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Important issues about patient history for myasthenic patient
 
Clinical manifestation of myasthenia gravis(MG) patients at different ages
 
Lifestyle behaviours for MG patients
 
Type of Traditional Chinese Medicine
 
MG typical case
 
Traditional Chinese Medicine
 
Western Medicine
 
Establishing follow-up center to supervise and guide patients
 
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modern medicine

Surgery
Totally 200 cases of MG received operation in 2009, which has advantages of being safe, reliable, good curative effect and lower incidence of myasthenic crisis after operation(3.5%).

1. Operation is suitable for those with stable physical condition and without infection and surgical contraindication. Patients treated by hormone require suitable range of hormone preoperatively, i.e. hormone should be decreased to below 20mg/d in patients with prednisone. Generally speaking, patients are advised to be treated by operation.

2. After operation, patients are encouraged to cough up phlegm so as to keep fluency of respiratory tract, and actively receive anti-infective therapy. Then, antibiotics should be used for 7-10 days after operation.

3. The drainage tube should be pulled up when the drainage flow is below 100ml within 24 hours after operation. Hemogram, blood gas analysis, electrolyte, sternite etc. should be ensured at normal range before pulling out drainage tube.

4. Intravenous gamma-globulin therapy, plasmapheresis and traditional Chinese medicine can be considered for type Ⅲ, Ⅳ patients, so as to pass through the dangerous surgical period successfully.

Internal medicine
1 Cortical hormone and immunosuppressive drugs therapy with rich clinical experience

1.1 Indication
(1 )Patients with purely ocular MG
(2 )Patients with exacerbating MG, without performing thymectomy
(3 )MG patients after taking thymectomy

1.2 Mechanism
(1 )Immunosuppression To inhibit composition of acetylcholine receptor antibody, avoiding or decreasing the destruction of acetylcholine receptor listed on the postsynaptic membrane of neuromuscular junction due to autoimmune attack. Also, it inhibits the antibody which aims at other compositions of skeletal muscle.
(2 )Facilitation To facilitate presynaptic membrane to release acetylcholine and to make excitement easier to transmit.
(3 )Regeneration To regenerate endplate and to double amount of acetylcholine receptor on postsynaptic membrane

1.3 Treatment methods
Generally, large doses of prednisone is advised to take daily(60-80, even100mg/d), and then gradually reduce doses, or completely stop taking cholinesterase inhibitors after observing continuous improvement . Advantages: achieving satisfactory effect in short period, reducing doses of cholinesterase or stopping taking cholinesterase; meanwhile, thymectomy is performed 2 months after observing obvious improvement, with which complications can be decreased.
Pulse therapy is used for critical cases, or patients who have been used tracheal intubation and artificial respirator. Methylprednisolone was given intravenously (1000mg/d ) for continuous 3 days, then reducing half dose every 3 days until drug withdrawal.

1.4 Attention
(1) About 48% patients’ condition may aggravate in the beginning of treatment, which may appear in the initial 1-17(1.9 on average)days and may last for 1-20days (4.2 on average). Totally 86% of the aggravated patients need breathing machine.
(2) Part of patients can consider applying adjunctive therapy of imuran or Cyclosporin immunosuppression at the beginning courses of adrenal cortical hormone therapy.
(3) During therapy, gastroduodenal mucosal protective agents should be added in order to avoid causing or aggravating stress ulcer.
(4) Pay attention to supplying potassium and calcium.
(5) Patients who are suffering from disease like infection,diabetes,hypertension,mental symptoms should be cautious or be prohibited to use this kind of medicine. Taking this medicine for a long term may result in diseases like osteoporosis, aseptic necrosis of femoral head , etc.

2 Immunosuppression
2.1 Cyclophosphamide
(1) Patients with malignant thymoma are advised to use cyclophosphamide
(2) Levels of leucocytes and blood plaque should be ensured at normal range before medication.
(3) Directions for its usage: In the first course, intravenously give 1000mg once every 5 days, or 200mg 2 to 3 times a week; or orally take 50mg twice every day. Cyclophosphamide should not be stopped until the total amount adds up to 10g. In the second course, orally take 50mg once every day until the total amount adds up to 20g. In the third course, continue to orally take 50mg once every two days until the total amount adds up to 30g.
(4) Children are advised to take 3 to 5 mg/kg (maximum of 100mg/d) twice per day, and then reduce dose after improvement. The level should be maintained at 2mg/kg(maximum of 50mg/d)
(5) Side-effects include decreasing of leucocytes and blood plaque; alopecie ; gastrointestinal reaction and hemorrhagic cystitis.
(6) The time taking effect mostly is 1 to 2 months.

2.2 Azathioprine
(1) Azathioprine (50-100mg/day) is applied with adrenal cortical hormone therapy , and can be taken for long-term (maximally 11 years)
(2 ) Levels of leucocytes should be ensured at normal range before medication. Adults are advised to take 50mgtwice per day and children 2mg/kg per day.
(3) During the first week after taking drugs, blood routine examination should be ensured normal level, which should be taken every two days in the first week, once a week during the 2nd to 4th week, once a month during the second months.
(4)Leucogen( 10 mg,tid)and batyl alcohol (50mg,tid) can be added in order to avoid hemogram inhibition.
(5) Reducing doses at the period of WBC being 3.5×109/L, stopping taking medicine at the period of WBC being 3.0×109/L.
(6) The time taking effect mostly is 4-26 weeks. The total effective rate is 92%, and remission rate is 40%.

2.3 Cyclosporin A
(1 )Cyclosporin A can be used for myelosuppressive patients, ensuring renal function be checked before medication.
(2) For patients with normal renal function, 3-8mg cyclosporin A is taken orally twice every day, with the total treatment period of 3-6 months.
(3 )Cyclosporin A blood concentration and renal function should be re-checked regularly, ensuring the blood concentration being at 200-400ng/ml and creatinine increasing twice or more. Renal function injury is reversable, and most of it can be recovered spontaneously after drug withdrawal
( 4 )Other side effects include nausea, apocleisis, diarrhea, drowsiness, trembling, hypertrichiasis, and gum hypertrophy etc.
( 5 )The time taking effect mostly is 2-3 months.

3 Advanced double filtration plasmapheresis
( 1 )Indication: The two commonest indications for double filtration plasmapheresis are treating myasthenic crisis and the preparation for thymectomy. Double filtration plasmapheresis combined with immune depressant such as glucocorticoid can achieve long-term remission of symptoms.
( 2 )Mechanism of action of double filtration plasmapheresis : The MG is treated by the mechanism that patients’ plasma is replaced with plasma of healthy people and blood plasma substitute and the acetylcholine receptor antibodies is decreased. This method has a rapid but non-long lasting onset of effect. The effect-lasting time depends on the half-life of acetylcholine receptor antibodies. And most symptoms recur after 6-10 days.
( 3 )Usage Direction: Averagely , there is exchange capacity of 2.5-3L each time, which is continued 3-8 times.
( 4 )Side effects: The application of blood plasma substitute easily leads to secondary infection due to decrease of immune globulin. The patients’ condition may worsen due to excessive synthesis of acetylcholine receptor antibodies. Sometimes, patients’ symptoms recur or aggravate after having continuous treatment 5-6 months.

Combined treatment of chemotherapy, radiotherapy and traditional Chinese medicine after removal of thymoma
The combined application of chemotherapy, radiotherapy and traditional Chinese medicine can increase patients’ resistant ability, decrease the side effect of chemotherapy and radiotherapy, stabilize patient’s condition, reduce incidence of recurrence and improve the life quality of patients.

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