Treatment Can Control Symptoms of Myasthenia Gravis

Nile cruise. (Dr. Noorali Bharwani)
Nile cruise. (Dr. Noorali Bharwani)

Recently, I was talking to a lady who told me she has been diagnosed to have myasthenia gravis.

Myasthenia gravis is a chronic autoimmune disorder that can affect people of any age. It is more common in women younger than 40 and in men older than 60. It can occur at any age but is most common in adults. It is not inherited. The condition affects the voluntary muscles of the body, especially those that control the eyes, mouth, throat and limbs.

Myasthenia means muscular weakness. Gravis means the condition is more virulent than average. The illness causes weakness of the skeletal muscles. This happens because there is breakdown in the normal communication between nerves and muscles. Nerves’ ability to control muscle activity is weakened or lost.

Normally, the immune system functions well, fighting infection and other foreign invaders to the body. But it also mistakenly attacks some of the body’s own tissue. In this case it attacks the neuromuscular junction, where nerve endings release chemical transmitters that stimulate the muscle to contract.

Myasthenia gravis is a disease of fluctuating weakness. The symptoms can range from mild to severe. In some cases, symptoms are so minimal that no treatment is necessary. Even in moderately severe cases, with treatment, most people can continue to work and live independently.

Quite often the symptoms get worse with repeated use and improve with rest. In most people with this condition, muscle weakness is temporary and reversible, and tends to wax and wane over time. It is not a progressive disease but the symptoms come and go.

The muscles that control the eyelids and movement of the eyes are most commonly affected, although the disease does not lead to loss of eyesight. In about 10 per cent of myasthenia gravis cases, only the eye muscles are affected. In most people, however, symptoms start in the eyes then spread to other muscles, which can include those that control speech, chewing, swallowing or breathing, or those of the neck, trunk or limbs.

The effects of myasthenia gravis tend to vary over time. The disease is often directly affected by a person’s general health, including physical condition, sleep patterns, hormonal changes, other diseases, medications and even emotional state. Stress and lack of rest are common culprits in aggravating myasthenia gravis symptoms. Maintaining a healthy lifestyle is key to managing the disorder.

There is no cure for myasthenia gravis, but treatment can provide some relief. Treatment with medications can correct the defective communication between nerves and muscles, thus improving strength. Fortunately, current treatments control symptom very effectively, and the outlook for a long and productive life is excellent for the majority of patients.

About 10 per cent of people with myasthenia gravis have a tumour of the thymus gland (located behind the breastbone) that should be surgically removed. In some people who have generalized disease, removing the thymus gland may reduce disease activity or trigger remission.

Life expectancy for myasthenia gravis patients is normal except in rare cases. Good news about myasthenia gravis is it can go into remission lasting for several years. Most people with myasthenia gravis are able to gain muscle strength through medication or immunotherapy.

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Promising breakthrough treatment for HIV using stem cells.

Senate Fountain beside the U.S. Capitol in Washington DC. (Dr. Noorali Bharwani)
Senate Fountain beside the U.S. Capitol in Washington DC. (Dr. Noorali Bharwani)

We will start by understanding what is HIV and what is stem cell. Then we will talk about the new breakthrough treatment for HIV and AIDS patients.

HIV (human immunodeficiency virus) is a virus that attacks the body’s immune system. Over time, HIV weakens a person’s immune system so it has a very hard time fighting diseases. If HIV is not treated, it can lead to AIDS (acquired immunodeficiency syndrome).

World-wide approximately 38 million people are currently living with HIV, and tens of millions of people have died of AIDS-related causes.

HIV spreads through sexual contact or blood, or from mother to child during pregnancy, childbirth or breast-feeding.

HIV presents with fever, chills, rash, night sweats, sore throat, fatigue and swollen lymph glands.

AIDS is a chronic, potentially life-threatening condition. There is no cure for HIV/AIDS, but medications can dramatically slow the progression of the disease. These drugs have reduced AIDS deaths in many developed nations.

What are stem cells?

Stem cells are primitive cells. They are body’s raw materials. From these cells all other cells with specialized functions are generated. They can help repair rebuild damaged cells. Stem cell therapy is mostly used for treating certain types of cancer or bleeding disorders, such as sickle cell disease.

Stem cells can be isolated from the body in different ways. They can be obtained from a donor’s bone marrow, from blood in the umbilical cord when a baby is born, or from a person’s circulating blood. Cord stem cells are often successful, even when their immune markers only partially match the recipient’s.

Now let us discuss recent newspaper headlines. “First Woman Has Been ‘Cured’ of HIV Using Stem Cells.” Another headline says, “Stem-cell treatment may have cured woman of HIV.” Why is this making headlines? Because this novel treatment using umbilical cord blood could help dozens of people with both HIV and aggressive cancers.

This exciting story is about a middle-aged woman of mixed race who had HIV and acute myeloid leukemia. A woman of mixed race has never been treated like this before. Doctors have cured HIV in two white men, and this is the first such report in a woman. It is also the first time a person who identifies as mixed race has received the treatment.

This lady first received high-dose chemotherapy for acute myeloid leukemia – a treatment that destroys blood cells – then she received the stem cell transplant from specialists at Weill Cornell Medicine, in New York City.

They used transplant cells from two sources: stem cells from a healthy adult relative and umbilical cord blood from an unrelated newborn. The stem cells, from umbilical cord blood, contained a gene variant that makes them resistant to HIV infection. Since the transplant 14 months ago the woman is doing well.

Scientists believe the success of the new method involving umbilical cord blood could allow doctors to help more people of diverse genders and racial backgrounds.

Why is this breakthrough treatment making news?

This was the first case of HIV treatment using umbilical cord blood, which is less invasive and more widely available than invasive bone marrow transplants that cured the two male patients. Cord blood donors don’t need to be matched as closely to the recipient as bone marrow donors, so it can be an option for patients with uncommon tissue types.

Scientists are carefully watching the situation. Despite the apparent success of the treatment, it won’t be available to most of the 38 million people living with HIV around the world just yet. In the meantime, scientists are carefully monitoring this lady’s long-term prognosis. Now, 14 months after the treatment, the HIV infection has not re-emerged. The patient has also been leukemia-free for four years.

We wish her well. Kudos to the doctors involved in her treatment. Let us hope we can get rid of COVID-19 soon so we can return to normal life. Take care and stay healthy.

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Does risk of stroke increase in people with COVID-19 infection?

Fairmont Banff Springs in Alberta, Canada. (Dr. Noorali Bharwani)
Fairmont Banff Springs in Alberta, Canada. (Dr. Noorali Bharwani)

We know COVID-19 affects different people in different ways. Most of the time the infection is mild with fever, cough, tiredness and loss of taste or smell. These individuals recover without hospitalization.

On average it takes five to six days when someone is infected with the virus for symptoms to show, however it can take up to 14 days. The incubation period ranges from 1 to 14 days. The median is 5 to 6 days between exposure and symptom onset.

Some individuals present with serious symptoms. The lungs are the organs most affected by COVID‐19. Symptoms like difficulty breathing, loss of speech, difficulty walking, confusion and chest pain are not uncommon. These individuals need to seek immediate medical attention.

Patients with COVID-19 infection can have neurological problems as well including stoke. This happens because of the change in the thickness of the blood called hypercoagulability. This may predispose an individual to stroke. Hypercoagulability is defined as the tendency to have thrombosis (blood clots) as a result of certain blood defects. Clinical manifestations of hypercoagulability can be devastating and even lethal.

Recently, researchers have found falling rates of new ischemic stroke admissions in hospitals, probably due to social consequences of the pandemic: fear to be infected or not adequately treated in the hospital. This phenomenon is of concern.

In one of the largest studies of its kind to date, published Aug. 14, 2021, in The Lancet (What is the association of COVID-19 with heart attacks and strokes?) researchers found strong evidence that heart attack and stroke risk rises sharply in the weeks following a COVID-19 diagnosis.

In the week after a COVID-19 diagnosis, the risk of a first heart attack increased by three to eight times. The risk of a first stroke caused by a blood clot multiplied by three to six times. In the following weeks, both risks decreased steadily but stayed elevated for at least a month.

Other bacterial and viral infections (such as influenza) are known to temporarily boost rates of heart attacks and strokes. But COVID-19 infections appear to be especially risky, perhaps because they trigger an exaggerated inflammatory response that makes blood clots more likely.

There are two factors responsible and dangerous to the production of strokes. First factor — COVID-19 infection creates inflammation throughout the body. Second factor — it also produces hypercoagulation of the blood that makes the blood to clot easily than normal.

There may be somebody you know who has had a stroke usually without a warning. There are various causes of stroke: 85 per cent are ischemic strokes, which are caused by a blood clot in an artery. Obesity, diabetes, high cholesterol, irregular heart rhythm, smoking, drug abuse and many other risk factors are all linked to an increased likelihood of a stroke. Now we can add COVID-19 to the list.

Outcome of a stoke can vary. Ten per cent of the people recover fully. Thirty per cent of the people recover with minimal of physical and mental deficiency and 60 per cent of the people have major paralysis and end up in a nursing home.

You should seek immediate medical attention if you see somebody exhibits sudden loss of balance and coordination, has trouble seeing out of one or both eyes, face drooping or lop-sided, shows weakness of one arm and speech is slurred then call 9-1-1 right away. Time is of the essence to start tPA therapy.

tPA is short for tissue plasminogen activator and can only be given to patients who are having a stroke caused by a blood clot (ischemic stroke). It can stop a stroke by breaking up the blood clot. It must be given as soon as possible and within 4.5 hours after stroke symptoms start.

You may be familiar with the acronym F.A.S.T. to help you recognize a stroke. F – is the face drooping? A – can the person raise both arms? S – speech slurred? T – time to call 9-1-1.

Take care and be safe. And remember mask, distance and vaccination.

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Oral COVID-19 Treatment

Shoveling snow. (Dr. Noorali Bharwani)
Shoveling snow. (Dr. Noorali Bharwani)

Scientists around the world are working hard to get one step ahead of the various COVID-19 viruses. Is victory in sight?

We have the highly infectious Omicron coronavirus variant causing less severe disease than the Delta strain but it remains a dangerous virus, particularly for those who are unvaccinated. The Omicron variant is the dominant strain in Alberta.

Like other variants, Omicron spreads from the nose and mouth through respiratory droplets at close range and through virus particles that float through the air and can stay suspended for quite a while, especially in places with poor ventilation. That is why use of face masks or coverings has been recommended in public settings to minimise the risk of transmissions.

Then there is Omicron subvariant BA.2. That raises more questions about the evolution of virus behind COVID-19. Alberta recently reported three cases of BA.2 variant. By the time you read this there may be more. Denmark recently reported a surge of BA.2 infections.

Omicron infections make up more than 90 per cent of Canada’s recent cases – and nearly all of those remain BA.1. But BA.2 infections totalled around one per cent of reported cases in early January.

We should not forget Alpha, Beta, Gamma and Delta variants. They are still around. We should continue to practice what reduces our risk of getting seriously ill with COVID-19 infection. Vaccination does not provide hundred per cent protection but it can reduce the risk of getting seriously ill. Vast majority of the patients with COVID-19 infection in the ICU are not vaccinated.

Here is the good news.

The new oral COVID-19 antiviral treatment is now available in Canada. This is Pfizer’s antiviral Paxlovid, which can be given to COVID-19 patients who are at high-risk of severe illness from the virus. A doctor has to prescribe the pills.

Paxlovid combines a new drug developed by Pfizer, Nirmatrelvir, with an existing antiretroviral drug named Ritonavir, a low-dose HIV drug that helps Nirmatrelvir remain active in the body longer.

The treatment comprises three pills – two of Nirmatrelvir and one of Ritonavir – taken at home twice a day for five days. That is 30 pills over five days. A person should start taking Paxlovid no more than five days after symptoms start. Hopefully, this will take pressure off the health-care system.

Health Canada has authorized the use of these drugs in high-risk adults (18 and older) with mild or moderate confirmed cases of COVID-19 patients. People who are immunocompromised, 80 years of age and over, or who may not have access to health care because of geographical or socioeconomic concerns are first in line – regardless of vaccination status.

Health Canada has warned the product should not be used while a patient is on any of a long list of other drugs, including common medications used to treat erectile dysfunction, high cholesterol and seasonal allergies, among others.

Here are few things to remember:

  • The treatment must be started within five days of the onset of symptoms.
  • It is designed to help the body fight off infection and shorten the period of illness.
  • It has been found highly effective – Paxlovid reduced the risk of hospitalization or death by 89 per cent compared to a placebo.
  • The treatment is likely to work against the Omicron variant.
  • Receiving the treatment does not exempt people from isolation requirements, and is not an alternative to vaccination.
  • These antiviral drugs are not a replacement for vaccines, which remain the best way to keep people out of hospital. Statistics show unvaccinated people are 19 times more likely to be hospitalized with COVID-19 than fully vaccinated people.

Coronaviruses die very quickly when exposed to the UV light in sunlight. The viruses survive longest when the temperature is at room temperature or lower, and when the relative humidity is low (<50 per cent).

We know most transmissions occur indoor. We should continue with preventive measures – physical distancing, quarantining, ventilation of indoor spaces, covering coughs and sneezes, hand washing, and keeping unwashed hands away from the face.

Take care and be safe.

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