title: Problems in the optimal management of myasthenia gravis patients--a prospective clinical survey at Kalafong Hospital.
abstract: OBJECTIVE
  This study forms part of a clinical survey of problems in the optimal management of patients with inherited neuromuscular diseases seen at Kalafong Hospital in Pretoria. Our objectives were to determine the problems associated with providing patients with optimal management until true remission (cure), and to apply the findings to ongoing improvement of optimal management. This is the first report of the series.
  
  
  METHODS
  Twenty-six patients were studied prospectively from 1986 to 1998. Early sternal-splitting thymectomy on class II-V patients as well as anticholinesterases, corticosteroids, azathioprine, plasma exchange, intensive care and various combinations of these constituted part of the optimal management. An assessment of the total monthly income and distance from hospital was done for each patient.
  
  
  RESULTS
  Five of the 15 thymectomised patients (33.3%) were lost to follow-up after reaching remission. Of the remaining 10 patients, 6 (40%) are in true remission and the remaining 4 (26.7%) are in pharmacological remission. Four of the 11 patients (36%) treated non-surgically were lost to follow-up. Of the remaining patients, 1 (9.1%) is in true remission and the remaining 6 (54.5%) are in pharmacological remission. The average monthly income of patients lost to follow-up in the thymectomised group was lower than that of patients who continued follow-up, and their homes were further away from hospital. In the non-surgical group the average monthly income of patients lost to follow-up was higher than that of patients who continued follow-up and their homes were nearer to the hospital.
  
  
  CONCLUSIONS
  Early thymectomy (the aggressive approach) resulted in 40% cures, 26.7% pharmacological remissions, no mortality, minimal morbidity, and early discharge. Loss to follow-up was one of the biggest problems in providing optimal management for these patients. We modified optimal management in response to our patients' concerns without sacrificing excellence, and found that poverty and poor access to tertiary hospitals were possible contributory factors to loss to follow-up. Suggestions are made with regard to tackling the problems. Myasthenia gravis (MG) is a disorder of neuromuscular function resulting from an immunologically based premature destruction of acetylcholine receptors.
authors.affiliation: Department of Neurology, Kalafong Academic Hospital, University of Pretoria.
authors.forename: N A
authors.initials: NA
authors.lastname: Mafojane
authors.forename: P L A
authors.initials: PL
authors.lastname: Bill
authors.forename: B P
authors.initials: BP
authors.lastname: Lotz
mesh_terms: D000328:Adult; D005260:Female; D019538:Health Care Surveys / Q000191:economics / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D009157:Myasthenia Gravis / Q000191:economics / Q000628:therapy*; D011446:Prospective Studies; D011787:Quality of Health Care / Q000191:economics / Q000706:statistics & numerical data*; D012720:Severity of Illness Index; D012959:Socioeconomic Factors; D013019:South Africa