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Widespread screening for hepatitis C virus (HCV) is necessary for Canada to meet its HCV elimination goals by 2030. People who currently or previously injected drugs are at high risk for HCV. Opioid agonist therapy (OAT, such as methadone and buprenorphine) has been shown to help stabilize the lives of people who are opioid‐dependent. The distribution of OAT in North America typically requires daily, weekly, or monthly clinic visits and presents an opportunity for engagement, screening and treatment for those at high‐risk of HCV. In this study, HCV screening was conducted by staff at OAT clinics in Ontario from 2016 to 2020 and those with chronic infections were treated on‐site with direct‐acting antivirals. Point‐of‐care or dried blood spot (DBS) testing was used for antibodies, DBS or serum for HCV RNA and serum for HCV RNA at SVR12 (sustained virological response). Clinics screened 1954 people (mean age 40 years ±12, 63% male). Forty‐five percent were antibody positive, of whom 64% were HCV RNA+. Eighty percent of those RNA+ set an appointment in which 99% attended. Ninety‐six percent started treatment with 87% completing treatment. Sixty‐eight percent of people who completed treatment submitted a sample for SVR12 testing of which 97% achieved a virological cure. Results suggest that HCV screening and treatment at OAT clinics is feasible, effective and warrants expansion. Data suggest strong treatment adherence due to high rates of SVR12 comparable with other OAT‐based HCV treatment programs. The lack of SVR12 sampling could be addressed by either on‐site phlebotomy or incentivizing SVR12 sampling. [ABSTRACT FROM AUTHOR]

Background: Stigma is a complex social phenomenon that leads to marginalization and influences the course of illness. In the context of hepatitis C virus (HCV), stigma is a well-documented barrier to accessing care, treatment, and cure. In recent years, HCV rates among women have increased, resulting in an urgent need to address stigma and its harmful effects. The purpose of this concept analysis was to investigate stigma in the context of women living with HCV using Rodgers' evolutionary method., Methods: PubMed, CINAHL, Scopus, Medline, PsycINFO, and Nursing and Allied Health were used to identify articles describing HCV stigma among women. Articles from peer-reviewed journals and geographic locations, published between 2002-2023, were included in the analysis. As specified in Rodgers' evolutionary method, articles were analyzed with a focus on the concept's context, surrogate and related terms, antecedents, attributes, examples, and consequences., Results: Following screening, 33 articles were selected for inclusion in the analysis. Discrimination and marginalization were identified as surrogate and related terms to stigma; and antecedents of stigma were identified as limited knowledge, fear of diagnosis, and disclosure. Prevalent attributes of stigma in the literature were described as feelings of decreased self-worth, negative stereotyping, and fear of transmission. Importantly, HCV stigma among women is unique in comparison to other forms of infectious disease-related stigma, primarily due its impact on women's identity as mothers and caregivers. Stigmatization of women living with HCV resulted in negative consequences to personal relationships and healthcare access due to decreased health-seeking behaviours. Although access to HCV treatment has changed considerably over time, a temporal analysis could not be completed due to the limited number of articles., Conclusions: Stigma in the context of women living with HCV has its own unique antecedents, attributes, and consequences. This enhanced understanding of stigma among women living with HCV has the potential to inform improved and more effective approaches to care, which will be required to reach HCV elimination. Furthermore, this analysis identifies stigma layering and stigma in the direct-acting antiviral  treatment era as areas for more in-depth future inquiry., (© 2024. The Author(s).)

Introduction: The on-going substance use crisis has led to unprecedented rates of hepatitis C virus (HCV) in Canada, with increasing positivity among women who use drugs (WWUD). Despite efforts to reduce barriers to HCV testing and treatment, follow-up remains a major issue., Methods: In this quality improvement project (QIP), we partnered with a short-stay trauma-informed residential drug treatment facility specifically for WWUD, to provide an engaging peer-led HCV education session, followed by low-barrier nurse and peer-led testing and treatment. We sought to evaluate these interventions, as well as determine what factors could improve engagement after women leave., Results: The session was attended by 217 participants, 130 completed the survey and 153 opted into testing. Survey results indicated that participants were highly motivated to access general care as well as HCV testing and treatment. The most frequently reported barriers to testing and treatment were a previous negative test and being asymptomatic, respectively. Follow-up facilitators included a non-judgmental provider (88%), monetary incentives (67%), follow-up phone calls (77%), e-mails (66%) and text messages (58%). Of those who were RNA positive, 5 of 13 initiated treatment on-site. By using the results of the QIP in real-time, 6 of 13 were started after leaving the centre (one pending and one lost to follow-up)., Discussion and Conclusions: The implementation of co-localised peer-led testing and treatment for HCV, along with persistent follow-up efforts, led to increases in linkage to care and treatment. Co-localisation of testing and care with substance-use services, especially if residential, is a viable, low-barrier strategy for increasing linkage to care among WWUD., (© 2023 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Objectives: International infectious disease/obstetrical societies have recently recommended universal hepatitis C virus (HCV) prenatal screening and these same recommendations are forthcoming in Canada. At present, there is no formal analysis of universal HCV screening or linkage to care of pregnant people in Ontario. The objectives of our study were to determine the seroprevalence of HCV using 2 different methods to evaluate universal screening, as well as identify opportunities that may improve linkage to care., Methods: To assess seroprevalence in a large urban area, we aimed to test 12 000 de-identified samples submitted for prenatal HIV testing in the catchment area of Toronto Public Health for HCV antibodies. Then, to assess the seroprevalence as well as the operational impact and follow-up in a real-world setting, we completed a Quality Improvement Project (QIP) for 1 year at a large tertiary care obstetrical centre in London, Ontario., Results: From 2019 to 2021, 11 999 de-identified samples were screened from Toronto with a seroprevalence of 0.40 (95% CI 0.29-0.53). In London, 5771 people were screened in 2021 with a seroprevalence of 0.55% (95% CI 0.38-0.78). Taken together, those aged 26-35 years had the highest positivity; in the QIP, 9% had no documented risk factor, and 59% of individuals were not linked to the next step in HCV care., Conclusions: HCV prenatal seroprevalence in Ontario is comparable to hepatitis B virus, and ∼15-30-fold higher than HIV. Diagnosis in pregnancy is critical to facilitate referrals for treatment between pregnancies and could increase screening among children born to positive women., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate uptake of hepatitis C virus (HCV) testing and treatment among psychiatry inpatients at Canada's largest mental health institution, the Centre for Addiction and Mental Health (CAMH)., Methods: We reviewed medical records for all forensic and long-stay mental health patients from January 2017 to May 2021 to examine rates of HCV testing (antibody and RNA), treatment, and follow-up and completed a logistical regression to identify predictors associated with HCV antibody (Ab) screening among inpatients., Results: Of 1,031 patients, 73% (n = 753) were male, mean age was 44 years (range: 20-92), and mean length of stay was 7.1 months (range: 0 days-24 years). Most, 83% (n = 856), were diagnosed with schizophrenia spectrum disorders. In total, 652/1,031 (63%) of individuals in this cohort received HCV Ab screening. When broken down by admission rather than individual, 570/1,303 (44%) forensic admissions had an associated HCV Ab screening, and 318/1,450 (22%) non-forensic admissions had an associated HCV Ab screening. Individuals admitted to a forensic unit and those diagnosed with schizophrenia or substance use disorders were more likely to undergo HCV Ab screening, while individuals of Asian ethnicity were less likely (all P  < .05). HCV Ab positivity was 4.9%, and most (84%, n = 27) HCV Ab-positive individuals had subsequent RNA testing, of whom 56% (n = 15) tested HCV RNA positive. Of 15 RNA-positive individuals, 10 initiated treatments, 7 on-site at CAMH and 3 at a local hepatology center. A total of 7 individuals (1 treated by specialists and 6 on-site) achieved sustained virological response or cure. The remaining 3 were lost to follow-up, 2 of whom were treated at the hepatology clinic., Conclusions: Based on the high prevalence of HCV, mental health inpatients should be included in groups for whom universal screening is recommended. Since on-site treatment was more successful than referral to external hepatology specialists, utilizing inpatient admission as an opportunity for HCV screening and treatment should receive more consideration., (© Copyright 2023 Physicians Postgraduate Press, Inc.)

Background: Few countries have implemented the necessary policy changes to reduce the number of steps in the cascade of care to achieve hepatitis C virus (HCV) elimination, including Canada. The aim of this study was to describe and compare legislation, scope of practice, and policy as it relates to the provision of HCV care in each province., Methods: We reviewed grey literature and regulatory and legislative documents which affect various aspects of the HCV cascade of care. Findings were verified by content experts., Results: HCV RNA reflex testing ensures those that are antibody positive get an HCV RNA test; however only 80% of provinces have reflex test. Point-of-care antibody testing can be offered in most community non-health care settings, yet many types of health care providers are unable to do this independently. Following a positive test, it may not be feasible to complete venipuncture; however only a single province processes HCV RNA dried blood spot cards. In many provinces, training and verification are required for novice prescribers, and in some provinces prescribing continues to be restricted to specialists. Only a single province has task-shifted treatment to a non-physician non-nurse practitioner model, where pharmacists can prescribe treatment. Finally, 80% of provinces require authorization forms, and 30% require proof of investigations for treatment., Conclusions: No single province is optimizing the use of diagnostic tools and task shifting and decreasing paperwork to expedite treatment initiation. Collaboration between provinces is needed to streamline practice, update policy, and promote equity in HCV diagnosis, care, and treatment., Competing Interests: MJ Biondi reports receiving research support and consulting fees from AbbVie, Gilead, and Specialty Rx Solutions. CH Dale is a paid employee of McKesson Canada, and receives consulting fees from AbbVie and Gilead. H Shah reports receiving consulting fees and research support from AbbVie and Gilead. JJ Feld reports receiving research support and consulting fees from AbbVie and Gilead. HLA Janssen reports receiving research support from AbbVie and Gilead. The other authors have nothing to disclose., (© Canadian Association for the Study of the Liver, 2023.)

Background: The World Health Organization recommends universal birth dose vaccination for hepatitis B virus (HBV), yet only 3 provinces and territories in Canada provide birth dose vaccination, and Canadian-born children in Ontario are acquiring HBV before adolescent vaccination. We sought to determine whether birth and/or infant HBV vaccination is cost-effective., Methods: We used a dynamic HBV model that incorporates population by year, disease stage, sex and the influence of immigration to quantify the disease and economic burden of chronic HBV infection in Ontario from 2020 to 2050. We compared 4 vaccination scenarios, which included a birth dose vaccine and variations of the 2 subsequent doses (either alone or as a part of the hexavalent vaccine) and a hexavalent-only strategy in infancy with the current adolescent vaccination strategy. Our costing estimates were based on values from 2020., Results: All 4 infant vaccination approaches prevented an additional 550-560 acute and 160 chronic pediatric HBV infections from 2020 to 2050 compared with adolescent vaccination. Whereas birth dose could be cost-effective, incorporating vaccination into a hexavalent vaccine was cost saving. By 2050, the hexavalent approach led to $428 000 in cost savings per disability-adjusted life years averted., Interpretation: At the current prevalence in Ontario, a switch to birth dose or infant dose will be cost-effective or even cost saving. Introducing any form of infant HBV immunization in Ontario will prevent acute and chronic pediatric HBV infections., Competing Interests: Competing interests: Harry Janssen has received consultant fees and honoraria from Aligos, Antios, Arbutus, Eiger, Gilead Sciences, GSK, Janssen, Merck, Roche, VBI Vaccines, Vir Biotechnology and Viroclinics. Jordan Feld has received consultant fees from AbbVie, Antios, Arbutus, Eiger, Enanta, BlueJay, GSK, Janssen and Roche. Mia Biondi has received honoraria from Gilead and AbbVie. Hemant Shah has received consultant fees and honoraria from AbbVie, Gilead, Intercept and Lupin SCOPE. He has also received travel support and is a member of the advisory boards of AbbVie, Gilead, Intercept and Lupin. Homie Razavi was a member of the advisory boards of Gilead, AbbVie, Abbott, Merck, Janssen, Roche and VBI Vaccines. He is also a member of the board of directors of the Center for Disease Analysis Foundation. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Health care initiatives, such as hepatitis C virus (HCV) screening, have been greatly overshadowed by the corona virus disease 2019 (COVID-19) pandemic. However, COVID-19 vaccination programs also provide an opportunity to engage with a high volume of people in a health care setting. We collaborated with a large COVID vaccination center to offer HCV point-of-care testing followed by dried blood spot collection for HCV RNA. Additionally, this opportunity was used to evaluate the practical significance of a 5-minute version of the OraQuick HCV antibody test in lieu of the standard 20-minute test. We tested 2317 individuals; 31 were HCV antibody positive and six were RNA positive of which four were treated and reached sustained virological response. Over a third of those surveyed said they would not have participated had the test required 20 minutes. Conclusion : Colocalizing HCV testing and linkage to care at a COVID vaccination clinic was found to be highly feasible; furthermore, a shortened antibody test greatly improves the acceptance of testing., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc on behalf of the American Association for the Study of Liver Diseases.)

Background: Two remote First Nations communities each collaborated with an urban-based liver clinic to organize wide-spread testing, followed by linkage to care for hepatitis C virus (HCV)., Method: Involvement of community members was central to planning and conduct of the programs. Samples were obtained using dry blood spot cards (DBS). A week-long pilot study in Community 1 investigated the effectiveness of the program, using DBS. Community 2, being larger, more remote, and known to be endemic for HCV was more challenging. Three-week-long testing drives plus a stand-alone testing day were used to collect samples over 5 months. Public Health Agency (PHAC)'s National Laboratory for HIV Reference Services (NLHRS) received and tested the DBS samples for HCV and other blood-borne infections. Outcomes were measured by number of people tested, the quality of the tests, and community members' satisfaction with the program and retained knowledge about HCV, based on interviews., Results: In Community 1, 226 people were tested for HCV over 4 days. 85% agreed to human immunodeficiency virus (HIV) testing as well. In Community 2, 484 people, one-half of the adult population, were tested. Surveys of participants showed food was the most significant draw, and Facebook the most effective way to inform people of the events. Interviews with staff and participants showed a high level of satisfaction., Conclusion: The results suggest this is an effective approach to testing for HCV in unusually challenging settings. Lessons from the program include the power of community involvement; and the effectiveness of a highly targeted health initiative when developed through collaboration., Competing Interests: The authors have nothing to disclose., (Copyright © 2022 Canadian Association for the Study of the Liver.)

Background: Widespread screening and treatment of hepatitis C virus (HCV) is required to decrease late-stage liver disease and liver cancer. Clinical practice guidelines and Canadian Task Force on Preventative Health Care recommendations differ on the value of one-time birth cohort (1945-75) HCV screening in Canada. To assess the utility of this approach, we conducted a real-world analysis of HCV antibody (Ab) prevalence among birth cohort individuals seen in different clinical contexts., Methods: Cross-sectional study of individuals born between 1945 and 1975 who completed HCV Ab testing at multiple participating centres in Ontario, Canada between January 2016 and December 2020. Differences in prevalence were compared by year of birth, gender, and setting., Results: Among 16,672 birth cohort individuals tested, HCV Ab prevalence was 3.2%. Prevalence was higher among younger individuals which increased from 0.9% among those born between 1945 and 1956 to 4.6% among those born between 1966 and 1975. Prevalence was higher among males (4.4%) compared with females (2.0%) and differed by test site. In primary care, the prevalence was 0.5%, whereas the prevalence was highest among those tested at drug treatment centres (28.7%) and through community outreach (14.0%)., Conclusions: HCV Ab prevalence remains high in the 1945-1975 birth cohort. These data highlight the need to re-evaluate existing Canadian Preventative Task Force recommendations, to consider incorporating one-time birth cohort and/or other population-based approaches to HCV screening into the clinical workflow as a preventative health measure, and to increase training among community providers to screen for and treat HCV., Competing Interests: MJ Biondi reports receiving research support and consulting fees from AbbVie, Gilead, and Specialty Rx Solutions. H Shah reports receiving consulting fees and research support from AbbVie and Gilead. JJ Feld reports receiving research support and consulting fees from AbbVie and Gilead. HLA Janssen reports receiving research support from AbbVie and Gilead. All other authors have nothing to disclose., (Copyright © 2022 Canadian Association for the Study of the Liver.)

Background & Aims: Global elimination of hepatitis C virus (HCV) will require increases in diagnosis. Point of care (POC) tests that detect antibodies against HCV can be useful for testing large and difficult to reach populations. The most accurate POC test requires a 20 min read time to identify antibody-positive samples. We investigated whether viremic patients could be identified using a shorter read time, to increase efficiency and reduce the need for reflex tests (a follow-up test for HCV RNA on the same specimen to confirm viremia)., Methods: Patients with past or current HCV infections provided samples at 2 clinics in Canada for evaluation by the OraQuick HCV Rapid antibody POC test. A community HCV-screening program in Madrid, Spain (real-world cohort) invited people to be tested for HCV with the same OraQuick test. Patients provided samples of whole blood, via finger prick. Fingerprick samples were tested immediately after collection. In the clinic cohort, photographs of the developing test were taken at 15 second intervals, and blinded readers recorded the time to positivity. In the real-world cohort, readers recorded the OraQuick result at 5 minutes, and each minute after, up to 10 minutes, and then again at 20 minutes; viremia was then evaluated using a POC HCV RNA test (GeneXpert HCV Viral Load Assay). Sera from viremic and non-viremic clinic patients were used to quantify antibody titers to investigate the relationship between the time of band appearance and antibody concentration. Fisher's exact test and exact logistic regression were used to determine factors associated with a positive result at 5 minutes., Results: Blood from all viremic patients produced a positive result in the antibody POC test by 5 min. Median time to a positive result for 171 viremic patients was 2.6 min (range, 1.8-4.6 min), vs 4.1 min (range, 2.3-14.4 min) for 108 patients with resolved infection (P < .001). The 5-min threshold identified all viremic cases among 176 HCV antibody-positive patients in the real-world cohort, confirmed by testing for HCV RNA. In the pooled cohorts, antibody positivity at 5 min identified viremic patients with 100% sensitivity (95% CI, 98.4%-100%); the negative predictive value was 100% (95% CI, 94.9%-100%). The positive predictive value at 5 min was 62.0% (95% CI, 56.7%-67.0%) and therefore insufficient alone to detect viremia; an HCV RNA test would still be necessary to confirm active infection., Conclusions: The wait time for the OraQuick HCV Rapid antibody POC blood test can be reduced from 20 min to 5 min and continue to reliably identify patients with HCV infection. Shortening the test time could increase high-throughput screening, reduce loss to follow up, and reduce the need for reflex HCV RNA testing., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Dried blood spots (DBS) are commonly used for serologic testing for viruses and provide an alternative collection method when phlebotomy and/or conventional laboratory testing are not readily available. DBS collection could be used to facilitate widespread testing for SARS-CoV-2 antibodies to document past infection, vaccination, and potentially immunity. We investigated the characteristics of Roche's Anti-SARS-CoV-2 (S) assay, a quantitative commercial assay for antibodies against the spike glycoprotein. Antibody levels were reduced relative to plasma following elution from DBS. Quantitative results from DBS samples were highly correlated with values from plasma ( r 2 = 0.98), allowing for extrapolation using DBS results to accurately estimate plasma antibody levels. High concordance between plasma and fingerpick DBS was observed in PCR-confirmed COVID-19 patients tested 90 days or more after the diagnosis (45/46 matched; 1/46 mismatched plasma vs. DBS). The assessment of antibody responses to SARS-CoV-2 using DBS may be feasible using a quantitative anti-S assay, although false negatives may rarely occur in those with very low antibody levels.

Competing Interests: Conflict of interest JJF reports research support and/or honoraria for scientific consulting unrelated to this work from: Abbvie, Alexion, Arbutus, Eiger, Enanta, Gilead, GlaxoSmithKlein, Janssen, Roche, Wako/Fujifilm. Please refer to the accompanying ICMJE disclosure forms for further details.

Background: Ontario is 1 of 5 provinces that immunize adolescents for hepatitis B virus (HBV), despite the World Health Organization recommendation for universal birth dose vaccination. One rationale for not vaccinating at birth is that universal prenatal screening and related interventions prevent vertical transmission. The aims of our study were to evaluate the uptake and epidemiology of prenatal HBV screening, and to determine the number of children in Ontario with a diagnosis of HBV before adolescent vaccination., Methods: We extracted data from ICES, Public Health Ontario and Better Outcomes & Registry Network (BORN) Ontario databases. We assessed prenatal screening uptake and prevalence of prenatal hepatitis B surface antigen (HBsAg) from 2012 to 2016, as well as subsequent hepatitis B e-antigen (HBeAg) and HBV DNA testing and percent positivity. We used age and region to subcategorize the results. In a separate unlinked analysis, we evaluated the number of children positive for HBV aged 0-11 years who were born in Ontario from 2003 to 2013., Results: From 2012 to 2016, 93% of pregnant women were screened for HBV, with an HBsAg prevalence of 0.6%. Prevalence of HBsAg increased with age, peaking at older than 45 years at 3%. North Toronto had the highest overall prevalence of 1.5%, whereas northern Ontario had the lowest. Of women who were HBsAg positive, HBeAg and HBV DNA tests were subsequently ordered in 13% and 38%, respectively. Of children born in Ontario between 2003 and 2013, 139 of 23 759 tested positive for HBV., Interpretation: Prenatal HBV screening is not universal and subsequent evaluation is poor, limiting optimal intervention and possibly contributing to some Ontario-born children being given a diagnosis of HBV before age 12 years. These findings underscore the limitations of the province's adolescent vaccination strategy., Competing Interests: Competing interests: Tony Mazzulli reports serving as a speaker, consultant or advisory board member for Merck, Pfizer, Qvella, Microbix, Roche, Verity Pharmaceuticals and Cipher Pharmaceuticals, and receiving research funding from Qvella and bioMérieux. Harry Janssen reports serving as a speaker, consultant or advisory board member for AbbVie, Arbutus, Benitec, Bristol Myers Squibb, Gilead Sciences, Glaxo, Janssen, Medimmune, Merck, Roche and Vir Biotechnology, and receiving research funding from AbbVie, Bristol Myers Squibb, Gilead Sciences, Janssen, Medimmune, Merck and Roche. Jordan Feld reports receiving research support or consulting fees from Abbott, AbbVie, Enanta, Gilead, Janssen, Roche, Arbutus and GlaxoSmithKline. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

Background and Aims: The World Health Organization's hepatitis C virus (HCV) elimination strategy recognizes the need for interventions that identify populations most affected by infection. The emergency department (ED) has been suggested as a setting for HCV screening. The study objective was to explore the health and economic impact of HCV screening in the ED setting., Methods: We used a microsimulation model to conduct a cost-utility analysis evaluating two ED setting-specific strategies: no screening, and screening and subsequent treatment. Strategies were examined for two populations: (a) the general ED patient population; and (b) ED patients born between 1945 and 1975. The analysis was conducted from a healthcare payer perspective over a lifetime time horizon. A reference and high ED HCV seroprevalence measure were examined in the Canadian healthcare setting.US costs of chronic infection were used for a scenario analysis of screening in the US healthcare setting., Results: For birth cohort screening, in comparison to no screening, one liver-related death was averted for every 760 and 123 persons screened for the reference and high seroprevalence measures. For general population screening, one liver-related death was averted for every 831 and 147 persons screened for the reference and high seroprevalence measures. In comparison to no screening, birth cohort screening was cost-effective at CAN$25,584/quality-adjusted life year (QALY) and US$42,615/QALY. General population screening was cost-effective at CAN$19,733/QALY and US$32,187/QALY., Conclusions: ED screening may represent a cost-effective component of population-based strategies to eliminate HCV. Further studies are warranted to explore the feasibility and acceptability of this approach., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Myasthenia gravis is an autoimmune neuromuscular disorder characterized by skeletal muscle involvement, causing muscle weakness and fatigue. The prevalence of the disease is approximately 1:7500 with a maximal prevalence during the second and third decade in women and the fifth and sixth decade in men, although it may appear at any age. The disease has a slight female preponderance, with a sex ratio of 3:2. Cardiac involvement in myasthenia gravis may take several forms, ranging from asymptomatic ECG changes to ventricular tachycardia, myocarditis, conduction disorders, heart failure and sudden death. We hereby report two cases of patients with myasthenia gravis who developed signs and symptoms of cardiovascular involvement, requiring admission in a cardiology ward for further investigation and treatment. The particular characteristics of the first case may be summarized by the symptomatic conduction disturbances with frequent episodes of syncope in a patient with myasthenia gravis who necessitated permanent pacing and the difficulties we encountered in the establishment of conduction disturbancies etiology (due to the disease or due to the treatment with acetylcolinesterase inhibitors). The second case shows a different kind of cardiac involvement in myasthenia gravis--the ECG changes (giant diffuse T waves in a patient with cardiovascular risk factors) which needed further investigation and long term surveillance.