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A disease in which antibodies made by a person's immune system prevent certain nerve-muscle interactions. It causes weakness in the arms and legs, vision problems, and drooping eyelids or head.

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Myasthenia gravis is caused by the body's antibodies impairing transmission of nerve impulses to muscles, resulting in fluctuating weakness and fatigue. Acute attacks can be life threatening because of swallowing or breathing difficulties. Seven randomised controlled trials which included in all 199 participants are published. None fulfilled the presently accepted standards of a high‐quality trial. All these studies have risks of bias and have a weak statistical power. Limited evidence from randomised controlled trials suggests that corticosteroids offer short‐term benefit compared with placebo (dummy treatment). This supports the conclusions of observational studies and expert opinion. Limited evidence from randomised controlled trials does not show any difference in efficacy between corticosteroids and either azathioprine or intravenous immunoglobulin. All trials had design flaws which limit the strength of the conclusions. Further randomised controlled trials are needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: April 20, 2005

We reviewed the evidence about the effect of ephedrine in adults and children with myasthenia gravis (MG), neonatal myasthenia and the congenital myasthenic syndromes (CMSs).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: December 17, 2014

Myasthenia gravis is caused by antibodies in the blood which attack the junctions between nerves and muscles they stimulate. Plasma exchange removes these circulating auto‐antibodies. Many case series suggest that plasma exchange helps to treat myasthenia gravis. Four randomised controlled trials were identified. In the first one, of 14 participants with moderate or severe myasthenia gravis, the myasthenic muscular score after one month was not significantly different for participants treated with plasma exchange and prednisone than for those treated with prednisone alone but there can be only low statistical confidence in the results of this study because of its small size. A randomised controlled cross‐over trial of only 12 participants reported the same efficacy, after four weeks, of plasma exchange or intravenous immunoglobulins for the treatment of moderate to severe myasthenia gravis, but because of bias and a very weak statistical power the data prevent any conclusion. The third, including 87 participants, showed the same efficacy, after two weeks, of plasma exchange or intravenous immunoglobulins for the treatment of myasthenia gravis exacerbation. The fourth randomised controlled trial involving 35 participants reported a benefit from plasma exchange before thymectomy but this trial was heavily biased. No trial addressed the new subtype with antibodies to a muscle specific kinase. Further research is needed to determine the value of long‐term plasma exchange for treating myasthenia gravis and to compare plasma exchange with alternative short‐term treatments for myasthenic crisis or before thymectomy in both types of autoimmune myasthenia.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 21, 2002

Myasthenia gravis is a disorder that causes muscle weakness and excessive muscle tiredness. In most people with myasthenia gravis, muscles throughout the body are affected in the first two years after the onset of symptoms, although there is also a form of the disease that affects only the eyes (ocular myasthenia). Myasthenia gravis occurs when the person’s own immune system attacks the vital structures that transmit impulses from nerves to muscle, the neuromuscular junctions. A tumour affecting an immune system organ called the thymus (a thymoma) is sometimes the underlying cause; this is known as thymomatous myasthenia gravis. Thymomatous myasthenia gravis was not the subject of this systematic review as the thymoma should be treated on its own merit, independently of the myasthenia gravis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 14, 2013

Myasthenia gravis is characterised by fluctuating muscle weakness and muscles that tire easily. An acute increase in symptoms can be life‐threatening because of swallowing difficulties or respiratory failure. Myasthenia gravis is an autoimmune disorder in which the body's own antibodies block the transmission of nerve impulses to muscles and damage the neuromuscular junction (where the nerve meets the muscle). With optimal treatment, including thymectomy, corticosteroids, immunosuppressive drugs and plasma exchange, most people with myasthenia gravis go into remission or improve but these treatments can cause many adverse events. Intravenous immunoglobulin (IVIg) (antibodies purified from human blood), is effective in other autoimmune diseases. The objective of this review was to examine the efficacy of IVIg for treating acute exacerbations or for chronic long‐term, persistent myasthenia. We identified seven randomised controlled trials (RCTs), all of which investigated short‐term benefit. Other than where study limitations are mentioned the risk of bias was generally low. Adverse events due to IVIg were observed in all trials. They were moderate (fever, nausea, headache), self‐limiting and are subjectively less severe than those with plasma exchange (although no statistical comparison was possible).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: December 12, 2012

Myasthenia gravis (MG) is caused by antibodies produced by the immune system that impair the transmission of nerve impulses to muscles. This results in muscle weakness that characteristically fluctuates. About one person in every 10 000 ‐ 50 000 develops MG each year. The natural history of the disorder is typically a series of exacerbations and remissions. Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 17, 2007

We reviewed the evidence about the effect of aceytlcholinesterase inhibitor drugs in people with myasthenia gravis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 13, 2014

Ocular myasthenia is a form of myasthenia gravis in which weakened eye muscles cause double vision or drooping eyelids. It accounts for approximately 50% of people with myasthenia gravis. Myasthenia gravis is an autoimmune disorder in which the body's own antibodies block the transmission of nerve impulses to muscles, causing fluctuating weakness and muscles that tire easily. Approximately half of people who have ocular myasthenia will go on to develop generalised myasthenia gravis and weakness affecting other muscles. For the majority of people this will be within the first two years of developing ocular symptoms.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: December 12, 2012

Thymectomy has become an increasingly popular procedure for myasthenia gravis. Knowledge of factors associated with a good outcome (remission) or those most likely to benefit from surgery can help clinical decision-making. A systematic review search was conducted in Medline and Embase for English language studies from 1985 through to February 2014. Studies which evaluated variables associated with, or predictive of, remission in adult (≥18 years) myasthenic patients after thymectomy and using multivariable regression models were included. Statistical pooling was not appropriate due to methodological heterogeneity. From 128 potentially relevant studies, 18 reports of 19 studies met the inclusion criteria. Preoperative mild disease classification (i.e. studies reported this variable as Osserman classification 1, 2A or MGFA I-II) showed the most consistent association with remission. Evidence for several other prognostic factors was inconclusive, or no evidence was found. Gender, age and absence of thymoma (or hyperplasia) were not associated with remission following thymectomy. Patients with mild disease preoperatively may have a better chance of remission of MG after thymectomy.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

There is continuous debate regarding the effectiveness of thymectomy in the treatment of non-thymomatous myasthenia gravis (MG). This systematic review was undertaken to determine whether thymectomy was effective in non-thymomatous MG. We retrieved articles published between January 1980 and September 2013. Sixteen cohort studies were included. Given the considerable heterogeneity, we used a descriptive method instead of statistical synthesis. The median relative rates (RRs) and their interquartile ranges were used to estimate the magnitude of benefit. Compared to conservatively treated MG patients, thymectomized patients had higher survival, clinical remission, pharmacologic remission and improvement rates, and RRs were 1.07 (1.01-1.17), 1.83 (0.82-2.99), 1.55 (1.22-1.95) and 1 (1.00-1.09), respectively. Subgroup analyses showed that patients with moderate to severe generalized MG benefited more from thymectomy, with RRs of survival and pharmacologic remission increasing to 1.35 (1.24-1.49) and 2.68 (1.73-4.17), respectively. These results suggested that thymectomy might be an effective procedure in non-thymomatous MG patients. The patients with moderate to severe generalized MG might benefit more. Taking into account the poor methodological quality of present studies, more well-designed prospective randomized controlled trials (RCTs) are still required to reach unequivocal conclusion.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

This review found that the accuracy of tests for the diagnosis of myasthenia gravis should be interpreted with caution, owing to the methodological limitations of the included studies. Although these conclusions appear appropriately cautious, they should be interpreted with extreme caution given the likelihood that relevant studies have been missed by the limited search conducted.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2006

The review assessed the diagnostic accuracy of signs, symptoms and simple tests for myasthenia gravis. The authors concluded that some symptoms (speech becoming unintelligible after prolonged periods) and signs (peek sign) may be useful to confirm the diagnosis of myasthenia gravis, while the results of some tests (ice test, sleep test, response to anticholinesterase agents) may be useful to rule-in or rule-out the condition. The authors highlighted deficiencies in the methodology of the review and the primary studies, thus the results should be interpreted cautiously.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

Mental, neurological and substance use (MNS) disorders are highly prevalent, accounting for a substantial burden of disease and disability globally. In order to bridge the gap between available resources and the significant need for services, the World Health Organization launched the Mental Health Gap Action Programme (mhGAP). The objective of mhGAP is to scale-up care and services using evidence-based interventions for prevention and management of priority MNS conditions. The mhGAP Intervention Guide version 1.0 for MNS disorders for non-specialist health settings was developed in 2010 as a simple technical tool to allow for integrated management of priority MNS conditions using protocols for clinical decision-making.

World Health Organization.

Version: 2016

Insomnia is a serious health problem that affects millions of people. Population surveys have estimated the prevalence of insomnia to be about 30% to 50% of the general population. About three-fourths of people who have trouble sleeping say that the problem is "occasional," averaging about 6 nights per month, with one-fourth having frequent or chronic insomnia, averaging about 16 nights per month. Individuals with insomnia most often report a combination of difficulty falling asleep and intermittent wakefulness during sleep. Treatment of insomnia involves behavioral changes, such as minimizing habits that interfere with sleep (for example, drinking coffee or engaging in stressful activities in the evening), and pharmacotherapy with sedating antidepressants (for example, trazodone), sedating antihistamines, anticholinergics, benzodiazepines, or nonbenzodiazepine hypnotics. The benzodiazepines and the newer sedative hypnotics zolpidem, zaleplon, zopiclone, and eszopiclone work through gamma-aminobutyric acid receptors. Ramelteon, a hypnotic approved by the United States Food and Drug Administration (FDA) in July 2005, is a selective melatonin receptor (MT1 and MT2) agonist. New nonbenzodiazepine drugs have been sought for multiple reasons, including reduction of the risk of tolerance, dependence, and abuse associated with benzodiazepines. The purpose of this review is to evaluate the comparative evidence on benefits and harms of these medications in people with insomnia to help policymakers and clinicians make informed choices about the use of newer drugs for insomnia.

Drug Class Reviews - Oregon Health & Science University.

Version: October 2008

This clinical guideline concerns the management of hypertensive disorders in pregnancy and their complications from preconception to the postnatal period. For the purpose of this guideline, ‘pregnancy’ includes the antenatal, intrapartum and postpartum (6 weeks after birth) periods. The guideline has been developed with the aim of providing guidance in the following areas: information and advice for women who have chronic hypertension and are pregnant or planning to become pregnant; information and advice for women who are pregnant and at increased risk of developing hypertensive disorders of pregnancy; management of pregnancy with chronic hypertension; management of pregnancy in women with gestational hypertension; management of pregnancy for women with pre-eclampsia before admission to critical care level 2 setting; management of pre-eclampsia and its complications in a critical care setting; information, advice and support for women and healthcare professionals after discharge to primary care following a pregnancy complicated by hypertension; care of the fetus during pregnancy complicated by a hypertensive disorder.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: August 2010

This review assessed the efficacy and safety of intravenous immunoglobulin (IVIG) in several neurologic conditions. IVIG appeared more effective than placebo in relapsing-remitting multiple sclerosis and idiopathic chronic inflammatory demyelinating polyneuropathy. The evidence to support the use of IVIG for all other neurologic conditions was insufficient. The review was generally well conducted and its conclusions seem reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

The objective of this report was to summarise clinically relevant effects of immunomodulatory treatments with intravenous immunoglobulins (IVIG).

Knowledge Centre for the Health Services at The Norwegian Institute of Public Health (NIPH).

Version: July 2008

Expert-reviewed information summary about the treatment of thymoma and thymic carcinoma.

PDQ Cancer Information Summaries [Internet] - National Cancer Institute (US).

Version: February 9, 2018

Lambert‐Eaton myasthenic syndrome (LEMS) is a rare disorder of the neuromuscular junction that causes muscle weakness (most commonly in the upper arms and legs). It is an autoimmune disease in which the body's own antibodies prevent the release of the chemical acetylcholine. This interferes with transmission of nerve impulses to the muscles. One of the main treatments is 3,4‐diaminopyridine which increases the release of acetylcholine. Four small randomised controlled trials involving 54 participants in total showed that 3,4‐diaminopyridine improves muscle strength. This was determined by measuring the compound muscle action potential (CMAP) which is a test that records the amount of electrical activity generated in a muscle when it is stimulated by its nerve. Although the number of trials is relatively small, the quality of evidence from these trials is moderate to high, which supports the findings of this review. The changes are measured over days only. A single trial involving nine participants showed that intravenous immunoglobulin also improved muscle strength up to 8 weeks from treatment. Other possible treatments such as plasma exchange, steroids and immunosuppressive agents have not been tested in randomised controlled trials. Further trials of these treatments are needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: February 16, 2011

Expert-reviewed information summary about the treatment of thymoma and thymic carcinoma.

PDQ Cancer Information Summaries [Internet] - National Cancer Institute (US).

Version: November 9, 2017

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