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AChR-binding antibodies are highly speci c for MG, but these can also be detected in patients with autoimmune liver disorders, approximately 13% of patients with LEMS, and about 3% of patient with lung cancer without an apparent neurological disorder228 It is important to emphasize that the value of any of these tests is strictly in initial diagnosis, or in the case of modulating antibodies, as a potential marker for thymoma The serum titer of any of these antibodies does not correlate with disease severity Following titers is generally not considered an accurate means to judge treatment response, although in some patients, a falling antibody titer following thymectomy seems to correlate with clinical improvement309 In 2001, the rst report of antibodies directed against MuSK antibodies in MG was published310 Currently, it is estimated that 40% of patients with MG who do not have one or more of the aforementioned AChR antibodies will be found to be MuSK seropositive Most studies have suggested no overlap between MuSK and AChR antibodies in patients with MG,85,310 although exceptions to this rule at least in Japanese patients occur118 Unlike AChR antibodies, there appears to be a correlation between anti-MuSK titers, disease severity, and the application of immunomodulatory therapy311 On the other hand, thymectomy does not signi cantly alter antiMuSK levels Striated muscle antibodies refer to a class of antibodies directed against components of skeletal muscle including titin, the ryanodine receptor, myosin, and -actinin312 These are discoverable in approximately 30% of adult patients with MG without thymoma, 24% of patients with thymoma without MG, and 70 80% of patients who have both71,228,313,314 These antibodies may also occur in high titer in individuals who do not appear at the time of testing to have either MG or thymoma Their ultimate signi cance in these situations is unknown In some patients, striated muscle antibodies may be the only serological marker of autoimmunity in patients with MG Unlike AChR antibodies, striational antibodies can be of value in monitoring the disease course Persistence or recurrence of high titers of these antibodies may suggest incomplete resection or recurrence of thymoma, respectively There is also a known association between MG and certain HLA genotypes Some studies have noted a predilection for HLA types A1, A3, B7, B8, and DRw3 in patients with MG315 These HLA subtypes may somehow predispose patients to autoimmune diseases HLA genotyping is not routinely used in the evaluation of patients suspected to have MG Antibodies directed against the Kv14 subunit of voltage-gated potassium channels have been described to occur in a percentage of patients with MG but not in patients with thymoma, in ammatory myopathy, or in healthy controls93 These were found exclusively in.

The permission model used by most mobile operating systems is fairly strong on the base device Although the permissions on the external SD card are usually supported using only the FAT permission model, which is not secure, the base device is well supported by most mobile operating system vendors For example, the new permission models used by Android and iPhone, where the applications are fairly isolated from each other, should be leveraged as much as possible There s always the lazy desire to grant a given application access to everything on the mobile device, which is the old Windows 98 way of thinking, but as we saw with Windows XP, that model does not work very well Although it is easier to create an application that is granted access to the entire OS (rather than taking the time to figure out which services, binaries, files, and processes it actually does need to function), the security architecture of mobile devices will not let the application have such access so easily (see operating system chapters, such as 1 5, for more details) Leveraging the permission model by the mobile operating system will ensure the application plays by the rules

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patients who were also AChR-binding antibody positive and are not commercially available Their role in the diagnosis of MG, if any, has yet to be de ned

The edrophonium (ie, Tensilon) test can be helpful in diagnosing MG28,30,316 Edrophonium is a short-acting anticholinesterase, the administration of which will result in a transient increase in ACh availability at the NMJ suf cient to transiently improve strength To perform the edrophonium test, a butter y needle is placed in an accessible vein A 2 mg (02 mL) test dose of edrophonium is administered initially, as some patients are extremely sensitive to such low doses Giving a full 10 mg dose initially may result in a false-negative conclusion in these individuals If there is no response after 30 seconds, the remaining 8 mg are administered in 2 mg increments every 10 15 seconds If the patient has an objective improvement or a severe side effect, the rest of the injection is aborted Performance of edrophonium testing should only be done in patients in whom an objective improvement can be documented In this regard, evaluating improvement of ptosis or ophthalmoparesis is most useful A test is not considered positive if the patient states that they feel stronger Unfortunately, false-negative edrophonium testing is not rare in patients with MG A modest response to edrophonium may be seen in other disorders as well LEMS,196 overlap MG/LEMS,219 amyotrophic lateral sclerosis (ALS),317 319 CMS,177 botulism,320 and Guillain Barr syndrome321 are notable examples Ace cordingly, a positive edrophonium test indicates abnormal NMT and does not specify a singular disease entity Edrophonium testing is reported to be positive in 50 70% of MuSK antibody-positive cases In general, false negative results are more common than with AChR seropositive patients73

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