Talk:Myasthenia gravis/Archive 1

The current editing and info on MG is terribly confusing and just too much “mumble jumble” for folks looking for more basic info.

I would recommend that an MG Specialist rewrite it or go on the MGNA website to get great, clearly written info.

In the meantime, Here is a good article to use as the introduction to the disease.

Myasthenia Gravis

Medically reviewed by Deborah Weatherspoon, PhD, RN, CRNA on April 23, 2018 — Written by Jaime Herndon Symptoms Causes Diagnosis Treatments Complications Outlook Myasthenia gravis Myasthenia gravis (MG) is a neuromuscular disorder that causes weakness in the skeletal muscles, which are the muscles your body uses for movement. It occurs when communication between nerve cells and muscles becomes impaired. This impairment prevents crucial muscle contractions from occurring, resulting in muscle weakness.

According to the Myasthenia Gravis Foundation of America, MG is the most common primary disorder of neuromuscular transmission. It’s a relatively rare condition that affects between 14 and 20 out of every 100,000 people in the United States.

What are the symptoms of myasthenia gravis? The main symptom of MG is weakness in the voluntary skeletal muscles, which are muscles under your control. The failure of muscles to contract normally occurs because they can’t respond to nerve impulses. Without proper transmission of the impulse, the communication between nerve and muscle is blocked and weakness results.

Weakness associated with MG typically gets worse with more activity and improves with rest. Symptoms of MG can include:

trouble talking problems walking up stairs or lifting objects facial paralysis difficulty breathing due to muscle weakness difficulty swallowing or chewing fatigue hoarse voice drooping of eyelids double vision Not everyone will have every symptom, and the degree of muscle weakness can change from day to day. The severity of the symptoms typically increases over time if left untreated.

What causes myasthenia gravis? MG is a neuromuscular disorder that’s usually caused by an autoimmune problem. Autoimmune disorders occur when your immune system mistakenly attacks healthy tissue. In this condition, antibodies, which are proteins that normally attack foreign, harmful substances in the body, attack the neuromuscular junction. Damage to the neuromuscular membrane reduces the effect of the neurotransmitter substance acetylcholine, which is a crucial substance for communication between nerve cells and muscles. This results in muscle weakness.

The exact cause of this autoimmune reaction is unclear to scientists. According to the Muscular Dystrophy Association, one theory is that certain viral or bacterial proteins may prompt the body to attack acetylcholine.

According to the National Institutes of Health, MG typically occurs in people over the age of 40. Women are more likely to be diagnosed as younger adults, whereas men are more likely to be diagnosed at 60 or older.

Congenital Myasthenic Syndrome

It is extremely important to edit CMS out of this article and to have a separate article on CMS. MG is an autoimmune disease, CMS is genetic. Two totally different classes of disease. They have a diffent etiology and therefore, except for some shared symptoms, nothing in common and should not be confused. In fact, CMS patients benefit from a clear distinction, as there are notable differences in medicating both diseases. —Preceding unsigned comment added by 78.53.120.173 (talk) 21:58, 27 June 2008 (UTC)

We (now) have Congenital myasthenic syndrome but the MG lead still says "Alternatively, in a much rarer form, muscle weakness is caused by a genetic defect in some portion of the neuromuscular junction that is inherited at birth..." which sounds like CMS since it is not auto-immune. Can we clarify if the genetic form mentioned is CMS, and if it is a subtype of MG ? - Rod57 (talk) 14:00, 18 November 2015 (UTC)

Marijuana

Has there been any research done about this disease and it's relationship to marijuana abuse?

Why are you asking? Have you tried google or the reference desk? JFW | T@lk 16:08, 9 December 2007 (UTC)

Help

Answer:

Dear Freazer,

I consulted several experts and the original author when improving the article. I suggest we collaborate to make a good article, in stead of reverting to older versions. For most changes i made i had good reasons, so perhaps you can discuss any changes you don't agree with, in stead of undoing all the effort that was put in it. It is very unfortunate that the article became victim to vandalism since february 1st so i suggest we both try to keep it vandalism-free. Perhaps we the wiki group can make editing members-only. Anyway, my changes were not vandalism.

The reason i added section you mentioned: As i see it, this article is intended to give information to people who want information about myasthenia gravis. That will mostly be patients, their friends and relatives and doctors, nurses and researchers. I also added a lot of information useful for doctors and researchers. But to patients thís is very useful info, and imo adding info like this makes the wiki better than any other encyclopedia. Because it actually answers one's questions. Nevertheless i left the section out, since it especially seemed to bother you. Hope to hear from you soon.

Pizzaman79 11:31, 9 March 2007 (UTC)

I doubt this

The article says: Applying ice to the weak muscle groups may characteristically improve the weakness. Is this true?

Yes, this factlet is specifically supported by the Scherer reference. JFW | T@lk 13:26, 22 December 2005 (UTC)

Yes, cooling increases the sensitivity of the postjunctional membrane to acetylcholine and decreases cholinesterase activity. (Nerve conduction speed and acetylcholine release are decreased by cooling and these adversely affects neuromuscular transmission. This, however, is partially counteracted by decreased muscle-ChE activity and increased sensitivity of the postjunctional membrane to ACh caused by cooling. In MG patients these last two effects have a much greater effect than in healthy individuals and neuromuscular transmission actually improves. See also PMID 690633) --WS 14:04, 22 December 2005 (UTC)

Myasthenia is derived from Greek; Gravis is from Latin

From the top of the page:

Myasthenia gravis (MG, Latin: "grave muscle weakness")

See

http://www.lef.org/protocols/prtcl-080.shtml

Myasthenia: from the Greek words, myelos, meaning muscle, and astheneia, meaning weakness Gravis: from the Latin word, gravidus, meaning heavy (serious) —Preceding unsigned comment added by 62.25.109.194 (talk • contribs)

Thank you for your suggestion regarding [[: regarding [[:{{{1}}}]]]]! When you feel an article needs improvement, please feel free to make whatever changes you feel are needed. Wikipedia is a wiki, so anyone can edit almost any article by simply following the Edit this page link at the top. You don't even need to log in! (Although there are some reasons why you might like to…) The Wikipedia community encourages you to be bold. Don't worry too much about making honest mistakes—they're likely to be found and corrected quickly. If you're not sure how editing works, check out how to edit a page, or use the sandbox to try out your editing skills. New contributors are always welcome. --WS 13:09, 11 January 2006 (UTC)

Doesn't the gravis refer to heavy as in the limbs/eyelids feeling progressively heavy when used (as opposed to serious)? Pizzaman79 (talk) 16:17, 30 July 2008 (UTC)

Re-write of Prognosis section

First, I wish to declare my bias, so you can call me on it if I let it affect my contributions. I have a friend who's been diagnosed with MG and her friends are visiting wikipedia for a quick summary. Unfortunately, the "Prognosis" section gives the impression MG is completely treatable, which is not true. When I went digging I found the origins of the pronosis section:

With treatment, most patients have a near-normal quality of life and no significant problems. Some cases of myasthenia gravis may go into remission temporarily and muscle weakness may disappear completely so that medication can be discontinued. Stable, long-lasting complete remissions are the goal of thymectomy, although this cannot always be achieved. (Wikipedia, current version)

It appears to be based on a factsheet from the US government, aimed at patients:

With treatment, the outlook for most patients with myasthenia gravis is bright: they will have significant improvement of their muscle weakness and they can expect to lead normal or nearly normal lives. Some cases of myasthenia gravis may go into remission temporarily and muscle weakness may disappear completely so that medications can be discontinued. Stable, long-lasting complete remissions are the goal of thymectomy. In a few cases, the severe weakness of myasthenia gravis may cause a crisis (respiratory failure), which requires immediate emergency medical care. (see above). (Fact Sheet).

The fact sheet is careful not to alarm people, but the wikipedia entry omits all negative information. Overall, the wikipedia entry gives a very rosy picture. Now I'm going to try and re-write that section based on other sources.

geoff_o 21:50, 26 October 2006 (UTC)

I think from a doctor's perspective there are many worse, less treatable diseases. Especially from a neurologist's perspective. I agree it should not sound too optimistic. On the other hand i see a lot of patients that googeled their disease and then come to the doctor with their heads full of worst case scenario's. Sometimes to the point where these thoughts bother the patient even more than the disease itself! So it's always difficult to strike a balance. If the update i did on the english version is read and corrected, i'll translate it to Dutch. Pizzaman79 13:33, 13 December 2006 (UTC)

Details

This is a great article, but i think it misses some details here and there. Some examples...

- The autoimmune process is NOT fully clarified imho. First of al some of the patients don't carry AchR or MuSK antibodies. Since they do respond to immunosuppresive therapy they probably have some other, yet unknown, auto-immune process. Also, MG seems different from other autoimmune diseases. Some genetical variations (SNP's) seem to have effects opposite to other auto immune diseases, sometimes ascribed to T-cell maturation in the thymus.

- The stuff about ice is a very neat trivia. But a reader will think this is the common way doctors examine patients and it's not. So that should be clarified. What i miss is an explenation about which tests doctorsactually do. For example, just asking a patient to keep his arms stretched out (Barré style) will clearly show fatiguability of a muscle with otherwise good strength (usually 5/5). I have an book about MG by Oosterhuis, i should look up what he sais in his chapter about the physical exam.

- The part on the blood test could state more clearly that the diagnostical use of the test is limited. The ultimate test is a patient's response to immunosuppressive therapy, in my experience. Also, wasn't the antibody titer useful for followup? (i'd have to look that up)

- Pathophysiology: again too optimistic to my taste. Even when testing for MuSK there are still sero-negative patients and i believe the MuSK test is not something many hospitals offer. Without that you'll have quite a lot of seronegative patients. (i'm not even sure if the AchR test is that common)

- Epidemiology: do we have figures about congenital MG? Also there are two epidemiologic peaks: females in their 30's and males in their 50's and 60's. This suggests perhaps hormonal influence or two distinct entities and should therefor be mentioned.

- I think if you mention thymectomy and chest (thymus) CT's for thymoma imaging, you should also explain the correlation a little more thorough than "There are various theories that explain why thymoma may predispose to MG"

These are just some things that cought my eye in a first quick read. Since i'm suggesting a lot more than a few minor changes i suggest the original author can contact me so we can perhaps collaborate on a rewerite.

Edit: i contacted the original author and another person doing research on the topic. It may take some time, but i'll do a rewrite.

Edit2: I changed the article now. It didn't need as much changing as i first expected. One point of discussion remains: prevalence. I have a neurology book stating it is 40/million, whereas myasthenia.org says 20/100.000 is an underestimation! Who can find an authorative reference?

Pizzaman79 03:31, 11 December 2006 (UTC)

I think improvements can be made to the Neurophysiological changes associated with the disease. SteveD 16:08 13 April 2008.

As an MG patient, I would think that myasthenia.org would have more recent info, however, as it is with everything realted to MG, I think a 100% accurate info is not available. Bengisuk 10:53, 9 February 2007 (UTC)

Agreed.

Good article nomination

Here are my suggestions:

• "At about 14 cases per 100,000 (in the U.S.), it is one of the lesser known autoimmune disorders." (reference?)
• According to Wikipedia:Manual of Style (medicine-related articles), classification should be placed before Signs and symptoms.
• "Often the physical examination is within normal limits." (a reference about an overview of the signs would be welcome)
• "Often symptoms come and go. The diagnosis of myasthenia gravis is often initially missed." (I don't think it's a proper sentence, you can't write that symptoms come and go)
• Reference for the classification?
• Please follow the manual of style regarding the order of sections
• and most of the diagnostic tests are unreferenced sections
• external links in the sections should be converted into references (see Epidemiology)
• I don't think we should include specific doses.

Thank you in advance! NCurse _work 16:58, 13 April 2007 (UTC)

No response to the hold, so I'm failing the GA on this. Please renominate if the concerns are addressed. Thanks Mike Christie (talk) 22:24, 24 April 2007 (UTC)

I've tried to incorporate all abovementioned suggestions. For this relatively rare disease it's tough to find good digital references for every stated fact, so i had to use one printed book. In addition to that, however, this article was reviewed by several experienced neurologists. Pizzaman79 (talk) 19:25, 30 July 2008 (UTC)

Thymectomy survey

I think this article would benefit from a mention of the large-scale survey into the effectiveness (or otherwise) of thymectomy, led by John Newsom-Davis until his recent sudden death. I was tempted to add something myself, but I think it would be better done by an expert in the field.
--NSH001 14:20, 10 October 2007 (UTC)

If the results were published, please provide a reference. If the results have not been published, I'm afraid WP:NOR applies. JFW | T@lk 16:08, 9 December 2007 (UTC)

(interrupting my wikibreak for a few moments - I won't be able to respond again for a while) There are plenty of refs in the JN-D article, and I'm sure google will provide a few more. I expect it'll be a while before full results are published, but some mention of the scope of, and reasons for, the survey would, I think, be appropriate.

--NSH001 (talk) 16:54, 9 December 2007 (UTC)

References

The following references were listed at the bottom of the article:

• Baets, MH de, Oosterhuis HJGH. Myasthenia gravis. Boca Raton: DRD Press, 1993
• Rowland LP, ed: Merritt's textbook of Neurology. 10th Ed. Philadelphia, Lippincott, Williams & Wilkins, 1995
• Cavel-Greant, D, Nicolle, MW ed; You, Me and Myasthenia Gravis Third ed. Ku:Reh Press, 2006

Generally, we are now avoiding article references. I have listed them here for other users to peruse while I try to update the article using recent journal reviews. JFW | T@lk 16:08, 9 December 2007 (UTC)

Apart from Conti-Fine et al, I have identified the following free reviews:

• Update (PMJ)
• PMID 16018742 - vaccines
• PMID 15767509 - striational antibodies
• PMID 11832968 - anesthetic implications
• PMID 10025421 - congenital syndromes —Preceding unsigned comment added by Jfdwolff (talk • contribs) 17:01, 9 December 2007 (UTC)

Not free: the entire first issue of Semin Neurol 2004: Pubmed search

PMID 11494281 - electrodiagnostic evaluation.

PMID 11445126 - Lancet seminar (2001)

JFW | T@lk 16:49, 9 December 2007 (UTC)

Pathophysiology section -revision of statements about normal physiology needed

The fourth paragraph under "Pathophysiology" is factually incorrect:

"In normal muscle contraction, cumulative activation of the ACh receptor leads to influx of sodium and calcium. Only when the levels of these electrolytes inside the muscle cell is high enough will it contract. "

Not so. Each activation of the ACh receptor (at the neuromuscular junction by means of the ACh released by each arriving motor action potential) opens a sodium-potassium permeable 'non specific' ion channel. This leads to a depolarisation of the muscle fibre membrane under the motor end-plate. Calcium entry is not favoured by ACh, but critically the 'levels of these electrolytes' (be they sodium and potassium) are not appreciably altered. It is the (small) flux of the ions across the membranes that carries and electric current sufficient to depolarise that local region of membrane. The 'levels' (concentrations) of sodium and potassium are not altered appreciably as a result of one, or indeed many action potentials. The depolarisation triggers an action potential in the muscle fibre which, in turn, triggers the release of calcium from internal stores in the muscle fibre (the sarcoplasmic reticulum). The rise in calcium concentration is what favours contraction.

So the problem of the antagonism of the ACh receptor by antibodies is that the incoming action potential fails to depolarise the motor end plate and thus fails to trigger a new action potential in the muscle fibre. This means there is no response by the muscle to the nerve's activity and hence paralysis. Repeated action potentials may allow sufficient receptors to be activated sufficiently for a response (though it is thereby weakened). This outcome is favoured by the use of anticholinesterase agents which inhibit the breakdown of ACh. The offending antibodies may be competitively antagonised by ACh if it is at a high enough local concentration for long enough. DoctorCaffeine (talk) 13:46, 27 May 2008 (UTC)

{{sofixit}} JFW | T@lk 19:27, 9 July 2008 (UTC)

GA Review

This review is transcluded from Talk:Myasthenia gravis/GA1. The edit link for this section can be used to add comments to the review.

This article does not meet the Good article criteria and has therefore failed. Issues include:

• The lead is too short. Please expand it to better summarize the entire article, per WP:LEAD.
• Too much information is unreferenced, including:
  • Most of "Signs and symptoms"
  • Entire " Pathophysiology" section
  • " Associations" section
  • Most of " Treatment" section
• References are placed incorrectly; they should be after all punctuation marks with no spaces in between, per WP:FN.

Please renominate the article once these issues have been resolved. Gary King (talk) 05:51, 31 July 2008 (UTC)

Some sections must go: associations is unsourced, and the content on pregnancy and children can be merged elsewhere. For sources I would use the recent Lancet review for clinical aspects and J Clin Invest for the molecular pathophysiology. Good work by Pizza so far. JFW | T@lk 13:01, 31 July 2008 (UTC)

Thanks for looking into it! (i've been editing it for so long that i've become rather blind to its flaws) Pizzaman79 (talk) 15:59, 1 August 2008 (UTC)

Crisis!

A review article especially about myasthenic crisis: doi:10.1093/qjmed/hcn152 JFW | T@lk 20:35, 22 January 2009 (UTC)

Notable patients section

I updated the Notable patients section with a redirect to Waldo_(short story) as Robert A. Heinlein's misanthropic character is one of the reasons that MG obtained cultural awareness and media exposure earlier than some other autoimmune diseases have. Marlberg (talk) 17:55, 27 July 2010 (UTC) —Preceding unsigned comment added by Marlberg (talk • contribs) 17:54, 27 July 2010 (UTC)

Notable patients II

Mary Broadfoot Walker is incorrectly listed as »notable patient«, I think, as the article on her doesn't mention her suffering from this disease. On the other hand it's obvious, that she definitely should be mentioned here for her research, so I'm a bit clueless at the moment; I guess this article probably lacks some kind of history-section. -- 83.65.195.12 (talk) 11:01, 20 January 2011 (UTC)

ABN guideline

doi:10.1136/practneurol-2015-001126 JFW | T@lk 08:24, 15 May 2015 (UTC)

article/peter c.

Peter.C • talk • contribs im beginning the process of signs/symptoms, cause and the intro (today)...any input would be very helpful, thanks--Ozzie10aaaa (talk) 14:05, 9 July 2015 (UTC)

WRT signs/symptoms I think you should reemphasize the fact that the symptoms develop progressivley over months/years. Besides that, I love everything. I would fix it right now but edit conflicts are the bane of my existence. Peter.C • talk • contribs 15:18, 9 July 2015 (UTC)

done with this ref [1]--Ozzie10aaaa (talk) 15:54, 9 July 2015 (UTC)

Peter.C • talk • contribs so lets take a look at pathophysiology today...--Ozzie10aaaa (talk) 15:15, 10 July 2015 (UTC)

Peter.C • talk • contribs ..if you have a chance see if you can find a newer ref for 19 and 20, I tried but didn't find anything,? thanks--Ozzie10aaaa (talk) 16:37, 11 July 2015 (UTC)

19  Done

20  In progress. Peter.C • talk • contribs 16:52, 11 July 2015 (UTC)

whenever we finish we can post this at wikiproject med, to get their opinion, if you want,--Ozzie10aaaa (talk) 20:25, 11 July 2015 (UTC)

Sounds good. Sorry I have left you out to hang and dry during this. I am trying to power through the college assignments I was unable to do this week (yay summer semester) and I have a full day class tomorrow (yay federal certification programs). Will attempt to work heavily on this Monday. Thanks again for all the time and effor you have put into helping me with this article :) Peter.C • talk • contribs 20:46, 11 July 2015 (UTC)

dysarthria / dysphonia

The former seems to have a more specific definition, however slightly more sources for this topic seem relate it to the latter. Matthew Ferguson (talk) 07:46, 12 July 2015 (UTC)

Looking at both of the wikipedia articles, I would say that the myasthenia gravis sources using the term dysphonia are incorrect, so I think we should use dysarthria only. Matthew Ferguson (talk) 09:45, 12 July 2015 (UTC)

@Matthew Ferguson 57: Dysarthria is where the voice changes due to facial muscle dysfunction, while in dysphonia it is the larynx/vocal cords. JFW | T@lk 10:27, 12 July 2015 (UTC)

would you agree that dysarthria seems to be more relevant to this condition? Matthew Ferguson (talk) 15:47, 12 July 2015 (UTC)

@Matthew Ferguson 57: Both are possible. Fatiguing bulbar/nasal dysarthria is characteristic in MG. If there is severe weakness (laryngeal and intercostal musculature) then the voice will be weak too. JFW | T@lk 18:04, 12 July 2015 (UTC)

Then maybe it would be better to list both, although I've only.seen sources which give one or the other so far, not.both. Matthew Ferguson (talk) 06:13, 14 July 2015 (UTC)

Subtypes

Treatment may depend on the clinical and immunological subtype: doi:10.1016/S1474-4422(15)00145-3 JFW | T@lk 14:59, 24 September 2015 (UTC)

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BLP issue

These need refs

• Indian actor Amitabh Bachchan was diagnosed with it in 1983.*Weeb Ewbank, New York Jets coach
• Henrique Mecking, Brazilian chess grandmaster
• Aristotle Onassis (1906-1975), Greek shipping magnate and businessman, suffered from the disease during the last years of his life.
• Days Of Our Lives actress Suzanne Rogers has the condition and so does the character she plays, Maggie Horton.
• Powhatan chief Opchanacanough (Uncle of Pocahontas ) was thought to have the condition.
• Stephen Garrett, also known as Static Major. He made up half of the R&B group "Playa".
• Anselmo Ralph, Angolan singer and song-writer.

Doc James (talk · contribs · email) 17:22, 8 August 2016 (UTC)

Associated Conditions

There's no such thing as "CNS Disease." The current reference for "CNS Disease" is broken and added post-hoc. Previously, "Demyelinating CNS diseases" was listed as an associated condition. "Demyelinating CNS diseases" makes sense as it's mentioned in the literature. For example, http://n.neurology.org/content/67/5/881 — Preceding unsigned comment added by Metaquanta (talk • contribs) 01:43, 25 May 2018 (UTC)

will look--Ozzie10aaaa (talk) 10:03, 25 May 2018 (UTC)

will leave your revert for now however this[2] does not comply w/ Wikipedia:Identifying reliable sources (medicine)#MEDRS... IMO--Ozzie10aaaa (talk) 22:27, 27 May 2018 (UTC)

Removed both items in this silly little bullet-pointed list because both items were based on non-WP:MEDRS sources and created an impression that these are widely accepted associations. JFW | T@lk 17:52, 28 May 2018 (UTC)

Thanks! That looks like the best solution. Metaquanta (talk) 04:39, 31 May 2018 (UTC)

References

NEJM

doi:10.1056/NEJMra1602678 JFW | T@lk 00:49, 29 December 2016 (UTC)

thank you(belated)--Ozzie10aaaa (talk) 10:07, 22 May 2018 (UTC)

Apparent typo needs attention from a medical expert

In the paragraph under SURGERY, the last three sentences (with my insertion of bold type,) are:

Surgery in the case of MG involves the removal of the thymus, although no clear consensus indicates it would be beneficial except in the presence of a thymoma. However, thymectomy should not be done in ocular myasthenia.[52] A 2016 randomized controlled trial found benefits from thymus removal for ocular MG.[53]

These two sentences are contradictory, and probably the word "no" should be inserted, so that the second phrase would read found no benefits from thymus removal. Please ask a medical professional to make a judgment about this.

Otherwise, this is a very well-written article. Janice Vian, Ph.D. (talk) 01:35, 30 October 2017 (UTC)

Thanks User:Janice Margaret Vian agree and adjusted. Doc James (talk · contribs · email) 01:46, 30 October 2017 (UTC)

Thank you. That was amazingly fast. Janice Vian, Ph.D. (talk) 05:20, 30 October 2017 (UTC)

Random people

Not sure how they are notable with respect to the disease. Yes notable themselves.

"==Notable cases==

• Aristotle Onassis, shipping magnate and second husband of Jacqueline Kennedy Onassis.
• Brandon Cox, starting Auburn quarterback from 2005–2007.
• Connie Haines, singer and actress.
• Christopher Robin Milne, the son of A. A. Milne, author of the Winnie-the-Pooh books and the person on whom Christopher Robin was based, lived with MG for several years before his death in 1996.
• Actor Roger Smith, husband of Ann-Margret, was diagnosed in 1980.
• Brazilian chess grandmaster Henrique Mecking, third in the world rankings at his career peak, abandoned playing because of the disease. Mecking eventually recovered and came back to playing over 10 years later.
• Augustus Pablo, Jamaican roots reggae and dub record producer, melodica player and keyboardist.
• Suzanne Rogers, actress known for playing Maggie Horton on the NBC soap opera Days of Our Lives."

Doc James we could trim it down to just a few(many articles have individuals that are affected by a condition and are publicly recognized people)...IMO--Ozzie10aaaa (talk) 10:05, 22 May 2018 (UTC)

References