There is some evidence that repetitive transcranial magnetic stimulation (rTMS) may be effective in treating depression. Using an intensive methodology of rTMS in two drug-resistant patients, we observed a good antidepressant effect, but also, induction of manic symptoms.
Sirs: Initially considered as a disease of the young [3], some 50 years ago myasthenia gravis (MG) began to be considered as a disease of young women but of older men [1,11,13]. However, there is evidence that the number of women developing the disease in later life increases [1,4, 12].The hypothesis has been formulated that there is a particular form of the disease, the late-onset MG, appearing after the age of 40 or 50 years independent of gender, in addition to the form of thymoma-associated MG, a disease of the middle-aged [1,15]. These forms or subtypes of MG, which have different HLA associations [1,5,15], could also have different clinical characteristics.The ability to follow the evolution of age at onset of male and female MG patients admitted in our center, the neurology department of the largest general hospital of Athens, since 1931, by referring to a previous study [7], allows us to investigate a potential increase of this age since this date (Table 1).There were included the 337 patients hospitalized during the 30-year period 1970-1999, for whom the diagnosis of MG could be retained a posteriori (data available on EMG and clinical symptomatology, positive response to edrophonium test). Clinical symptoms were classified in 4 groups: pure ocular form (ptosis, diplopia); bucopharyngeal form with or without ocular involvement; generalized muscular form with or without the former; and respiratory involvement. Among the patients there were more women (59.6 %) than men (40.4 %) (p = 0.01) [4,[8][9][10]. Onset of the disease occurred 13 years earlier in women (42.2 years) than men (55.0 years) (p < 0.0001) [8-10]. The thymus was ablated in 99 patients and thymoma was histologically proven in 42 (12.5 % of all patients; onset of MG: 43.7 years). Fig. 1 shows the distribution of age at onset. The proportion of patients older than 50 years was 64 % in men and 34 % in women without thymoma respectively (p < 0.001). The peak onset of thymoma-associated MG was at the fourth to sixth decade [15].Pearson correlation coefficients between year of admission and age at onset were positive, and significantly different from 0 for women without thymoma (total group: n = 337, r = 0.10, p = 0.07; thymomas: n = 42, r = 0.09, p = 0.57; men without thymoma: n = 123, r = 0.12, p = 0.17; and women without thymoma: n = 172, r = 0.15, p < 0.05). The proportion of women without thymoma and an age at onset of 60 years or more, increased significantly following the period of admission (from 9 % in 1970-74, to 35.5 % in 1995-99; p = 0.02) [1, 2, 14].Mean age at onset was significantly younger when the disease initially appeared as generalized muscular weakness, rather than as a pure ocular and/or bucopharyngeal form (p = 0.0005). Patients with thymoma presented less frequently with pure ocular or respiratory symptoms at onset (p = 0.003).Clinical or laboratory data on immune pathology and on thyroid abnormalities were available in 184 patients: 18 had an either clinical or laboratory suspicion and 17 actually suffered an immune dise...
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