212/01.wnl.0000903308.81107.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
ObjectiveTo evaluate the safety and efficacy of efgartigimod in patients with generalized myasthenia gravis (MG) enrolled in the ADAPT+ long-term extension study.BackgroundTreatment with efgartigimod, a human IgG1 antibody Fc-fragment that blocks neonatal Fc receptor, resulted in clinically meaningful improvement (CMI) in MG-specific outcome measures in the ADAPT phase 3 clinical trial. All patients who completed ADAPT were eligible to enroll in its ongoing open-label, 3-year extension study, ADAPT+.Design/MethodsEfgartigimod (10 mg/kg IV) was administered in cycles of once-weekly infusions for 4 weeks, with subsequent cycles initiated based on clinical evaluation. Efficacy was assessed during each cycle utilizing Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scales.ResultsNinety-one percent of ADAPT patients (151/167) entered ADAPT+. As of February 2021, 106 AChR-Ab+ and 33 AChR-Ab– patients had received at least 1 dose of open-label efgartigimod (including 66 ADAPT placebo [PBO] patients). The mean (SD) study duration was 363 (114) days, resulting in 138 patient-years of observation. Similar incidence rates per patient year (IR/PY) of serious adverse events were seen in ADAPT (efgartigimod: 0.11; placebo: 0.29) compared to ADAPT+ (0.25). Five deaths (acute myocardial infarction, COVID-19 pneumonia/septic shock, bacterial pneumonia/MG crisis, malignant lung neoplasm, and unknown [multiple cardiovascular risk factors identified on autopsy]) occurred; none were considered related to efgartigimod by the investigator. AEs were predominantly mild or moderate. CMI was observed in AChR-Ab+ patients during each cycle (up to 10 cycles) at magnitudes comparable to improvements observed at week 3 of cycle 1 (mean[SE] improvements: MG-ADL, –5.1[0.34]; QMG, –4.7[0.41]). Clinical improvements mirrored maximal reductions in total IgG and AChR-Abs across all cycles.ConclusionsThis analysis suggests the efficacy of long-term treatment with efgartigimod was consistent across multiple cycles. No new safety signals were identified, despite being conducted before vaccine availability during the COVID-19 pandemic.
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Ramchandren S, Guptill J, Antozzi C, Bril V, Gamez J, Meuth S, Nowak R, Quan D, Sevilla Mantecon MT, Ling L, Zhu Y, Karcher K, Sun H. Serum Autoantibody Lowering by the Anti-FcRn Monoclonal Antibody, Nipocalimab, Correlates With Clinical Improvement in Generalized Myasthenia Gravis Patients. Neurology 2022. [DOI: 10.1212/01.wnl.0000903304.73134.e3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
ObjectiveTo evaluate the relationship between clinical improvement in Myasthenia Gravis-Activities of Daily Living (MG-ADL) scores and the pharmacodynamic effects of IgG autoantibody lowering induced by nipocalimab in the Vivacity MG Phase 2 study.BackgroundNipocalimab is a fully human, aglycosylated, effectorless IgG1 anti-FcRn monoclonal antibody that targets the neonatal Fc receptor (FcRn) with high affinity, thereby lowering IgG pathogenic antibodies in autoimmune disease.Design/MethodsThe relationship between the reduction in acetylcholine-receptor (AChR)- and Muscle-Specific-Tyrosine-Kinase (MuSK)- autoantibodies with improvement in MG-ADL scores were explored across the four nipocalimab dose arms in the Vivacity MG Phase 2 Study in generalized myasthenia gravis (gMG) patients.ResultsOf the 68 patients enrolled, 54 were randomized to one of the four nipocalimab dosing arms. 51 (94%) were seropositive for anti-AChR, 3 (6%) for anti-MuSK. Nipocalimab was well-tolerated and achieved substantial, dose-dependent and rapid reductions in serum total IgG, including all IgG subtypes and anti-AChR autoantibodies. These reductions were associated with dose-dependent, durable and rapid MG-ADL responses in all nipocalimab-treated groups. A similar trend in IgG4 reduction was noted, though the sample size of MuSK positive patients was small.ConclusionsThe results support the rapid, dose-dependent and predictable effect of nipocalimab in lowering pathogenic autoantibodies and inducing clinical improvement in patients with gMG. In addition, the close correlation between serum IgG, anti-AChR and clinical response suggest the potential of using serial serum IgG levels as a biomarker in management of gMG patients treated with nipocalimab; this will be tested in the ongoing Phase 3 gMG trial.
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Lytvyn Y, Albakr R, Bjornstad P, Lovblom LE, Liu H, Lovshin JA, Boulet G, Farooqi MA, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZI. Renal hemodynamic dysfunction and neuropathy in longstanding type 1 diabetes: Results from the Canadian study of longevity in type 1 diabetes. J Diabetes Complications 2022; 36:108320. [PMID: 36201892 PMCID: PMC10187942 DOI: 10.1016/j.jdiacomp.2022.108320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 08/29/2022] [Accepted: 09/23/2022] [Indexed: 11/28/2022]
Abstract
AIMS To determine the relationship between renal hemodynamic function and neuropathy in adults with ≥50-years of type 1 diabetes (T1D) compared to nondiabetic controls. METHODS Glomerular filtration rate (GFR, inulin), effective renal plasma flow (ERPF, p-aminohippurate), modified Toronto Clinical Neuropathy Score (mTCNS), corneal confocal microscopy, nerve conduction, and heart rate variability (autonomic function) were measured; afferent (RA) and efferent (RE) arteriolar resistances were estimated using the Gomez equations in 74 participants with T1D and in 75 controls. Diabetic kidney disease (DKD) non-resistors were defined by eGFRMDRD < 60 ml/min/1.73 m2 or 24-h urine albumin excretion >30 mg/day. Linear regression was applied to examine the relationships between renal function (dependent variable) and neuropathy measures (independent variable), adjusted for age, sex, HbA1c, systolic blood pressure, low density lipoprotein cholesterol, and 24-h urine albumin to creatinine ratio. RESULTS Higher mTCNS associated with lower renal blood flow (β ± SE:-9.29 ± 4.20, p = 0.03) and greater RE (β ± SE:32.97 ± 15.43, p = 0.04) in participants with T1D, but not in controls. DKD non-resistors had a higher mTCNS and worse measures of corneal nerve morphology compared to those without DKD. Renal hemodynamic parameters did not associate with autonomic nerve function. CONCLUSIONS Although neurological dysfunction in the presence of diabetes may contribute to impaired renal blood flow resulting in ischemic injury in patients with T1D, early autonomic dysfunction does not appear to be associated with kidney function changes.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rehab Albakr
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hongyan Liu
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julie A Lovshin
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alanna Weisman
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Bril V, Silvestri NJ, Barnett-Tapia C. Like a Game of Chess, Every Move Matters: The Role of Antibodies in the Myasthenia Gravis Treatment Landscape. Prim Care Companion CNS Disord 2022; 24:AR21018AH3C. [PMID: 36301008 DOI: 10.4088/pcc.ar21018ah3c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Symptoms and disease pathophysiology of myasthenia gravis (MG) vary considerably with each patient, and their individual preferences and priorities add to the need for individualized treatment of this autoimmune disease. Research in MG has grown substantially in recent years. New treatments have the potential of being both effective and well tolerated, addressing the trade-off of choosing either efficacy or tolerability when selecting treatments. Promising investigational treatments that may become available in the future may allow more patients than ever before to achieve an asymptomatic state, with the ultimate goal being to turn off abnormal antibody production.
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Affiliation(s)
- Vera Bril
- Division of Neurology, University of Toronto, and University Health Network
| | - Nicholas J Silvestri
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, New York
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Jacob S, Howard J, Bril V, Peric S, Bleecker JD, T’joen C, Travers J, Utsugisawa K, Verschuuren J, Mantegazza R. Long-term assessment of efgartigimod in patients with generalised myasthenia gravis: ADAPT+ study interim results. J Neurol Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionIn ADAPT, efgartigimod, a human IgG1 antibody Fc-fragment blocking neonatal Fc receptor, resulted in clinically meaningful improvement (CMI) in myasthenia gravis (MG)-specific measures. Patients completing ADAPT were eligible to enrol in ADAPT+ (open-label, 3-year extension study).MethodsEfgartigimod, 10 mg/kg intravenous infusion administered once-weekly for 4 weeks; subsequent cycles initiated based on predefined criteria. Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative MG (QMG) scales were completed every cycle.ResultsFrom ADAPT 91% patients (151/167) entered ADAPT+. As of February 2021, 106 AChR-Ab+ and 33 AChR-Ab– had received ≥1 dose of efgartigimod (including 66 ADAPT placebo patients). Mean(SD) study duration: 363(114) days. The most common adverse events (AEs) in the efgartigimod-efgartigimod and placebo-efgartigimod arms: headache (15.1%/30.3%), nasopharyngitis (8.2%/13.6%), diarrhoea (6.8%/10.6%). Five deaths occurred, none considered efgartigimod-related by investigators. AEs were predominantly mild or moderate. CMI was observed in AChR-Ab+ patients during each cycle (up to 10 cycles), comparable to improvements at week 3, cycle 1 (mean[SE]: MG-ADL, –5.1[0.34]; QMG, –4.7[0.41]). Clinical improvements mirrored maximal reductions in total IgG and AChR-Abs across all cycles. Similar results observed in AChR-Ab– patients.ConclusionsThis suggests long-term efgartigimod was well-tolerated and efficacious, regardless of antibody status. No new safety signals were identified.
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Urra Pincheira A, Alnajjar S, Katzberg H, Barnett C, Daniyal L, Rohan R, Bril V. Retrospective study on the safety of COVID-19 vaccination in myasthenia gravis. Muscle Nerve 2022; 66:558-561. [PMID: 35673960 PMCID: PMC9347864 DOI: 10.1002/mus.27657] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION/AIM Given the lack of information on safety of coronavirus disease 2019 (COVID-19) vaccination in myasthenia gravis (MG) patients, we aimed to review our experience after surveying patients, as part of routine clinical practice, to ensure that advice on safety is accurate. METHODS We performed a retrospective chart review of MG patients from the Prosserman Family Neuromuscular Clinic at the Toronto General Hospital who received two injections of any COVID-19 vaccine from February to August 2021. Demographic data were abstracted from the patient medical records. We assessed changes in the severity of MG using the virtual Myasthenia Gravis Impairment Index (vMGII), the simple single question (SSQ), and Patient Acceptable Symptom State (PASS). We also assessed adverse effects after vaccination. RESULTS We included 200 patients with a mean age of 64.3 ± 13.9 y, 51.5% were men, and 82% had generalized MG. The vMGII, SSQ, and PASS scores remained stable after each vaccine dose, and at last follow-up. Of the patients, 60% reported an adverse reaction after the first injection, and 56% after the second. The most common adverse reactions reported were local pain at the injection site, fatigue, headache, and fever. DISCUSSION COVID-19 vaccinations were well tolerated in MG patients and were not associated with worsening severity of their MG. The prevalence of vaccine-related adverse reactions was the same as in the general population.
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Affiliation(s)
- Alejandra Urra Pincheira
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada,University of TorontoTorontoOntarioCanada
| | - Sara Alnajjar
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada,University of TorontoTorontoOntarioCanada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada,University of TorontoTorontoOntarioCanada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada,University of TorontoTorontoOntarioCanada
| | - Lubna Daniyal
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada,University of TorontoTorontoOntarioCanada
| | - Ritesh Rohan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General HospitalUniversity Health NetworkTorontoOntarioCanada,University of TorontoTorontoOntarioCanada
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Lee A, Fine NM, Bril V, Delgado D, Hahn C. Hereditary transthyretin amyloidosis: a case report. J Med Case Rep 2022; 16:248. [PMID: 35751086 PMCID: PMC9233400 DOI: 10.1186/s13256-022-03437-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hereditary transthyretin amyloidosis is an uncommon multisystem disorder caused by mutation of the transthyretin protein, leading to peripheral neuropathy often with autonomic features, cardiomyopathy, or a mixed phenotype. Multiple other organ systems can be involved with ophthalmologic, renal, hematologic, gastrointestinal, and/or genitourinary symptoms and signs. This often results in assessments by multiple specialists and significant delays before the diagnosis is recognized. With the recent advent of potentially lifesaving therapies, early diagnosis has become even more important. Our case highlights the protean aspects of this disease as well as the difficulty of making this diagnosis, especially in the absence of a clear family history. CASE PRESENTATION We report the case of a 64-year-old man of East-Asian descent who presented with diarrhea, mild anemia, and symptoms of peripheral neuropathy. Numerous investigations and specialist evaluations did not identify a cause. Progression of neurologic symptoms and the development of new hematologic abnormalities ultimately led to consideration of hereditary transthyretin amyloidosis. The diagnosis was confirmed after re-examining previously acquired gastrointestinal biopsies and pursuing genetic testing, which confirmed a pathogenic mutation in the transthyretin gene. He was subsequently started on a novel gene-silencing therapy. On clinical follow-up 8 months after initiation of therapy, the patient described stabilization of previously progressive numbness, weakness, and weight loss with an unchanged neurologic examination and stable repeat electrophysiologic testing. CONCLUSIONS Hereditary transthyretin amyloidosis is a challenging disease to recognize in early stages owing to its multisystem and nonspecific manifestations. Recent approval of novel therapies highlights the importance of early diagnosis before irreversible organ damage occurs.
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Affiliation(s)
- Angela Lee
- Division of Neurology, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nowell M Fine
- Divsion of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Diego Delgado
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Christopher Hahn
- Division of Neurology, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,South Health Campus Hospital, 4448 Front Street SE, Calgary, Alberta, T3M 1M4, Canada.
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Alcantara M, Barnett C, Katzberg H, Bril V. An update on the use of immunoglobulins as treatment for myasthenia gravis. Expert Rev Clin Immunol 2022; 18:703-715. [PMID: 35639497 DOI: 10.1080/1744666x.2022.2084074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies. AREAS COVERED We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease. EXPERT OPINION The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient's status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Abstract
Myasthenia gravis (MG) is a chronic, fluctuating, antibody-mediated autoimmune disorder directed against the post-synaptic neuromuscular junctions of skeletal muscles, resulting in a wide spectrum of manifestations ranging from mild to potentially fatal. Given its unique natural course, designing an ideal trial design for MG has been wrought with difficulties and evidence in favour of several of the conventional agents is weak as per current standards. Despite this, acetylcholinesterases and corticosteroids have remained the cornerstones of treatment for several decades with intravenous immunoglobulins (IVIG) and therapeutic plasma exchange (PLEX) offering rapid treatment response, especially in crises. However, the treatment of MG entails long-term immunosuppression and conventional agents are viable options but take longer to act and have a number of class-specific adverse effects. Advances in immunology, translational medicine and drug development have seen the emergence of several newer biological agents which offer selective, target-specific immunotherapy with fewer side effects and rapid onset of action. Eculizumab is one of the newer agents that belong to the class of complement inhibitors and has been approved for the treatment of refractory general MG. Zilucoplan and ravulizumab are other agents in this group in clinical trials. Neisseria meningitis is a concern with all complement inhibitors, mandating vaccination. Neonatal Fc receptor (FcRn) inhibitors prevent immunoglobulin recycling and cause rapid reduction in antibody levels. Efgartigimod is an FcRn inhibitor recently approved for MG treatment, and rozanolixizumab, nipocalimab and batoclimab are other agents in clinical trial development. Although lacking high quality evidence from randomized clinical trials, clinical experience with the use of anti-CD20 rituximab has led to its use in refractory MG. Among novel targets, interleukin 6 (IL6) inhibitors such as satralizumab are promising and currently undergoing evaluation. Cutting-edge therapies include genetically modifying T cells to recognise chimeric antigen receptors (CAR) and chimeric autoantibody receptors (CAAR). These may offer sustained and long-term remissions, but are still in very early stages of evaluation. Hematopoietic stem cell transplantation (HSCT) allows immune resetting and offers sustained remission, but the induction regimens often involve serious systemic toxicity. While MG treatment is moving beyond conventional agents towards target-specific biologicals, lack of knowledge as to the initiation, maintenance, switching, tapering and long-term safety profile necessitates further research. These concerns and the high financial burden of novel agents may hamper widespread clinical use in the near future.
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Affiliation(s)
- Deepak Menon
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, 5EC-309, Toronto General Hospital, University of Toronto, 200 Elizabeth St, Toronto, M5G 2C4, Canada.
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Bril V, Silvestri NJ, Barnett-Tapia C. A Review of Disease Mechanisms and Current and Emerging Treatment Options for Generalized Myasthenia Gravis. Prim Care Companion CNS Disord 2022; 24. [DOI: 10.4088/pcc.ar21018wc2c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Idiaquez Rios JF, Lovblom LE, Perkins BA, Bril V. Orthostatic blood pressure changes and diabetes duration. J Diabetes Complications 2022; 36:108169. [PMID: 35307262 DOI: 10.1016/j.jdiacomp.2022.108169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
UNLABELLED To determine the prevalence and the associated clinical characteristics of orthostatic hypotension and orthostatic hypertension in patients with diabetic sensorimotor polyneuropathy (DSP). METHODS A single-center retrospective cross-sectional study was conducted on 200 DSP patients who had 3-minute orthostatic measures as part of the standard clinic evaluation. We measured the heart rate (HR) and blood pressure (BP) supine and again after 3 min of standing. RESULTS The prevalence of orthostatic hypotension was 19.5% and that of orthostatic hypertension was 23%. Subjects with orthostatic hypotension had significantly longer diabetes duration than subjects who were normotensive and those with orthostatic hypertension. Quantitatively, BP changes from supine to standing correlated with diabetes duration (R = 0.306; P = 0.0582) and age (R = 0.434; P = 0.006) in subjects with orthostatic hypotension. CONCLUSIONS Orthostatic hypertension and orthostatic hypotension are frequent in patients with DSP. Orthostatic hypertension is associated with shorter diabetes duration than orthostatic hypotension.
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Affiliation(s)
- Juan F Idiaquez Rios
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases University Health Network, University of Toronto, Canada
| | - Leif Erik Lovblom
- Division of Endocrinology, Department of Medicine, Leadership Sinai Centre for Diabetes, Sinai Health System, University of Toronto, Toronto, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology, Department of Medicine, Leadership Sinai Centre for Diabetes, Sinai Health System, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases University Health Network, University of Toronto, Canada.
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Alcantara M, Ngo M, de la Cruz J, Menon D, Barnett-Tapia C, Katzberg H, Bril V. Temporal Dispersion and Duration of the Distal Compound Muscle Action Potential Do Not Distinguish Diabetic Sensorimotor Polyneuropathy From Chronic Inflammatory Demyelinating Polyneuropathy. Front Neurol 2022; 13:872762. [PMID: 35557614 PMCID: PMC9087194 DOI: 10.3389/fneur.2022.872762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo investigate the contribution of duration and temporal dispersion (TD) of the distal compound muscle action potential (CMAP) in discriminating chronic inflammatory demyelinating polyneuropathy (CIDP) from diabetic sensorimotor polyneuropathy (DSP) and from CIDP+DSP.MethodsWe performed a retrospective review of patients diagnosed with CIDP, DSP and CIDP+DSP (responsive to immunotherapy) and examined differences in CMAP duration and TD at baseline.ResultsWe included 59 subjects: 17 CIDP, 21 DSP and 21 CIDP+DSP. Of these, 16 (94.1%) CIDP, 18 (85.7%) CIDP+DSP and 1 (4.7%) DSP fulfilled the 2010 EFNS/PNS criteria for definite CIDP. There was no difference in CMAP duration or TD in all nerves (compound outcome) or in individual motor nerves. Patients with CIDP/CIDP+DSP had more conduction blocks, slower conduction velocities and more prolonged F wave latencies than those with DSP.ConclusionMeasures of CMAP duration and TD were not helpful in distinguishing CIDP, DSP or CIDP+DSP patients; however, parameters such as F-wave latencies, conduction blocks or the number of demyelinating parameters were useful in this separation.SignificanceThere are no definite nerve conduction criteria to distinguish patients with CIDP+DSP from DSP alone. Further studies focusing on measures of demyelination may provide stronger evidence to guide treatment decisions in CIDP + DSP patients.
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Affiliation(s)
- Monica Alcantara
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - Mylan Ngo
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - James de la Cruz
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - Deepak Menon
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Carolina Barnett-Tapia
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - Hans Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network (UHN), Toronto, ON, Canada
- *Correspondence: Vera Bril
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Merkies ISJ, van Schaik IN, Bril V, Hartung HP, Lewis RA, Sobue G, Lawo JP, Mielke O, Cornblath DR. Analysis of Relapse by Inflammatory Rasch-built Overall Disability Scale Status in the PATH Study of Subcutaneous Immunoglobulin in Chronic Inflammatory Demyelinating Polyneuropathy. J Peripher Nerv Syst 2022; 27:159-165. [PMID: 35266243 PMCID: PMC9310622 DOI: 10.1111/jns.12487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/24/2022] [Accepted: 03/05/2022] [Indexed: 11/30/2022]
Abstract
Clinical trials in chronic inflammatory demyelinating polyneuropathy (CIDP) often assess efficacy using the ordinal Inflammatory Neuropathy Cause and Treatment (INCAT) disability score. Here, data from the PATH study was reanalyzed using change in Inflammatory Rasch‐built Overall Disability Scale (I‐RODS) to define CIDP relapse instead of INCAT. The PATH study comprised an intravenous immunoglobulin (IVIG) dependency period and an IVIG (IgPro10 [Privigen]) restabilization period; subjects were then randomized to weekly maintenance subcutaneous immunoglobulin (SCIG; IgPro20 [Hizentra]) 0.2 g/kg or 0.4 g/kg or placebo for 24 weeks. CIDP relapse was defined as ≥1‐point deterioration in adjusted INCAT, with a primary endpoint of relapse or withdrawal rates. This retrospective exploratory analysis redefined relapse using I‐RODS via three different cut‐off methods: an individual variability method, fixed cut‐off of ≥8‐point deterioration on I‐RODS centile score or ≥4‐point deterioration on I‐RODS raw score. Relapse or withdrawal rates were 47% for placebo, 34% for 0.2 g/kg IgPro20 and 19% for 0.4 g/kg IgPro20 using the raw score; 40%, 28% and 15%, respectively using the centile score, and 49%, 40% and 27%, respectively using the individual variability method. IgPro20 was shown to be efficacious as a maintenance therapy for CIDP when relapse was defined using I‐RODS. A stable response pattern was shown for I‐RODS across various applied cut‐offs, which could be applied in future clinical trials.
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Affiliation(s)
- Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Neurology, Curaçao Medical Center, Willemstad, Curaçao
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Spaarne Gasthuis, Haarlem, Netherlands
| | - Vera Bril
- Department of Medicine (Neurology), University Health Network, University of Toronto, Toronto, Canada.,Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hans-Peter Hartung
- Department of Neurology, UKD and Center for Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,Brain and Mind Centre, University of Sydney, Sydney, Australia.,Medical University of Vienna, Vienna, Austria
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gen Sobue
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lewis EJH, Lovblom LE, Lanctot S, Scarr D, Cardinez N, Boulet G, Weisman A, Lovshin JA, Lytvyn Y, Keenan HA, Brent MH, Paul N, Cherney DZI, Bril V, Perkins BA. The association between physical activity time and neuropathy in longstanding type 1 diabetes: A cross-sectional analysis of the Canadian study of longevity in type 1 diabetes. J Diabetes Complications 2022; 36:108134. [PMID: 35123866 DOI: 10.1016/j.jdiacomp.2022.108134] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/18/2021] [Accepted: 09/25/2021] [Indexed: 11/24/2022]
Abstract
AIM Physical activity (PA) is recommended to improve glycemic control in T1D; however, the effect of PA on distal symmetric polyneuropathy (DSPN) and cardiac autonomic function in longstanding T1D is unknown. METHODS Data from 75 participants were collected as part of the Canadian Study of Longevity in T1D. Participants completed a physical exam, medical history, extensive complications phenotyping and reported their daily PA from the preceding 12-months. Pearson and Spearman correlations were used to assess PA time and complications variables. Linear regression was used to test associations between PA time, neurological and electrophysiological measures. Univariable regression was used to indicate the change in the given independent variables associated with a 30-min increase in PA per week. RESULTS Participants were 66 ± 8 years old with diabetes duration of 54 [52,58] years, HbA1c was 7.3 ± 0.8, 65(89%) had DSPN. Weekly PA time was 156 ± 132 min, and 35(47%) reported ≧150 min/week. Participants with DSPN reported lower PA time compared to individuals without DSPN (141 ± 124 min/week vs. 258 ± 129 min/week; p = 0.015). PA time was associated with better cooling detection threshold (r = 0.24; p = 0.043), peroneal and sural amplitude (r = 0.36; p = 0.0017, rs = 0.26; p = 0.024) and conduction velocity (rs = 0.28; p = 0.015, r = 0.23; p = 0.050). Linear regression adjusting for age and HbA1c, showed that for each 30-min of PA there was a 0.09mv higher peroneal amplitude (p = 0.032) and 0.048 ms lower peroneal F-wave latency (p = 0.022). CONCLUSION In longstanding T1D, PA time is associated with superior large nerve fibre function in the lower limbs and some better measures of small nerve fibre function.
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Affiliation(s)
- Evan J H Lewis
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sebastien Lanctot
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nancy Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
| | - Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
| | - Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto. Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto. Toronto, Ontario, Canada
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Hamoy-Jimenez G, Elahmar HA, Mendoza M, Kim RH, Bril V, Barnett C. A cross-sectional study of gender differences in quality of life domains in patients with neurofibromatosis type 1. Orphanet J Rare Dis 2022; 17:40. [PMID: 35135568 PMCID: PMC8822866 DOI: 10.1186/s13023-022-02195-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited data regarding gender differences in quality of life between women and men with Neurofibromatosis type 1. We aimed to study differences in quality of life domains between women and men with Neurofibromatosis type 1 living in Canada. METHODS This is a cross sectional study of adults with Neurofibromatosis type 1 attending a tertiary NF centre at Toronto General Hospital between January 2016 to December 2017. Demographic and clinical data were collected. We compared scores of generic measures (SF-36, EQ-5D-5L, pain interference) and a disease-specific measure (PedsQL-NF1 module) between women and men. We also assessed the relationship between disease visibility scored by an examiner (Ablon's visibility index) and self-reported perceived physical appearance, stratified by gender. RESULTS One hundred and sixty-two participants were enrolled, 92 females and 70 males. Ablon's index score 1 was in 43% and score 2 in 44%, while only 13% of patients had a score 3. Women had worse scores on the total PedsQL-NF1 scales, and also in the perceived physical appearance, anxiety and emotional health domains. In women, there was a low but significant correlation between Ablon's index and perceived physical appearance (r = - 0.27, p = 0.01, ANOVA p < 0.001). In men, there was no difference in self-reported physical appearance by Ablon's index. There were no differences between men and women in the SF-36 or EQ-5D-5L scores. CONCLUSION Women with NF1 reported worse NF1-related quality of life than men, with worse perceived physical appearance, anxiety, and mental health. Perceived physical appearance does not always correlate to disease visibility; therefore, healthcare providers should inquire about body image, physical appearance concerns, and mental health, especially among women with NF1.
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Affiliation(s)
- G Hamoy-Jimenez
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, 200 Elizabeth ST, 5EC Room 334, Toronto, ON, M5G 2C4, Canada
| | | | - M Mendoza
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, 200 Elizabeth ST, 5EC Room 334, Toronto, ON, M5G 2C4, Canada
| | - R H Kim
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, 200 Elizabeth ST, 5EC Room 334, Toronto, ON, M5G 2C4, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - V Bril
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, 200 Elizabeth ST, 5EC Room 334, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - C Barnett
- Elisabeth Raab Neurofibromatosis Clinic, University Health Network, 200 Elizabeth ST, 5EC Room 334, Toronto, ON, M5G 2C4, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Verschuuren JJGM, Palace J, Murai H, Tannemaat MR, Kaminski HJ, Bril V. Advances and ongoing research in the treatment of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:189-202. [DOI: 10.1016/s1474-4422(21)00463-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/16/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
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Banner H, Niles KM, Ryu M, Sermer M, Bril V, Murphy KE. Myasthenia Gravis in pregnancy: Systematic review and case series. Obstet Med 2022; 15:108-117. [PMID: 35845224 PMCID: PMC9277733 DOI: 10.1177/1753495x211041899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Myasthenia gravis is an autoimmune disease which can impact pregnancy. Methods Six databases were systematically searched for studies with at least five
subjects reporting pregnancy outcomes for women with myasthenia gravis in
pregnancy. Assessment of bias was performed for all included studies.
Forty-eight cases from our own centre were also included in the
analysis. Results In total, 32 publications met inclusion criteria for systematic review, for a
total of 33 unique data sets including 48 cases from our institution.
Outcome data was available for 824 pregnancies. Spontaneous vaginal delivery
occurred in 56.3% of pregnancies. Overall risk of myasthenia gravis
exacerbation was 33.8% with a 6.4% risk of myasthenic crisis in pregnancy
and 8.2% postpartum. The incidence risk of transient neonatal myasthenia
gravis was 13.0%. Conclusions The current systematic review provides the best estimates of risk currently
available to aid in counselling women with myasthenia gravis in
pregnancy.
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Affiliation(s)
- Harrison Banner
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
| | - Kirsten M Niles
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
| | - Michelle Ryu
- Sidney Liswood Library, Mount Sinai Hospital, University of Toronto, Canada
| | - Mathew Sermer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
| | - Vera Bril
- Division of Neurology, University Health Network, University of Toronto, Canada
| | - Kellie E Murphy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada
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Price R, Smith D, Franklin G, Gronseth G, Pignone M, David WS, Armon C, Perkins BA, Bril V, Rae-Grant A, Halperin J, Licking N, O'Brien MD, Wessels SR, MacGregor LC, Fink K, Harkless LB, Colbert L, Callaghan BC. Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee. Neurology 2022; 98:31-43. [PMID: 34965987 DOI: 10.1212/wnl.0000000000013038] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/15/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To update the 2011 American Academy of Neurology (AAN) guideline on the treatment of painful diabetic neuropathy (PDN) with a focus on topical and oral medications and medical class effects. METHODS The authors systematically searched the literature from January 2008 to April 2020 using a structured review process to classify the evidence and develop practice recommendations using the AAN 2017 Clinical Practice Guideline Process Manual. RESULTS Gabapentinoids (standardized mean difference [SMD] 0.44; 95% confidence interval [CI], 0.21-0.67), serotonin-norepinephrine reuptake inhibitors (SNRIs) (SMD 0.47; 95% CI, 0.34-0.60), sodium channel blockers (SMD 0.56; 95% CI, 0.25-0.87), and SNRI/opioid dual mechanism agents (SMD 0.62; 95% CI, 0.38-0.86) all have comparable effect sizes just above or just below our cutoff for a medium effect size (SMD 0.5). Tricyclic antidepressants (TCAs) (SMD 0.95; 95% CI, 0.15-1.8) have a large effect size, but this result is tempered by a low confidence in the estimate. RECOMMENDATIONS SUMMARY Clinicians should assess patients with diabetes for PDN (Level B) and those with PDN for concurrent mood and sleep disorders (Level B). In patients with PDN, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain (Level B) and consider factors other than efficacy (Level B). Clinicians should offer patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class (Level B) and not use opioids for the treatment of PDN (Level B).
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Affiliation(s)
- Raymond Price
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Don Smith
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Gary Franklin
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Gary Gronseth
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Michael Pignone
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - William S David
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Carmel Armon
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Bruce A Perkins
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Vera Bril
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Alexander Rae-Grant
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - John Halperin
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Nicole Licking
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Mary Dolan O'Brien
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Scott R Wessels
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor.
| | - Leslie C MacGregor
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Kenneth Fink
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Lawrence B Harkless
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Lindsay Colbert
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
| | - Brian C Callaghan
- From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor
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Callaghan BC, Armon C, Bril V, Colbert L, David WS, Del Toro DR, Fink K, Jones LK, Kleemeier R, MacGregor LC, Bennett A, Shenoy A. Polyneuropathy Quality Measurement Set: Quality Improvement in Neurology. Neurology 2022; 98:22-30. [PMID: 34965986 DOI: 10.1212/wnl.0000000000013037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/07/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Brian C Callaghan
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Carmel Armon
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Vera Bril
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Lindsay Colbert
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - William S David
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - David R Del Toro
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Kenneth Fink
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Lyell K Jones
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Robert Kleemeier
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Leslie C MacGregor
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
| | - Amy Bennett
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA.
| | - Anant Shenoy
- From the Department of Neurology (B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine, Israel; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; The Foundation for Peripheral Neuropathy (L.C.); Buffalo Grove, IL; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Physical Medicine and Rehabilitation (D.R.D.T.), Medical College of Wisconsin, Milwaukee; Kamehameha Schools (K.F.), Honolulu, HI; Department of Neurology (L.K.J.), Mayo Clinic, Rochester, MN; Minnesota Neuropathy Association (R.K.), Eau Claire, WI; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; American Academy of Neurology (A.B.), Minneapolis, MN; and Division of Neurology (A.S.), Mount Auburn Hospital, Springfield, MA
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Martín-Aguilar L, Lleixà C, Pascual-Goñi E, Caballero-Ávila M, Martínez-Martínez L, Díaz-Manera J, Rojas-García R, Cortés-Vicente E, Turon-Sans J, de Luna N, Suárez-Calvet X, Gallardo E, Rajabally Y, Scotton S, Jacobs BC, Baars A, Cortese A, Vegezzi E, Höftberger R, Zimprich F, Roesler C, Nobile-Orazio E, Liberatore G, Hiew FL, Martínez-Piñeiro A, Carvajal A, Piñar-Morales R, Usón-Martín M, Albertí O, López-Pérez MÁ, Márquez F, Pardo-Fernández J, Muñoz-Delgado L, Cabrera-Serrano M, Ortiz N, Bartolomé M, Duman Ö, Bril V, Segura-Chávez D, Pitarokoili K, Steen C, Illa I, Querol L. Clinical and Laboratory Features in Anti-NF155 Autoimmune Nodopathy. Neurol Neuroimmunol Neuroinflamm 2022; 9:e1098. [PMID: 34728497 PMCID: PMC8564865 DOI: 10.1212/nxi.0000000000001098] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES To study the clinical and laboratory features of antineurofascin-155 (NF155)-positive autoimmune nodopathy (AN). METHODS Patients with anti-NF155 antibodies detected on routine immunologic testing were included. Clinical characteristics, treatment response, and functional scales (modified Rankin Scale [mRS] and Inflammatory Rasch-built Overall Disability Scale [I-RODS]) were retrospectively collected at baseline and at the follow-up. Autoantibody and neurofilament light (NfL) chain levels were analyzed at baseline and at the follow-up. RESULTS Forty NF155+ patients with AN were included. Mean age at onset was 42.4 years. Patients presented with a progressive (75%), sensory motor (87.5%), and symmetric distal-predominant weakness in upper (97.2%) and lower extremities (94.5%), with tremor and ataxia (75%). Patients received a median of 3 (2-4) different treatments in 46 months of median follow-up. Response to IV immunoglobulin (86.8%) or steroids (72.2%) was poor in most patients, whereas 77.3% responded to rituximab. HLA-DRB1*15 was detected in 91.3% of patients. IgG4 anti-NF155 antibodies were predominant in all patients; anti-NF155 titers correlated with mRS within the same patient (r = 0.41, p = 0.004). Serum NfL (sNfL) levels were higher in anti-NF155+ AN than in healthy controls (36.47 vs 7.56 pg/mL, p < 0.001) and correlated with anti-NF155 titers (r = 0.43, p = 0.001), with I-RODS at baseline (r = -0.88, p < 0.001) and with maximum I-RODS achieved (r = -0.58, p = 0.01). Anti-NF155 titers and sNfL levels decreased in all rituximab-treated patients. DISCUSSION Anti-NF155 AN presents a distinct clinical profile and good response to rituximab. Autoantibody titers and sNfL are useful to monitor disease status in these patients. The use of untagged-NF155 plasmids minimizes the detection of false anti-NF155+ cases. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that anti-NF155 antibodies associate with a specific phenotype and response to rituximab.
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Affiliation(s)
| | | | - Elba Pascual-Goñi
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Marta Caballero-Ávila
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Laura Martínez-Martínez
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Jordi Díaz-Manera
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Ricard Rojas-García
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Elena Cortés-Vicente
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Janina Turon-Sans
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Noemi de Luna
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Xavier Suárez-Calvet
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Eduard Gallardo
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Yusuf Rajabally
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Sangeeta Scotton
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Bart C. Jacobs
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Adája Baars
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Andrea Cortese
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Elisa Vegezzi
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Romana Höftberger
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Fritz Zimprich
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Cornelia Roesler
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Eduardo Nobile-Orazio
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Giuseppe Liberatore
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Fu Liong Hiew
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Alicia Martínez-Piñeiro
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Alejandra Carvajal
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Raquel Piñar-Morales
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Mercedes Usón-Martín
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Olalla Albertí
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Maria Ángeles López-Pérez
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Fabian Márquez
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Julio Pardo-Fernández
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Laura Muñoz-Delgado
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Macarena Cabrera-Serrano
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Nicolau Ortiz
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Manuel Bartolomé
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Özgür Duman
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Vera Bril
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Darwin Segura-Chávez
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Kalliopi Pitarokoili
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Claudia Steen
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Isabel Illa
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
| | - Luis Querol
- From the Neuromuscular Diseases Unit (L.M.-A., C.L., E.P.-G., M.C.-Á., R.R.-G., E.C.-V., J.T.-S., E.N.-O., I.I., L.Q.), Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona; Biomedical Research Institute Sant Pau (IIB Sant Pau) (L.M.-A., C.L., E.P.-G., M.C.-Á., J.D.-M., E.C.-V., X.S.-C., E.G.); Immunology Department (L.M.-M.), Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (J.D.-M., R.R.-G., E.C.-V., N.L., X.S.-C., E.G., I.I., L.Q.); University Hospital Birmingham (Y.R., S.S.), UK; Erasmus Medical Center (B.C.J., A.B.), Rotterdam, the Netherlands; IRCCS Mondino Foundation (Andrea Cortese, E.V.), Pavia, Italy; Department of Neurology (R.H., F.Z.), Medical University of Vienna; Paracelsus Medical University (C.R.), Salzburg, Austria; IRCCS Humanitas Research Hospital (G.L.), Milan University, Rozzano, Italy; Kuala Lumpur General Hospital (F.L.H.), Jalan Pahang, Kuala Lumpur, Malaysia; Hospital Universitari Germans Trias I Pujol (A.M.-P.), Badalona; Hospital Universitario Virgen de Las Nieves (Alejandra Carvajal), Granada, Spain; Hospital Universitario Clínico San Cecilio (R.P.-M.), Granada; Hospital Son Llàtzer (M.U.-M.), Palma de Mallorca; Hospital San Jorge (O.A.), Huesca, España; Hospital San Pedro (M.Á.L.-P.), Logroño; Hospital Universitari Josep Trueta (F.M.), Girona; Hospital Clínico Universitario de Santiago (J.P.-F.), Santiago de Compostela; Hospital Universitario Virgen Del Rocío (L.M.-D., M.C.-S.), Sevilla; Hospital Universitari Sant Joan (N.O.), Reus; Complejo Asistencial de Ávila (M.B.), Ávila, Spain; Akdeniz University (Ö.D.), Antalya, Turkey; Toronto General Hospital (V.B.), University Health Network, University of Toronto, Canada; Instituto Nacional de Ciencias Neurológicas. Lima (D.S.-C.), Perú; St. Josef-Hospital (K.P.), Ruhr-University Bochum; and Sant Joseph Hospital (C.S.), Berlin, Germany
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Menon D, Lewis EJH, Perkins BA, Bril V. Omega-3 Nutrition Therapy for the Treatment of Diabetic Sensorimotor Polyneuropathy. Curr Diabetes Rev 2022; 18:e010921196028. [PMID: 34488588 DOI: 10.2174/1573399817666210901121111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 04/06/2021] [Accepted: 05/06/2021] [Indexed: 11/22/2022]
Abstract
Despite advances in clinical and translational research, an effective therapeutic option for diabetic sensorimotor polyneuropathy (DSP) has remained elusive. The pathomechanisms of DSP are diverse, and along with hyperglycemia, the roles of inflammatory mediators and lipotoxicity in the development of microangiopathy have been well elucidated. Omega-3 (n-3) polyunsaturated fatty acids (PUFA) are essential fatty acids with a vital role in a number of physiological processes, including neural health, membrane structure integrity, anti-inflammatory processes, and lipid metabolism. Identification of n-3 PUFA derived specialised proresolving mediators (SPM), namely resolvins, neuroprotectin, and maresins which also favour nerve regeneration, have positioned n-3 PUFA as potential treatment options in DSP. Studies in n-3 PUFA treated animal models of DSP showed positive nerve benefits in functional, electrophysiological, and pathological indices. Clinical trials in humans are limited, but recent proof-of-concept evidence suggests n-3 PUFA has a positive effect on small nerve fibre regeneration with an increase in the small nerve fiber measure of corneal nerve fibre length (CNFL). Further randomized control trials with a longer duration of treatment, higher n-3 PUFA doses, and more rigorous neuropathy measures are needed to provide a definitive understanding of the benefits of n-3 PUFA supplementation in DSP.
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Affiliation(s)
- Deepak Menon
- Ellen and Martin Prosserman Centre for Neuromuscular Disorders. Division of Neurology, University Health Network, University of Toronto, Toronto, Canada
| | - Evan J H Lewis
- Lunenfeld-Tanenbaum Research Institute, Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Disorders. Division of Neurology, University Health Network, University of Toronto, Toronto, Canada
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Menon D, Mansfield P, Cordice D, Studer C, O’Leary M, Sheean G, Bril V. A pilot study of a novel transmembranous electromyography device for assessment of oral cavity and oropharyngeal muscles. Muscle Nerve 2021; 65:303-310. [DOI: 10.1002/mus.27479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 12/19/2021] [Accepted: 12/23/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Deepak Menon
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto Toronto Canada
| | - Perry Mansfield
- Senta Clinic, Division of Otolaryngology – Head and Neck Surgery San Diego California USA
| | - Derrick Cordice
- Senta Clinic, Division of Otolaryngology – Head and Neck Surgery San Diego California USA
| | | | - Michael O’Leary
- Senta Clinic, Division of Otolaryngology – Head and Neck Surgery San Diego California USA
| | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto Toronto Canada
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