Article In Brief

Neurologists and neuroethicists discuss the different pathways to careers and involvement in ethical decisions involving neurology patients.

Ethics is a critical component of all medical practice, but perhaps no other medical specialty deals with basic ethical issues more frequently than does neurology, because the brain and its function is so central to human identity. An individual could undergo a heart, lung, kidney, or liver transplant and still remain essentially the same person, but even if such a thing as a brain transplant were medically possible, it would alter the fundamental essence of who that person is. States of consciousness, ability to communicate and consent, issues of cognitive enhancementall pose inherent ethical challenges to the clinician.

The very nature of neurologic disease, in that it affects the brain, means that our patients are highly vulnerable, said Justin A. Sattin, MD, associate professor of neurology at the University of Wisconsin and a former member of the AAN's Ethics, Law, and Humanities Committee. Ethical concerns attach to their conditions, whether it's emergent decision-making in stroke, which is my area of subspecialty interest, or end-of-life-care, or disorders of consciousness such as minimally conscious and persistent vegetative states.

While every neurologist confronts ethical questions in his or her clinical practice periodicallysome more than otherssome clinicians have elected to take a deeper dive into the specialty's ethical questions by doing work in the field of neuroethics. As Neurology Today found when we spoke with several leaders in the field, there is no single training or career path that leads to a professional focus on neuroethics.

Some clinicians who specialize in neurology and ethics have undergone advanced specialty training in the field, while others have found themselves drawn into roles on ethics committees at their institutions through on-the-job training. But they all typically share a passion for the intersection of medicine and the humanitiesa passion that manifested itself early in their medical training.

Neuroethics pioneer Joseph J. Fins, MD, MACP, FRCP, the E. William Davis, Jr., M.D., Professor of Medical Ethics, professor of medicine, and chief of the division of medical ethics at Weill Cornell Medical College, is an internist and not a neurologist by training, although he has a secondary appointment in neurology. He majored in the humanities as an undergraduate, studying literature, history, and philosophy at Wesleyan University. During his fellowship in general internal medicine at The New York Hospital-Cornell Medical Center, he also served as a visiting associate at the Hastings Center, a bioethics research institute. In 2000, he was appointed Weill Cornell's inaugural chief of its division of medical ethics. He also teaches at Yale Law School.

A few years later, his interest in ethics intersected with neurology when two events aligned: He was editing an ethics rounds column for the Journal of Pain and Symptom Management when he received a submission about a patient in a coma in the ICU, which raised questions about whether the patient might perceive pain or experience depression.

Nicholas D. Schiff, MD, now the Jerold B. Katz Professor of Neurology and Neuroscience in the Feil Family Brain and Mind Research Institute at Weill Cornell, was studying disorders of consciousness, and Dr. Fins asked him to write a commentary for the journal. That conversation has led to a more than 20-year collaboration investigating disorders of consciousness and understanding the mechanisms of brain injury and resilience. Together, Drs. Fins and Schiff co-direct the Consortium for the Advanced Study of Brain Injury at Weill Cornell and Rockefeller University.

Neurointensivist Michael Rubin, MD, associate professor of neurology and neurotherapeutics at UT Southwestern Medical Center in Dallas and chair of the UT Southwestern Ethics Committee, followed a similar undergraduate path to Dr. Fins.

As a college student studying the humanities, I knew I wanted to be an MD but always was looking for ways to incorporate my love of literature and philosophy into daily practice. Clinical ethics was that way for me to work on those problems, he said. While completing his neurocritical care fellowship at Washington University School of Medicine in St. Louis, he also earned his master's degree in bioethics from Loyola University. He has since served on the AAN Ethics, Law, and Humanities Committeea joint committee of the AAN, American Neurological Association, and Child Neurology Societyincluding the committee's Brain Death Working Group.

Dr. Rubin noted that most people who get involved in neuroethics, however, are traditional autodidacts, having entered the field after being asked to serve on a hospital ethics committee or reading ethics-focused articles in Neurology and other scientific journals. For example, renowned neuroethicist James L. Bernat, MD, FAAN, the Louis and Ruth Frank Professor of Neuroscience at Dartmouth Medical School, who directs the Program in Clinical Ethics at Dartmouth-Hitchcock and has authored seminal texts in the field, including Ethical Issues in Neurology, contributed to the development of the field before there was accessible graduate training in clinical ethics or neuroethics.

Dr. Sattin found his way into clinical neuroethics after participating for a number of years as a member of University of Wisconsin's institutional review board. I've always had an interest in the more philosophical aspects of our field. The protection of human subjects has a major ethical domain, and that was my first entry into that world. But unlike some of my colleagues, I have not pursued formal fellowship training in bioethics.

While Dr. Sattin does not serve on the hospital's ethics committee, he has been asked to serve as a consultant to the committee for certain cases, such as one involving a patient with multifocal brain infarcts and disordered consciousness, in which he provided expertise on the patient's likely outcome and rehabilitative needs.

Dr. Sattin estimated that, as a stroke neurologist, some ethical issues arise during the treatment of as many as one-third of his patients. I estimate it to be so high because my patients are often quite ill, and a relatively high percentage of them lack decision-making capacity. Even someone who is aphasic has impaired decision-making ability, so it's truly a daily part of my practice when I'm on service.

Ariane Lewis, MD, director of the division of neurocritical care at NYU Langone Health and a member of the AAN's Ethics, Law, and Humanities Committee who has led a course on ethical conundrums in neurology at the AAN Annual Meeting, is another of those autodidacts who has rapidly become a thought leader in neuroethics.

With Dr. Bernat, Dr. Lewis guest edited a 2018 edition of Seminars in Neurology focused on ethics. Like Drs. Fins and Rubin, who majored in the humanities, her undergraduate major was not in biology or chemistry, but rather in psychology. I always liked thinking about decision-making, and the many questions in medicine that fit into the category of ethics, she said.

Most hospital ethics committees are very welcoming to those with a genuine interest, said Dr. Rubin, who first began participating in ethics committee work as a medical student. It's a great way for people to explore their interest and decide if ethics is something they want to explore in their career, similarly to how medical students rotate through other specialties.

Virtually all hospitals now have some form of ethics committee, but not all operate exactly the same way. Dr. Fins chairs the ethics committee at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, which is composed of credentialed ethicists approved by the hospital's medical board, which takes calls 24/7.

These cases are often brought to us by the clinical team based on a conflict or an uncertainty about goals of care. We help to cultivate the narrative, bring relevant ethical analysis to the case, and provide guidance in framing the kind of discussions that are important. We don't make decisions; we help make decision-making better.

NYU Langone has two different committees that address ethical issues: the ethics committee, which leads discussion about cases but does not help to formulate a decision, and the Case Review Escalation Support Team (CREST), which takes consultative calls from any service in the hospital with regard to whether it is medically, ethically, and/or legally appropriate to perform certain procedures.

For example, a consult could address the question of whether or not it's appropriate to do an exploratory laparotomy on a patient who has anoxic brain injury, said Dr. Lewis, who serves on both teams. CREST decision-making is binding in a particular case, while the ethics committee meets once a month to discuss major issues of clinical importance and is more didactically based rather than interacting directly with practice.

Issues of consciousness, brain activity, enduring neurologic impairment, and quality of life considerations are some of the most common triggers for a neuroethics consultation, said Dr. Fins, who noted that the evolution in the medical and scientific understanding of consciousness over the past two decades has led to major changes in how disorders of consciousness are categorized and characterized.

Things are very different today from when I was a medical student learning about the vegetative state. We had little understanding about other brain states or disorders of consciousness that have emerged since, said Dr. Fins, whose book, Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness (Cambridge University Press, 2015) explores the clinical and ethical questions involved in caring for patients with severe brain injuries.

Patients who might appear unconscious at the bedside may actually be conscious, he said. More than 40 percent of patients thought to be vegetative from traumatic brain injury in chronic care facilities when carefully assessed with the Coma Recovery Scale are minimally conscious, rather than vegetative. This has major implications for how we think about their prospects for recovery, their perception of pain, and their isolation.

He noted that recent advances in the use of functional MRI and machine learning have also suggested that as many as 15 percent of individuals who look unresponsive in the neuro-ICU actually may be conscious and in a state that Dr. Schiff has termed cognitive motor dissociation, in which they cannot purposefully move but demonstrate brain activity on neuroimaging associated with volitional prompts.

We have to do something paradoxical and bimodal in neuroethics, which is preserving a patient's right to die and at the same time affirming the right to care for those patients and families who desire care, he argued, while also giving people a better sense of which patients can and cannot be helped through the development of better biomarkers.

So much of this depends on our ability to take limited data that we have on individual patients and come up with an idea of what the future may hold for them, so that we can provide proper guidance to families, said Dr. Rubin.

They all have the same questions: If my loved one is to survive this, what is their life going to be like? Will they wake up, talk, be independent? Our ethical challenge as neurologists in these situations is to provide the most reliable prognosis we can, and to engage with families in way that helps elicit their values so that we can, in a shared decision-making process, figure out the best choices for that patient and family.

Although these existential questions may seem daunting to address on a regular basis, Dr. Fins believes that pursuing medical ethics can be sustaining for the practicing neurologist. Medical ethics is a marvelous way to bridge science and humanities in a meaningful way. For me, it's a good balance between the active and contemplative life and keeps me engaged and bringing ideas into the clinic, he said.

Even if neurologists don't become clinical ethicists, by gaining an awareness of ethics, they will have more tools to engage in ethical reasoning and think about choices. Having the vocabulary to translate one's reasoning into angst or concern will help build resilience, prevent burnout, and make them better neurologists.

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How These Neurologists and Neuroethicists Navigate the... : Neurology Today - LWW Journals

Article In Brief

Evidence from a study of children who had stroke found the safety profile for the use of endovascular recanalization in those with acute, large-vessel occlusion was similar to findings from studies of adult stroke patients. The data support off-label thrombectomy for pediatric stroke.

Pediatric stroke patients undergoing endovascular thrombectomy appear to have mostly favorable neurologic outcomes with low complication rates, a new multicenter retrospective review indicated.

The findings lend support to performing mechanical recanalization for childhood stroke even though prospective randomized clinical trials have investigated its use only in adults, the authors reported in the Save ChildS study published online October 14 in JAMA Neurology.

After reviewing the databases from 27 stroke centers in Europe and the United States, the researchers concluded that endovascular recanalization appeared to be safe with positive outcomes in a real-world setting. The overall proportion of successful recanalization totaled 87 percent.

Several sizeable randomized clinical trials in adults have demonstrated the safety and efficacy of thrombectomy for large intracranial vessel occlusions. However, other than small case series, the potential for this intervention in children had not yet been examined systematically, the study's authors noted.

Etiologies are very different in children and adults, said lead author Peter B. Sporns, MD, MHBA, assistant professor of radiology/neuroradiology at University Hospital Muenster in Muenster, Germany. Results from adult trials cannot be extrapolated to pediatric populations, Dr. Sporns told Neurology Today.

Few children experience this emergency, posing challenges to researchers in designing randomized clinical trials. Arterial ischemic stroke rarely occurs in childhood, but when it strikes two to eight of 100,000 children per year, it can inflict severe disabilities with long-term social and financial consequences. Standard of care relies on supportive medical management tailored to the underlying etiology of arterial ischemic stroke. Thrombolytic and endovascular therapy is only recommended as a last resort, the authors noted.

Dr. Sporns expects the findings to have implications for current treatment guidelines. Endovascular recanalization will become first-line therapy in children with acute ischemic stroke due to large-vessel occlusion, he said. The main message is that endovascular thrombectomy in children can be performed with a similar safety profile and recanalization rate as in adults. Therefore, all physicians should keep this in mind and refer their patients to highly specialized neurointerventional centers.

Meanwhile, Dr. Sporns emphasized the need for pediatric stroke centers worldwide to contribute data to the Save ChildS Pro registry, which he is launching in 2020. We hope that this registry will provide the highest level of evidence for the use of endovascular thrombectomy in children with large intracranial arterial occlusion, he said.

From January 1, 2000 to December 31, 2018, researchers analyzed data for all pediatric patients (<18 years) with ischemic stroke who underwent endovascular recanalization at 27 participating stroke centers. The researchers initially had contacted 42 tertiary stroke centers, but 15 of those centers (36 percent) did not treat any pediatric patients with this technique.

The total cohort at 27 centers consisted of 73 children, with a median age of 11.3 years. Sixty-three children (86 percent) had treatment for anterior circulation occlusion and 10 patients (14 percent) received intervention for posterior circulation occlusion; 16 patients (22 percent) underwent intravenous thrombolysis concomitantly. Median follow-up was 16 months.

The primary outcome was a decline on the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score from admission day; the score ranges from 0 for no deficit to 34 for maximum deficit.

Secondary clinical outcomes, measured on the modified Rankin scale (mRS)where 0 (for no deficit) to 6 (death)at six and 24 months, evaluated the rate of complications.

The researchers reported improvements in neurologic outcome, with a median PedNIHSS score of 14.0 at admission and 4.0 at day seven. Median mRS score was 1.0 at six months and at 24 months. One patient developed postinterventional bleeding and four patients exhibited transient peri-interventional vasospasm.

To facilitate interpretation of the results in a broader context, investigators compared long-term outcomes in their Save ChildS study to available data from the HERMES meta-analysis trials of adults. They extracted data from intervention arms of seven published HERMES trials.

The proportion of symptomatic intracerebral hemorrhage events in Save ChildS was 1.37 compared with 2.79 in the HERMES meta-analysis.

This is a very optimistic time for pediatric stroke because these techniques of mechanical recanalization are so powerful in adults, said Christine Fox, MD, MAS, co-author of an editorial published concurrently in JAMA Neurology and associate professor of neurology and director of the Pediatric Stroke and Cerebrovascular Disease Center at the University of California, San Francisco.

While she was enthusiastic about the investigation of recanalization in children, Dr. Fox and her co-author advised caution in interpreting long-term outcome measures from the Save ChildS research.

Stroke recovery is heterogeneous in children at various stages of brain development, and the natural history of recovery may be good even in the absence of recanalization, they wrote.

For instance, they pointed out that while only 4 percent of children in the Swiss Neuropediatric Stroke Registry underwent thrombolysis, about half experienced good outcomes without functional deficits. In addition, despite the positive two-year outcomes in the Save ChildS study, selection bias may have affected the results due to data missing for more than one-third of subjects.

More complete data were available for earlier outcomes, but this may not represent the full picture, considering that disabilities in children could emerge over time.

Cognitive and language deficits may initially go unrecognized in a toddler but become apparent as skills required for success in school grow increasingly complex, the editorialists noted.

Furthermore, there are drawbacks to using published studies for comparison purposes. The modified Rankin scales may not accurately reflect outcomes in the youngest children in the Save ChildS study. In addition, outcomes in different studies may not be measured in parallel ways: For example, in the Save ChildS study, the outcomes were evaluated at discharge and at 180 days, compared to at 90 days in the HERMES trials, rendering the comparisons questionable.

However, Dr. Fox stressed the significance of the Save ChildS research. Childhood stroke is difficult to study because it's a relatively uncommon event, she acknowledged. Parents and pediatricians may not recognize symptoms swiftly after onset and within the four-and-a-half-hour treatment window. Bringing together experts across related fields would advance knowledge of stroke mechanisms and recovery with the aim of prevention and better outcomes, Dr. Fox told Neurology Today.

Those with a common interest in childhood cerebrovascular diseasefrom physicians and surgeons to nurses, psychologists, therapists, and scientistscan share their insights through professional groups, she said. Among them is the International Pediatric Stroke Organization, founded in February 2019.

To really understand how to best treat children who have a stroke, we need to continue to collaborate broadly across a number of different disciplines, said Dr. Fox, who often consults with neurointerventional radiologists, neurosurgeons, physiatrists, and hematologists.

If publication of the Save ChildS study raises awareness of pediatric stroke, the heightened attention would be a positive step toward encouraging the design of improved protocols to streamline diagnosis and deliver time-sensitive treatment, said David Y. Huang, MD, PhD, FAHA, FAAN, FANA, professor and chief of the division of stroke and vascular neurology at the University of North Carolina at Chapel Hill.

It's heartening because some data is better than the absence of data, Dr. Huang said, allowing neurologists to feel more confident in recommending endovascular thrombectomy to parents of sick children now that there is data supporting the safety of the procedure. Furthermore, in the absence of alternatives, most parents would agree to it, he added.

In rural areas without a large stroke center in relatively close proximity, it is important to consider lowering the threshold for suspecting a stroke and prompting physicians to seek outside input sooner rather than later, Dr. Huang said.

Even in an era of advanced emergency medical services and improved public awareness of stroke, few pediatric patients arrive at hospitals within the optimal treatment window, said Dana D. Cummings, MD, PhD, associate professor of pediatrics and director of the pediatric stroke program at the University of Pittsburgh Medical Center's Children's Hospital of Pittsburgh.

My hat is off to the centers that provided thrombectomy for these patients at the early time frame in the study, but that's going to be hard to replicate in most settings, said Dr. Cummings, who would like to see a study looking at outcomes in children who present more than 4.5 hours after stroke onset and undergo mechanical recanalization.

As the editorial commentators noted, there may be more neuroplasticity in kids, which complicates the interpretation of outcomes, he said. You wouldn't want to have a stroke at any age, but if you have a stroke at age three, you probably have maximal plasticity for recovery.

The editorial also addressed special considerations for performing thrombectomy in children. It should ideally be undertaken by neurointerventional radiologists skilled in both pediatric endovascular procedures and stroke embolectomy to guide selection of devices appropriate for the smaller cerebrovasculature in children. However, as stent retriever devices have been developed for embolectomy of more distal cerebral arteries, size may become less of a barrier in experienced hands. Caution remains advisable even early after stroke, particularly in young or small patients, the authors wrote.

Planning for a neurointerventional procedure in a child is inherently different, and most adult cases are handled at hospitals with minimal or no pediatric experience.

Clinicians with only adult experience shouldn't feel a sense of obligation to undertake pediatric cases based on this study alone, said Heather Fullerton, MD, MAS, professor and chief of the division of child neurology and medical director of the Pediatric Brain Center in the Benioff Children's Hospital at the University of California, San Francisco.

I am aware of complications anecdotally that haven't been reported in medical literature, she said, citing the tendency to publish successful cases. Nonetheless, the Save ChildS study is a great contribution to this field. It's the first large series on children who have received hyperacute therapy for stroke since all of these new thrombectomy trials really changed standard of care in adults.

To make additional strides in treating childhood stroke, rigorous prospective studies are needed. That's the only way we're going to get really reliable safety data, Dr. Fullerton said.

Dr. Sporns, Fox, and Fullerton had no competing interests. Dr. Cummings has received fees as a consultant on pediatric cerebrovascular disorders from the Vaccine Injury Compensation Program. Dr. Huang has received honoraria for service on a data safety and monitoring boards for Cerenova, LLC and ReNeuron.

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Endovascular Recanalization Is Safe and Effective for... : Neurology Today - LWW Journals

I often repeat her presentation to medical students: my only patient ever to fall walking into a clinic visit had progressive supranuclear palsy (PSP).

Her impaired postural reflexes were no match for a set of brick steps. Perhaps she didn't notice the ramp, or didn't appreciate how rapidly her balance had deteriorated. Fortunately, her injuries that day were only minor. As is often the case with PSP, that would not always be the case.

In June 1963, neurologist Dr James Richardson reported eight cases of what would come to be called PSP at the American Neurological Association meeting. A year later, he and his neurologist colleagues John Steele and Jerzy Olszewski first described the disease in the literature.

The classical PSP syndromecalled "Richardson syndrome"is characterized by poor balance, vertical gaze abnormalities, executive dysfunction, and speech impairment. Falls are frequent, and often injurious. Patients can also present with impaired facial expressions, changes in mood, and waning dexterity. Given its rarity and diffuse array of symptoms, PSP is often misdiagnosed as Parkinson disease, or even Alzheimer disease.

The challenge for clinicians is that PSP is an incredibly varied condition, with not all patients presenting the same way. Beyond the classic symptoms, they may also experience a freezing gait, or corticobasal syndrome, an atypical form of parkinsonism. PSP pathology can even present with predominant language impairment, known as "primary progressive aphasia."

I'll call my patient Mrs X. Once she was in the exam room, her abnormal eye movements, changes in speech, and reduced facial expressions confirmed the diagnosis suggested by her falls. She showed classic signs of this little known neurodegenerative disease.

Not surprisingly, she and her husband had never heard of PSP. Most medical students will never learn about it unless they encounter it during their neurology rotation. I reviewed the prognosis and treatment options and introduced an ongoing clinical trial, in which she ultimately enrolled.

Over many visits, I learned about her grandson, whose soccer games she often attended with her husband. We bantered about the local college basketball team. As her disease progressed, I learned how devoted her husband was to her and how appreciative she was for his care. Given the grievous combination of physical and mental impairment that comes with PSP, having support from friends and family can be an essential part of care.

PSP is rare, but not as rare as once thought. The disorder occurs in about 5 in 100,000 persons, a prevalence similar to that of amyotrophic lateral sclerosis. However, given that clinicians have only recently come to appreciate the disease, it is probably underdiagnosed, or misdiagnosed as another movement disorder.

[M]edications rarely help the motor symptoms of PSP. Falls intensify; speech and swallowing worsen....

The early symptoms of PSP can mimic those of Parkinson disease, which is much more common. The lack of response to medications used for Parkinson diseasenamely, levodopaand PSP's more rapid progression can lead to the diagnosis being revised. Singer Linda Ronstadt recently publicly shared that she has PSP, which negatively affected her ability to sing. It was first reported that she had Parkinson disease.

The cause of PSP is unknown. Pathologic reports show that the brains of people with the condition have accumulations of tau protein, a finding also seen in other "tauopathies," such as Alzheimer disease and chronic traumatic encephalopathy. And although variants in the gene coding for tau have been associated with PSP, the condition rarely runs in families. It's for the most part a sporadic condition.

Unlike in Parkinson disease, medications rarely help the motor symptoms of PSP. Physical, occupational, and speech therapy, on the other hand, can be useful, encouraging patients to develop compensatory mechanisms and strategies to reduce falls and improve speech and swallowing. But ultimately, falls intensify; speech and swallowing worsen; and independence is eventually lost.

As is the case with all neurodegenerative diseases, the major unmet need in PSP is a treatment that stops or slows the disorderin other words, a disease-modifying therapy. A number of ongoing treatment trials are investigating monoclonal antibodies directed at tau. Many believe that the accumulation of abnormal tau is pathogenic in PSP, and that clearing it from the extracellular space will disrupt the spread of further pathology. Time will tell whether this strategy pans out.

A silver lining to the rapid decline seen in patients with PSP is that changes in neurologic functioning are easily measured. As more and more therapies are tested, any disease-modifying effect should be evident relatively quickly, which is not the case in many other neurodegenerative disorders, such as Alzheimer disease.

It is a helpless feeling to watch patients worsen, yet have no way to stop their disease or even improve their symptoms. Participating in clinical trials is one way for patients and providers to combat the helplessness. Providing compassionate, multidisciplinary care, when that is all that is available, is another.

Watching Mrs X decline over time, especially her increasingly impaired ability to walk safely, only confirmed for me the importance of developing treatments to lessen the burden of PSP.

Matthew J. Barrett is an associate professor of neurology and a movement disorder specialist at Virginia Commonwealth University in Richmond, Virginia.

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The Falls and Frustrations of Progressive Supranuclear Palsy - Medscape

Alexandra Angelova was 16 when she began experiencing blurry vision and occasional dizzy spells. Instead of going away, symptoms gradually grew worse. Now nearly a decade later, with her vision at one percent of its original strength and with balance problems that prevent standing or walking unassisted, these symptoms inform every aspect of her daily life.

Angelova gets around the house and walks her dog, Sunny, using a rollator, or seated walker. She presses her back against the wall for balance when going up and down stairs. Every item in her house has a set location so she can find it with her limited vision.

I cannot perform many basic things which are normal for a healthy person, Angelova said. I have to plan every movement and how to do it--how to hold a fork, how to take a shower, and so on.

Angelovas case is typical for people with spinocerebellar ataxia type 7, or SCA7, a chronic, inherited neurodegenerative disease. A child with a parent with SCA7 has a 50 percent chance of inheriting the condition. It is caused by a genetic mutation which causes the body to produce a malformed, toxic version of a normally healthy protein.

Read the full story on Magnify, an online magazine from the Duke University School of Medicine.

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Finding hope in darkness: Duke neurologist develops and tests new therapy to help understand and prevent neurodegenerative diseases - Duke Department...

The PSNI has confirmed it is assessing whether any criminal offences have been identified following the recall of more than 3,000 neurology patients in Northern Ireland.

The recall happened last year after an independent review of work carried out by consultant neurologist Dr Michael Watt, who has been suspended from practising medicine.

Recent BBC Spotlight programmes reported that one-in-five of the patients who were re-examined were found to have been misdiagnosed by the neurologist.

Dr Watt, who worked at the Royal Victoria Hospital in Belfast, dealt with conditions such as epilepsy, Parkinsons Disease and multiple sclerosis. A report into the cases that was due to be published in June of last year by the Norths Department of Health. However, it never was.

Spotlight reported that it had obtained details of the report and that it indicated that out of almost 3,000 patients, about 2,000 were said to have received a secure diagnosis. More than 600 were given insecure diagnoses, while another 329 diagnoses were uncertain, the BBC programme reported.

The PSNI on Wednesday said it was investigating the matter.

We are aware of the recall of neurology patients by the Belfast Health and Social Care Trust and have met with senior officials within the Department of Health to discuss the issue, a PSNI spokeswoman said.

The department has agreed to provide us with further information so that we can assess how best to move forward and to enable us to determine if any potential criminal offences can be identified.

SDLP deputy leader Nichola Mallon, who has campaigned on behalf of Dr Watts patients, said she had seen at first hand the emotional and mental impact of the ordeal on the patients.

There are serious questions for the Belfast Trust and Department of Health about how theyve handled this situation, she said. These patients were also promised openness and transparency and yet they are continually met with a wall of silence...They feel abandoned and ignored. They deserve better.

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PSNI assessing if any offences linked to recall of 3,000 neurology patients - The Irish Times

Jyotindra Narayan Goswami,1 Suvasini Sharma2

1Department of Pediatrics, Army Hospital (Research & Referral), New Delhi 110010, India; 2Neurology Division, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Childrens Hospital, New Delhi 110001, India

Correspondence: Suvasini SharmaNeurology Division, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Childrens Hospital, Connaught Place 110001, New Delhi Tel +91-9910234344Email sharma.suvasini@gmail.com

Abstract: Drug-refractory epilepsy is a commonly prevalent pediatric neurological illness of global significance. Ketogenic diet (KD) is a time-tested therapeutic modality for refractory epilepsy, which has reemerged as a robust alternative to anti-epileptic pharmacotherapy. There is a growing body of evidence which supports the anti-seizure efficacy, safety profile and feasibility of KD use in childhood epilepsy. In addition, this modality has been recognized to reduce anti-epileptic exposure, improve cognition and behavioral profile of patients as well as improve the quality-of-life of care-givers. Current indications of KD include refractory epilepsy syndromes, selected metabolic disorders (such as pyruvate dehydrogenase deficiency) and a host of varied neurological entities. KD research has broadened the knowledge-base about its mechanisms of action. Four types of KD are in vogue currently with varying nutritional constitution, palatability, administration protocols and comparable efficacy. KD initiation and maintenance are the result of concerted effort of a team of pediatric neurologist/epileptologist, nutritionist and patients primary care-giver. Consensus is being formulated about various practical aspects of KD such as patient-selection, parental counseling, baseline work-up, dietary prescription, nutritional supplementation, concurrent anti-epileptic drug administration, follow-up and treatment-duration. Novel applications of KD include its use in neonatal epilepsy and super-refractory status epilepticus and tailor-made formulations such as cooking oil-based KD in predominantly rice-fed populations. Increasing body of clinical experience, improved nutritional designs and translational research are promoting KD as a major therapeutic modality. Currently, KD forms a core essence in the armamentarium against refractory epilepsy. In this review, we summarize the recent advances and current perspectives in the use of KD in refractory epilepsy.

Keywords: Modified Atkins Diet, low glycemic index diet, ketosis, intractable epilepsy, epileptic encephalopathies, ketogenic diet, epilepsy

This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License.By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.

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Current Perspectives On The Role Of The Ketogenic Diet In Epilepsy Man | NDT - Dove Medical Press

GENEVA--(BUSINESS WIRE)--Regulatory News:

GeNeuro (Paris:GNRO) (Euronext Paris: CH0308403085 - GNRO), announced today a collaboration for a new clinical trial of temelimab in multiple sclerosis (MS) with clinical researchers of Karolinska Institutet and the Academic Specialist Center (ASC), Stockholm, Sweden. This single-center study will be led by Dr. Fredrik Piehl, Professor of Neurology at the Department of Clinical Neurosciences of the Karolinska Institutet, and head of research at the MS clinic at ASC.

The trial will be conducted at Center for Neurology of ASC, the largest MS center in Sweden with approximately 2,400 patients. The one-year trial will enroll patients whose disability progresses without relapses, and will document the safety and tolerability of temelimab following higher doses, as well as efficacy based on the latest biomarkers associated with disease progression. The study aims to start enrolling patients in Q1 2020.

It is evident that currently available disease modulatory therapies for MS exert very limited effects on the progressive aspect of MS and that this phase starts early in the disease course. A role of pHERV-W Env in progressive disease worsening is supported by accumulating preclinical and clinical evidence. We are excited to explore the therapeutic potential of temelimab in patients progressing without relapses. This constitutes a key unmet medical need in MS and will allow us to push the boundaries of current therapeutic possibilities, said Prof. Fredrik Piehl, Principal Investigator of the study.

Temelimab is a monoclonal antibody designed to neutralize a pathogenic envelope protein, pHERV-W Env, which has been shown to activate microglia in the brain resulting in an aggressive phenotype attacking myelin1, and to impair the remyelination capacity of the brain through the inhibition of oligodendrocyte precursor cell differentiation2. This collaboration follows the data from GeNeuros ANGEL-MS clinical trial results, presented at ECTRIMS, which demonstrated positive results at two years on key markers associated with disease progression.

Long-term data have confirmed the neuroprotective effect of temelimab in MS and demonstrated its potential to make significant improvements in the lives of patients. We are very proud to be working with Prof. Piehl, who is recognized for his leading research at the Karolinska Institutet and the ASC, to further advance the development of temelimab as a potential treatment against disability progression in MS, said Jess Martin-Garcia, CEO of GeNeuro.

About GeNeuro

GeNeuros mission is to develop safe and effective treatments against neurological disorders and autoimmune diseases, such as multiple sclerosis, by neutralizing causal factors encoded by HERVs, which represent 8% of human DNA. GeNeuro is based in Geneva, Switzerland and has R&D facilities in Lyon, France. It has 24 employees and rights to 17 patent families protecting its technology.

For more information, visit: https://www.geneuro.com

About the Academic Specialist Center

The Academic Specialist Centre is a collaboration between Stockholm Health Care Services and Karolinska Institutet, providing a novel concept for research and intensive outpatient care. It is a part of the Swedish investment in future healthcare aimed at forging stronger links between research and development, education and healthcare.

The ASC provides specialist care to patients with diabetes, MS, Parkinsons and rheumatological disorders, and conducts cutting-edge clinical trials in these indications.

For more information, visit https://ki.se/en/collaboration/collaboration-with-the-health-services

Disclaimer

This press release contains certain forward - looking statements and estimates concerning GeNeuros financial condition, operating results, strategy, projects and future performance and the markets in which it operates. Such forward-looking statements and estimates may be identified by words, such as anticipate, believe, can, could, estimate, expect, intend, is designed to, may, might, plan, potential, predict, objective, should, or the negative of these and similar expressions. They incorporate all topics that are not historical facts. Forward looking statements, forecasts and estimates are based on managements current assumptions and assessment of risks, uncertainties and other factors, known and unknown, which were deemed to be reasonable at the time they were made but which may turn out to be incorrect. Events and outcomes are difficult to predict and depend on factors beyond the companys control. Consequently, the actual results, financial condition, performances and/or achievements of GeNeuro or of the industry may turn out to differ materially from the future results, performances or achievements expressed or implied by these statements, forecasts and estimates. Owing to these uncertainties, no representation is made as to the correctness or fairness of these forward-looking statements, forecasts and estimates. Furthermore, forward-looking statements, forecasts and estimates speak only as of the date on which they are made, and GeNeuro undertakes no obligation to update or revise any of them, whether as a result of new information, future events or otherwise, except as required by law.

1 Kremer et al., PNAS July 20192 Kremer et al., Annals of Neurology, June 2013; Gttle et al, Glia, August 2018

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While there is a clear association between major depressive disorder (MDD) and migraine, data published in Cephalgia provide evidence for divergent association of lifetime MDD, and MDD subtypes, with the prevalence and severity of symptoms in patients with migraine with and without aura.

It is well known that migraine and depression show a high rate of comorbidity and previous studies have suggested the association is bidirectional, with each disorder increasing the risk for onset of the other. However, limited data are available on the association between MDD subtypes and migraine.

The goal of this cross-sectional study was to assess the associations between atypical, melancholic, combined, and unspecified subtypes of MDD and migraine with and without aura. In addition, the researchers aimed to explore the associations between MDD and its subtypes with the severity of migraine.

The study included 446 patients with migraine (294 with migraine without and 152 with migraine with aura) from the population-based CoLaus/PsyCoLaus cohort study. Researchers only included patients with available information on the comorbidity of MDD. The control group was comprised of 2511 patients with MDD, or its subtypes, but no migraine.

Despite a significant association between lifetime MDD and migraine regardless of subtype, a stronger association was observed in migraine with vs without aura. Further, while all MDD subtypes were associated with migraine in general, all subtypes but atypical MDD were associated with migraine with aura; only melancholic MDD was significantly associated with increased frequency of migraine without aura.

As for the association between MDD and migraine intensity, the statistical analysis revealed a significant association between unspecified MDD subtype with higher migraine intensity only in patients with but not without aura.

Combined MDD, which included subjects with both melancholic and atypical characteristics, was found to be associated with higher migraine frequency, regardless of migraine subtype.

The researchers acknowledged that the study had several limitations, including its cross-sectional design, use of semi-structured interviews that can be associated with inaccurate recall of remote episodes, and a relatively small sample of patients with atypical or combined MDD.

Further studies exploring the pathophysiological mechanisms shared between melancholic depression and migraine are warranted, concluded the researchers.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors disclosures

Reference

Pisanu C, Lundin E, Preisig M, et al. Major depression subtypes are differentially associated with migraine subtype, prevalence and severity. [published online October 1, 2019]. Cephalgia. doi:10.1177/0333102419884935

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The Association Between Different Subtypes of Major Depressive Disorder and Migraine - Neurology Advisor

Vaught Neurological Services, PLLC, is expanding to provide easier access of care to the people of Wyoming County, and BK Vaught, MD, and Rachael Riggins, MSN, FNP-C, are accepting patients at their new satellite office location in Oceana, three days a week.

OnMonday, Wednesday and Friday at 833 Cook Parkway in Oceana, they are sharingoffices with The Foot and Ankle Clinic of the Virginias, which will continue to serveits patients Tuesday and Thursday.

According to a press release, Riggins has already begun seeing patients as of Nov. 18, and Vaught will begin seeing patients Dec. 13.

The new location will offer follow-up visits for established patients who have been seen at least once in Beckley by Vaught,EMG/NCV testing for established or new patients. The testing is performed by Vaught (a board-certified EMG specialist) and is typically scheduled on Fridays, the press release stated.

All insurances are accepted, but a referral is required. All scheduling will be coordinated through the main location in Beckley.

Contact 304-252-4222 for more information, to make an appointment, or to change an existing appointment.

Email: jnelson@register-herald.com; follow on Twitter @jnelsonRH

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Vaught Neurological to expand services to Wyoming County - Beckley Register-Herald

The Prognosis for MS is Changing Due to Advancements in Treatment and Awareness, Yet Access to Care is Top of Mind for Global Neurologists

World Federation of Neurology: November 15, 2019 | London Are regulators keeping up with new treatments and management strategies that can greatly improve the lives of patients with multiple sclerosis (MS)? That question is being debated following the unveiling of significant clinical advances in the diagnostic criteria and treatment of MS at the XXIV World Congress of Neurology (WCN 2019) in Dubai, UAE.

MS has gone from being an untreatable condition to being a manageable disease which is an extraordinary story of achievement, but there is still a long way to go.

MS affects an estimated 2.3 million people around the world, and research shows that access to quality treatment is vital in altering the progression of the disease, especially during the inflammatory part of the disease.

On a global level, there is a concerning gap between the results of clinical trials and regulators approval of advanced therapies, leaving some patients without access to the most effective options.

In fact, therapeutic lags have resulted in entire regions where MS patients will be disabled for longer, due to restrictions or lags in regulatory approvals that restrict doctors from prescribing treatments with the best outcomes.

The understanding of the disease and disease phenotypes are changing, said Prof. Bill Carroll, president of the World Federation of Neurology (WFN) and neurologist at the Department of Neurology and Neurophysiology at the Sir Charles Gairdner Hospital in Perth, Western Australia.

To see improved developments in MS treatment and diagnosis, global awareness and advocacy are in order. International initiatives and awareness will help unlock greater funding for MS research and lead to more effective treatments, says Prof. Thompson.

Our patients should be the number one priority, and its time for neurologists and MS physicians to adopt the approach that they should consider prescribing what is most appropriate for their patients today, despite what restrictions may have put in place yesterday by regulators, said Prof. Carroll.

WCN 2019, hosted by the World Federation of Neurology, brought together leaders in neurology to present new research, hold educational sessions and inspire action on topics ranging from MS and migraine to epilepsy and climate change.

About the World Federation of Neurology

The World Federation of Neurology represents 120 member neurological societies around the globe to foster quality neurology and brain health worldwide by promoting neurological education and training with an emphasis on under-resourced areas of the world. WFN supports the spread of accurate research and clinical information in the pursuit of improvements in the field of neurology. With support from member organizations around the globe, WFN unites the world to allow patients greater access to brain health. For more information, please visit the WCN 2019 web site at http://www.wfneurology.org or by searching using the tag #WCN2019.

Media ContactYakkety Yak ContactAshley Logan, Yakkety Yak LLCpress@yakketyyak.com

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Prognosis for MS changing due to advancements in treatment and awareness, yet access to care is top of mind for neurologists - WFN News