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Montellano FA, Rücker V, Ungethüm K, Penalba A, Hotter B, Giralt M, Wiedmann S, Mackenrodt D, Morbach C, Frantz S, Störk S, Whiteley WN, Kleinschnitz C, Meisel A, Montaner J, Haeusler KG, Heuschmann PU. Biomarkers to improve functional outcome prediction after ischemic stroke: Results from the SICFAIL, STRAWINSKI, and PREDICT studies. Eur Stroke J 2024:23969873241250272. [PMID: 38711254 DOI: 10.1177/23969873241250272] [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: 05/08/2024] Open
Abstract
BACKGROUND AND AIMS Acute ischemic stroke (AIS) outcome prognostication remains challenging despite available prognostic models. We investigated whether a biomarker panel improves the predictive performance of established prognostic scores. METHODS We investigated the improvement in discrimination, calibration, and overall performance by adding five biomarkers (procalcitonin, copeptin, cortisol, mid-regional pro-atrial natriuretic peptide (MR-proANP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP)) to the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) and age/NIHSS scores using data from two prospective cohort studies (SICFAIL, PREDICT) and one clinical trial (STRAWINSKI). Poor outcome was defined as mRS > 2 at 12 (SICFAIL, derivation dataset) or 3 months (PREDICT/STRAWINSKI, pooled external validation dataset). RESULTS Among 412 SICFAIL participants (median age 70 years, quartiles 59-78; 63% male; median NIHSS score 3, quartiles 1-5), 29% had a poor outcome. Area under the curve of the ASTRAL and age/NIHSS were 0.76 (95% CI 0.71-0.81) and 0.77 (95% CI 0.73-0.82), respectively. Copeptin (0.79, 95% CI 0.74-0.84), NT-proBNP (0.80, 95% CI 0.76-0.84), and MR-proANP (0.79, 95% CI 0.75-0.84) significantly improved ASTRAL score's discrimination, calibration, and overall performance. Copeptin improved age/NIHSS model's discrimination, copeptin, MR-proANP, and NT-proBNP improved its calibration and overall performance. In the validation dataset (450 patients, median age 73 years, quartiles 66-81; 54% men; median NIHSS score 8, quartiles 3-14), copeptin was independently associated with various definitions of poor outcome and also mortality. Copeptin did not increase model's discrimination but it did improve calibration and overall model performance. DISCUSSION Copeptin, NT-proBNP, and MR-proANP improved modest but consistently the predictive performance of established prognostic scores in patients with mild AIS. Copeptin was most consistently associated with poor outcome in patients with moderate to severe AIS, although its added prognostic value was less obvious.
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Affiliation(s)
- Felipe A Montellano
- Institute of Clinical Epidemiology and Biometry, Julius-Maximilians-Universität (JMU) Würzburg, Würzburg, Germany
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
- Interdisciplinary Center for Clinical Research, University Hospital Würzburg, Würzburg, Germany
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, Julius-Maximilians-Universität (JMU) Würzburg, Würzburg, Germany
| | - Kathrin Ungethüm
- Institute of Clinical Epidemiology and Biometry, Julius-Maximilians-Universität (JMU) Würzburg, Würzburg, Germany
- Institute of Medical Data Science, University Hospital Würzburg, Würzburg, Germany
| | - Anna Penalba
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Benjamin Hotter
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marina Giralt
- Department of Biochemistry, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Silke Wiedmann
- Institute of Clinical Epidemiology and Biometry, Julius-Maximilians-Universität (JMU) Würzburg, Würzburg, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Daniel Mackenrodt
- Institute of Clinical Epidemiology and Biometry, Julius-Maximilians-Universität (JMU) Würzburg, Würzburg, Germany
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Caroline Morbach
- Department Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Frantz
- Department Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Department Clinical Research & Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuroscience and Behavioural Science (C-TNBS), University Hospital Essen, Essen, Germany
| | - Andreas Meisel
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
- Stroke Research Program, Instituto de Biomedicina de Sevilla/Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/University of Seville, Seville, Spain
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, Julius-Maximilians-Universität (JMU) Würzburg, Würzburg, Germany
- Institute of Medical Data Science, University Hospital Würzburg, Würzburg, Germany
- Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
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Chuquisana O, Stascheit F, Keller CW, Pučić-Baković M, Patenaude AM, Lauc G, Tzartos S, Wiendl H, Willcox N, Meisel A, Lünemann JD. Functional Signature of LRP4 Antibodies in Myasthenia Gravis. Neurol Neuroimmunol Neuroinflamm 2024; 11:e200220. [PMID: 38507656 PMCID: PMC10959168 DOI: 10.1212/nxi.0000000000200220] [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] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/26/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND AND OBJECTIVES Antibodies (Abs) specific for the low-density lipoprotein receptor-related protein 4 (LRP4) occur in up to 5% of patients with myasthenia gravis (MG). The objective of this study was to profile LRP4-Ab effector actions. METHODS We evaluated the efficacy of LRP4-specific compared with AChR-specific IgG to induce Ab-dependent cellular phagocytosis (ADCP), Ab-dependent cellular cytotoxicity (ADCC), and Ab-dependent complement deposition (ADCD). Functional features were additionally assessed in an independent AChR-Ab+ MG cohort. Levels of circulating activated complement proteins and frequency of Fc glycovariants were quantified and compared with demographically matched 19 healthy controls. RESULTS Effector actions that required binding of Fc domains to cellular FcRs such as ADCC and ADCP were detectable for both LRP4-specific and AChR-specific Abs. In contrast to AChR-Abs, LRP4-binding Abs showed poor efficacy in inducing complement deposition. Levels of circulating activated complement proteins were not substantially increased in LRP4-Ab-positive MG. Frequency of IgG glycovariants carrying 2 sialic acid residues, indicative for anti-inflammatory IgG activity, was decreased in patients with LRP4-Ab-positive MG. DISCUSSION LRP4-Abs are more effective in inducing cellular FcR-mediated effector mechanisms than Ab-dependent complement activation. Their functional signature is different from AChR-specific Abs.
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Affiliation(s)
- Omar Chuquisana
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Frauke Stascheit
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Christian W Keller
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Maja Pučić-Baković
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Anne-Marie Patenaude
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Gordan Lauc
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Socrates Tzartos
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Heinz Wiendl
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Nick Willcox
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Andreas Meisel
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
| | - Jan D Lünemann
- From the Department of Neurology with Institute of Translational Neurology (O.C., C.W.K., H.W., J.D.L.), University Hospital Münster; Department of Neurology with Experimental Neurology (F.S., A.M.); Neuroscience Clinical Research Center (F.S., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany; Genos Glycoscience Research Laboratory (M.P.-B., A.-M.P., G.L.), Zagreb; Faculty of Pharmacy and Biochemistry (G.L.), University of Zagreb, Croatia; Tzartos NeuroDiagnostics (S.T.); Department of Neurobiology (S.T.), Hellenic Pasteur Institute, Athens, Greece; Nuffield Department of Clinical Neurosciences (N.W.), Weatherall Institute of Molecular Medicine, University of Oxford, United Kingdom; and Center for Stroke Research Berlin (A.G.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Germany
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Lehnerer S, Herdick M, Stegherr R, Gerischer L, Stascheit F, Stein M, Mergenthaler P, Hoffmann S, Meisel A. Burden of disease in Lambert-Eaton myasthenic syndrome: taking the patient's perspective. J Neurol 2024; 271:2824-2839. [PMID: 38421419 PMCID: PMC11055781 DOI: 10.1007/s00415-024-12206-6] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune-mediated neuromuscular disorder leading to muscle weakness, autonomic dysregulation and hyporeflexia. Psychosocial well-being is affected. Previously, we assessed burden of disease for Myasthenia gravis (MG). Here, we aim to elucidate burden of disease by comparing health-related quality of life (HRQoL) of patients with LEMS to the general population (genP) as well as MG patients. METHODS A questionnaire-based survey included sociodemographic and clinical data along with standardized questionnaires, e.g. the Short Form Health (SF-36). HRQoL was evaluated through matched-pairs analyses. Participants from a general health survey served as control group. RESULTS 46 LEMS patients matched by age and gender were compared to 92 controls from the genP and a matched cohort of 92 MG patients. LEMS participants showed lower levels of physical functioning (SF-36 mean 34.2 SD 28.6) compared to genP (mean 78.6 SD 21.1) and MG patients (mean 61.3 SD 31.8). LEMS patients showed lower mental health sub-scores compared to genP (SF-36 mean 62.7 SD 20.2, vs. 75.7 SD 15.1) and MG patients (SF-36 mean 62.7 SD 20.2, vs. 66.0 SD 18.). Depression, anxiety and fatigue were prevalent. Female gender, low income, lower activities of daily living, symptoms of depression, anxiety and fatigue were associated with a lower HRQoL in LEMS. DISCUSSION HRQoL is lower in patients with LEMS compared to genP and MG in a matched pair-analysis. The burden of LEMS includes economic and social aspects as well as emotional well-being. TRIAL REGISTRATION INFORMATION: drks.de: DRKS00024527, submitted: February 02, 2021, https://drks.de/search/en/trial/DRKS00024527 .
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Affiliation(s)
- Sophie Lehnerer
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany.
| | - Meret Herdick
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Regina Stegherr
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Lea Gerischer
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Maike Stein
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Philipp Mergenthaler
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Hoffmann
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology With Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Neuroscience Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Heider D, Stetefeld H, Meisel A, Bösel J, Artho M, Linker R, Angstwurm K, Neumann B. POLAR: prediction of prolonged mechanical ventilation in patients with myasthenic crisis. J Neurol 2024; 271:2875-2879. [PMID: 38329540 PMCID: PMC11055720 DOI: 10.1007/s00415-024-12208-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Dominik Heider
- Department of Machine Learning for Medical Data, Institute for Computer Science, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Henning Stetefeld
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Meisel
- Department of Neurology With Experimental Neurology, Neuroscience Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Marie Artho
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Ralf Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany.
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Perlasberger Straße 41, 94469, Deggendorf, Germany.
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Howard JF, Vu T, Mantegazza R, Kushlaf H, Suzuki S, Wiendl H, Beasley KN, Liao S, Meisel A. Efficacy of ravulizumab in patients with generalized myasthenia gravis by time from diagnosis: A post hoc subgroup analysis of the CHAMPION MG study. Muscle Nerve 2024; 69:556-565. [PMID: 38380691 DOI: 10.1002/mus.28044] [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: 04/14/2023] [Revised: 01/05/2024] [Accepted: 01/14/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION/AIMS The CHAMPION MG study demonstrated that ravulizumab significantly improved Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) total scores versus placebo in adults with acetylcholine receptor antibody-positive generalized myasthenia gravis (AChR+ gMG). This post hoc analysis aimed to assess these outcomes by time from MG diagnosis. METHODS Changes from baseline to week 26 in MG-ADL and QMG total scores were analyzed by time from MG diagnosis to study entry (≤2 vs. >2 years). Within each subgroup, least-squares (LS) mean changes for ravulizumab and placebo were compared using mixed models for repeated measures. RESULTS In ravulizumab-treated patients, differences in LS mean (standard error of the mean) changes from baseline to week 26 were not statistically significant in the ≤2-years subgroup versus the >2-years subgroup for MG-ADL (-4.3 [0.70] vs. -2.9 [0.37]; p = .0511) or QMG (-4.3 [0.94] vs. -2.5 [0.50]; p = .0822) scores. No clear trends were observed in the placebo group. LS mean changes from baseline were significantly greater for ravulizumab versus placebo in both the ≤2 and >2 years from diagnosis subgroups for MG-ADL and QMG scores (all p < .05). The difference in treatment effect between the ≤2-years and >2-years subgroups was not statistically significant. No clinically meaningful between-subgroup differences in treatment-emergent adverse events were observed in ravulizumab-treated patients. DISCUSSION Ravulizumab treatment improved clinical outcomes for patients with AChR+ gMG regardless of time from diagnosis. A numerical trend was observed favoring greater treatment effect with earlier versus later treatment after diagnosis. Further studies are required for confirmation.
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Affiliation(s)
- James F Howard
- The University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | | | | | | | | | | | - Serena Liao
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
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Ünlü S, Sánchez Navarro BG, Cakan E, Berchtold D, Meleka Hanna R, Vural S, Vural A, Meisel A, Fichtner ML. Exploring the depths of IgG4: insights into autoimmunity and novel treatments. Front Immunol 2024; 15:1346671. [PMID: 38698867 PMCID: PMC11063302 DOI: 10.3389/fimmu.2024.1346671] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/29/2024] [Indexed: 05/05/2024] Open
Abstract
IgG4 subclass antibodies represent the rarest subclass of IgG antibodies, comprising only 3-5% of antibodies circulating in the bloodstream. These antibodies possess unique structural features, notably their ability to undergo a process known as fragment-antigen binding (Fab)-arm exchange, wherein they exchange half-molecules with other IgG4 antibodies. Functionally, IgG4 antibodies primarily block and exert immunomodulatory effects, particularly in the context of IgE isotype-mediated hypersensitivity reactions. In the context of disease, IgG4 antibodies are prominently observed in various autoimmune diseases combined under the term IgG4 autoimmune diseases (IgG4-AID). These diseases include myasthenia gravis (MG) with autoantibodies against muscle-specific tyrosine kinase (MuSK), nodo-paranodopathies with autoantibodies against paranodal and nodal proteins, pemphigus vulgaris and foliaceus with antibodies against desmoglein and encephalitis with antibodies against LGI1/CASPR2. Additionally, IgG4 antibodies are a prominent feature in the rare entity of IgG4 related disease (IgG4-RD). Intriguingly, both IgG4-AID and IgG4-RD demonstrate a remarkable responsiveness to anti-CD20-mediated B cell depletion therapy (BCDT), suggesting shared underlying immunopathologies. This review aims to provide a comprehensive exploration of B cells, antibody subclasses, and their general properties before examining the distinctive characteristics of IgG4 subclass antibodies in the context of health, IgG4-AID and IgG4-RD. Furthermore, we will examine potential therapeutic strategies for these conditions, with a special focus on leveraging insights gained from anti-CD20-mediated BCDT. Through this analysis, we aim to enhance our understanding of the pathogenesis of IgG4-mediated diseases and identify promising possibilities for targeted therapeutic intervention.
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Affiliation(s)
- Selen Ünlü
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Koç University School of Medicine, Istanbul, Türkiye
| | - Blanca G. Sánchez Navarro
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Elif Cakan
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA, United States
| | - Daniel Berchtold
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rafael Meleka Hanna
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Secil Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Dermatology and Venereology, Koç University School of Medicine, İstanbul, Türkiye
| | - Atay Vural
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology, Koç University School of Medicine, İstanbul, Türkiye
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam L. Fichtner
- Koç University Research Center for Translational Medicine (KUTTAM), İstanbul, Türkiye
- Department of Neurology with Experimental Neurology, Integrated Myasthenia Gravis Center, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
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7
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Meisel A, Saccà F, Spillane J, Vissing J. Expert consensus recommendations for improving and standardising the assessment of patients with generalised myasthenia gravis. Eur J Neurol 2024:e16280. [PMID: 38523419 DOI: 10.1111/ene.16280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/26/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Regular and consistent disease assessment could provide a clearer picture of burden in generalised myasthenia gravis (gMG) and improve patient care; however, the use of assessment tools in practice lacks standardisation. This modified Delphi approach was taken to review current evidence on assessment tool use in gMG and develop expert-derived consensus recommendations for good practice. METHODS A European expert panel of 15 experienced gMG neurologists contributed to development of this consensus, four of whom formed a lead Sub-committee. The PICO (Population, Intervention, Control, Outcomes) framework was used to define six clinical questions on gMG assessment tools, a systematic literature review was conducted, and evidence-based statements were developed. According to a modified Delphi voting process, consensus was reached when ≥70% of the experts rated agreement with a statement as ≥8 on a scale of 1-10. RESULTS Eighteen expert- and evidence-based consensus statements based on six themes were developed. Key recommendations include: consistent use of the Myasthenia Gravis Activities of Daily Living score (MG-ADL) across clinical settings, followed by a simple question (e.g., Patient Acceptable Symptom State [PASS]) or scale to determine patient satisfaction in clinical practice; use of a Quantitative Myasthenia Gravis [QMG] or quality of life [QoL] assessment when the MG-ADL indicates disease worsening; and consideration of symptom state to determine the timing and frequency of recommended assessments. Expert panel consensus was reached on all 18 statements after two voting rounds. CONCLUSIONS This process provided evidence- and expert consensus-based recommendations for the use of objective and subjective assessment tools across gMG research and care to improve management and outcomes for patients.
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Affiliation(s)
- Andreas Meisel
- Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Francesco Saccà
- GENESIS Department, Federico II University of Naples, Naples, Italy
| | - Jennifer Spillane
- National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, UK
| | - John Vissing
- Copenhagen Neuromuscular Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Draxler J, Meisel A, Stascheit F, Stein M, Gerischer L, Mergenthaler P, Herdick M, Doksani P, Lehnerer S, Verlohren S, Hoffmann S. Pregnancy in myasthenia gravis: a retrospective analysis of maternal and neonatal outcome from a large tertiary care centre in Germany. Arch Gynecol Obstet 2024:10.1007/s00404-024-07436-y. [PMID: 38492082 DOI: 10.1007/s00404-024-07436-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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/14/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Myasthenia gravis (MG) is a rare, potentially life-threatening autoimmune disease with fluctuating muscle weakness frequently affecting women of childbearing age. MG can affect maternal as well as neonatal outcome with risk of worsening of myasthenic symptoms in the mothers and risk of transient neonatal myasthenia gravis (TNMG) and arthrogryposis multiplex congenita (AMC) or foetal acetylcholine receptor antibody-associated disorders (FARAD) in the neonates. METHODS Retrospective analysis of maternal and neonatal outcome in a cohort of pregnant MG patients treated at a tertiary care centre in Germany. RESULTS Overall, 66 pregnancies were analysed. During 40 (63%) pregnancies, women experienced a worsening of myasthenic symptoms, of whom 10 patients (15.7%) needed acute therapy with IVIg or plasma exchange. There was no case of myasthenic crisis. Rate of caesarean section was comparable to the overall C-section rate at our centre (38% vs. 40%). However, there was a slightly higher rate for operative vaginal delivery (15% vs. 10%) as potential indicator for fatiguing striated musculature in MG patients during the expulsion stage. Rate of TNMG as well as AMC was 3% (two cases each). CONCLUSIONS Maternal and neonatal outcome in our cohort was favourable with a low rate of myasthenic exacerbations requiring acute therapies and a low rate of TNMG and AMC/FARAD. Our data might help neurologists and obstetricians to advice MG patients with desire to have children.
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Affiliation(s)
- Jakob Draxler
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Maike Stein
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Lea Gerischer
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Philipp Mergenthaler
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Meret Herdick
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Paolo Doksani
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sophie Lehnerer
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan Verlohren
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Obstetrics, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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9
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Huo S, Nelde A, Meisel C, Scheibe F, Meisel A, Endres M, Vajkoczy P, Wolf S, Willms JF, Boss JM, Keller E. A supervised, externally validated machine learning model for artifact and drainage detection in high-resolution intracranial pressure monitoring data. J Neurosurg 2024:1-9. [PMID: 38489814 DOI: 10.3171/2023.12.jns231670] [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: 07/19/2023] [Accepted: 12/13/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE In neurocritical care, data from multiple biosensors are continuously measured, but only sporadically acknowledged by the attending physicians. In contrast, machine learning (ML) tools can analyze large amounts of data continuously, taking advantage of underlying information. However, the performance of such ML-based solutions is limited by different factors, for example, by patient motion, manipulation, or, as in the case of external ventricular drains (EVDs), the drainage of CSF to control intracranial pressure (ICP). The authors aimed to develop an ML-based algorithm that automatically classifies normal signals, artifacts, and drainages in high-resolution ICP monitoring data from EVDs, making the data suitable for real-time artifact removal and for future ML applications. METHODS In their 2-center retrospective cohort study, the authors used labeled ICP data from 40 patients in the first neurocritical care unit (University Hospital Zurich) for model development. The authors created 94 descriptive features that were used to train the model. They compared histogram-based gradient boosting with extremely randomized trees after building pipelines with principal component analysis, hyperparameter optimization via grid search, and sequential feature selection. Performance was measured with nested 5-fold cross-validation and multiclass area under the receiver operating characteristic curve (AUROC). Data from 20 patients in a second, independent neurocritical care unit (Charité - Universitätsmedizin Berlin) were used for external validation with bootstrapping technique and AUROC. RESULTS In cross-validation, the best-performing model achieved a mean AUROC of 0.945 (95% CI 0.92-0.969) on the development dataset. On the external validation dataset, the model performed with a mean AUROC of 0.928 (95% CI 0.908-0.946) in 100 bootstrapping validation cycles to classify normal signals, artifacts, and drainages. CONCLUSIONS Here, the authors developed a well-performing supervised model with external validation that can detect normal signals, artifacts, and drainages in ICP signals from patients in neurocritical care units. For future analyses, this is a powerful tool to discard artifacts or to detect drainage events in ICP monitoring signals.
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Affiliation(s)
- Shufan Huo
- 1Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Germany
- 2Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Switzerland
- 3Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Alexander Nelde
- 4Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Christian Meisel
- 3Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
- 4Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
- 5Berlin Institute of Health (BIH), Berlin, Germany
| | - Franziska Scheibe
- 1Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Germany
- 6NeuroCure Cluster of Excellence, Charité - Universitätsmedizin Berlin, Germany
| | - Andreas Meisel
- 1Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Germany
- 3Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
- 6NeuroCure Cluster of Excellence, Charité - Universitätsmedizin Berlin, Germany
| | - Matthias Endres
- 1Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, Germany
- 3Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
- 6NeuroCure Cluster of Excellence, Charité - Universitätsmedizin Berlin, Germany
- 7German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany
- 8German Center for Cardiovascular Research (DZHK), partner site Berlin, Germany
- 9German Center for Mental Health (DZPG), partner site Berlin, Germany; and
| | - Peter Vajkoczy
- 10Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Germany
| | - Stefan Wolf
- 10Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Germany
| | - Jan F Willms
- 2Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Switzerland
| | - Jens M Boss
- 2Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Switzerland
| | - Emanuela Keller
- 2Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Switzerland
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10
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Mehnert A, Bershan S, Kollmus-Heege J, Gerischer L, Herdick ML, Hoffmann S, Lehnerer S, Scheibe F, Stascheit F, Stein M, Buchan AM, Meisel A, Aigner A, Mergenthaler P. Identifying patients at risk for myasthenic crisis with hemogram and inflammation-related laboratory parameters - a pilot study. Front Neurol 2024; 15:1297997. [PMID: 38469587 PMCID: PMC10925644 DOI: 10.3389/fneur.2024.1297997] [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: 09/20/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease characterized by fatigable weakness of the voluntary muscles and can exacerbate to life-threatening myasthenic crisis (MC), requiring intensive care treatment. Routine laboratory parameters are a cost-effective and widely available method for estimating the clinical outcomes of several diseases, but so far, such parameters have not been established to detect disease progression in MG. Methods We conducted a retrospective analysis of selected laboratory parameters related to inflammation and hemogram for MG patients with MC compared to MG patients without MC. To identify potential risk factors for MC, we applied time-varying Cox regression for time to MC and, as a sensitivity analysis, generalized estimating equations logistic regression for the occurrence of MC at the next patient visit. Results 15 of the 58 examined MG patients suffered at least one MC. There was no notable difference in the occurrence of MC by antibody status or sex. Both regression models showed that higher counts of basophils (per 0.01 unit increase: HR = 1.32, 95% CI = 1.02-1.70), neutrophils (per 1 unit increase: HR = 1.40, 95% CI = 1.14-1.72), potentially leukocytes (per 1 unit increase: HR = 1.15, 95% CI = 0.99-1.34), and platelets (per 100 units increase: HR = 1.54, 95% CI = 0.99-2.38) may indicate increased risk for a myasthenic crisis. Conclusion This pilot study provides proof of the concept that increased counts of basophils, neutrophils, leukocytes, and platelets may be associated with a higher risk of developing MC in patients with MG.
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Affiliation(s)
- Anne Mehnert
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Sivan Bershan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Jil Kollmus-Heege
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Meret Luise Herdick
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
- Berlin Institute of Health at Charité, Digital Health Center, Berlin, Germany
| | - Franziska Scheibe
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Maike Stein
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Alastair M. Buchan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Annette Aigner
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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11
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Nelde A, Krumm L, Arafat S, Hotter B, Nolte CH, Scheitz JF, Klammer MG, Krämer M, Scheib F, Endres M, Meisel A, Meisel C. Machine learning using multimodal and autonomic nervous system parameters predicts clinically apparent stroke-associated pneumonia in a development and testing study. J Neurol 2024; 271:899-908. [PMID: 37851190 PMCID: PMC10827826 DOI: 10.1007/s00415-023-12031-3] [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: 04/24/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Stroke-associated pneumonia (SAP) is a preventable determinant for poor outcome after stroke. Machine learning (ML) using large-scale clinical data warehouses may be able to predict SAP and identify patients for targeted interventions. The aim of this study was to develop a prediction model for identifying clinically apparent SAP using automated ML. METHODS The ML model used clinical and laboratory parameters along with heart rate (HR), heart rate variability (HRV), and blood pressure (BP) values obtained during the first 48 h after stroke unit admission. A logistic regression classifier was developed and internally validated with a nested-cross-validation (nCV) approach. For every shuffle, the model was first trained and validated with a fixed threshold for 0.9 sensitivity, then finally tested on the out-of-sample data and benchmarked against a widely validated clinical score (A2DS2). RESULTS We identified 2390 eligible patients admitted to two-stroke units at Charité between October 2020 and June 2023, of whom 1755 had all parameters available. SAP was diagnosed in 96/1755 (5.5%). Circadian profiles in HR, HRV, and BP metrics during the first 48 h after admission exhibited distinct differences between patients with SAP diagnosis vs. those without. CRP, mRS at admission, leukocyte count, high-frequency power in HRV, stroke severity at admission, sex, and diastolic BP were identified as the most informative ML features. We obtained an AUC of 0.91 (CI 0.88-0.95) for the ML model on the out-of-sample data in comparison to an AUC of 0.84 (CI 0.76-0.91) for the previously established A2DS2 score (p < 0.001). The ML model provided a sensitivity of 0.87 (CI 0.75-0.97) with a corresponding specificity of 0.82 (CI 0.78-0.85) which outperformed the A2DS2 score for multiple cutoffs. CONCLUSIONS Automated, data warehouse-based prediction of clinically apparent SAP in the stroke unit setting is feasible, benefits from the inclusion of vital signs, and could be useful for identifying high-risk patients or prophylactic pneumonia management in clinical routine.
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Affiliation(s)
- Alexander Nelde
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Laura Krumm
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Bernstein Center for Computational Neuroscience, Berlin, Germany
- Einstein Center for Neurosciences, Berlin, Germany
| | - Subhi Arafat
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | | | - Franziska Scheib
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Berlin, Germany
| | - Christian Meisel
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Berlin, Germany.
- Berlin Institute of Health, Berlin, Germany.
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Bernstein Center for Computational Neuroscience, Berlin, Germany.
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12
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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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13
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GomezMancilla B, Meriggioli MN, Genge A, Roubenoff R, Espié P, Dupuy C, Hartmann N, Pezous N, Kinhikar A, Tichy M, Dionne A, Vissing J, Andersen H, Schoser B, Meisel A, Jordan B, Devlikamova F, Poverennova I, Stuchevskaya F, Lin TS, Rush JS, Gergely P. Efficacy and safety of iscalimab, a novel anti-CD40 monoclonal antibody, in moderate-to-severe myasthenia gravis: A phase 2 randomized study. J Clin Neurosci 2024; 119:76-84. [PMID: 37988976 DOI: 10.1016/j.jocn.2023.11.013] [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: 07/18/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Increased morbidity in many patients with myasthenia gravis (MG) on long-term immunosuppression highlights the need for improved treatments. The aim of this study is to investigate the safety and efficacy of iscalimab (CFZ533), a fully human anti-CD40 monoclonal antibody, in patients with moderate-to-severe MG receiving standard-of-care (SoC) therapies. METHODS In this double-blind, placebo-controlled phase 2 study, symptomatic patients (n = 44) despite SoC were randomized 1:1 to receive intravenous iscalimab (10 mg/kg; n = 22) or placebo (n = 22) every 4 weeks for 6 doses in total. Patients were followed up for 6 months after the last dose. The total duration of the study was 52 weeks. RESULTS In total, 34 of 44 patients (77.3 %) completed the study. The primary endpoint, Quantitative MG score, did not change significantly between baseline and week 25 for iscalimab (median [90 % CI], -4.07 [-5.67, -2.47]) versus placebo (-2.93 [-4.53, -1.33]); however, non-thymectomized patients (n = 29) showed more favorable results (iscalimab, -4.35 [-6.07, -2.64] vs placebo, -2.26 [-4.16, -0.36]). A statistically significant difference between iscalimab and placebo groups was observed in MG Composite score (adjusted mean change: -4.19 [-6.67, -1.72]; p = 0.007) at week 13, and MG-Activities of Daily Living score (-1.93 [-3.24, -0.62]; p = 0.018) at week 21. Adverse events were comparable between the iscalimab (91 %) and placebo (96 %) groups. CONCLUSION Iscalimab showed favorable safety and improvements compared with placebo in non-thymectomized patients with moderate-to-severe MG. It did not show any protective effect in patients with moderate-to-severe MG.
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Affiliation(s)
| | | | - Angela Genge
- Montreal Neurological Institute and Hospital, Montreal, Canada
| | | | - Pascal Espié
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Cyrielle Dupuy
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nicole Hartmann
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nicole Pezous
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Arvind Kinhikar
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Mia Tichy
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - John Vissing
- Rigshospitalet, University of Copenhagen, Denmark
| | | | - Benedikt Schoser
- Friedrich-Baur-Institute, Dep. of Neurology, LMU Klinikum Muenchen, Muenchen, Germany
| | - Andreas Meisel
- Charité Universitätsmedizin Berlin, Department of Neurology, Germany
| | - Berit Jordan
- Department of Neurology, University Hospital of Halle, Halle, Germany; epartment of Neurology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Irina Poverennova
- Samara Regional Clinical Hospital named after M.I.Kalinin, Samara, Russia
| | | | - Thy-Sheng Lin
- National Cheng Kung University Hospital, Tainan, Taiwan
| | - James S Rush
- Novartis Institutes for BioMedical Research, Basel, Switzerland; Kling Biotherapeuetics BV, Amsterdam, the Netherlands
| | - Peter Gergely
- Novartis Institutes for BioMedical Research, Basel, Switzerland
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14
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Neumann B, Angstwurm K, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Lee DH, Gerner ST, Huttner HB, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Reichmann H, Fuhrer H, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schroeter M, Linker R, Meisel A, Bösel J, Stetefeld HR. Weaning and extubation failure in myasthenic crisis: a multicenter analysis. J Neurol 2024; 271:564-574. [PMID: 37923937 DOI: 10.1007/s00415-023-12016-2] [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: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/06/2023]
Abstract
Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.
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Affiliation(s)
- Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Sana Klinikum Landkreis Biberach, Biberach, Germany
| | | | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
- Department of Neurology, HELIOS Klinik Mühlheim, Mühlheim, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Moenchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Ralf Linker
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning R Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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15
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Wiendl H, Abicht A, Chan A, Della Marina A, Hagenacker T, Hekmat K, Hoffmann S, Hoffmann HS, Jander S, Keller C, Marx A, Melms A, Melzer N, Müller-Felber W, Pawlitzki M, Rückert JC, Schneider-Gold C, Schoser B, Schreiner B, Schroeter M, Schubert B, Sieb JP, Zimprich F, Meisel A. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord 2023; 16:17562864231213240. [PMID: 38152089 PMCID: PMC10752078 DOI: 10.1177/17562864231213240] [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: 05/26/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
| | - Angela Abicht
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Andrew Chan
- Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland
| | - Adela Della Marina
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Tim Hagenacker
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | | | - Sarah Hoffmann
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Sebastian Jander
- Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Alexander Marx
- Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Arthur Melms
- Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany
| | - Nico Melzer
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Müller-Felber
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany
| | - Marc Pawlitzki
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Benedikt Schoser
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Bettina Schreiner
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany
| | | | | | - Fritz Zimprich
- Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
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16
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Stein M, Grittner U, Stegherr R, Gerischer L, Stascheit F, Hoffmann S, Herdick M, Legg D, Marbin D, Meisel A, Lehnerer S. The burden of myasthenia gravis - highlighting the impact on family planning and the role of social support. Front Neurol 2023; 14:1307627. [PMID: 38162439 PMCID: PMC10755901 DOI: 10.3389/fneur.2023.1307627] [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: 10/04/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease and chronic condition that necessitates specialized care. Patients experience a significant burden of disease affecting various aspects of their lives. The aim of this study was to investigate the impact of MG on family planning, challenges associated with pregnancy, childcare responsibilities and the extent to which MG patients perceive and utilize social support. Methods This analysis used data from our main data of a large cross-sectional study built on a questionnaire-based survey encompassing 1,660 MG patients and members of the German Myasthenia Association (Deutsche Myasthenie Gesellschaft), and focused on sociodemographic, clinical and family planning relevant data points. Results Decisions regarding family planning were significantly impacted for individuals with MG when MG symptoms started either before or during their family planning (men: n = 19 and 29.7%; women: n = 156 and 58.4%). In this subgroup a substantial proportion opted against parenthood due to MG (men: n = 8 and 50.0%; women: n = 54 and 38.0% and/or another n = 12 and 8.4% of female participants encountered partner-related refusals). In the subgroup of female SP with MG starting before or during family planning who have reported ever been pregnant the self-reported miscarriage rate was 29.0% (n = 51). MG patients with medium incomes or moderate disease severity reported lower levels of perceived social support. 42.7% (n = 606) of participants needed assistance in negotiations with health insurers and 28.0% (n = 459) needed support for transportation to medical appointments. Conclusion This study shows a significant impact of MG on family planning decisions, affecting both women and men, and often resulting in life-altering decisions such as voluntary childlessness due to MG. The significance of social support becomes evident as a vital factor, especially when navigating through the healthcare system. Tailored healthcare approaches, organized guidance and comprehensive support is needed to enable informed decision-making and offer assistance for MG patients. Clinical trial registration https://clinicaltrials.gov/study/NCT03979521, Registered 7 June 2019 (retrospectively registered).
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Affiliation(s)
- Maike Stein
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Regina Stegherr
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Meret Herdick
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - David Legg
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Derin Marbin
- Department of Psychiatry of University Hospital Charité in St. Hedwig Hospital Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Neurosciences, Berlin, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
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Knab F, Koch SP, Major S, Farr TD, Mueller S, Euskirchen P, Eggers M, Kuffner MT, Walter J, Berchtold D, Knauss S, Dreier JP, Meisel A, Endres M, Dirnagl U, Wenger N, Hoffmann CJ, Boehm-Sturm P, Harms C. Prediction of Stroke Outcome in Mice Based on Noninvasive MRI and Behavioral Testing. Stroke 2023; 54:2895-2905. [PMID: 37746704 PMCID: PMC10589430 DOI: 10.1161/strokeaha.123.043897] [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: 05/23/2022] [Revised: 07/06/2023] [Accepted: 08/02/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Prediction of poststroke outcome using the degree of subacute deficit or magnetic resonance imaging is well studied in humans. While mice are the most commonly used animals in preclinical stroke research, systematic analysis of outcome predictors is lacking. METHODS We intended to incorporate heterogeneity into our retrospective study to broaden the applicability of our findings and prediction tools. We therefore analyzed the effect of 30, 45, and 60 minutes of arterial occlusion on the variance of stroke volumes. Next, we built a heterogeneous cohort of 215 mice using data from 15 studies that included 45 minutes of middle cerebral artery occlusion and various genotypes. Motor function was measured using a modified protocol for the staircase test of skilled reaching. Phases of subacute and residual deficit were defined. Magnetic resonance images of stroke lesions were coregistered on the Allen Mouse Brain Atlas to characterize stroke topology. Different random forest prediction models that either used motor-functional deficit or imaging parameters were generated for the subacute and residual deficits. RESULTS Variance of stroke volumes was increased by 45 minutes of arterial occlusion compared with 60 minutes. The inclusion of various genotypes enhanced heterogeneity further. We detected both a subacute and residual motor-functional deficit after stroke in mice and different recovery trajectories could be observed. In mice with small cortical lesions, lesion volume was the best predictor of the subacute deficit. The residual deficit could be predicted most accurately by the degree of the subacute deficit. When using imaging parameters for the prediction of the residual deficit, including information about the lesion topology increased prediction accuracy. A subset of anatomic regions within the ischemic lesion had particular impact on the prediction of long-term outcomes. Prediction accuracy depended on the degree of functional impairment. CONCLUSIONS For the first time, we developed and validated a robust tool for the prediction of functional outcomes after experimental stroke in mice using a large and genetically heterogeneous cohort. These results are discussed in light of study design and imaging limitations. In the future, using outcome prediction can improve the design of preclinical studies and guide intervention decisions.
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Affiliation(s)
- Felix Knab
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Stefan Paul Koch
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence and Charité Core Facility, 7T Experimental MRIs, Germany (S.P.K., T.D.F., S. Mueller, P.B.-S.)
| | - Sebastian Major
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Tracy D. Farr
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence and Charité Core Facility, 7T Experimental MRIs, Germany (S.P.K., T.D.F., S. Mueller, P.B.-S.)
- School of Life Sciences, University of Nottingham, United Kingdom (T.D.F.)
| | - Susanne Mueller
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence and Charité Core Facility, 7T Experimental MRIs, Germany (S.P.K., T.D.F., S. Mueller, P.B.-S.)
| | - Philipp Euskirchen
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Moritz Eggers
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Melanie T.C. Kuffner
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Josefine Walter
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, QUEST Center for Transforming Biomedical Research, Germany (J.W.)
| | - Daniel Berchtold
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Samuel Knauss
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Berlin Institute of Health (BIH), Germany (S.K., N.W., C.J.H., C.H.)
| | - Jens P. Dreier
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Einstein Center for Neuroscience, Berlin, Germany (J.P.D., M. Endres, U.D., N.W., C.H.)
- Bernstein Center for Computational Neuroscience (J.P.D.)
| | - Andreas Meisel
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
| | - Matthias Endres
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Einstein Center for Neuroscience, Berlin, Germany (J.P.D., M. Endres, U.D., N.W., C.H.)
- German Center for Cardiovascular Research (DZHK), partner site Berlin (M. Endres, U.D., C.H.)
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany (M. Endres., U.D.)
- German Center for Neurodegenerative Diseases (DZNE) (M. Endres, U.D.)
| | - Ulrich Dirnagl
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Einstein Center for Neuroscience, Berlin, Germany (J.P.D., M. Endres, U.D., N.W., C.H.)
- German Center for Cardiovascular Research (DZHK), partner site Berlin (M. Endres, U.D., C.H.)
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany (M. Endres., U.D.)
- German Center for Neurodegenerative Diseases (DZNE) (M. Endres, U.D.)
| | - Nikolaus Wenger
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Berlin Institute of Health (BIH), Germany (S.K., N.W., C.J.H., C.H.)
- Einstein Center for Neuroscience, Berlin, Germany (J.P.D., M. Endres, U.D., N.W., C.H.)
| | - Christian J. Hoffmann
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Berlin Institute of Health (BIH), Germany (S.K., N.W., C.J.H., C.H.)
| | - Philipp Boehm-Sturm
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence and Charité Core Facility, 7T Experimental MRIs, Germany (S.P.K., T.D.F., S. Mueller, P.B.-S.)
| | - Christoph Harms
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Klinik und Hochschulambulanz für Neurologie, Department of Experimental Neurology, Germany (F.K., S.P.K., S. Major, T.D.F., S. Mueller, P.E., M. Eggers, M.T.C.K., J.W., D.B., S.K., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Charité Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (F.K., S.P.K., S. Major, S. Mueller., M. Eggers, M.T.C.K., J.W., D.B., J.P.D., A.M., M. Endres, U.D., N.W., C.J.H., P.B.-S., C.H.)
- Berlin Institute of Health (BIH), Germany (S.K., N.W., C.J.H., C.H.)
- Einstein Center for Neuroscience, Berlin, Germany (J.P.D., M. Endres, U.D., N.W., C.H.)
- German Center for Cardiovascular Research (DZHK), partner site Berlin (M. Endres, U.D., C.H.)
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Palà E, Penalba A, Bustamante A, García‐Berrocoso T, Lamana‐Vallverdú M, Meisel C, Meisel A, van der Worp HB, R Macleod M, Kallmünzer B, Schwab S, Montaner J. Blood biomarker changes following therapeutic hypothermia in ischemic stroke. Brain Behav 2023; 13:e3230. [PMID: 37721534 PMCID: PMC10636403 DOI: 10.1002/brb3.3230] [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: 03/25/2023] [Revised: 07/23/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION Therapeutic hypothermia is a promising candidate for stroke treatment although its efficacy has not yet been demonstrated in patients. Changes in blood molecules could act as surrogate markers to evaluate the efficacy and safety of therapeutic cooling. METHODS Blood samples from 54 patients included in the EuroHYP-1 study (27 treated with hypothermia, and 27 controls) were obtained at baseline, 24 ± 2 h, and 72 ± 4 h. The levels of a panel of 27 biomarkers, including matrix metalloproteinases and cardiac and inflammatory markers, were measured. RESULTS Metalloproteinase-3 (MMP-3), fatty-acid-binding protein (FABP), and interleukin-8 (IL-8) increased over time in relation to the hypothermia treatment. Statistically significant correlations between the minimum temperature achieved by each patient in the hypothermia group and the MMP-3 level measured at 72 h, FABP level measured at 24 h, and IL-8 levels measured at 24 and 72 h were found. No differential biomarker levels were observed in patients with poor or favorable outcomes according to modified Rankin Scale scores. CONCLUSION Although the exact roles of MMP3, FABP, and IL-8 in hypothermia-treated stroke patients are not known, further exploration is needed to confirm their roles in brain ischemia.
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Affiliation(s)
- Elena Palà
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Anna Penalba
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Alejandro Bustamante
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Stroke Unit, Hospital Universitari Germans Trias i PujolBadalonaSpain
| | - Teresa García‐Berrocoso
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- CSIC/UAB Proteomics LaboratoryInstitute of Biomedical Research of BarcelonaSpanish National Research Council (IIBB‐CSIC/IDIBAPS)BarcelonaSpain
| | - Marcel Lamana‐Vallverdú
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Christian Meisel
- Institute for Medical ImmunologyCharité–Universitätsmedizin BerlinBerlinGermany
- Department of ImmunologyLabor Berlin–Charité VivantesBerlinGermany
| | - Andreas Meisel
- Department of Neurology and Center for Stroke Research BerlinCharité University Hospital BerlinBerlinGermany
| | - H. Bart van der Worp
- Department of Neurology and NeurosurgeryBrain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghScotlandUK
| | - Bernd Kallmünzer
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Joan Montaner
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of NeurologyHospital Universitario Virgen MacarenaSevilleSpain
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Vu T, Meisel A, Mantegazza R, Annane D, Katsuno M, Aguzzi R, Enayetallah A, Beasley KN, Rampal N, Howard JF. Summary of Research: Terminal Complement Inhibitor Ravulizumab in Generalized Myasthenia Gravis. Neurol Ther 2023; 12:1435-1438. [PMID: 37351816 PMCID: PMC10444731 DOI: 10.1007/s40120-023-00514-4] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
This article provides a summary of a previously published paper: Terminal Complement Inhibitor Ravulizumab in Generalized Myasthenia Gravis. The paper reported the results of the CHAMPION-MG trial which investigated the drug ravulizumab in the rare disease, myasthenia gravis. Terminal Complement Inhibitor Ravulizumab in Generalized Myasthenia Gravis (MP4 594600 KB).
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Affiliation(s)
- Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | | | | | - Djillali Annane
- Hôpital Raymond Poincaré, University of Versailles, Garches, France
| | | | - Rasha Aguzzi
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | | | | | - Nishi Rampal
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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Schwarzbach CJ, Eichner FA, Rücker V, Hofmann AL, Keller M, Audebert HJ, von Bandemer S, Engelter ST, Geis D, Gröschel K, Haeusler KG, Hamann GF, Meisel A, Sander D, Schutzmeier M, Veltkamp R, Heuschmann PU, Grau AJ. The structured ambulatory post-stroke care program for outpatient aftercare in patients with ischaemic stroke in Germany (SANO): an open-label, cluster-randomised controlled trial. Lancet Neurol 2023; 22:787-799. [PMID: 37459876 DOI: 10.1016/s1474-4422(23)00216-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Patients with ischaemic stroke are at risk of recurrent stroke. In this study, we aimed to compare the effect of a structured ambulatory post-stroke care programme versus usual care on recurrent vascular events and death and control of cardiovascular risk factors. METHODS We did a prospective, open-label, cluster-randomised controlled trial (SANO) at stroke centres in regions of Germany. A cluster was defined as a region in which acute stroke care is provided by a participating stroke centre. Patients were eligible for participation if they were aged 18 years or older, had no severe disabilities before the index stroke (modified Rankin scale 0-1), had at least one modifiable cardiovascular risk factor, and presented within 14 days of symptom onset of their first ischaemic stroke. The participating regions were randomly assigned (1:1) to the intervention and control group (usual care) by the statistician using block randomisation (block sizes of six), stratified by rural and urban regions. In intervention regions, a cross-sectoral multidisciplinary network was established to provide a 1-year organisational and patient-centred intervention. Due to the type of intervention, masking of participants and study physicians was not possible. Endpoint adjudication was performed by an independent endpoint adjudication committee who were masked to cluster allocation. The primary endpoint was a composite of recurrent stroke, myocardial infarction, and all-cause death within 12 months after baseline assessment, assessed in the modified intention-to-treat (mITT) population, which included all patients who did not withdraw consent and completed the primary endpoint assessment at 12 months. This study was registered with the German Clinical Trials Register, DRKS00015322. FINDINGS Between Jan 1, 2019 and Dec 22, 2020, 36 clusters were assessed for eligibility, of which 30 were randomly assigned to the intervention group (n=15 clusters) or control group (n=15 clusters). No clusters dropped out of the study. 1203 (86%) of 1396 enrolled patients in the intervention group and 1283 (92%) of 1395 enrolled patients in the control group were included in the mITT population. The primary endpoint was confirmed in 64 (5·3%) of 1203 patients in the intervention group and 80 (6·2%) of 1283 patients in the control group (unadjusted odds ratio [OR] 0·80 [95% CI 0·49-1·30]; adjusted OR [aOR] 0·95 [95% CI 0·54-1·67]). All-cause deaths occurred in 31 (2·4%) of 1203 patients in the intervention group and 12 (1·0%) of 1283 patients in the control group. The incidence of serious adverse events was higher in the intervention group (266 [23·1%] of 1151) than the control group (106 [9·2%] of 1152). Falls (134 [11·4%] of 1203 patients in the intervention group; 39 [3·3%] of 1152 patients in the control group), hypertensive crisis (55 [4·7%]; 34 [2·8%]), and diagnosis of depression (51 [4·3%]; 13 [1·1%]) were the most frequent adverse events in both groups. No differences were identified in the rate of readmission to hospital between groups. INTERPRETATION No differences were identified between patients with ischaemic stroke in the intervention group and control group with regard to the incidence of vascular events 1 year after baseline assessment, despite positive effects with regard to the control of some cardiovascular risk factors. Longer-term effects and other potentially favourable effects on stroke-related sequelae and quality of life require further evaluation. FUNDING Innovation Fund of the Federal Joint Committee.
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Affiliation(s)
| | - Felizitas Anna Eichner
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Viktoria Rücker
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Anna-Lena Hofmann
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Moritz Keller
- Department of Neurology, Catholic Hospital Koblenz-Montabaur, Koblenz, Germany
| | - Heinrich J Audebert
- Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stefan T Engelter
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Dieter Geis
- Bavarian General Practitioners̓ Association, München, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Gerhard F Hamann
- Clinic for Neurology and Neurological Rehabilitation, District Hospital Günzburg, Günzburg, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Sander
- Department of Neurology, Benedictus Hospital, Tutzing, Germany
| | - Martha Schutzmeier
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital Rüttenscheid, Essen, Germany; Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Ulrich Heuschmann
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany; Clinical Trial Centre Würzburg, University Hospital Würzburg, Würzburg, Germany; Institute for Medical Data Science, University Hospital Würzburg, Würzburg, Germany
| | - Armin J Grau
- Department of Neurology, Ludwigshafen Municipal Hospital, Ludwigshafen, Germany
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21
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Andina ME, Nelde A, Nolte CH, Scheitz JF, Olma MC, Krämer M, Meisel E, Bingel A, Meisel A, Scheibe F, Endres M, Schlemm L, Meisel C. Datawarehouse-enabled quality control of atrial fibrillation detection in the stroke unit setting. Heliyon 2023; 9:e18432. [PMID: 37534004 PMCID: PMC10391946 DOI: 10.1016/j.heliyon.2023.e18432] [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: 04/26/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
Objective (1) To assess the accuracy of a standard operating procedure (SOP) regarding the utilization of atrial fibrillation (AF) alarms in everyday clinical practice, and (2) to evaluate the performance of automated continuous surveillance for atrial fibrillation (AF) in hospitalized acute stroke patients. Design Retrospective cohort study. Setting Two stroke units from two tertiary care hospitals in Berlin, Germany. Participants We identified 635 patients with ischemic stroke diagnosis for the time period between 01. January and 30. September 2021 of which 176 patients had recorded AF alarms during monitoring. Of those, 115 patients were randomly selected for evaluation. After excluding 6 patients with hemorrhagic stroke in their records, 109 patients (mean age: 79.1 years, median NIHSS at admission: 6, 57% female) remained for analysis. Intervention Using a clinical data warehouse for comprehensive data storage we retrospectively downloaded and visualized ECG data segments of 65 s duration around the automated AF alarms. We restricted the maximum number of ECG segments to ten per patient. Each ECG segment plot was uploaded into a REDCap database and categorized as either AF, non-AF or artifact by manual review. Atrial flutter was subsumed as AF. These classifications were then matched with 1) medical history and known diseases before stroke, 2) discharge diagnosis, and 3) recommended treatment plan in the medical history using electronic health records. Main outcome measures The primary outcome was the proportion of previously unknown AF diagnoses correctly identified by the monitoring system but missed by the clinical team during hospitalization. Secondary outcomes included the proportion of patients in whom a diagnosis of AF would likely have led to anticoagulant therapy. We also evaluated the accuracy of the automated detection system in terms of its positive predictive value (PPV). Results We evaluated a total of 717 ECG alarm segments from 109 patients. In 4 patients (3.7, 95% confidence interval [CI] 1.18-9.68%) physicians had missed AF despite at least one true positive alarm. All four patients did not receive long-term secondary prevention in form of anticoagulant therapy. 427 out of 717 alarms were rated true positives, resulting in a positive predictive value of 0.6 (CI 0.56-0.63) in this cohort. Conclusion By connecting a data warehouse, electronic health records and a REDCap survey tool, we introduce a path to assess the monitoring quality of AF in acute stroke patients. We find that implemented standards of procedure to detect AF during stroke unit care are effective but leave room for improvement. Such data warehouse-based concepts may help to adjust internal processes or identify targets of further investigations.
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Affiliation(s)
- Mario E. Andina
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Nelde
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Cite Berlin, Germany
| | - Jan F. Scheitz
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | | | | | | | - Anne Bingel
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Cite Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Germany
| | - Ludwig Schlemm
- Center for Stroke Research Berlin, Berlin, Germany
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience, Berlin, Germany
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22
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Meisel A. Are CAR T cells the answer to myasthenia gravis therapy? Lancet Neurol 2023; 22:545-546. [PMID: 37353270 DOI: 10.1016/s1474-4422(23)00211-9] [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: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Andreas Meisel
- Neuroscience Clinical Research Center, Center for Stroke Research Berlin, and Department of Neurology with Experimental Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany.
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23
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Gödde K, Fügemann H, Goerling U, Grittner U, Kohl R, Meisel A, Reinhold T, Schnitzer S, Deckert PM, Frost N, Schreiber SJ, Rieckmann N, Holmberg C. Feasibility of a patient-oriented navigation programme for patients with lung cancer or stroke in Germany: Protocol of the CoreNAVI study. PLoS One 2023; 18:e0287638. [PMID: 37384672 PMCID: PMC10309639 DOI: 10.1371/journal.pone.0287638] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 04/28/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Patient navigation programmes were introduced in the United States and recently gained interest in Germany, where the health care system is fragmented. Navigation programmes aim to decrease barriers to care for patients with age-associated diseases and complex care paths. Here we describe a feasibility study to evaluate a patient-oriented navigation model that was developed in a first project phase by integrating data about barriers to care, vulnerable patient populations and existing support services. METHODS We designed a mixed-methods feasibility study that consists of two two-arm randomized controlled trials aligned with observational cohorts. The intervention group of the RCTs gets support by personal navigators for 12 months. The control group receives a brochure with regional support offers for patients and caregivers. The feasibility of the patient-oriented navigation model for two prototypic age-associated diseases, lung cancer and stroke, is evaluated with regard to its acceptance, demand, practicality and efficacy. This investigation includes process evaluation measures with detailed documentation of the screening and recruitment process, questionnaires about satisfaction with navigation, observant participation and qualitative interviews. Estimates of efficacy for patient-reported outcomes are obtained at three follow-up time points including satisfaction with care and health-related quality of life. Furthermore, we analyze health insurance data from patients of the RCT insured at a large German health insurance (AOK Nordost) to investigate heath care utilization, costs and cost effectiveness. TRIAL REGISTRATION The study is registered at the German Clinical Trial Register (DRKS-ID: DRKS00025476).
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Affiliation(s)
- Kathrin Gödde
- Institute of Public Health, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hella Fügemann
- Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Berlin, Germany
| | - Ute Goerling
- Charité Comprehensive Cancer Center, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Raphael Kohl
- Institute of Medical Sociology and Rehabilitation Science, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Meisel
- Center for Stroke Research (CSB), Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Reinhold
- Institute of Social Medicine, Epidemiology and Health Economics, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Susanne Schnitzer
- Institute of Medical Sociology and Rehabilitation Science, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - P. Markus Deckert
- Oncology and Palliative Care and Faculty of Health Sciences, Department of Hematology, Both: Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Berlin, Germany
| | - Nikolaj Frost
- Department of Infectious Diseases and Pulmonary Medicine, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Stephan J. Schreiber
- Department of Neurology, Oberhavel Kliniken, Clinic Hennigsdorf, Hennigsdorf, Germany
| | - Nina Rieckmann
- Institute of Public Health, Charité—Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christine Holmberg
- Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Berlin, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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24
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Nelke C, Schroeter CB, Stascheit F, Huntemann N, Pawlitzki M, Willison AG, Räuber S, Melzer N, Distler U, Tenzer S, Stühler K, Roos A, Meisel A, Meuth SG, Ruck T. Eculizumab treatment alters the proteometabolome beyond the inhibiton of complement. JCI Insight 2023:169135. [PMID: 37227781 PMCID: PMC10371336 DOI: 10.1172/jci.insight.169135] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Therapeutic strategies targeting complement have revolutionized the treatment of myasthenia gravis (MG). However, a deeper understanding of complement modulation in the human system is required to improve treatment responses and identify "off-target effects" shaping long-term outcomes. For this purpose, we studied a cohort of MG patients treated with either eculizumab (n = 10) or azathioprine (n = 10) as well as treatment-naïve (n = 10) patients using a combined proteomics and metabolomics approach. This strategy confirmed known effects of eculizumab on the terminal complement cascade. Beyond that, eculizumab modulated the serum proteometabolome as distinct pathways were altered in eculizumab-treated patients including the oxidative stress response, mitogen-activated protein kinase signaling and lipid metabolism with particular emphasis on arachidonic acid signaling. We detected reduced levels of arachidonate 5-lipoxygenase (ALOX5) and leukotriene A4 (LTA4) in eculizumab-treated patients. Mechanistically, ligation of the C5a receptor (C5aR) is needed for ALOX5 metabolism and generation of downstream leukotrienes. As eculizumab prevents cleavage of C5 into C5a, decreased engagement of C5aR may inhibit ALOX5-mediated synthesis of pro-inflammatory leukotrienes. These findings indicate distinct "off-target effects" induced by eculizumab, illuminating potential mechanisms of action that may be harnessed to improve treatment outcomes.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Niklas Huntemann
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marc Pawlitzki
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alice G Willison
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Saskia Räuber
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Nico Melzer
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ute Distler
- Luxembourg Clinical Proteomics Center, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Luxembourg
| | - Stefan Tenzer
- Institute of Immunology, University Medical Center of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Kai Stühler
- Molecular Proteomics Laboratory, Heinrich Heine University, Düsseldorf, Germany
| | - Andreas Roos
- Department of Neuropediatrics, University of Duisburg-Essen, Essen, Germany
| | - Andreas Meisel
- Neuroscience Clinical Research Center, Charité - Universitätsmedizin Berlin, berlin, Germany
| | - Sven G Meuth
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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25
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Berrih-Aknin S, Palace J, Meisel A, Claeys KG, Muppidi S, Saccà F, Amini F, Larkin M, Quinn C, Beauchamp J, Philips G, De Ruyck F, Ramirez J, Paci S. Patient-reported impact of myasthenia gravis in the real world: findings from a digital observational survey-based study (MyRealWorld MG). BMJ Open 2023; 13:e068104. [PMID: 37169499 DOI: 10.1136/bmjopen-2022-068104] [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] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES This study aims to explore the impact of myasthenia gravis (MG) - in terms of treatments, side effects, comorbidities, psychological health and work or study- in the real world from a patient perspective. DESIGN AND PARTICIPANTS This is a prospective, observational, digital, longitudinal study. Adults diagnosed with MG residing in the USA, Japan, Germany, the UK, Italy, Spain or Canada were eligible to participate in the study. There were no other exclusion criteria. Participants used a bespoke smartphone application to confirm eligibility, provide consent and enter data about their MG into a profile, a tracker to record MG-related events and a series of patient-reported outcome instruments. 1693 participants completed at least 1 survey and were included in this analysis. RESULTS Results are presented as a percentage of respondents to each survey question. The study population was largely female (69% of 1586 respondents), with an average age of 49.9 years (SD 14.8). In the previous 12 months, 83.7% of 1412 respondents confirmed that they had received one or more routine treatments for MG, and 67.1% of 255 respondents confirmed that they had experienced a side effect in the previous month. Commonly experienced comorbidities reported by 966 respondents were thyroid problems, hypertension and anxiety, experienced by 37.5%, 31.4% and 28.0% of respondents, respectively.According to 889 respondents to the Hospital Anxiety and Depression Scale survey, 52.7% and 43.2% had a score indicative of at least mild anxiety and mild depression, respectively. Of 257 respondents, 33.0% reported experiencing a work or study impact in the past month. CONCLUSIONS This analysis of baseline characteristics of the MyRealWorld MG study population indicates that, despite current treatments, patients experience notable burden. Further scheduled analyses will develop a longitudinal picture of MG burden. TRIAL REGISTRATION NUMBER NCT04176211.
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Affiliation(s)
- Sonia Berrih-Aknin
- INSERM, Institute of Myology, Center of Research in Myology, Sorbonne Université, Paris, France
| | - Jacqueline Palace
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford, UK
| | - Andreas Meisel
- Department of Neurology, Neuroscience Clinical Research Center, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Kristl G Claeys
- Department of Neurology, KU Leuven University Hospitals, Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University, Stanford, California, USA
| | - Francesco Saccà
- Department of DNSRO, University of Naples Federico II, Napoli, Italy
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26
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Dewilde S, Janssen MF, Tollenaar NH, Vanoli F, Frangiamore R, Phillips G, Paci S, Mantegazza R, Meisel A, Stascheit F. Concordance between patient- and physician-reported Myasthenia Gravis Activities of Daily Living (MG-ADL) scores. Muscle Nerve 2023. [PMID: 37144893 DOI: 10.1002/mus.27837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION/AIMS Myasthenia gravis (MG) is a neuromuscular disease characterized by abnormal skeletal muscle fatiguability. The MG Activities of Daily Living (MG-ADL) scale assesses eight symptoms and is often used as primary endpoint in MG clinical trials where it is completed by neurologists. However, in observational studies, patients frequently complete the MG-ADL scale independently of their neurologist. In this study we aimed to assess the concordance between self- and physician-reported MG-ADL scores. METHODS An international observational study was conducted among adult patients with MG scheduled for a routine visit or who entered the hospital via emergency services. Consenting patients and physicians completed the MG-ADL. Concordance between assessments was calculated using Gwet's agreement coefficient (Gwet's AC) for the MG-ADL individual items and the intraclass correlation coefficient (ICC) for the MG-ADL total score. RESULTS Data were collected from 137 patients (63% female; mean age, 57.7 years). Physicians assessed the patient's symptoms as slightly more severe (8.1 vs 7.5 MG-ADL total score, respectively), corresponding to a difference of 0.6 on a range from 0 to 24. The ICC for the MG-ADL total score between the patient and the physician assessment was 0.94 (95% confidence interval, 0.89 to 0.95), showing excellent concordance. Gwet's AC showed substantial to almost perfect agreement for all items, except eyelid droop, for which the agreement was moderate. DISCUSSION Our results demonstrate that patients and neurologists have a concordant assessment of the patient's MG symptoms when using the MG-ADL scale. This evidence supports patient self-administration of the MG-ADL in clinical practice and research.
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Affiliation(s)
| | - M F Janssen
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Fiammetta Vanoli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milan, Italy
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | - Glenn Phillips
- Health Economics & Outcomes Research, argenx BV, Boston, Massachusetts, USA
| | - Sandra Paci
- Health Economics & Outcomes Research, argenx BV, Boston, Massachusetts, USA
| | | | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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27
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Stascheit F, Chuquisana O, Keller CW, Ambrose PA, Hoffmann S, Gross CC, Lehnerer S, Wiendl H, Willcox N, Meisel A, Lünemann JD. Complement activation profiles in anti-acetylcholine receptor positive myasthenia gravis. Eur J Neurol 2023; 30:1409-1416. [PMID: 36752022 DOI: 10.1111/ene.15730] [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: 09/01/2022] [Revised: 10/24/2022] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND PURPOSE Complement component 5 (C5) targeting therapies are clinically beneficial in patients with acetylcholine receptor antibody+ (AChR-Ab+ ) generalized myasthenia gravis (MG). That clearly implicates antibody-mediated complement activation in MG pathogenesis. Here, classical and alternative complement pathways were profiled in patients from different MG subgroups. METHODS In a case-control study, concentrations of C3a, C5a and sC5b9 were simultaneously quantified, indicating general activation of the complement system, whether via the classical and lectin pathways (C4a) or the alternative pathway (factors Ba and Bb) in MG patients with AChR or muscle-specific kinase antibodies (MuSK-Abs) or seronegative MG compared to healthy donors. RESULTS Treatment-naïve patients with AChR-Ab+ MG showed substantially increased plasma levels of cleaved complement components, indicating activation of the classical and alternative as well as the terminal complement pathways. These increases were still present in a validation cohort of AChR-Ab+ patients under standard immunosuppressive therapies; notably, they were not evident in patients with MuSK-Abs or seronegative MG. Neither clinical severity parameters (at the time of sampling or 1 year later) nor anti-AChR titres correlated significantly with activated complement levels. CONCLUSIONS Markers indicative of complement activation are prominently increased in patients with AChR-Ab MG despite standard immunosuppressive therapies. Complement inhibition proximal to C5 cleavage should be explored for its potential therapeutic benefits in AChR-Ab+ MG.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Omar Chuquisana
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Christian W Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Philip Alexander Ambrose
- Department of Clinical Neurology, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Sarah Hoffmann
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Sophie Lehnerer
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Nick Willcox
- Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
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Meisel A, Annane D, Vu T, Mantegazza R, Katsuno M, Aguzzi R, Frick G, Gault L, Howard JF. Long-term efficacy and safety of ravulizumab in adults with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis: results from the phase 3 CHAMPION MG open-label extension. J Neurol 2023:10.1007/s00415-023-11699-x. [PMID: 37103755 PMCID: PMC10134722 DOI: 10.1007/s00415-023-11699-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Ravulizumab demonstrated efficacy and an acceptable safety profile versus placebo in the randomized controlled period (RCP) of the phase 3 CHAMPION MG trial in patients with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. We report an interim analysis of the ongoing open-label extension (OLE) designed to evaluate long-term treatment effects. METHODS Following completion of the 26-week RCP, patients could enter the OLE; patients who received ravulizumab in the RCP continued the drug; patients who previously received placebo switched to ravulizumab. Patients receive body-weight-based maintenance dosing of ravulizumab every 8 weeks. Efficacy endpoints up to 60 weeks included Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores, with least-squares (LS) mean change and 95% confidence intervals (95% CI) reported. RESULTS Long-term efficacy and safety in the OLE were analyzed in 161 and 169 patients, respectively. Improvements in all scores were maintained through 60 weeks in patients who received ravulizumab during the RCP; LS mean change from RCP baseline in MG-ADL score was - 4.0 (95% CI: - 4.8, - 3.1; p < 0.0001). Rapid (within 2 weeks) and sustained improvements occurred in patients previously receiving placebo; LS mean change in MG-ADL score from OLE baseline to Week 60 was - 1.7 (95% CI: - 2.7, - 0.8; p = 0.0007). Similar trends were seen in QMG scores. Ravulizumab treatment was associated with a decreased rate of clinical deterioration events compared with placebo. Ravulizumab was well tolerated; no meningococcal infections were reported. CONCLUSION Findings support the sustained efficacy and long-term safety of ravulizumab, administered every 8 weeks, in adults with anti-acetylcholine receptor antibody-positive generalized myasthenia gravis. CLINICALTRIALS gov identifier: NCT03920293; EudraCT: 2018-003243-39.
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Affiliation(s)
| | | | - Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | - Rasha Aguzzi
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Glen Frick
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Laura Gault
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
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Nelde A, Klammer MG, Nolte CH, Stengl H, Krämer M, von Rennenberg R, Meisel A, Scheibe F, Endres M, Scheitz JF, Meisel C. Data lake-driven analytics identify nocturnal non-dipping of heart rate as predictor of unfavorable stroke outcome at discharge. J Neurol 2023:10.1007/s00415-023-11718-x. [PMID: 37079032 DOI: 10.1007/s00415-023-11718-x] [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: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Post-stroke heart rate (HR) and heart rate variability (HRV) changes have been proposed as outcome predictors after stroke. We used data lake-enabled continuous electrocardiograms to assess post-stroke HR and HRV, and to determine the utility of HR and HRV to improve machine learning-based predictions of stroke outcome. METHODS In this observational cohort study, we included stroke patients admitted to two stroke units in Berlin, Germany, between October 2020 and December 2021 with final diagnosis of acute ischemic stroke or acute intracranial hemorrhage and collected continuous ECG data through data warehousing. We created circadian profiles of several continuously recorded ECG parameters including HR and HRV parameters. The pre-defined primary outcome was short-term unfavorable functional outcome after stroke indicated through modified Rankin Scale (mRS) score of > 2. RESULTS We included 625 stroke patients, 287 stroke patients remained after matching for age and National Institute of Health Stroke Scale (NIHSS; mean age 74.5 years, 45.6% female, 88.9% ischemic, median NIHSS 5). Both higher HR and nocturnal non-dipping of HR were associated with unfavorable functional outcome (p < 0.01). The examined HRV parameters were not associated with the outcome of interest. Nocturnal non-dipping of HR ranked highly in feature importance of various machine learning models. CONCLUSIONS Our data suggest that a lack of circadian HR modulation, specifically nocturnal non-dipping, is associated with short-term unfavorable functional outcome after stroke, and that including HR into machine learning-based prediction models may lead to improved stroke outcome prediction.
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Affiliation(s)
- Alexander Nelde
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Helena Stengl
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | | | - Regina von Rennenberg
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Christian Meisel
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Bonhoefferweg 3, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Berlin, Germany.
- Berlin Institute of Health, Berlin, Germany.
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Bernstein Center for Computational Neuroscience, Berlin, Germany.
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Meisel A, Baggi F, Behin A, Evoli A, Kostera-Pruszczyk A, Mantegazza R, Juntas Morales R, Punga AR, Sacconi S, Schroeter M, Verschuuren J, Crathorne L, Holmes K, Leite MI. Reply to the Letter to the Editor in response to "Role of autoantibody levels as biomarkers in the management of patients with myasthenia gravis: A systematic review and expert appraisal". Eur J Neurol 2023; 30:1162-1164. [PMID: 36692238 DOI: 10.1111/ene.15690] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/25/2023]
Affiliation(s)
- Andreas Meisel
- Department of Neurology, Integrated Myasthenia Gravis Center, NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fulvio Baggi
- Neuroimmunology and Neuromuscular Diseases Unit, Scientific Institute for Research and Health Care Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Anthony Behin
- Department of Neuromyology, Pitié-Salpêtrière Hospital, Public Hospital Network of Paris, Institute of Myology, Paris, France
| | - Amelia Evoli
- Scientific Institute for Research and Health Care, Catholic University of the Sacred Heart and Agostino Gemelli University Polyclinic Foundation, Rome, Italy
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Scientific Institute for Research and Health Care Foundation Carlo Besta Neurological Institute, Milan, Italy
| | | | - Anna Rostedt Punga
- Department of Medical Science, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | | | - Michael Schroeter
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Jan Verschuuren
- Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Maria-Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Stascheit F, Della Marina A, Meisel A. [Myasthenia in adults, children, and adolescents: what's new?]. Nervenarzt 2023:10.1007/s00115-023-01463-x. [PMID: 36995386 DOI: 10.1007/s00115-023-01463-x] [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] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 03/31/2023]
Abstract
Therapy of myasthenia gravis (MG) is increasingly oriented to the patient's antibody status. In addition to symptomatic therapy, steroids, classic long-term immunosuppressive therapies and thymectomy are regularly used. In recent years, new therapeutic approaches have been developed that particularly benefit acetylcholine receptor (AChR) antibody (Abs) positive patients with highly active disease. While the C5 complement inhibitor eculizumab was reserved for treatment-refractory generalized courses of AChR-Abs positive MG, two new drugs, the neonatal Fc receptor inhibitor efgartigimod and the more advanced C5 complement inhibitor ravulizumab, have recently been approved as add-on therapy for AChR-Abs positive generalized MG (gMG). In highly active courses of MG with Abs against the muscle-specific receptor tyrosine kinase (MuSK), the use of rituximab should be considered early in the course of the disease. The efficacy of the new drugs in children and adolescents with juvenile MG (JMG) is currently being tested in clinical trials. The new guideline recommends the use of modern immunomodulators based on a step-by-step approach depending on disease activity. With the German Myasthenia Register (MyaReg), the changing therapeutic landscape and quality of life of patients with myasthenic syndromes can be assessed, thus providing real-world data on the care of MG patients. Despite treatment based on the previous guideline, many MG patients suffer considerable impairment to their quality of life. With the new immunomodulators, there is the possibility of early intensified immunotherapy, which, in contrast to long-term immunosuppressants, can lead to a rapid improvement in the course of the disease.
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Affiliation(s)
- Frauke Stascheit
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität und Humboldt-Universität zu Berlin, Berlin, Deutschland.
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität und Humboldt-Universität zu Berlin, Berlin, Deutschland.
- Klinik für Neurologie und experimentelle Neurologie, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Adela Della Marina
- Klinik für Kinderheilkunde 1, Abteilung für Neuropädiatrie, Entwicklungsneurologie und Sozialpädiatrie, Zentrum für Neuromuskuläre Erkrankungen, Zentrum für Translationale Neuro- und Verhaltenswissenschaften, Universitätsklinikum Essen, Hufelandstraße, 45147, Essen, Deutschland.
| | - Andreas Meisel
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität und Humboldt-Universität zu Berlin, Berlin, Deutschland
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität und Humboldt-Universität zu Berlin, Berlin, Deutschland
- Centrum für Schlaganfallforschung Berlin, Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität und Humboldt-Universität zu Berlin, Berlin, Deutschland
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Mevius A, Jöres L, Biskup J, Heidbrede T, Mahic M, Wilke T, Maywald U, Lehnerer S, Meisel A. Epidemiology and treatment of myasthenia gravis: a retrospective study using a large insurance claims dataset in Germany. Neuromuscul Disord 2023; 33:324-333. [PMID: 36921445 DOI: 10.1016/j.nmd.2023.02.002] [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: 07/07/2022] [Revised: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 03/05/2023]
Abstract
Myasthenia gravis (MG) is a rare, chronic autoimmune disease with symptoms of fluctuating muscular weakness and fatigability. The aim of this retrospective cohort study was to estimate the prevalence and incidence of MG in Germany, and to understand the burden of disease and treatment patterns, based on anonymized German claims data. Two patient samples were identified: (1) incident MG patients with newly onset disease between 2015 and 2019, and (2) prevalent MG patients in 2019. In total, 775 incident MG patients with a mean age of 66.9 years; and 1,247 prevalent MG patients with a mean age of 68.6 years were included. The prevalence for Germany was estimated to be 39.3/100,000 on 31/12/2019; the incidence in 2019 was 4.6 cases/100,000 persons. The 12-month mortality was 5.7. For 31.5% of the incident patients, no MG treatment was observed in the first year after the index date. Of all incident patients, 29.9% experienced an exacerbation, and 6.7% a myasthenic crisis during the observation. Our study indicates that a substantial proportion of MG patients remains untreated. Many MG patients still experience exacerbations / MG crises. MG seems to be associated with an excess mortality in comparison to the general non-MG population.
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Affiliation(s)
- Antje Mevius
- Ingress-health HWM GmbH, Alter Holzhafen 19, Wismar 23966, Germany.
| | - Lars Jöres
- UCB Pharma, Alfred-Nobel-Str. 10,Monheim 40789, Germany
| | - Jutta Biskup
- UCB Pharma, Alfred-Nobel-Str. 10,Monheim 40789, Germany
| | | | | | - Thomas Wilke
- IPAM e.V., University of Wismar, Alter Holzhafen 19, Wismar 23966, Germany
| | - Ulf Maywald
- AOK PLUS, Sternplatz 7, Dresden 01067, Germany
| | - Sophie Lehnerer
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany; BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany; BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
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33
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Hoffmann S, Stenzel W, Meisel A. Comment on: Nagaoka, A. et al., Motor end-plate analysis to diagnose immune-mediated myasthenia gravis in seronegative patients. J Neurol Sci, 2022. 443: p. 120494. J Neurol Sci 2023; 445:120542. [PMID: 36621038 DOI: 10.1016/j.jns.2023.120542] [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] [Received: 12/09/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Affiliation(s)
- Sarah Hoffmann
- Department of Neurology and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.
| | - Werner Stenzel
- Department of Neuropathology, Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Andreas Meisel
- Department of Neurology and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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Schwarz L, Akbari N, Prüss H, Meisel A, Scheibe F. Clinical characteristics, treatments, outcome, and prognostic factors of severe autoimmune encephalitis in the intensive care unit: Standard treatment and the value of additional plasma cell-depleting escalation therapies for treatment-refractory patients. Eur J Neurol 2023; 30:474-489. [PMID: 36176208 DOI: 10.1111/ene.15585] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE To investigate severe autoimmune encephalitis (AE) in the intensive care unit (ICU) with regard to standard treatment in responsive patients and additional escalation therapies for treatment-refractory cases. METHODS This retrospective, single-center study analyzed medical records of ICU-dependent AE patients for clinical characteristics, treatments, prognostic factors, and neurological outcome as quantified by modified Rankin Scale (mRS) and Clinical Assessment Scale for Autoimmune Encephalitis (CASE). RESULTS From 40 enrolled patients (median age = 52 years; range = 16-89 years) with AE mediated by neuronal surface antibodies (nsAb; 90%) and AE with onconeuronal antibodies (10%), 98% received first-line therapy. Of those, 62% obtained additional second-line therapy, and 33% received escalation therapy with bortezomib and/or daratumumab. Good neurological outcome, defined as mRS = 0-2, was observed in 47% of AE with nsAb (CASE = 5), 77% of anti-N-methyl D-aspartate receptor encephalitis patients (CASE = 1), whereas AE patients with onconeuronal antibodies had the poorest outcome (mRS = 6, 100%). Treatment-refractory AE patients with nsAb requiring escalation therapy achieved similarly good recovery (mRS = 0-2, 39%, CASE = 3) as patients improving without (mRS = 0-2, 54%, CASE = 4), although they presented a higher disease severity at disease maximum (mRS = 5 100% versus 68%, CASE = 24 versus 17; p = 0.0036), had longer ICU stays (97 versus 23 days; p = 0.0002), and a higher survival propability during follow-up (p = 0.0203). Prognostic factors for good recovery were younger age (p = 0.025) and lack of preexisting comorbidities (p = 0.011). CONCLUSIONS Our findings suggest that treatment-refractory AE patients with nsAb in the ICU can reach similarly good outcomes after plasma cell-depleting escalation therapy as patients already responding to standard first- and/or second-line therapies.
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Affiliation(s)
- Lisa Schwarz
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nilufar Akbari
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, NeuroCure Clinical Research Center, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, NeuroCure Clinical Research Center, Berlin, Germany
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Hoffmann S, Waters P, Jacobson L, Schuelke M, Stenzel W, Ruck T, Lehnerer S, Stascheit F, Preuße C, Meisel A. Autoantibody detection by a live cell-based assay in conventionally antibody-tested triple seronegative Myasthenia gravis. Neuromuscul Disord 2023; 33:139-144. [PMID: 36746691 DOI: 10.1016/j.nmd.2023.01.002] [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: 09/08/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
Autoantibody testing is the mainstay in confirming the diagnosis of autoimmune myasthenia gravis (MG). However, in approximately 15% of patients, antibody testing in clinical routine remains negative (seronegative MG). This study aimed at assessing the prevalence of "clustered" AChR- and MuSK- and LRP4- autoantibodies using a live cell-based assay in a large German cohort of seronegative myasthenia gravis (SNMG) patients. A total of 67 SNMG patients were included. Clustered AChR-ab were identified in 4.5% (n = 3) of patients. Two out of the three patients showed binding to the adult AchR as well as the fetal AchR. None of the patients was positive for MuSK- or LRP4-autoantibodies. There were no differences in clinical characteristics between the patients with and without clustered AChR-ab detection. Comparison of clinical data of our cohort with clinical data from the nationwide Myasthenia gravis registry showed broad similarities between seronegative MG patients of both cohorts.
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Affiliation(s)
- Sarah Hoffmann
- Department of Neurology and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany.
| | - Patrick Waters
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom
| | - Markus Schuelke
- Department of Neuropediatrics and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sophie Lehnerer
- Department of Neurology and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Corinna Preuße
- Department of Neuropathology, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Andreas Meisel
- Department of Neurology and NeuroCure Clinical Research Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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Dewilde S, Philips G, Paci S, Beauchamp J, Chiroli S, Quinn C, Day L, Larkin M, Palace J, Berrih-Aknin S, Claeys KG, Muppidi S, Mantegazza R, Saccà F, Meisel A, Bassez G, Murai H, Janssen MF. Patient-reported burden of myasthenia gravis: baseline results of the international prospective, observational, longitudinal real-world digital study MyRealWorld-MG. BMJ Open 2023; 13:e066445. [PMID: 36720569 PMCID: PMC9890761 DOI: 10.1136/bmjopen-2022-066445] [Citation(s) in RCA: 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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Myasthenia gravis (MG) is a rare, chronic, autoimmune neuromuscular disease which can affect functional and mental aspects of health and health-related quality of life (HRQoL). This study aims to obtain detailed knowledge of the impact of MG on HRQoL in a broad population from the perspective of the patient. DESIGN Prospective, observational, digital, longitudinal real-world study. SETTING Adult patients with MG from seven countries (USA, Japan, Germany, UK, Italy, Spain and Canada) downloaded a mobile application onto their phones and entered data about themselves and their MG. OUTCOME MEASURES Data was collected using the following general and disease-specific patient-reported outcome measurements: EuroQol 5 Domains Health-Related Quality of Life Questionnaire (EQ-5D-5L), Myasthenia Gravis Activities of Daily Living (MG-ADL), Myasthenia Gravis Quality of Life 15-item revised scale (MG-QoL-15r), Hospital Anxiety and Depression Scale (HADS) and Health Utilities Index III (HUI3). Patients were categorised by their self-assessed Myasthenia Gravis Foundation of America (MGFA) class (I-V). RESULTS Baseline results of 841 participants (mean age 47 years, 70% women) are reported . The distribution across the MGFA classes was: 13.9%, 31.0%, 38.1%, 15.5% and 1.6% for classes I-V. The MGFA class was a strong predictor of all aspects of HRQoL, measured with disease-specific and with generic instruments. The domains in which patients with MG most frequently mentioned problems were usual activities, anxiety and depression, tiredness, breathing and vision. The mean total MG-ADL Score was positively associated with increasing MGFA classes: 2.7, 4.4, 6.3 and 8.4 for MGFA classes I-IV. Mean baseline EQ-5D-5L utility was also associated with MGFA classes and was 0.817, 0.766, 0.648 and 0.530 for MGFA class I-IV. CONCLUSIONS MG has a large impact on key aspects of health and HRQoL. The impact of this disease increases substantially with increasing disease severity.
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Affiliation(s)
| | | | - Sandra Paci
- Market Access & Patient Advocacy, argenx, Ghent, Belgium
| | - Jon Beauchamp
- Market Access & Patient Advocacy, argenx, Ghent, Belgium
| | | | | | | | | | | | - Sonia Berrih-Aknin
- INSERM, Institute of Myology, Center of Research in Myology, Sorbonne Université, Paris, France
| | - Kristl G Claeys
- Department of Neurology, KU Leuven University Hospitals, Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University, Stanford, California, USA
| | - Renato Mantegazza
- Fondazione IRCCS, Istituto Nazionale Neurologico Carlo Besta, Milano, Italy
- Associazione Italiana Miastenia e Malattie Immunodegenerative, Milan, Italy
| | - Francesco Saccà
- DNSRO Department, University of Naples Federico II, Napoli, Italy
| | - Andreas Meisel
- Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Guillaume Bassez
- Neuromuscular Diseases Reference Center, Pitié-Salpêtrière University Hospital, Paris, France
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - M F Janssen
- Department of Medical Psychology and Psychotherapy, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Stascheit F, Aigner A, Mergenthaler P, Hotter B, Hoffmann S, Lehnerer S, Meisel C, Meisel A. Serum neurofilament light chain in myasthenia gravis subgroups: An exploratory cohort and case-Control study. Front Neurol 2023; 13:1056322. [PMID: 36712429 PMCID: PMC9875128 DOI: 10.3389/fneur.2022.1056322] [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: 09/28/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023] Open
Abstract
Background This study aimed to evaluate the association of neurofilament light chain (Nfl) with neuromuscular destruction and disease severity in the serum of patients with myasthenia gravis (MG). Materials and methods Sera from 134 patients with MG with varying degrees of disease severity and autoantibody (Abs) status were analyzed and compared to controls in a cross-sectional design. Prospectively, we additionally measured serum NfL (sNfl) levels in patients with MG longitudinally for up to 3 years. Based on linear regression, differences between patients and controls were assessed. With correlation coefficients and mixed linear regression, the association among sNfl levels, socio-demographics, disease activity (Quantitative Myasthenia Gravis (QMG) score and Myasthenia Gravis Activities of Daily Living (MG-ADL) scale), Abs-status (acetylcholine receptor antibody (AChR-Abs), muscle-specific receptor tyrosine kinase antibody (MuSK-Abs), lipoprotein-related protein 4 (LRP4), and seronegative), Abs titer, treatment regime (pyridostigmine, steroids, and immunosuppressive therapies), and thymectomy were investigated. Results sNfl levels were higher in patients with MG compared to controls (median: 11.2 vs. 7.88), where sNfl levels were highest in anti-AChR-Abs positive patients (median 12.6), followed by anti-MuSK-Abs positive, anti-LRP4-Abs positive, and seronegative patients. Adjusting for age and sex, sNfl levels of patients with MG were on average 35% higher compared to controls (35.1, 95% CI: 8.4;68.3) and highest for patients with seronegative MG (44.35; 95% CI 16.47; 78.90). We found no relevant relationship between individual changes in sNfl and changes in QMG and MG-ADL scores. Conclusion sNfl levels are higher in patients with MG than in controls but were not consistently associated with clinical severity. Thus, sNfl is not a suitable biomarker to monitor individual disease progression in patients with MG.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,*Correspondence: Frauke Stascheit ✉
| | - Annette Aigner
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Philipp Mergenthaler
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sophie Lehnerer
- NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Berlin Institute of Health (BIH), Berlin, Germany
| | - Christian Meisel
- Department of Immunology, Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, Berlin, Germany,Labor Berlin, Charité Vivantes GmbH, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,NeuroCure Clinical Research Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany,Integrated Myasthenia Gravis Center, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Stascheit F, Grittner U, Hoffmann S, Mergenthaler P, Schroeter M, Ruck T, Pawlitzki M, Blaes F, Kaiser J, Schara U, Della-Marina A, Thieme A, Hagenacker T, Jacobi C, Berger B, Urban PP, Knop KC, Schalke B, Lee DH, Kalischewski P, Wiendl H, Meisel A. Risk and course of COVID-19 in immunosuppressed patients with myasthenia gravis. J Neurol 2023; 270:1-12. [PMID: 36166068 PMCID: PMC9512984 DOI: 10.1007/s00415-022-11389-0] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with myasthenia gravis (MG) are potentially prone for a severe COVID-19 course, but there are limited real-world data available on the risk associated with COVID-19 for patients with MG. Here, we investigate whether current immunosuppressive therapy (IST) influences the risk of SARS-CoV-2 infection and COVID-19 severity. METHODS Data from the German myasthenia gravis registry were analyzed from May 2020 until June 2021 and included patient demographics, MG disease duration, comorbidities, current IST use, COVID-19 characteristics, and outcomes. Propensity score matching was employed to match MG patients with IST to those without, and multivariable binary logistic regression models were used to determine associations between IST with (1) symptomatic SARS-CoV-2 infection and (2) severe COVID-19 course, as measured by hospitalization or death. RESULTS Of 1379 patients with MG, 95 (7%) patients (mean age 58 (standard deviation [SD] 18) presented with COVID-19, of which 76 (80%) received IST at time of infection. 32 patients (34%) were hospitalized due to COVID-19; a total of 11 patients (12%) died. IST was a risk factor for hospitalization or death in the group of COVID-19-affected MG patients (odds ratio [OR] 3.04, 95% confidence interval [CI] = 1.02-9.06, p = 0.046), but current IST was not associated with a higher risk for SARS-CoV-2 infection itself. DISCUSSION In this national MG cohort study, current IST use was a risk factor for a severe disease course of COVID-19 but not for SARS-CoV-2 infection itself. These data support the consequent implementation of effective strategies to prevent COVID-19 in this high-risk group. TRIAL REGISTRATION INFORMATION German clinical trial registry ( https://www.drks.de ), DRKS00024099, first patient enrolled: February 4th, 2019.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany ,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Mergenthaler
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany ,Center for Stroke Research Berlin, Charité — Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Schroeter
- Department of Neurology, University of Cologne and University Hospital, Cologne, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mark Pawlitzki
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Franz Blaes
- Department of Neurology, Kreiskrankenhaus Oberberg GmbH, Oberberg, Germany
| | - Julia Kaiser
- Department of Neurology, LVR Klinik Bonn, Bonn, Germany
| | - Ulrike Schara
- Department of Neuropediatric, University of Duisburg-Essen, Essen, Germany
| | - Adela Della-Marina
- Department of Neuropediatric, University of Duisburg-Essen, Essen, Germany
| | - Andrea Thieme
- Department of Neurology, Helios Hospital Erfurt, Erfurt, Germany
| | - Tim Hagenacker
- Department of Neurology Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, Essen, Germany
| | - Christian Jacobi
- Department of Neurology, Sankt Katharinen Krankenhaus GmbH, Frankfurt, Germany
| | - Benjamin Berger
- Department of Neurology, Helios Hospital Pforzheim, Pforzheim, Germany ,Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter P. Urban
- Department of Neurology, Asklepios Hospital Hamburg Barmbek, Hamburg, Germany
| | | | - Berthold Schalke
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - De-Hyung Lee
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany ,Center for Stroke Research Berlin, Charité — Universitätsmedizin Berlin, Berlin, Germany
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Meisel A, Baggi F, Behin A, Evoli A, Kostera-Pruszczyk A, Mantegazza R, Morales RJ, Punga AR, Sacconi S, Schroeter M, Verschuuren J, Crathorne L, Holmes K, Leite MI. Role of autoantibody levels as biomarkers in the management of patients with myasthenia gravis: A systematic review and expert appraisal. Eur J Neurol 2023; 30:266-282. [PMID: 36094738 DOI: 10.1111/ene.15565] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/26/2022] [Accepted: 09/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Although myasthenia gravis (MG) is recognized as an immunoglobulin G autoantibody-mediated disease, the relationship between autoantibody levels and disease activity in MG is unclear. We sought to evaluate this landscape through systematically assessing the evidence, testing the impact of predefined variables on any relationship, and augmenting with expert opinion. METHODS In October 2020, a forum of leading clinicians and researchers in neurology from across Europe (Expert Forum for Rare Autoantibodies in Neurology in Myasthenia Gravis) participated in a series of virtual meetings that took place alongside the conduct of a systematic literature review (SLR). RESULTS Forty-two studies were identified meeting inclusion criteria. Of these, 10 reported some correlation between a patient's autoantibody level and disease severity. Generally, decreased autoantibody levels (acetylcholine receptor, muscle-specific kinase, and titin) were positively and significantly correlated with improvements in disease severity (Quantitative Myasthenia Gravis score, Myasthenia Gravis Composite score, Myasthenia Gravis Activities of Daily Living score, Myasthenia Gravis Foundation of America classification). Given the limited evidence, testing the impact of predefined variables was not feasible. CONCLUSIONS This first SLR to assess whether a correlation exists between autoantibody levels and disease activity in patients with MG has indicated a potential positive correlation, which could have clinical implications in guiding treatment decisions. However, in light of the limited and variable evidence, we cannot currently recommend routine clinical use of autoantibody level testing in this context. For now, patient's characteristics, clinical disease course, and laboratory data (e.g., autoantibody status, thymus histology) should inform management, alongside patient-reported outcomes. We highlight the need for future studies to reach more definitive conclusions on this relationship.
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Affiliation(s)
- Andreas Meisel
- Department of Neurology, Integrated Myasthenia Gravis Center, NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fulvio Baggi
- Neuroimmunology and Neuromuscular Diseases Unit, Scientific Institute for Research and Health Care Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Anthony Behin
- Department of Neuromyology, Pitié-Salpêtrière Hospital, Public Hospital Network of Paris, Institute of Myology, Paris, France
| | - Amelia Evoli
- Catholic University of the Sacred Heart and Agostino Gemelli University Polyclinic Foundation, Scientific Institute for Research and Health Care, Rome, Italy
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Scientific Institute for Research and Health Care Foundation Carlo Besta Neurological Institute, Milan, Italy
| | | | - Anna Rostedt Punga
- Department of Medical Science, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | | | - Michael Schroeter
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Jan Verschuuren
- Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Maria-Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Stein M, Hoffmann S, Gerischer L, Stascheit F, Legg D, Meisel A, Lehnerer S. Myasthenia gravis - a retrospective analysis of e-mail inquiries made to a patient organisation and specialized center to uncover unmet needs from patients and caregivers. BMC Neurol 2022; 22:455. [PMID: 36476357 PMCID: PMC9727989 DOI: 10.1186/s12883-022-02981-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Myasthenia Gravis requires expert treatment from specialized neurologists. In Germany, this treatment is mainly provided by 18 Integrated Myasthenia Centers (iMZ) accredited by the German Myasthenia Gravis Association (DMG). The DMG is a large and well-organized patient organisation that is regarded as a trusted source for disease-specific information. The aim of this study was to analyse the type of requests that each of these institutions receives in order to identify any potential unmet needs regarding the availability of advice for patients and caregivers. This data can then be used in further research to tailor modern digital communication tools to the specific needs of MG patients. METHODS Counselling requests sent via e-mail to both institutions were extracted for defined examination periods and divided into a period 'before COVID-19 pandemic' (01.07.2019-31.12.2019) and 'during COVID-19 pandemic' (01.07.2020-31.12.2020). Requests were then analysed using four main categories: medical requests, organisational issues, COVID-19 and social legislation inquiries. RESULTS One thousand seven hundred eleven requests for advice were addressed to DMG and iMZ Charité. Most inquiries directed to the DMG (47%; n = 750) were related to medical issues, most frequently to side effects of medications (n = 325; 20%) and questions about treatment (n = 263; 16%), followed by inquiries regarding organisational issues (26%; n = 412). About half of the inquiries (n = 69; 58%) to the iMZ Charité were related to medical issues and almost one in three inquiries concerned organisational issues (n = 37; 30%). About one in ten inquiries concerned socio-legal matters (iMZ: n = 7; 6% and DMG: n = 177; 11%). During the pandemic, COVID-19 related issues accounted for 8% (n = 6) of inquiries at iMZ, and 16% (n = 253) at DMG. CONCLUSIONS MG sufferers have a high demand for timely advice. In the current setting, they address their requests to both iMZs and the DMG via e-mail. Our findings confirm that the DMG is highly trusted by patients and caregivers and is used to obtain second opinions. A relevant proportion of requests to the iMZ could be answered more effectively through standardized responses or improved process management. The implementation of modern digital solutions, including telemedicine, for communication between patient and specialist should be evaluated in further research.
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Affiliation(s)
- Maike Stein
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany. .,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany. .,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - David Legg
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Charitéplatz 1, 10117, Berlin, Germany
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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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Schubert M, Pelz A, Trautmann G, Block K, Furlan S, Gutsmann M, Kohler S, Volpe P, Blottner D, Meisel A, Salanova M. Opposite Regulation of Homer Signal at the NMJ Postsynaptic Micro Domain between Slow- and Fast-Twitch Muscles in an Experimentally Induced Autoimmune Myasthenia Gravis (EAMG) Mouse Model. Int J Mol Sci 2022; 23:ijms232315052. [PMID: 36499379 PMCID: PMC9738765 DOI: 10.3390/ijms232315052] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/17/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022] Open
Abstract
Accelerated postsynaptic remodelling and disturbance of neuromuscular transmission are common features of autoimmune neurodegenerative diseases. Homer protein isoform expression, crosslinking activity and neuromuscular subcellular localisation are studied in mouse hind limb muscles of an experimentally induced autoimmune model of Myasthenia Gravis (EAMG) and correlated to motor end plate integrity. Soleus (SOL), extensor digitorum longus (EDL) and gastrocnemius (GAS) skeletal muscles are investigated. nAChR membrane clusters were studied to monitor neuromuscular junction (NMJ) integrity. Fibre-type cross-sectional area (CSA) analysis is carried out in order to determine the extent of muscle atrophy. Our findings clearly showed that crosslinking activity of Homer long forms (Homer 1b/c and Homer2a/b) are decreased in slow-twitch and increased in fast-twitch muscle of EAMG whereas the short form of Homer that disrupts Homer crosslinking (Homer1a) is upregulated in slow-twitch muscle only. Densitometry analysis showed a 125% increase in Homer protein expression in EDL, and a 45% decrease in SOL of EAMG mice. In contrast, nAChR fluorescence pixel intensity decreased in endplates of EAMG mice, more distinct in type-I dominant SOL muscle. Morphometric CSA of EAMG vs. control (CTR) revealed a significant reduction in EDL but not in GAS and SOL. Taken together, these results indicate that postsynaptic Homer signalling is impaired in slow-twitch SOL muscle from EAMG mice and provide compelling evidence suggesting a functional coupling between Homer and nAChR, underscoring the key role of Homer in skeletal muscle neurophysiology.
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Affiliation(s)
- Martin Schubert
- Institute of Integrative Neuroanatomy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10115 Berlin, Germany
| | - Andreas Pelz
- Department of Experimental Neurology, Charité—Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Gabor Trautmann
- Institute of Integrative Neuroanatomy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10115 Berlin, Germany
| | - Katharina Block
- Center of Space Medicine Berlin, Neuromuscular Signaling and System, 10115 Berlin, Germany
| | - Sandra Furlan
- C.N.R. Institute of Neuroscience, 35131 Padova, Italy
| | - Martina Gutsmann
- Institute of Integrative Neuroanatomy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10115 Berlin, Germany
| | - Siegfried Kohler
- Department of Experimental Neurology, Charité—Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Pompeo Volpe
- Department of Biomedical Sciences, University of Padova, 35122 Padova, Italy
| | - Dieter Blottner
- Institute of Integrative Neuroanatomy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10115 Berlin, Germany
- Center of Space Medicine Berlin, Neuromuscular Signaling and System, 10115 Berlin, Germany
| | - Andreas Meisel
- Department of Experimental Neurology, Charité—Universitätsmedizin Berlin, 10115 Berlin, Germany
| | - Michele Salanova
- Institute of Integrative Neuroanatomy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10115 Berlin, Germany
- Center of Space Medicine Berlin, Neuromuscular Signaling and System, 10115 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450528-354
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Meisel A, Mark M, Haider A, Holer L, Hayoz S, Gebhard C, Bengs S, Treyer V, Rothschild S, Hochmair M, Gandara D, Cappuzzo F, Reck M, Stenner-Liewen F, von Moos R. 1051P Radiotherapy (RT) and efficacy of immune checkpoint inhibitors (ICI), chemotherapy (CTx) and chemoimmunotherapy (CIT) in patients with non-small cell lung cancer (NSCLC). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Li F, Zhang H, Tao Y, Stascheit F, Han J, Gao F, Liu H, Carmona-Bayonas A, Li Z, Rueckert JC, Meisel A, Zhao S. Prediction of the generalization of myasthenia gravis with purely ocular symptoms at onset: a multivariable model development and validation. Ther Adv Neurol Disord 2022; 15:17562864221104508. [PMID: 35755967 PMCID: PMC9218496 DOI: 10.1177/17562864221104508] [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: 11/15/2021] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background About half of myasthenia gravis (MG) patients with purely ocular symptoms at onset progress to generalized myasthenia gravis (gMG). Objectives To develop and validate a model to predict the generalization of MG at 6 months after disease onset in patients with ocular-onset myasthenia gravis (OoMG). Methods Data of patients with OoMG were retrospectively collected from two tertiary hospitals in Germany and China. An accelerated failure time model was developed using the backward elimination method based on the German cohort to predict the generalization of OoMG. The model was then externally validated in the Chinese cohort, and its performance was assessed using Harrell's C-index and calibration plots. Results Four hundred and seventy-seven patients (275 from Germany and 202 from China) were eligible for inclusion. One hundred and three (37.5%) patients in the German cohort progressed from OoMG to gMG with a median follow-up time of 69 (32-116) months. The median time to generalization was 29 (16-71) months. The estimated cumulative probability of generalization was 30.5% [95% CI (confidence interval), 24.3-36.2%) at 5 years after disease onset. The final model, which was represented as a nomogram, included five clinical variables: sex, titer of anti-AChR antibody, status of anti-MuSK antibody, age at disease onset and the presence of other autoimmune disease. External validation of the model using the bootstrap showed a C-index of 0.670 (95% CI, 0.602-0.738). Calibration curves revealed moderate agreement of predicted and observed outcomes. Conclusion The nomogram is a good predictor for generalization in patients with OoMG that can be used to inform of the individual generalization risk, which might improve the clinical decision-making.
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Affiliation(s)
- Feng Li
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbin Zhang
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, Berlin, Germany
| | - Ya Tao
- Department of Obstetrics, The First Affiliated Hospital of Zhengzhou University, Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China
| | - Frauke Stascheit
- Department of Neurology, Integrated Center for Myasthenia Gravis, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité - University Medicine Berlin, Berlin, Germany
| | - Jiaojiao Han
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongbo Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Alberto Carmona-Bayonas
- Hospital Universitario Morales Meseguer, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, Berlin, Germany
| | - Jens-C Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Integrated Center for Myasthenia Gravis, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité - University Medicine Berlin, Berlin, Germany
| | - Song Zhao
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
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Stascheit F, Rübsam A, Otto C, Meisel A, Ruprecht K, Pleyer U. Anti-CD20 therapy for multiple sclerosis associated uveitis: a case series. Eur J Neurol 2022; 29:3028-3038. [PMID: 35716269 DOI: 10.1111/ene.15453] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND About 1% of patients with multiple sclerosis (MS) suffer from uveitis, but data on the effects of immunotherapies for MS on MS-associated uveitis are scarce. OBJECTIVE To investigate the ophthalmological outcomes in patients with MS-associated uveitis treated with anti-CD20 therapy. METHODS Retrospective study of 12 eyes of 6 patients with MS-associated uveitis, refractory to previous immunotherapies. Uveitis activity was assessed before initiation of anti-CD20 therapy and at regular follow-up visits. Primary outcome measures were vitreous haze score, retinal vasculitis score determined on fluorescein angiography images, macular edema as quantified by central retinal thickness (CRT) on optical coherence tomography, and visual acuity. Secondary outcomes included the number of annualized uveitis or MS relapses, disease activity on cerebral magnetic resonance imaging (cMRI) and the expanded disability status scale (EDSS). RESULTS After a median (IQR) treatment time of 28.5 (8-43) months, anti-CD20 therapy was associated with an improvement of vitreous haze score (p=0.002), retinal vasculitis score (p=0.001), CRT (p=0.002), and visual acuity (p=0.007). The median (IQR) annualized uveitis relapse rate declined from 0.59 (0.56-0.94) before to 0 (0-0.49) after the start of anti-CD20 therapy. The median (IQR) annualized MS relapse rate declined from 0.62 (0.26-2.84) before to 0 (0-0) after the start of anti-CD20 therapy. After initiation of anti-CD20 therapy, there was no disease activity on cMRI and the EDSS improved (n=2) or remained stable (n=4). No severe adverse events were observed. CONCLUSION These findings suggest that anti-CD20 therapy may be a valuable treatment option for MS-associated uveitis.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anne Rübsam
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carolin Otto
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Uwe Pleyer
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Lehnerer S, Jacobi J, Schilling R, Grittner U, Marbin D, Gerischer L, Stascheit F, Krause M, Hoffmann S, Meisel A. Burden of disease in myasthenia gravis: taking the patient's perspective. J Neurol 2022; 269:3050-3063. [PMID: 34800167 PMCID: PMC9120127 DOI: 10.1007/s00415-021-10891-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/10/2021] [Accepted: 11/02/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) leads to exertion-dependent muscle weakness, but also psychological and social well-being are limited. We aim to describe the burden of disease in MG including sociodemographic, economical, psychosocial as well as clinical aspects, to compare health-related quality of life (HRQoL) of patients with MG to the general population (genP) and to explore risk factors for a lower HRQoL. METHODS This case-control study was conducted with MG patients of the German Myasthenia Association. A questionnaire-based survey included sociodemographic and clinical data as well as standardized questionnaires, e.g. the Short Form Health (SF-36). HRQoL was compared to genP in a matched-pairs analysis. Participants of the German Health Interview and Examination Survey for Adults (DEGS1) served as control group. RESULTS In our study, 1660 MG patients participated and were compared to 2556 controls from the genP. Patients with MG showed lower levels of physical functioning (SF-36 mean 56.0, SD 30.3) compared to the genP (mean 81.8, SD 22.1, adjusted difference: 25, 95% CI 22-29) and lower mental health sub-score (SF-36 mean 67.3, SD 19.8, vs. 74.1, SD 16.7, adjusted difference: 5, 95% CI 2-8). Female gender, higher age, low income, partnership status, lower activities of daily life, symptoms of depression, anxiety and fatigue and self-perceived low social support were associated with a lower HRQoL in MG patients. DISCUSSION HRQoL is lower in patients with MG compared to genP. The burden of MG on patients includes economic and social aspects as well as their emotional well-being. New therapies must achieve improvements for patients in these areas. TRIAL REGISTRATION INFORMATION Clinicaltrials.gov, NCT03979521, submitted: June 7, 2019, first patient enrolled: May 1, 2019, https://clinicaltrials.gov/ct2/show/NCT03979521.
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Affiliation(s)
- Sophie Lehnerer
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Jonas Jacobi
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ralph Schilling
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medicine Berlin, Luisenstraße 57, 10117, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Core Facility Genomics, Berlin Institute of Health at Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Derin Marbin
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, Charité University Medicine Berlin at St. Hedwig Hospital, Große Hamburger Straße 5-11, 10115, Berlin, Germany
| | - Lea Gerischer
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Maike Krause
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Meisel A, Sieb JP, Le Masson G, Postila V, Sacconi S. The European Lambert-Eaton Myasthenic Syndrome Registry: Long-Term Outcomes Following Symptomatic Treatment. Neurol Ther 2022; 11:1071-1083. [PMID: 35511347 PMCID: PMC9338181 DOI: 10.1007/s40120-022-00354-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/07/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Lambert-Eaton myasthenic syndrome (LEMS) is characterized by autoantibodies against voltage-gated calcium channels (VGCC) at the neuromuscular junction causing proximal muscle weakness, decreased tendon reflexes, and autonomic changes. The European LEMS registry aimed to collate observational safety data for 3,4-diaminopyridine phosphate (3,4-DAPP) and examine long-term outcomes for patients with LEMS. METHODS Thirty centers across four countries participated in the non-interventional European LEMS registry. Any patients diagnosed with LEMS by means of clinical assessment and abnormal neurophysiological testing, or clinical assessment and positive for VGCC antibodies were eligible to participate. Patients were monitored using standard assessments for LEMS-related clinical manifestations. RESULTS Among 96 evaluable participants, 50 (52.1%) were being treated with 3,4-DAPP, 21 (21.9%) with 3,4-diaminopyridine (3,4-DAP), and 25 (26.0%) with other treatments (e.g., pyridostigmine, corticosteroids, immunoglobulins, and azathioprine); 74 participants (77.1%) were exposed to 3,4-DAPP at any time. Quantitative myasthenia gravis scores were similar across treatment groups. Muscle strength was generally good and maintained during follow-up. Cerebellar ataxia, defined as a negative Romberg's test and at least one other positive ataxia test, was observed in 30 (56.6%) patients. Most participants had reduced reflex tone and limited functioning. Sustained or improved functioning was observed in participants administered 3,4-DAPP. Inconsistent and sporadic functional improvement and regression was observed with 3,4-DAP and other treatments. Fifty-five treatment-related adverse events (AEs) were reported by 32 (33.3%) participants. Eight (8.3%) participants reported nine treatment-related serious AEs. No new safety signals were identified. CONCLUSION No new safety signals were observed following long-term management of LEMS with 3,4-DAPP.
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Affiliation(s)
- Andreas Meisel
- Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Jörn P Sieb
- HELIOS Hanseklinikum Stralsund, Stralsund, Germany
| | | | | | - Sabrina Sacconi
- Service Système Nerveux Périphérique et Muscles, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
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Vu T, Meisel A, Mantegazza R, Annane D, Katsuno M, Aguzzi R, Enayetallah A, Beasley KN, Rampal N, Howard JF. Terminal Complement Inhibitor Ravulizumab in Generalized Myasthenia Gravis. NEJM Evid 2022; 1:EVIDoa2100066. [PMID: 38319212 DOI: 10.1056/evidoa2100066] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Ravulizumab in Generalized Myasthenia GravisIn this randomized controlled trial, ravulizumab provided rapid and efficacious treatment of adult patients with anti-acetylcholine reception antibody-positive generalized myasthenia gravis, as determined by both patient- and clinician-rated outcomes, with few adverse events.
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Affiliation(s)
- Tuan Vu
- University of South Florida Morsani College of Medicine, Tampa
| | | | - Renato Mantegazza
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan
| | - Djillali Annane
- Hôpital Raymond Poincaré, University of Versailles, Garches, France
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Nelke C, Schroeter CB, Stascheit F, Pawlitzki M, Regner-Nelke L, Huntemann N, Arat E, Öztürk M, Melzer N, Mergenthaler P, Gassa A, Stetefeld H, Schroeter M, Berger B, Totzeck A, Hagenacker T, Schreiber S, Vielhaber S, Hartung HP, Meisel A, Wiendl H, Meuth SG, Ruck T. Eculizumab versus rituximab in generalised myasthenia gravis. J Neurol Neurosurg Psychiatry 2022; 93:548-554. [PMID: 35246490 PMCID: PMC9016243 DOI: 10.1136/jnnp-2021-328665] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/22/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Myasthenia gravis (MG) is the most common autoimmune disorder affecting the neuromuscular junction. However, evidence shaping treatment decisions, particularly for treatment-refractory cases, is sparse. Both rituximab and eculizumab may be considered as therapeutic options for refractory MG after insufficient symptom control by standard immunosuppressive therapies. METHODS In this retrospective observational study, we included 57 rituximab-treated and 20 eculizumab-treated patients with MG to compare the efficacy of treatment agents in generalised, therapy-refractory anti-acetylcholine receptor antibody (anti-AChR-ab)-mediated MG with an observation period of 24 months. Change in the quantitative myasthenia gravis (QMG) score was defined as the primary outcome parameter. Differences between groups were determined in an optimal full propensity score matching model. RESULTS Both groups were comparable in terms of clinical and demographic characteristics. Eculizumab was associated with a better outcome compared with rituximab, as measured by the change of the QMG score at 12 and 24 months of treatment. Minimal manifestation of disease was more frequently achieved in eculizumab-treated patients than rituximab-treated patients at 12 and 24 months after baseline. However, the risk of myasthenic crisis (MC) was not ameliorated in either group. INTERPRETATION This retrospective, observational study provides the first real-world evidence supporting the use of eculizumab for the treatment of refractory, anti-AChR-ab positive MG. Nonetheless, the risk of MC remained high and prompts the need for intensified monitoring and further research effort aimed at this vulnerable patient cohort.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | | | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc Pawlitzki
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany.,Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Liesa Regner-Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Niklas Huntemann
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Ercan Arat
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Menekse Öztürk
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Nico Melzer
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Philipp Mergenthaler
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Asmae Gassa
- Department of Cardiothoracic Surgery, University Hospital Cologne, Koln, Germany
| | - Henning Stetefeld
- Departement of Neurology, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | | | - Benjamin Berger
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Freiburg, Germany
| | - Andreas Totzeck
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefan Vielhaber
- Otto von Guericke Universität Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology - Inflammatory Disorders of the Nervous System and Neurooncology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
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Abstract
Inflammation and immune mechanisms are crucially involved in the pathophysiology of the development, acute damage cascades, and chronic course after ischemic stroke. Atherosclerosis is an inflammatory disease, and, in addition to classical risk factors, maladaptive immune mechanisms lead to an increased risk of stroke. Accordingly, individuals with signs of inflammation or corresponding biomarkers have an increased risk of stroke. Anti-inflammatory drugs, such as IL (interleukin)-1β blockers, methotrexate, or colchicine, represent attractive treatment strategies to prevent vascular events and stroke. Lately, the COVID-19 pandemic shows a clear association between SARS-CoV2 infections and increased risk of cerebrovascular events. Furthermore, mechanisms of both innate and adaptive immune systems influence cerebral damage cascades after ischemic stroke. Neutrophils, monocytes, and microglia, as well as T and B lymphocytes each play complex interdependent roles that synergize to remove dead tissue but also can cause bystander injury to intact brain cells and generate maladaptive chronic inflammation. Chronic systemic inflammation and comorbid infections may unfavorably influence both outcome after stroke and recurrence risk for further stroke. In addition, stroke triggers specific immune depression, which in turn can promote infections. Recent research is now increasingly addressing the question of the extent to which immune mechanisms may influence long-term outcome after stroke and, in particular, cause specific complications such as poststroke dementia or even poststroke depression.
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Affiliation(s)
- Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Excellence Cluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,German Center for Neurodegenerative Diseases, Partner Site Berlin, Germany (M.E.).,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Maria A Moro
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (M.A.M.).,Departamento de Farmacología yToxicología, Unidad de Investigación Neurovascular, Universidad Complutense de Madrid, Madrid, Spain (M.A.M.).,Instituto Universitario de Investigación en Neuroquímica, UCM, Madrid, Spain (M.A.M.).,Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain (M.A.M.)
| | - Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Claudia Dames
- Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Institute for Medical Immunology (C.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.S.B.).,Wu Tsai Neurosciences Institute, Stanford University, CA (M.S.B.)
| | - Andreas Meisel
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,NeuroCure Clinical Research Center (A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
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