International consensus guidance for management of myasthenia gravis

ObjectiveTo update the 2016 formal consensus-based guidance for the management of myasthenia gravis (MG) based on the latest evidence in the literature.MethodsIn October 2013, the Myasthenia Gravis Foundation of America appointed a Task Force to develop treatment guidance for MG, and a panel of 15 international experts was convened. The RAND/UCLA appropriateness method was used to develop consensus recommendations pertaining to 7 treatment topics. In February 2019, the international panel was reconvened with the addition of one member to represent South America. All prior recommendations were reviewed for currency, and new consensus recommendations were developed on topics that required inclusion or updates based on recent literature. Up to 3 rounds of anonymous e-mail votes were used to reach consensus, with modifications to recommendations between rounds based on panel input. A simple majority vote (80% of panel members voting “yes”) was used to approve minor changes in grammar and syntax to improve clarity.ResultsThe previous recommendations for thymectomy were updated. New recommendations were developed for the use of rituximab, eculizumab and methotrexate as well as for the following topics: early immunosuppression in ocular MG and MG associated with immune checkpoint inhibitor treatment.ConclusionThis updated formal consensus guidance of international MG experts, based on new evidence, provides recommendations to clinicians caring for MG patients worldwide.

The Making of a Watchdog

The Consumer Financial Protection Bureau’s strategy was to push through the political opposition by acting aggressively for consumers. Early on, the bureau worked to make the terms of financial products more understandable for consumers, creating streamlined forms for mortgages, student loans, and credit cards. It took major enforcement actions against credit card companies for deceptive marketing, returning billions of dollars to consumers. As Cordray’s nomination languished in the Senate, President Obama made an extraordinary recess appointment to install him on a temporary basis. The financial industry immediately challenged the appointment in court, and Republicans pushed back hard in tough oversight hearings. In July 2013, the Democratic Senate majority leader, Harry Reid, moved to invoke the “nuclear option” to approve nominations by a simple majority vote. The Republicans yielded, and Cordray was confirmed in a bipartisan vote of sixty-six to thirty-four. In a tough two-year battle, the bureau prevailed over the strenuous opposition.

The handling of the proposal to conserve the name Acacia at the 17th International Botanical Congress—an attempt at minority rule

The handling of controversial Proposal 1584 to conserve the name Acacia with a conserved type for the Australian acacias during the Nomenclature Section meeting at the 17th International Botanical Congress (Vienna) in 2005 is reviewed. Through a simple majority vote, this Section adopted rules requiring a 60% majority of votes to approve any proposal to modify the International Code of Botanical Nomenclature and a simple majority to approve all other motions; motions not receiving the required majority were to be rejected. However, for the motion addressing Proposal 1584, 45.1% voted to conserve the type of the name Acacia for Australian acacias, and 54.9% voted to retain the current African type for the name Acacia. Even though this motion failed to get a 60% majority either way as required by the Section’s own rules, Section officials have concluded that the name Acacia is to be conserved for Australian acacias. Treating a motion as approved, even though it received only minority support, also violates the fundamental principle of standard parliamentary procedure—the right of the majority to approve proposals. For Acacia to be formally conserved, the Nomenclature Section needed to approve a motion addressing Proposal 1584 with a majority vote, and this never happened in Vienna. Recommendations are made on how this process might be improved.