These models may have clinical value in assisting decision-making, the authors wrote. Further research is must be conducted on their predictive value and diagnostic accuracy while taking into account invasive adjuvant strategies.

In addition, blood pressure (BP), heart rate, glucose level, consciousness level, National Institutes of Health Stroke Scale (NIHSS) score and a history of diabetes mellitus (DM) were all determined to be associated with MNI. Age, glucose level, BP, hemoglobin A1c, history of DM, stroke subtype and NIHSS score were all significant factors affecting long-term stroke outcomes.

BP was found to be especially crucial in both prediction models, with both low and high BP appearing to impact patients short-term and long-term outcomes after thrombolysis.

Patients with lower BP during the acute phase of AIS are associated with brain injury and poor outcome they wrote. A higher initial BP may imply a later reduction in BP in response to thrombolysis and a better neurological improvement. The dynamic changes in BP during AIS are associated with impaired cerebral autoregulation, reperfusion injury, edema, and hemorrhagic transformation.

Read more here:
AI predicts outcomes for stroke patients following thrombolysis - AI in Healthcare

CONVERSATIONS IN CRITICAL PSYCHIATRY

Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.

Peter Whitehouse MD, PhDneurologist, cognitive neuroscientist, and bioethicist by formal training and transdisciplinarian in practiceis Professor of neurology, psychiatry, cognitive science, neuroscience, and organizational behavior at Case Western Reserve University, with additional past appointments in the departments of psychology, bioethics, history, and nursing. He is also a Professor at University of Toronto, honorary research fellow at University of Oxford, and the founding president of Intergenerational Schools International. He has served in national and international leadership positions in neurology, geriatrics, and public health. He has authored numerous academic, peer-reviewed research publications. His current main foci are on ecopsychosocial models of brain health and aging, as well as the role of the arts and humanities in health. He considers himself a wising-up, intergenerative, transdisciplinary, action-oriented scholar, and an emerging artist. He is the author of The Myth of Alzheimers: What You Aren't Being Told About Today's Most Dreaded Diagnosis (co-written with Daniel George, published in 2008, St Martins Press) in which he criticized the conceptualization of Alzheimer disease as a disease distinct from the aging process.

I became acquainted with Dr Whitehouse and his ideas during my geriatric psychiatry fellowship as I explored conceptual and philosophical issues related to aging. Up to that point I had considered dementias to be relatively immune to social constructivist ideas given that the underlying neurodegeneration had been convincingly demonstrated. What I had not accounted for, however, was the complexity of the relationship between aging and AD, and to what extent these two constructsthe former considered a natural, universal feature of human existence, the latter a horrendous diseaseare enmeshed with each other. There is a provocative side to Dr Whitehouses ideas, and it is easy for some to get distracted by thatbut the underlying arguments are well-constructed and backed by scientific evidence. It helps that Dr Whitehouse has the stellar academic credentials that he has, along with the experience of working with pharmaceutical companies in the development of acetylcholinesterase inhibitors, because his views cannot be summarily dismissed as a product of lack of expertise. Dr Whitehouse forces us to challenge our preconceived notions and to think anew about aging from a very different perspective.

Aftab: Lets talk about The Myth of Alzheimers. Its a very well-written and provocative book that challenges conventional wisdom in how we understand this condition. Some themes that stood out to me in your arguments:

We tend to think of Alzheimer disease (AD) as a single entity, but it is actually highly heterogenous and is an umbrella term for many different conditions.

We think of AD as a disease but its status as a disease is questionable because it is a consequence of natural aging processes; seeing it as related to aging still acknowledges that the individuals diagnosed with AD do suffer, can be highly impaired, and are in need of help.

We have focused so much of our efforts in trying to cure this disease with a medication that we have forgotten the issue that really matters: how do we create social conditions in which the aging members of the communityincluding those with dementiacan flourish and have some measure of well-being.

Do you agree with this characterization? Have your views changed much since this book was published in 2008?

Whitehouse: Thanks, Awais, for your positive comments and the opportunity to speak with you. My writing and academic collaboration with Danny George has been a productive joy and is manifesting in a second coauthored book tentatively called Brain Health in an Unhealthy Society (forthcoming Johns Hopkins University Press) that addresses exactly your first questions. We do believe time has supported the claims of The Myth that AD is heterogenous and intimately related to aging processes, although I might argue with the label natural for all the changes that occur with aging or dementia.

In this new book, we argue that the potentially more modifiable causes of dementia lie in economics, politics, and ecology, not only in aging processes themselves. Eleven years have passed since our first book was published and income inequity and environmental deterioration are increasingly deadly forces affecting health. In Brain Health we present further evidence, not available in 2008, that the excessive emphasis on medicalized approaches is harmful to individuals and society, and once again argue for broader public health and more fundamental cultural responses to the challenges of age-related cognitive decline.

Aftab: How was the book received by the medical community? Did it have the impact you were hoping it would?

Whitehouse: The dominant power players either rejected it with uncritical anger or more commonly ignored it. Prominent lay organizations (and their experts) locally and nationally publicly rejected the book as irresponsible and inaccurate apparently before reading our gift copies. The title was too provocative for them. Their livelihood is based on, in our view, an irresponsible and inaccurate social construction of Alzheimers. Many of my friends and other dementia experts would privately agree with us. So, I think we did serve to get people thinking about different ways of framing AD and related conditions. Slowly we are moving more toward prevention and care rather than sticking with our obsession with drugs, biologics, and cure.

Aftab: Was the title of your book The Myth of Alzheimers in any way a hat-tip or nod to Thomas Szaszs infamous The Myth of Mental Illness?

Whitehouse: Yes, it was. Szasz influenced me during my training in neurology and psychiatry at Johns Hopkins. As my mentor Jerry Frank said to me the medical model is not even good for medicine. So, I extended the ideas of social construction into neurological conditions and beyond biopsychosocial to ecopsychosocial, especially in the new book. This latter term emphasizes that health is imbedded in ecosystems and that often biomedicine gets the biology wrong by focusing too much on reductionistic and static models rather than systemic and evolutionary conceptions. We wanted to call the book The End of Alzheimers to mimic other concept-based books like The End of History and The End of Nature, but the publisher wisely thought that would imply promising a cure. The Myth title rightly emphasized the power of grand stories.

Aftab: Even if we accept that AD is a form of brain aging, one may argue that AD should nonetheless be seen as a disorder of brain aging. This could be in a qualitative sense, such that some aging process has gone awry (for instance, genetic mutations in pre-senile dementias) or quantitative sense, such that AD is at the extreme end of the spectrum of biological aging.

Whitehouse: First, we must keep the plural in mind. AD includes various forms of brain aging and a panoply of biological processes we may never fully understand. Each persons AD is unique to them because of the personal nature of their own genetic makeup and their life circumstances over time. Since both AD and brain aging are heterogenous, it is very difficult to define the boundaries between them. Yes, we think it better to call AD a disorder, condition, illness, or syndrome rather than well-defined disease. Eventually it is all about economic and political power surrounding who gets to control the labeling process. Do we want the often self-serving professional purveyors of false hope and profit-at-any-cost Big Pharma to control our brains (and minds) and our aging or do we want to embrace our collective responsibility to create opportunities for and with each other in community?

Aftab: Youve had a hard, unforgiving look at AD. What about other dementias, such as frontotemporal or Lewy body? Do you approach them with the same sort of skepticism that you do AD? Or do you accept the standard biomedical narratives of these dementias?

Whitehouse: Awais, this is a fundamentally important question. After our new chair of neurology praised (excessively I thought) our book in a department meeting for the second time, I tongue-in-cheek suggested we need a series of books emanating from our departmentthe Myth of Parkinson Disease and the Myth of Stroke! What I say is that every disease is socially constructed, and everyone has a biology (however complex). Lewy body dementia was controversial in the beginning as to whether it was a variant of AD or a separate entity with UCSD and Newcastle advocating different views.

Similarly, we can take a look at how the labels arteriosclerotic, multi-infarct, and vascular dementia have evolved over time. What of studies that show some decline in executive functions with normal aging? The essential issue is how do we help people at risk for or who suffer from brain conditions that impair quality of life. Yes, I am skeptical of essentially all claims from modern medicine which has lost a bit of its soul in my view, no thanks to the proliferation of bioethicists who do not in my opinion adequately challenge the incessant claims of progress in medicine.

Aftab: Every disease is socially constructed in the sense that there is a particular inter-subjective way in which we describe it, classify it, treat it, understand its relationship with other conditions, and these particular ways are influenced by a host of social-historical-political factors. I would like to think that different conceptualizations of disease differ in the degree to which they capture the objective reality or carve nature at its joints. Neurasthenia and tuberculosis may both be socially constructed but their correspondence to nature is likely very different. I guess what Im trying to say is that if we are not careful, we are at risk of trivializing the notion of social construction and what it may have to offer medicine. If everythingwhether Parkinson disease, or stroke, or glioblastoma multiformeis a myth, then calling something a myth (such as AD) doesnt possess much of a significance or sense of alarm that something is amiss.

Whitehouse: I would not want to trivialize social construction! All diagnostic labels are words first that we agree (with varying degrees of controversy) to use that signal something about patterns that we think we see in nature. Before we understood the role of bacteria in disease, the clinical phenomenology of diseases such tuberculosis and syphilis and so on were socially constructed in different ways. Social construction is informed by biologybut the real issue for me is how dis-ease and suffering are viewed and who gets the power over attempts to relieve them.

Read more from the original source:
Social Constructionism Meets Aging and Dementia - Psychiatric Times

BALTIMORE Neurologists should repeatedly remind young female patients with epilepsy, particularly those who are black, to take folic acid, new research suggests.

Deepti Zutshi, MD

A new pregnancy-outcomes study showed that black women with epilepsy are about half as likely to take folic acid as their counterparts of other racial backgrounds and are significantly more likely to have an unplanned pregnancy and later complications.

Clinicians should discuss the importance of taking folic acid with their female patients with epilepsy not just once but at every visit, said study investigator Deepti Zutshi, MD, assistant professor of neurology, Comprehensive Epilepsy Center, Wayne State University, Detroit, Michigan.

"It's important to really enforce this message and start when patients are young; start at puberty," Zutshi told Medscape Medical News.

The findings were presented here at the American Epilepsy Society (AES) 73rd Annual Meeting 2019.

The study included 104 pregnancies in patients at the High Risk Pregnancy and Epilepsy Clinic in Detroit. Of these pregnancies, 79.8% were among black women.

"I had a unique opportunity to add to what we know already about pregnancy outcomes in this population," Zutshi said.

Black participants were comparable to the other participants in terms with a mean age of 26 years, duration of epilepsy of just over 10 years, and seizure type, which was mostly focal and generalized.

Nevertheless, black participants were significantly more likely to have an unplanned pregnancy (83% vs 63%, respectively; P = .02).

"The next step is to figure out the reason for this discrepancy," said Zutshi.

This includes looking at cultural differences, stigma, and whether they receive or have access to birth control counseling and counseling on the potential risks of birth defects associated with antiepileptic drugs, she added.

The study also showed that black women were less likely to have taken folic acid pre-conception (22% vs 55%), possibly because they weren't counseled to do so, said Zutshi.

"The problem could be lack of access to prenatal care, lack of access to an OB-GYN, maybe lack of access to a neurologist who needs to prescribe folic acid to women who are on antiepileptic drugs," Zutshi said.

However, even if women are prescribed folic acid, they may not take it, she added.

"Anecdotally, that's because they don't know why they should be taking it. When you prescribe it, you have to explain what it is and what it does" to help prevent complications such as neural tube defects, Zutshi noted.

Most doctors already counsel their female patients with epilepsy to take folic acid, but patients need reminding as they may be taking antiseizure medicines and dealing with numerous other issues, Zutshi said. "It's all about repetition," she added.

Barriers to prenatal care for black women, especially those with epilepsy, include younger age at pregnancy, no means of transportation, not realizing they are pregnant until later gestation, and lack of education.

About 48% of black participants, vs 41% of the other women in the study, had at least one seizure during pregnancy.

Pregnancy complications, including miscarriages and premature deliveries, were skewed toward black women and again, likely reflects lack of prenatal care, Zutshi said.

In the nonblack participant group, there was one case of threatened miscarriage vs five cases in the group of black women. The latter group also had six cases of premature delivery and three cases each of eclampsia/preeclampsia and congenital malformation vs zero cases in the group of nonblack participants.

Black women are not well represented in national pregnancy registries; and most of these registries recruit women in the first trimester before they have their 18- to 22-week ultrasound, Zutshi noted.

"I'm getting patients way into their second and third trimester. Why weren't they referred to me beforehand?" said Zutshi.

Future studies should compare pregnancy outcomes in black women with, and without, epilepsy, Zutshi said.

"That research needs to control for whether [black patients] receive prenatal care. I think that's probably one of the biggest confounding factors you have to consider when you do that comparison," she added.

Commenting on the study for Medscape Medical News, Anna Serafini, MD, director of the Epilepsy Monitoring Unit and assistant professor in the Department of Neurology and Rehabilitation, University of Illinois, Chicago, said the new information is useful.

"It shows that we need to target the African American population even more, and we need to remember that the majority of pregnancies in this population are unplanned," said Serafini, who was not involved in the research.

She said she prescribes 1 mg of folate per day to all her patients with epilepsy of childbearing age, even if they insist they are not planning to become pregnant. She raises the dose to 4 mg once a woman does become pregnant. Many multivitamins geared to women contain folate.

However, she acknowledged that many patients don't follow her advice.

A limitation cited by Serafini was that there were relatively few nonblack women in the study. "It would be interesting to increase that number to have a better comparison," she said.

She also agreed that data in national pregnancy registries come from very select patient populations.

"We need to start to include more populations such as African Americans because the data might be different," said Serafini.

American Epilepsy Society (AES) 73rd Annual Meeting 2019: Abstract 3.24. Presented December 9, 2019.

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Link:
Folate in Young Women With Epilepsy: Start Early, Remind Often - Medscape

The high cost of multiple sclerosis treatments has forced 40% of patients to take drastic actions and alter their use of the medicines, such as cutting back or skipping dosages altogether. And many report the financial burden is not only hurting their lifestyle, but impairing their ability to save for retirement or college for their children, a new survey found.

For instance, 14% reported they switched to a generic, despite being satisfied with their existing treatment; 12% stopped using their medication for a period of time; 9% skipped or delayed filling a prescription; and 8% took less of their medicine than prescribed, according to the survey by the National Multiple Sclerosis Society.

Meanwhile, the out-of-pocket costs associated with the medicines meant that 25% of the nearly 600 patients who responded to the survey spent less on themselves. In addition, 16% saved less for retirement or college, 11% spent less on groceries, 9% postponed paying other bills, 4% postponed retirement, and 2% took a second job.

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The survey findings continue to tell the real story of what its like for people with MS to get the treatment that they need, said Bari Talente, executive vice president of advocacy for the National Multiple Sclerosis Society, which canvassed patients last summer. It is these experiences and perspectives that should lead every conversation happening about drug pricing and access.

The results emerge amid a wider national debate over the cost of medicines in general. Drug pricing has become a key pocketbook issue for many Americans, prompting the Trump administration to devise several plans, none of which have gained traction, and Congress to propose numerous bills. But whether legislation will proceed remains unclear.

The cost of multiple sclerosis medicines, however, has been one of the flashpoints, as studies have demonstrated that patients and taxpayers face rising costs.

Last year,astudyin Neurology found that multiple sclerosis patients paid $15 a month average out-of-pocket costs in 2004, but that jumped to an average of $309 a month by 2016, a 20-fold increase over a 12-year period. Patients with high-deductible plans paid an average of $661 per month compared to $246 a month for those not in a high-deductible plan two years ago.

A recentlystudy in JAMA Neurology found that over a recent 10-year period, rising prices for multiple sclerosis drugs caused Medicare spending for the medicines to rise more than 10 times, and Part D beneficiaries saw out-of-pocket costs increase more than sevenfold. Spending per 1,000 beneficiaries by the health program jumped from nearly $7,800 in 2006 to more than $79,400 in 2016.

Meanwhile, the wholesale, or list, prices for a dozen drugs new and old continued to risebetween 2014 and 2019, according to academics at Oregon Health and Science University, whoseearlier researchfound prices for older medicines kept rising even as newer treatments were launched. The prices for the medicines ranged from approximately $76,000 to nearly $99,000.

Drug pricing mechanisms and economics that have attracted so much negative attention in recent years remain very much intact

Christopher Raymond, PiperJaffray analyst

For instance, Gilenya, a Novartis (NVS) drug, rose from $63,444 to $99,896, while the cost of Avonex, which is sold by Biogen (BIIB), increased from $59,085 to $$90,035. Tecfidera, another Biogen drug, climbed from $59,957 to $94,991. List prices do not reflect any rebates a drug maker may pay for favorable placement on formularies, the list of medicines covered by health plans.

Price hikes have not gone unnoticed on Wall Street, either.

Earlier this month, PiperJaffray analyst Christopher Raymond expressed surprise that Biogen boosted prices as it did. As an example, he cited the Tysabri, which rose 3.5% and experienced price hikes in January 2019 and again in July 2019 by the same amount. Similarly, the list price for Tecfidera rose 6%, mirroring the price hike early last year.

We think this is somewhat remarkable, given how much scrutiny has been assigned to pharmaceutical drug pricing both in terms of tactics and industry structure over the last several years, he wrote in an investor note. But the broader point here is that drug pricing mechanisms and economics that have attracted so much negative attention in recent years remain very much intact.

A spokesman for the BIO trade group wrote us that patients should never have to go without the medicines they need because of what they are forced to pay out of their own pockets. As the results of this survey show, people face difficult choices when insurance companies discriminate against those who rely on prescription medicines and restrict patients access to the therapies their doctors prescribe. This is exactly why we need a holistic solution, because its the only way to ensure all patients have access to the medicines they need with out-of-pocket costs they can afford.

More than once, pricing has prompted the National Multiple Sclerosis Society to take companies to task.

Last fall, the organization criticized Biogen for boasting that a newly approved pill would have the lowest annual wholesale price of any such medicine, although the difference amounted to $500 less than another new treatment from Novartis. The move was designed to appease criticism, but the organization accused the company of being disingenuous.

A Biogen spokeswoman wrote us to say the company will continue to work closely with PBMs and payers to help minimize the impact of out-of-pocket costs to patients. Our approach is to consider modest price adjustments only for products we continue to substantially invest in (new research and increasing clinical evidence base) and limit adjustments for other products to minimum levels, in-line with inflation.

And over the past year, the patient group also chided Novartis for pricing its new Mayzent pill at $88,500 and EMD Serono for charging $99,500 for its new Mavenclad tablet. Such public statements are unusual from patient groups that accept industry funding. Drug makers provide about 4% of total revenue to the organization, and Biogen is the largest donor, contributing more than $1.3 million in 2018.

A paper in Neurology last November detailed how four unnamed executives acknowledged that pricing for multiple sclerosis drugs is based on competition, insurance rebates, and the ability to set U.S. prices higher than in other countries, rather than a long-standing industry argument about the high cost of research and development.

MS has seen remarkable treatment innovations in the last 25 years, but that progress doesnt mean much ifpeople with MS cant access these innovations due to price considerations, nor should they experience the enormous challenges and choices we heard about in our survey, said Tim Coetzee, chief advocacy, services and research officer, at the National Multiple Sclerosis Society.

See the original post:
High cost of MS medicines forcing patients to take 'drastic actions' - STAT

By Richard Robinson January 23, 2020

Investigators review the scientific evidence for targeting amyloid oligomers and outline the case for a new drug in development for Alzheimer's disease, ALZ-801, an orally administered prodrug of tramiprosate.

What is the right target for drugs for Alzheimer's disease (AD) and what is the right population to test them in? For one biopharmaceutical company, the answers are amyloid-beta (Abeta) oligomers and APOE4 homozygotes, and they plan to test a drug that inhibits oligomerization in this genetic subgroup of AD patients in the coming year.

But while the target is increasingly recognized as an important one in AD pathogenesis, not every expert believes that the rationale for restricting such a trial to the small number of AD patients who carry two copies of e4 is compelling.

The case for oligomeric forms of Abeta as central to AD is persuasive, according to Marwan Sabbagh, MD, FAAN, co-author of a November 4, 2019 perspective in the journal Alzheimer's & Dementia that reviews the scientific evidence for targeting amyloid oligomers and outlines the case for the new drug. Dr. Sabbagh is the Camille and Larry Ruvo Chair for Brain Health and director of the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, NV. His co-authors are neurologists Martin Tolar, MD, PhD, and Susan Abushakra, MD, both of Alzheon, the company that is developing the drug, called ALZ-801, a prodrug of tramiprosate.

Monomeric forms Abeta don't tend to cause damage or activate microglia, and plaques are essentially graveyards, said Dr. Sabbagh. Oligomers, on the other hand, cause damage particularly to synapses, and microglial activation often starts when you get to the oligomeric phase, so we as a field think that oligomeric species tend to be more toxic than other species of Abeta.

The distinction between amyloid species is important, he added, because different treatmentsespecially the monoclonal antibodiestarget different forms of amyloid. Crenezumab and solanezumab bind most strongly to monomers, while bapineuzumab targets both soluble forms and plaques. The newest group of monoclonals, including aducanumab and BAN 2401, target both oligomers and plaques, but with different selectivity.

The concept of targeting oligomers was recently given a boost by the whipsaw change in fate for aducanumab. After announcing disappointing results and withdrawing the drug from further development early in 2019, Biogen this fall announced they had reanalyzed their data to suggest it did in fact lead to slowing of cognitive decline in patients with early AD, and that they would be submitting it to the US Food and Drug Administration for approval of the drug.

The data suggest that monoclonals that include oligomers within their targets have had better effects than the previous generation of monoclonals, both in terms of clearance of amyloid, and downstream cognitive effects, Dr. Sabbagh said, including reduction in tau and clinical stabilization, so targeting oligomeric species seems to be holding up scientifically.

All of that has led Alzheon to move ahead with a phase 3 trial of ALZ-801, an orally administered prodrug of tramiprosate. In preclinical studies, ALZ-801 inhibited the formation of oligomers without affecting fibrils or plaques. Those studies have shown that multiple molecules of tramiprosate reversibly bind and envelop the Abeta monomer, stabilizing it and preventing it from aggregating into an oligomeric form.

Previous clinical trials of ALZ-801 have shown good long-term safety, but phase 3 trials of tramiprosate did not demonstrate efficacy in the whole group of patients with mild to moderate AD. However, a prespecified analysis published in 2017 in The Journal of Prevention of Alzheimer's Disease did show that those patients carrying two copies of the APOE4 allele experienced a statistically significant slowing of decline in the Alzheimer's Disease Assessment Scale-Cognitive Subscale compared with placebo.

This time, the trial will not enroll across the AD spectrum, but instead will be limited to patients with early AD who are e4/e4 homozygotes. In this group, the production of amyloid is elevated and the clearance is reduced, said Dr. Sabbagh, and the clinical course is both more uniform and more rapid than in the general AD population. Researchers are hoping that this will allow an efficacy signal to emerge clearly and quickly. The 78-week phase 3 trial is expected to start this year.

The rationale for specifically targeting oligomers is sound, William Klein, PhD, professor of neurology at Northwestern University in Chicago told Neurology Today. Dr. Klein, who studies Abeta oligomerization, said, This is an intensely studied field, and most of the results point to disruption of signaling by oligomers in particular.

That appears to trigger phosphorylation of tau, a major step in AD pathogenesis, he noted. Much about Alzheimer's disease is controversial, but there have been [more than] 4,000 papers on Abeta oligomers, and the preponderance of evidence favors these as being important players.

There is an additional reason for targeting Abeta oligomers, Dr. Klein noted. The transition from monomeric Abeta to higher molecular weight forms is not a linear set of reactions, but rather a spiderweb of pathways, and so depleting fibrils, for instance, as some therapies have attempted, does not necessarily deplete oligomers. It's not a simple equilibrium, he said.

Depletion of monomers is also a challenge, because it is really hard to get rid of enough monomer to really make a difference in the quantity of oligomers, he said. A lot of the products haven't been developed to uniquely focus on oligomers, which is why they have requirements for very high doses, and lead to side effects.

Restricting the trial to e4 homozygotes is more problematic, said Paul Aisen, MD, professor of neurology and director of the Alzheimer's Therapeutic Research Institute at the University of Southern California Keck School of Medicine.

APOE genotype is the most important risk factor for sporadic AD, and determination of APOE genotype has played an important role in our trials for many years, Dr. Aisen said, but mainly as a covariate in assessing outcomes, not as an inclusion criterion for enrollment. Treating only those with two copies of the e4 allele is certainly a valid approach, but it raises important regulatory issues.

If the study is successful, he asked, where does that leave the one third of AD individuals that don't carry an e4 allele? Will approval be restricted to e4 carriers? Do you have an obligation to test in the e4-negative group?

In addition, Dr. Aisen said it is not clear why this drug should have a special effect on e4 homozygotes versus other patients who also produce amyloid. The drug doesn't target the biology of e4 in particular, he pointed out, and so it is not clear that the drug effect should be restricted to one genotype versus another. I would expect an anti-aggregation agent to work across genotypes. My own view is that unless you are testing a drug that is specifically related to APOE, it may be more appropriate to target your therapeutics for everybody with AD.

Dr. Sabbagh receives stock options as an advisor to ALzheon on the design of their phase 3 clinical trial. Dr. Klein has stockin Acumen Pharmaceuticals, which he co-founded in the 1990s. Acumen has a humanized antibody that is very specific for A-beta oligomers and is being readied for clinical trials in 2020; his lab received research funding from AbbVie and RxGen for oligomer-related studies. Dr. Aisen had no disclosures.

Original post:
Is Targeting Oligomers in APOE4 Homozygotes the Path... : Neurology Today - LWW Journals

This transcript has been edited for clarity.

Dear colleagues, I am Christoph Diener, a neurologist from the University of Duisburg-Essen in Germany. Today I would like to discuss six noteworthy publications that came out in September of this year.

The EPIC-Oxford study recruited 48,000 people without stroke or ischemic heart disease and followed them for 20 years. Participants were divided into three groups: meat eaters, fish- but not meat eaters, and vegetarians.

Researchers published the results of 18 years of follow-up of these participants in the BMJ,[1] reporting 2820 cases of ischemic heart disease and 1072 cases of stroke during that time. Compared with meat eaters, fish eaters and vegetarians had a 13% and 22% relative risk reduction of developing ischemic heart disease, respectively. In absolute numbers, this accounts for 10 fewer cases of heart disease per 1000 for vegetarians compared with meat eaters over 10 years. Interestingly, and surprisingly, vegetarians had a 20% higher risk for stroke than meat eaters, mostly due to cerebral hemorrhage. In absolute numbers, this accounts for three more cases out of 1000 over 10 years.

I think the most likely explanation for why meat eaters have a higher risk for ischemic heart disease is LDL cholesterol. This could also explain the increased risk for cerebral hemorrhage, as it's known that very low LDL can [be associated with] a slightly higher risk for stroke.

The European Stroke Organisation offered guidelines on antithrombotic therapy for secondary stroke prevention in patients with atrial fibrillation in the European Stroke Journal.[2]

The most important recommendation is that antiplatelet therapy should no longer be used. The second recommendation is that vitamin K antagonists should be used compared with no treatment or with aspirin, and nonvitamin K antagonist oral anticoagulants are preferred over vitamin K antagonists. There is no recommendation about the timing of when to initiate treatment after ischemic stroke. Another important recommendation is that no bridging with low-molecular-weight heparin is needed until anticoagulation is started. At the moment, there is no recommendation on occlusion of the left atrial appendage in patients with contraindications for long-term anticoagulation, given that the ongoing trials are not yet finished.

A third, very interesting paper was published in Lancet Neurology,[3] looking at people with cerebral cavernous malformations. Investigators identified 300 patients in a registry and followed them for 7 years to determine whether antithrombotic therapy or anticoagulation had an impact on the risk for intracerebral bleeding. Approximately 20% of patients were on antiplatelet therapy or anticoagulation, and they clearly had a lower risk for intracranial hemorrhage. They also performed a meta-analysis of six cohort studies with 1342 patients, which basically showed the same result: a reduced risk for intracerebral hemorrhage with antithrombotic therapy.

The most likely explanation for these results is that antithrombotic therapy allows you to avoid venous thrombosis that can lead to hemorrhage.

We recently published the results of the RE-SPECT CVT Study in JAMA Neurology.[4] This was a safety study in 100 patients with cerebral venous thrombosis, who were randomized to either high-dose dabigatran (150 mg twice daily) or warfarin for 25 weeks after an initial treatment period of low-molecular-weight heparin. There was one intestinal bleed on the dabigatran, two intracranial bleeds on warfarin, and no recurrent venous events.

The good news here is that dabigatran is as safe as warfarin for the prevention of recurrent venous events in cerebral venous thrombosis. However, the drug is not approved for this indication.

In a study published in Annals of Neurology,[5] 140 patients with epilepsy and current major depressive disorder were randomized to receive sertraline or cognitive-behavioral therapy for 16 weeks. Both treatments were effective, with over 50% of patients achieving remission. Importantly, sertraline does not increase the risk for seizures.

Ideally, I think these two treatment methods should be combined in such patients.

The last study dealt with Duchenne muscular dystrophy and was published in Neurology.[6] Young boys with this disorder are usually treated with prednisone, with all of the adverse events that this entails when given long-term.

There is now a new drug called vamorolone which has similar activity to prednisone, but it doesn't have the side effects. In this dose-finding study, vamorolone at 2 mg/day improved motor function and clearly had fewer adverse events than the historical controls of prednisone or cortisone. We now need phase 3 trials to show whether this effect is also replicated in everyday clinical practice.

Ladies and gentlemen, we have six new studies of interest: four on stroke, one on depression and epilepsy, and one on Duchenne muscular dystrophy. Thank you very much for watching and listening.

Hans-Christoph Diener, MD, PhD, is a professor in the Department of Neurology at University Duisburg-Essen in Essen, Germany. He is widely published and best known for his contributions to stroke and headache medicine.

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See the original post:
Meat, Fish, and Vegetables: New Data on Heart Disease and Stroke - Medscape

The CBD craze has taken the world by storm, seizing promotional and consumer dollars as fast as anything in recent memory: cryptocurrencies, fake (but edible and delicious)meat, or vaping. According to estimates fromdata research firm Brightfield, the U.S. CBD market in 2019 is expected to reach $5 billion 706% growth compared to 2018.

But whilecelebrityaftercelebrity has endorsedcannabidiol (CBD) products, to which they can personally attest to the benefits, the science isnt so sure.

Kim Kardashian is one of many celebrities and athletes to have endorsed CBD products. (Photo by Angela Weiss / AFP)

While the efficacy of CBD to treat everything fromanxiety to Crohns diseaseisnt clear, its a real substance with real medical potential.

In June 2018, the FDAapproved the first drug containingCBD oil, an epilepsy drug called Epidiolex from Greenwich Biosciences, a subsidiary of GW Pharmaceuticals (GWPH). On Nov. 5, GWreported $91 million in salesin the third quarter, of which $86 million came from Epidiolex, which helped the company beat sales expectations.

But the rest of CBDs claims remain untested and unapproved as far as FDA standards are concerned. Yahoo Finance spoke to Dr. Susan M. Lippmann and Dr. William E. Rosenfeld, neurologists and co-directors at the Comprehensive Epilepsy Care Center for Children and Adults in St. Louis, Mo.

The duo have performed studies on epilepsy drugs for over 40 years through Phases I, II, III, and IV of the FDA approval process. They performed the double-blind FDA trials for Epidiolex, and though they saw positive results in terms of epilepsy, the pair remain skeptical of the drugs meteoric entry into mainstream society and the business world.

Emoji gummies by JustCBD are displayed at the Cannabis World Congress & Business Exposition trade show, Thursday, May 30, 2019 in New York. The treats contain non-psychoactive cannabidiol, CBD. (AP Photo/Jeremy Rehm)

We believe it has been proven by double-blind placebo studies to be successful in reducing certain types of seizures, said the doctors in a joint email to Yahoo Finance. For other diseases, much of the information out in the public domain is not based on FDA studies and is based on hearsay and anecdotes.

Lippmann and Rosenfeld were quick to point out that this doesn't mean that some of these usages won't later prove to be true, but without the studies, theres no proof.

Double-blind studies when neither the researchers nor the patients know which drugs are placebo and which are real are especially important given the fact that the placebo effect can typically result in 10% to 30% improvements in epilepsy studies, and potentially higher for other diseases, according to Lippmann and Rosenfeld.

Looking at the surge ofCBD products, the physicians view the CBD craze as based on peoples own perceptions about cannabis combined withbig businesshype.

It is large financial interests who want to take advantage of a financial boom, Lippmannn and Rosenfeld said. Some well-meaning individuals may even be taking advantage of a potential boom, basing it only on a personal bias, having used CBD oil themselves and feeling it helped them, all the while not realizing the potential for the well-known placebo effect.

For epilepsy, the doctors said, a 10 to 30% improvement for patients can come from the placebo effect, and in other diseases it can be even more pronounced.

Story continues

Unfortunately to date, the sale of CBD is based on little fully blinded proven data, much like the snake oil salesman or Carters little liver pill of days gone past, the doctors said. Will CBD make lots of money for its growers and sales stores and corporations? I am sure it will. Is it all based on science? The answer is no.

The trials Lippmann and Rosenfeld performed used a dosage of 10 to 30 mg/kg/day and the recommended dosage for the approved drug is 10 to 20 mg/kg/day for Lennox Gastaut or Dravets Syndrome, with a starting dose of 5 mg/kg/day. For a 150-pound person, thats 680 mg to 2041 mg. Contrast this with capsules on the market that are 25 mg of CBD.

Many patients come to the office and are only taking droppers amounts of CBD with very minimal amounts of CBD, the doctors said. Some of these may well be placebo doses. This may well explain why patients often feel they are having little or no side effects.

In the doses that were effective for epilepsy, CBD does have side effects, on both the liver and cognitive functions.

People feel that because it comes from a plant, they believe there are no side effects, said Rosenfeld and Lippmann. They do not realize that many drugs come from plants and that clearly there is a potential for side effects from CBD.

The doctors pointed out a key additional problem with other CBD drugs that comes from the fact that the space is almost entirely unregulated by the FDA or other parts of the federal government. Many CBD products could easily contain little or no CBD or contaminants which could be potentially very toxic, Lippmann and Rosenfeld said.

-

Ethan Wolff-Mannis a writer at Yahoo Finance focusing on consumer issues, personal finance, retail, airlines, and more. Follow him on Twitter@ewolffmann.

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'Snake oil salesmen': Two neurologists respond to the CBD craze - Yahoo Finance

New York Neurology Associates is a top-rated and respected provider of neurological care and pain management services, relying on state-of-the-art diagnostic evaluations to provide the most advanced, effective, patient-centered care for men, women and pediatric patients on Long Island, NY, and throughout the New York City metro area, including Manhattans Upper East Side, Upper West Side and Downtown (Lower Manhattan) neighborhoods. The practice providers have extensive experience in the diagnosis and treatment of simple and complex issues, including acute and chronic diseases and conditions like migraines and other chronic headache disorders, dizziness, vertigo and balance-related problems, memory problems, stroke, tremors, multiple sclerosis, hyperhidrosis and TMJ (temporomandibular joint disorder). The practice is equipped with cutting-edge technology to enable patients to receive the most accurate diagnoses using state-of-the-art approaches like nerve conduction studies (NCS), EEG, EMG and NCV tests, carotid and transcranial Doppler studies, and evoked potential studies (VEP, BAER, SSEP). With licensed and certified neurologists and pain management specialists on staff, New York Neurology Associates provides custom care options based on each patients unique needs, including

BOTOX injections for headaches and other conditions, sacroiliac joint blocks and injections, epidural steroid injections, facet joint blocks, TMJ injections, carpal tunnel steroid injections, radiofrequency facet joint ablation and deep brain stimulation (DBS).

Recognized as a leading New York City medical practice, New York Neurology Associates welcomes new patients, and the practice accepts most major medical insurance plans.

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NY Neurology Associates: Neurologists: Upper East Side New ...

University Hospitals is committed to transparency in our interactions with industry partners, such as pharmaceutical, biotech, or medical device companies. At UH, we disclose practitioner and their family members ownership and intellectual property rights that are or in the process of being commercialized. In addition, we disclose payments to employed practitioners of $5,000 or more from companies with which the practitioners interact as part of their professional activities. These practitioner-industry relationships assist in developing new drugs, devices and therapies and in providing medical education aimed at improving quality of care and enhancing clinical outcomes. At the same time, UH understands that these relationships may create a conflict of interest. In providing this information, UH desires to assist patients in talking with their practitioners about industry relationships and how those relationships may impact their medical care.

UH practitioners seek advance approval for certain new industry relationships. In addition, practitioners report their industry relationships and activities, as well as those of their immediate family members, to the UH Office of Outside Interests annually. We review these reports and implement management plans, as appropriate, to address conflicts of interest that may arise in connection with medical research, clinical care and purchasing decisions.

View UHs policy (PDF) on practitioner-industry relationships.

As of December 31, 2016, Leonard Weinberger did not disclose any Outside Relationships with Industry.

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Leonard Weinberger MD Doctor Profile & Reviews ...

The pain experts at Comprehensive Pain & Neurology Center provide our patients with the most effective interventional pain procedures and therapies to help patients relieve pain and reclaim their lives.

Pain is a very personal experience. Chronic pain can result from illness or injury, and we treat a wide range of pain conditions, such as neck and back pain, migraines, arthritis, carpel tunnel syndrome, sciatica, diabetic neuropathy and nerve pain. When left untreated, pain can become chronic and physically disable a person.

While there are different types of pain, we understand that your pain is unique to you. With proper management, pain is treatable. We are committed to provide you with the best patient care by performing a thorough medical evaluation and utilizing scientifically proven interventional pain treatments for painful disorders. You will be treated with respect, compassion and care. Our goal is to help you find the correct diagnosis and to provide you with an optimal treatment plan to improve your life so you can get back to the activities you enjoy.

Comprehensive Pain & Neurology Center has been named to The Centers of Pain Excellence Network. This designation identifies CPNC as a leader in the advanced pain care of Tennessee patients.

Congratulations to Dr. John Schneider and the entire CPNC team!

CPNC is now accepting same day New Patient appointments from referring providers.Please call 615-410-4990 today or fax your referral to 615-410-4250.

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Relieve Pain & Reclaim Life - TN Pain Doctors

Headaches, stroke, pain and other conditions related to the nervous system can sometimes evade precise diagnosis and treatment. University Hospitals Neurological Institute at UH Ahuja Medical Centers Risman Pavilion provides immediate access to an unprecedented level of neurological care for patients in Clevelands eastern suburbs. From standard diagnostic evaluations to advanced neurosurgical procedures, we offer a full range of neurological services and a sophisticated level of care that cannot be found anywhere else on the eastside.

More than just neurology and neurosurgery, our integrated multidisciplinary clinic is staffed by our senior faculty, many of whom are nationally recognized experts in a wide variety of disciplines.

In addition to general neurology, we specialize in:

At UH Ahuja Medical Center, our expert team treats the full range of neurological conditions, including:

UH Ahuja Medical Center offers direct access to the same multidisciplinary team of specialists, advanced technology and full range of medical resources available at UH Neurological Institute, based at University Hospitals Cleveland Medical Center. Learn more about the services provided at University Hospitals Neurological Institute.

Visit link:
UH Neurological Institute | University Hospitals Ahuja ...

Contact number|202-476-2120 Nationally Ranked for Neurological Care

U.S. News & World Report ranks our pediatric neurology program #5 nationally.

The Childrens National Health System Division of Neurology includes an expert team of neurologists, neurology nurses, social workers and others. They work together to provide your child with effective, compassionate care. In fact, Childrens National consistently ranks among the top pediatric neurology programs in the country according to U.S. News & World Report.

At Childrens National, our sole focus is to provide age-appropriate care that improves your childs quality of life. Every one of our neurologists has specialized training in child neurology and all have fields of expertise in subsets of child neurology.We use the latest diagnostic imaging tests and the least invasive, most effective treatments to care for even the most complex neurological conditions.

Our programs include:

You can be assured that:

We treat many different conditions including:

Our team uses the latest techniques and technologies to provide accurate diagnosis and rapid treatment for children with neurological disorders. We take the time to explain the diagnostic tests available for your child, answering your questions and making sure that you are completely comfortable with the process. In fact, we are nationally recognized by organizations such as National Association of Epilepsy Centers for maintaining the highest levels of testing and quality.

Advanced neurologic testing available at Childrens National includes:

As well as:

For more information, call us at 202-476-2120.

To make an appointment, call us at 202-476-3611.

William D. Gaillard Division Chief, Epilepsy and Neurophysiology Division Chief, Neurology

Roger Packer Senior Vice President, Center for Neuroscience & Behavioral Health Director, Gilbert Neurofibromatosis Institute Director, Brain Tumor Institute

Andrea Gropman Division Chief , Neurodevelopmental Pediatrics and Neurogenetics

Elizabeth Wells Director, Inpatient Neurology Neurologist

Marc DiFazio Medical Director, Montgomery County Regional Outpatient Center Medical Director, Ambulatory Neurology Neurologist

Marc DiSabella Director, Headache ProgramProgram Director, Child Neurology FellowshipMedical Director, Neurology Education Neurologist

Jessica Carpenter Director, Neuro Critical Care Neurologist

Adre Du Plessis Director, Fetal Medicine Institute Division Chief, Fetal and Transitional Medicine

Lauren Dome Nurse Practitioner

Kathryn Havens Physician Assistant

Amy Kao Director, Dietary Therapies for Epilepsy Clinic Neurophysiologist

Sarah Mulkey Fetal Neonatal Neurologist

Jennifer Shipley Nurse Practitioner

Laura Tochen Co-Director, Myelin Disorders Program Neurologist

Tammy Tsuchida Neurophysiologist Neonatal Neurologist

Mara Zaiderman Nurse Practitioner

Joseph Scafidi Neonatal Neurologist

Thomas Chang Pediatric Rehabilitation Specialist

Diana Bharucha Goebel Neuromuscular Neurologist/Neurophysiologist

Thuy-Anh Vu Pediatric Neurologist Epileptologist | Neurophysiologist

Anne Vasiliadis Nurse Practitioner

Marian Kolodgie Nurse Practitioner

Raquel Langdon Co-Director, Pediatric Headache Clinic Neurologist

Nancy Elling Tuberous Sclerosis Clinic Nurse Coordinator

Taeun Chang Neonatal and Fetal Neurologist

Margaret Parker Pediatric Nurse

Archana Pasupuleti Pediatric Epileptologist

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Neurology | Children's National

It is my pleasure to welcome you to the Department of Neurology at the University of California, San Francisco (UCSF). Our mission includes delivering the most exceptional clinical care to our patients, leading transformative cutting-edge research, and training the leaders of tomorrow in both neurology and neuroscience. Our departments faculty, trainees, and staff work at a University and in a community that values and embraces diversity and strives to make an impact worldwide through our global and public health efforts.

It could not be a more exciting time for our field. Advances in the laboratory are increasingly being brought to the bedside to help the millions of patients suffering from neurologic disorders. Our unique structure as an integrated group of scientists and clinicians working closely together allows us to rapidly move discoveries into the clinic and the hospital while practicing models of care that are focused on putting patients and their families first.

The individuals featured throughout these pages have dedicated their work to solving the deeply personal neurological diseases that impact us all. Working together as a team, we fully believe that we have an environment of discovery, clinical care, and education that can lead to incredible advances in the coming years. We invite you to explore our website to see what our department can offer.

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Department of Neurology | Neurology

Peripheral Nerve Disorders includes other areas of care:

- Acute Inflammatory Demyelinating Polyradiculoneuropathy

- Alcoholic Neuropathy

- Alcoholic Polyneuropathy

- Anterior Ischemic Optic Neuropathy

- Auditory Neuropathy

- Autonomic Disorders

- Autonomic Dysreflexia

- Autonomic Neuropathy

- Carcinomatous Polyneuropathy

- Carotid Sinus Syncope

- Chronic Demyelinating Neuropathy With IgM Monoclonal Gammapathy

- Chronic Inflammatory Demyelinating Polyneuropathy

- Chronic Inflammatory Demyelinating Polyradiculoneuropathy

- Congenital Neuropathy With Arthrogryposis Multiplex Congenita

- Congenital Sensory Neuropathy With Neurotrophic Keratitis

- Demyelinating Polyneuropathy

- Diabetic Neuropathy

- Diabetic Polyneuropathy

- Hand Neuropathy

- Hereditary Neuropathy With Liability to Pressure Palsies

- Hereditary Sensory and Autonomic Neuropathy, Type I

- Infantile Refsum Disease

- Inflammatory and Toxic Neuropathy

- Inflammatory Neuropathies

- Leber Hereditary Optic Neuropathy

- Metabolic Neuropathy

- Motor and Sensory Neuropathy With Sensorineural Hearing Loss, Bouldin Type

- Motor Neuropathy

- Motor Neuropathy, Peripheral With Dysautonomia

- Multifocal Motor Neuropathy

- Multifocal Motor Neuropathy With Conduction Block

- Neuropathy, Distal Hereditary Motor

- Neuropathy, Distal Hereditary Motor, Jerash Type

- Neuropathy, Distal Hereditary Motor, Type III

- Neuropathy, Distal Hereditary Motor, Type VIIa

- Neuropathy, Hereditary Motor and Sensory, Lom Type

- Neuropathy, Hereditary Motor and Sensory, Okinawa Type

- Neuropathy, Hereditary Sensory, Radicular

- Neuropathy, Hereditary Sensory, Type I

- Neuropathy, Hereditary Sensory, Type II

- Neuropathy, Hereditary Sensory, Type IV

- Neuropathy, Motor & Sensory

- Optic Neuropathy

- Peripheral Neuropathy

- Peroneal Muscular Atrophy

- Polyneuropathy

- Polyradiculoneuropathy

- Pudenal Neuropathy

- Reflex Sympathetic Dystrophy

- Retrobulbar Neuropathy

- Sensory Neuropathy With Spastic Paraplegia

- Spinal Bulbar Motor Neuropathy

- Spinocerebellar Ataxia With Axonal Neuropathy, Type 2

- Spinocerebellar Ataxia, Autosomal Recessive, With Axonal Neuropathy

- Toxic Polyneuropathy Due to Acrylamide

- Ulnar Neuropathy

- Vascular Neuropathy

See the rest here:
Dr. James Anderson, MD - Clarksville, TN - Neurology ...

The Division of Neurology cares for infants, children and teens with conditions of the nervous system. The nervous system includes the brain, spinal cord and neuromuscular system.

Ranked No. 14 in the nation in by U.S.News&WorldReport.

Diagnosing and treating neurological disorders or injuries requires a team of experienced specialists, with access to advanced technology.

Expert care is provided by the highly skilled neurologists ofRady Childrens Specialists of San Diego. And state-of-the-art equipment, including electroencephalography (EEG), computed tomography (CT) and magnetic resonance imaging (MRI), is used to diagnose a wide range of neurological problems.

Amongour services, weoffer acomprehensive epilepsy centeralong with specialty clinics forRett syndrome,movement disorders,neuromuscular disorders, including muscular dystrophy,cerebrovascular disordersandheadaches. We also haveaTic/Tourette Center.

Research is a major focus ofour division, with the goal of improving diagnosis and treatment, especially for neurological conditions that are difficult to treat.

One hundredpercent of your tax-deductible gift benefits RadyChildrens. To make a donation,click here.

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Neurology - Rady Children's Hospital

LEXINGTON, Ky. (WKYT) More than 270,000 Kentuckians are living with Alzheimer's, and nearly all of them are considered high-risk for COVID-19.

Dr. Gregory Jicha, a neurologist at UK Healthcare, says that while most Alzheimer patients can perform simple tasks like hand washing to stop the spread of the virus, however, there are other complications that arise.

"They're not going to remember to do that, he explains. So, that really requires the caregiver to not just be telling their loved one with Alzheimer what to do, but to try to turn it into a routine and a shared activity."

Doctor Jicha also has advice for caregivers if they do get frustrated.

"There are several critical issues here, some of them fall on the patient they are emotional mirrors so if we're stressed or frantic, that's going to reflect in their behavior which is going to make caregiving even more difficult so, they need to help maintain a calm routine, says Dr. Jicha. But, on the other side of the coin, we have to worry about the caregiver. So, we're always pushing for respite. Take a few moments to yourself to hit the refresh button so you can be your best for yourself and your loved one."

There are resources out there for those in need, including the Sanders Brown Center on Aging in Lexington, and the Alzheimers Associations 24-hour call center at 1-800-272-3900.

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UK neurologist gives advice to Alzheimer's caregivers on COVID-19 routines - WKYT

Orlando Health is revamping its pediatric neurology and neurosurgery programs at its Winnie Palmer and Arnold Palmer hospitals in downtown Orlando, aiming to offer state-of-the-art procedures, such as fetal surgery.

To lead the multiyear effort, the health system has brought on board pediatric and fetal neurosurgeon Dr. Samer Elbabaa, who specializes in repairing spinal anomalies in unborn babies.

Our goal is to add expertise to treat the most complex conditions, in addition to focusing on coordination of care and research and education, said Elbabaa who arrived here three months ago from St. Louis, Mo.

The initiative adds another layer to the competition among the three childrens hospitals in Orlando, which, just by their sheer existence in a city this size, are an anomaly.

Florida Hospital currently boasts one of the most robust childrens neuroscience programs in the Southeast with the highest epilepsy surgery volume in Florida.

Nemours Childrens Hospital in Lake Nona has been recognized for its unique Muscular Dystrophy Association Clinic, led be world-renowned neurologist, Dr. Richard Finkel.

Elbabaas ultimate goal is for Winnie Palmer Hospital for Women & Babies to become a destination for spina bifida fetal surgery.

The condition is a neural tube anomaly. Each year, about 1,500 babies are born with it with various degrees of severity. Fetal surgeons like Elbabaa fix the defect in the fetus by opening moms pregnant belly.

Winnie Palmers program is at least a year away from accepting its first patient, but when open, it would be one of a first in Florida and one of the few in the Southeast, after Childrens Hospital at Vanderbilt in Tennessee.

In the meantime, Elbabaa has been working on establishing a coordinated system of care for kids with medical and surgical needs, ranging from brain tumors and epilepsy to autism and developmental delays.

He recently helped launch the Children Neuroscience Center of Excellence at Arnold Palmer Hospital for Children, bringing together various disciplines of pediatric neuroscience under one umbrella.

To further build the program, Arnold Palmer Hospital is planning to bring on board more pediatric specialists, including neuropsychiatrists, neurologists, psychologists and therapists for inpatient rehab. The center will eventually have its own physical space and an outpatient neurology clinic.

Creating a comprehensive multi-disciplinary approach to treating different conditions is a national trend. Florida Hospital and Nemours said they too have multi-disciplinary neurology programs.

Such programs can lead to better-coordinated care for patients. The model also allows hospitals to hire their own specialists, which can create competition for smaller, independent physician practices.

But thats not likely to happen for pediatric neurologists here because they are in short supply.

Orlando Health expands trauma center

There is a high demand and need for such specialized care, said Dr. Germano Falcao, a local independent pediatric neurologist. Its an underserved area, so they would be bringing additional resources here, said Falcao, who has privileges at Arnold Palmer Hospital.

Elbabaa is also gradually increasing the complexity level of pediatric surgeries to include skull-based and minimally invasive neurosurgeries at Arnold Palmer Hospital and eventually fetal surgery at Winnie Palmer Hospital, where more than 14,000 babies are delivered each year.

Im coming to a center with high volume of delivery, and this community deserves to have a fetal surgery program, he said.

Treating the fetus in the womb is a field thats constantly changing, spurred by individual innovators, hospitals and competition, according to the Society of Maternal-Fetal Medicine.

There are currently about two dozen institutions in the U.S. and Canada that perform more complex fetal procedures, many of which are part of North American Fetal Therapy Network. But there are other centers that perform basic fetal procedures, such as transfusions and shunts. Taken together, it would be reasonable to estimate that there approximately 50 programs across the country, according to Society of Maternal-Fetal Medicine.

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Similar to complex procedures like organ transplantation, parents usually have to travel to another state for fetal surgery.

Port Orange resident Elizabeth Watkins, for instance, decided to go to Childrens Hospital of Philadelphia last October, shortly after she found out that her unborn child had spina bifida.

The financial resources are a challenge, said Watkins, a social worker. She spent a month in Philadelphia, and after returning home, she was on bed rest until she delivered Scout six months ago at Winnie Palmer Hospital via Cesarean section.

Scout is a happy, healthy baby now, but she still needs close monitoring. Watkins has been driving regularly to Arnold Palmer Hospital to go to the Spina Bifida Clinic, where Elbabaa now cares for Scout.

We totally lucked out in getting him, she said. Having everyone together under the same roof benefits the parents and the patient, because everyone is on the same page.

Elbabaa also has his eye on the next generation of doctors and surgeons. He is planning to create learning opportunities for University of Central Florida medical students and eventually hopes to establish fellowships in pediatric neurology and neurosurgery.

We want to be a destination in which parents have confidence, he said. The community really deserves this.

nmiller@orlandosentinel.com, 407-420-5158 or @naseemmiller

More headlines...

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Orlando Health revamping pediatric neurology services - Orlando Sentinel

MIAMI BEACH, Fla.--(BUSINESS WIRE)--RIST Neurovascular, Inc., a neuro-interventional medtech company, today announced it has received U.S. Food and Drug Administration (FDA) 510(k) clearance to market the RIST Cath Radial Access Long Sheath (RIST Cath) for the introduction of interventional devices into the peripheral, coronary, and neurovascular system. RIST Cath is the first device specifically designed for the unique demands of accessing the neurovasculature through the radial artery in the wrist, enabling the full gamut of neurovascular procedures to be performed transradially.

Although transradial techniques have become the standard of care in the cardiac interventional communities, neurointerventionalists have not previously had the appropriate tools to allow these advantages for patients undergoing neurovascular procedures, said Pascal M. Jabbour, MD, Professor of Neurological Surgery and chief of the Division of Neurovascular and Endovascular Neurosurgery in the Department of Neurological Surgery at the Sidney Kimmel Medical College at Thomas Jefferson University. Clearance of the RIST Cath provides neuroendovascular specialists a safe and durable tool to perform neuroendovascular interventions via a transradial approach, and allows us to offer improved care for patients while pushing the envelope of what our field has to offer.

The RIST Cath was developed to meet a well-documented need expressed among physicians conducting neurovascular surgeries, said Martin Dieck, Director, RIST Neurovascular. This FDA clearance will allow us to make the RIST Cath broadly available to these surgeons, improving care for the millions of patients undergoing procedures to treat conditions such as stroke, brain aneurysms and other neurovascular conditions.

While the American Heart Association has recommended a radial-first strategy for acute coronary syndrome since 2018, there has never before been a FDA cleared device that enabled the use of this strategy specifically for neurointerventional procedures.

Cardiology studies have demonstrated a significant reduction in access site complications as well as mortality with radial access. Furthermore, radial access procedures offer several additional advantages, including strong patient preference, immediate ambulation, and reduced costs.

At the International Stroke Conference 2020, being held in Los Angeles, California February 18 21, there will be several presentations exploring the benefits of radial access for neurointerventional Surgery.

About RIST Neurovascular, Inc.

Founded in 2018, RIST Neurovascular, Inc is focused on creating a portfolio of access products designed to allow neuroendovascular procedures to be performed via the radial artery.

For more information, please visit our website at RISTNeuro.com.

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RIST Neurovascular, Inc. Announces FDA Clearance of the First Catheter Specifically Designed to Access the Neurovasculature through the Radial Artery...

Columbia neurologist Mitchell Elkindbecomes the president of the American Heart Association in July 2020, only the second time a neurologist has served as president of the organization. Photo: Columbia University Irving Medical Center.

The good news about cardiovascular disease in the United States is that its becoming less deadly: From 2006 to 2016, the death rate from all cardiovascular diseases decreased by 18.6%and by 31.8% for heart disease related to atherosclerosis.

The bad news is that cardiovascular disease remains the leading cause of death, responsible for 840,768 deaths in 2016.

For nearly 100 years, the American Heart Association has been dedicated to fighting heart disease and stroke.

And starting in July, the organization will be presided over by a neurologist, Mitchell Elkind, MD, professor of neurology at Columbia University Vagelos College of Physicians and Surgeons and an attendingatNewYork-Presbyterian Hospital.

We recently spoke with Elkind about heart disease and its relationship to brain health. The following transcript has been edited for brevity and clarity.

The AHA is not a professional organization for physicians, its really a public health organization. It's geared towardpreventing cardiovascular disease, especially heart attacks and strokes. And it does this through a combination of public education campaigns, raising physician awareness of best practices, and research.

So its not just an organization of cardiologists; there areneurologists, public health specialists, epidemiologists, nutritionists, physical therapists, occupational therapists, nurses, all kinds of people interested in preventing cardiovascular disease.

Also, over the last 20 to 30 years, stroke has become a really important focus of the AHA, and, more recently, the association has gotten interested in brain health in general.

I think some of the most exciting research now is at the intersection among heart disease, stroke, and brain health.

Were learning that sleep, for example, is important for heart health, an area that Columbia researchers are involved in.

For women, poor sleep could contribute to unhealthy food choices, increasing the risk of obesity and heart disease, a new study from researchers at Columbia University Irving Medical Center reports. Read more here.

Were also finding that depression and anxiety often take a toll on peoples physical health; people stop exercising, or they smoke to help themselves cope. By the same token, when people have heart disease or a stroke, it's not uncommon that they develop depression or anxiety afterward.

There's a lot of interest now in atrial fibrillation, when the small chambers of the heart don't beat normally and people feel their heart racing. The biggest complication of a-fib though, is a stroke, because blood clots can form in the heart and travel to the brain.

We're learning that atrial fibrillation is much more common than we thought. The condition isnt always persistent; it can come and go, and some people may have only a few minutes of atrial fibrillation every few weeks. But they still carry a risk of stroke.

These heart problems underlie many of the unexplained strokes that neurologists see. And if we can detect people with these problems, its possible that treating them with blood thinners, like atrial fibrillation patients, will reduce the risk to the brain.

We actually got pretty close; since 2010 weve reduced deaths from cardiovascular disease overall by about 10%and from heart disease alone by 28%.

So in some specific areas we have seen tremendous declines in cardiovascular disease over the last couple of decades. But we're actually starting to see that level off now, and for stroke were actually seeing an increase over the past few years.

There area few things that may be reversing the trend. Substance abuse may be a factor, along with increasing obesity and sedentary lifestyles. And were worried that the popularity of vaping among young people could potentially lead to an increase in smoking.

Overall, the picture has been positive, but we don't want to lose the progress that we've made.

One step is creating a simple message for the public. The AHA createdLife's Simple 7, which are seven things people should do to maintain health: exercise at least five days a week, watch your diet, maintain a healthy weight, do not smoke, reduce blood sugar, control cholesterol, and manage blood pressure.

How do we get people to change behavior? That's been very challenging, but through what we call implementation science, people are coming up with new ideas.

It doesn't all have to happen at the doctor's office, either. Were using non-traditional approaches to reach people, whether it's through churches, which has been very effective in the African American community, or in hair salons and barbershops, where you can get your blood pressure checked while waiting to get your hair cut.

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The Next President of the American Heart Association Is a Columbia Neurologist - Columbia University Irving Medical Center

WEST PALM BEACH, FL Using newer disease-modifying therapies for the initial treatment of pediatric multiple sclerosis may be more effective than injectables at controlling disease activity, according to study results presented at the 2020 Forum for Americas Committee for Treatment and Research in Multiple Sclerosis held February 27-29, 2020, in West Palm Beach, Florida.

Most disease-modifying therapies used in the treatment of multiple sclerosis are not well studied in children; therefore, the treatment of multiple sclerosis in the pediatric population remains a challenge. The objective of this study was to assess the efficacy of initial treatment with new disease-modifying therapies vs injectable therapies on disease activity in pediatric multiple sclerosis and clinically isolated syndrome.

Researchers examined demographic data and clinical outcomes of children with multiple sclerosis and clinically isolated syndrome who received initial therapy with new disease-modifying therapies (such as fingolimod, dimethyl fumarate, and rituximab) or injectable disease-modifying therapies (interferon beta or glatiramer acetate). They used logistic regression to compute propensity score that could be used to predict use of new therapies, including preidentified confounders such as gender, race, age at onset, and relapse count within 6 months. Relapse rate after prescription of initial therapy and time to new or enlarging brain lesions were adjusted for propensity scores-quintile.

Researchers found that 741 children started therapy before 18 years of age, 197 of whom received newer therapies and 544 of whom received injectable therapies. Patients who wer prescribed newer therapies tended to be older (15.2 years vs injectable at 14.4 years; P =.001) and less likely to have a monofocal presentation (37% vs injectable 55%; P <.001). Patients who were prescribed newer therapies had a lower number of relapses in the past 6 months compared with those who were prescribed injectables (0.8 vs 1.0), as well as lower rates of new or enlarging T2 brain lesions (hazard ratio, [HR] 0.51; 95% CI, 0.36-0.72; P <.001) and gadolinium-enhancing brain lesions (HR, 0.38; 95% CI, 0.23-0.63; P <.001).

The researchers concluded that in pediatric multiple sclerosis and clinically isolated syndrome, treatment with newer disease-modifying therapies could be more effective in controlling disease activity than injectable therapies.

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Reference

Krysko KM, Graves JS, Rensel M, et al. Real-world effectiveness of initial treatment with newer versus injectable disease-modifying therapies in pediatric multiple sclerosis. Presented at: Annual Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum; February 27-29, 2020; West Palm Beach, FL. Abstract P066.

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New Pediatric Multiple Sclerosis Therapies More Effective Than Injectables - Neurology Advisor