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NY Neurology Associates: Neurologists: Upper East Side New …

Posted on November 11, 2018 by Danzig

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.

Leonard Weinberger MD Doctor Profile & Reviews …

Posted on March 9, 2019 by Danzig

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 ...

Relieve Pain & Reclaim Life – TN Pain Doctors

Posted on October 19, 2019 by Danzig

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

UH Neurological Institute | University Hospitals Ahuja …

Posted on June 5, 2018 by Danzig

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.

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UH Neurological Institute | University Hospitals Ahuja ...

Neurology | Children’s National

Posted on October 11, 2018 by Danzig

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

Neurology – Rady Children’s Hospital

Posted on April 23, 2018 by Danzig

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

Department of Neurology | Neurology

Posted on April 29, 2018 by Danzig

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

Dr. James Anderson, MD – Clarksville, TN – Neurology …

Posted on May 24, 2018 by Danzig

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

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Dr. James Anderson, MD - Clarksville, TN - Neurology ...

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

Posted on March 29, 2020 by Danzig

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 revamping pediatric neurology services – Orlando Sentinel

Posted on August 21, 2017 by Danzig

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.

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

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Orlando Health revamping pediatric neurology services - Orlando Sentinel

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

Posted on February 10, 2020 by Danzig

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.

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

Posted on February 22, 2020 by Danzig

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.

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

Posted on February 29, 2020 by Danzig

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.

Visit Neurology Advisors conference section for continuous coverage from the ACTRIMS 2020 Forum.

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

The Drilldown: Neurological problems, birth defects and cancer among possible health risks linked to fracking – iPolitics.ca

Posted on January 29, 2020 by Danzig

The Lead

Findings from a report written by the Canadian Association of Physicians for the Environment show that the chemicals involved in the fracking of natural gas have wide-ranging impacts on humans including the potential for birth defects, cancer, neurological issues, psychological impacts, disease and illness, reports the Toronto Star.

According to Dr. Melissa Lem, a board member of the association, the majority of the reports research comes from the United States. She stressed that Canadas fracking practices still need to be better understood.

Canadians have to be aware that fracking is happening in our country and that its causing some extreme harms to our water sources, our air quality, our land, and also contributing to the climate crisis, she said.

Were hoping by bringing the health voice to this issue, that we can help change peoples minds and just make them more aware.

The report says that Canada is the fourth largest producer of natural gas in the world and recommends a rapid and just transition away from natural gas and oil extracted with fracking to clean and equitable renewable energy sources.

Internationally

Ovintiv Inc. previously Encana Corp. is expected to meet with investors today to discuss the companys progress since purchasing Newfield Exploration Co. for US$5.5 billion in 2018. The oil giant decided to ditch Canada in order to improve its standing, but there hasnt been a large improvement since Ovintiv began to trade on the U.S. market this past Monday. Shares have dropped nine per cent in two days, according to Bloomberg.

On Wednesday morning, Brent Crude was at US$59.13 and West Texas Intermediate US$53.64.

In Canada

Canadian Natural Resources Ltd. is opposed to Enbridge Inc.s newest proposal to turn services from the mainline pipeline project into long-term contracts, as opposed to the existing monthly services. According to a filing that the company made with the Canada Energy Regulator, changing the contracts would be an abuse of Enbridges market power, reported Bloomberg.

The proposed conversation of the Mainline from common carriage to contract carriage is unprecedented and inconsistent with the common carriage obligations established in the CER Act, Canadian Natural wrote in the filing.

In other news, the federal government has until the end of February to decide whether or not to approve the $20.6 billion Frontier mine proposed by Teck Resources Ltd. There is also the potential that the minority Liberal government could delay the project, Environment Minister Jonathan Wilkinson stated, according to the Calgary Herald.

Noteworthy

In Opinion

When asked about the indecision on the Frontier mine project on Monday, Premier Jason Kenney said responding to First Nations and Indigenous Canadians doesnt simply mean saying no when theres some opposition. It means saying yes to projects and prosperity when there is a broad Indigenous support. Rick Bell has more in his latest for the Calgary Herald.

The Florida Spine Institute combines excellence and compassion in pain management, neurology, surgery, rehabilitation, physical and regenerative…

Posted on February 5, 2020 by Danzig

CLEARWATER, Fla., Feb. 4, 2020 /PRNewswire/ --Florida Spine Institute (FSI)is the leading, and one of the most trusted, medical facilities specializing in pain management, neurology, surgery, physical medicine and rehabilitationin Tampa Bay. FSI offers a comprehensive wellness program with a multi-disciplinary spine care team, and board-certified diagnostic, medical, and surgical specialists that provide the most advanced care available. All patient consultations and most treatments are done on a single campus.

The state-of-the-art treatment modalities offered range from physical therapy and a variety of injections to procedures including radiofrequency ablation, spinal cord stimulation implants, toKetamine treatmentsand regenerative medicinesuch as stem cell treatments. Each patient's treatment is customized for the best results.

The Florida Spine Institute has a team of elite spine, neuro, and orthopedic surgeonswho combine surgical skills with experience for the most accurate and effective treatment. Our focus is on minimally invasive spine surgical techniques, motion preservation surgery, cervical and lumbar disc replacement surgery, as well as disc restoration.

FSI offers physical medicine and rehabilitation, a branch of medicine emphasizing the prevention, diagnosis, and treatment of nerve, muscle, bone and brain disorders. The Florida Spine Institute also has a friendly and relaxed in-house MRI imaging center, saving our patients valuable time to access this sophisticated procedure.

Neurologytreats disorders of the nervous system which include the brain and spinal cord, and the peripheral nervous system. Our staff neurologistis board certified by the American Board of Psychiatry & Neurology, the American Board of Electrodiagnostic Medicine, and the American Academy of Balance Medicine. He specializes in the treatment of headache, stroke, and epilepsy.

Botox injections, an FDA-approved treatment, has been safely used for treating various medical conditions since 1989, including muscle spasms, myofascial pain, headache, and back and neck pain. Our physicians can use Botox injections in a safe and effective manner to help ease your pain.

A relatively new cutting-edge treatment, Radiofrequency Ablation (RFA), is often favored over laser spine surgery because it utilizes smaller needles, so it is less invasive and is covered by insurance. RFA is used to treat not only neck and back pain, but also hip and knee pain.

IV Ketamine Infusion Therapy is the latest breakthrough treatment that is producing extraordinary results. Ketamine blocks receptors in the brain that, when overstimulated, are responsible for releasing chemicals that cause inflammation of the nervous system. IV Ketamine treatment has been found to be very effective in treating Depression, Pain, CRPS, PTSD, Fibromyalgia, Lyme Disease and more with excellent results.

Regenerative medicine is a game-changing area of medicine with the potential to heal damaged tissues and organs, offering solutions and hope for people who have conditions that might otherwise be thought to be beyond repair. The Florida Spine Institute offers cutting-edge regenerative medicine therapies that can help you feel better. From stem cell therapy to amniotic tissue treatments, we have a solution that is customized for you.

For more information, please visit http://www.floridaspineinstitute.comor call 727-797-7463

If you have questions regarding treatments with IV Ketamine, please visit http://www.ivketamine.comor call 727-KETAMINE or 727-538-2646.

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Defending Trump Is a Has-Beens Best Hope – The Atlantic

Posted on January 22, 2020 by Danzig

But now, at ages 81 and 73, respectively, Dershowitz and Starr are back at center stage. They are the latest faded luminaries seeking to revive their fameand blemish their reputationby shilling for Donald Trump. Call it the revenge of the has-beens.

Theres nothing new about aging celebrities craving a return to the limelight. Many of Americas most famous athletesMichael Jordan, Mario Lemieux, Reggie White, Ryne Sandbergcame out of retirement, usually with unhappy results. Gary Harta serious contender for the Democratic presidential nomination in 1984 and 1988almost launched a long-shot bid two decades later, in 2004. George McGovern, the Democratic nominee in 1972, ran again quixotically in 1984. Mike Gravel, a former senator from Alaska who achieved notoriety by entering the Pentagon Papers into the official Senate record in 1971, unsuccessfully sought the 2008 Democratic and libertarian presidential nominations and enteredand soon dropped out ofthe Democratic presidential race last year, at the age of 89.

The impulse isnt hard to understand. Donna Rockwell, a co-author of one of the few academic studies on the psychology of celebrity, told me, Fame is an addiction like any other addiction where ones neurological set gets acclimated to a particular level of incoming stimuli. When that recedes, the neurology keeps grasping after that People become addicted to being in the show. And once youve been in the show and you know the heady experience that that is, there is a clamoring forevermore to be back in the show. A former child actor told Rockwell, Ive been addicted to almost every substance known to man at one point or another, and the most addicting of them all is fame.

David Graham: Does anyone dare tell Trump the truth?

Whats new in the Trump era isnt the yearning for political rehabilitation, but the opportunity. Trumps recklessness, cruelty, and corruption have led many Republicans in the prime of their career to avoid working for, or publicly defending, him. Help Wanted, read a 2017 Washington Post headline: Why Republicans Wont Work for the Trump Administration. In 2018, CNN reported that Trump was experiencing an unheard-of problem: The president cant find a lawyer.

This has provided the has-beens their opening. One early example was Paul Manafort, who in the Ronald Reagan era helped run a lobbying firm that Newsweek once called the hottest shop in town. But by 2016, as my colleague Franklin Foer has detailed, this once indispensable man, now in his late 60s, was no longer missed in professional circles. He was without a big-paying client, and held heavy debts. The Trump campaign, which Manafort briefly ran, offered a return to relevance.

While Manafort was angling to be Trumps campaign manager, Newt Gingrich was angling to be his running mate. Two decades earlier, Time had named Gingrich, then the 52-year-old Republican speaker of the House, its Man of the Year. But after a failed 2012 presidential bid, Gingrichs star had dimmed, an excruciating prospect for a man who once said, If youre not in The Washington Post every day, you might as well not exist.

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Weekly review: The 5 ‘anxiety traps’ you fall into at workand how to escape them – The Daily Briefing

Posted on January 22, 2020 by Danzig

January 21, 2020

The 5 'anxiety traps' you fall into at workand how to escape them (Monday, Jan. 13)Writing for the Harvard Business Review, leadership adviser Sabina Nawaz outlines five "anxiety traps" that often occur at work and how to deal with them.

This flu season could be one of the worst in decades (Tuesday, Jan. 14)Officials are comparing this season to the 2017-2018 season, which was the deadliest in more than 40 years.

Between life and death: What a neurologist learned when his brother-in-law fell into a coma (Wednesday, Jan. 15)In neurology, there's a "middle ground" between life and death that providers and patients' family members alike struggle to navigatebut a new subspecialty could help improve communication around patients' care, Joseph Stern, a neurologist who's found himself on both the provider and family side of these difficult brain injuries, writes for the New York Times' "Well."

The happiest physiciansand the most burned-out ones in 2020, according to Medscape (Thursday, Jan. 16)More than 40% of physicians are burned out, but some specialtiesand generationsare suffering more than others, according to Medscape's 2020 National Physicians Burnout & Depression Report.

Millennials are sicker and poorer than prior generations. Here's how that's changing health care. (Friday, Jan. 17)Millennials are delaying care because of costs, have higher medical debt than previous generations, and are sicker than earlier generations were at the same agebut the generation is also poised to spur change in the U.S. health system, Daily Briefing's Ashley Fuoco Antonelli writes.

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Weekly review: The 5 'anxiety traps' you fall into at workand how to escape them - The Daily Briefing

Neurologists and Neurologic Care to Benefit from… : Neurology Today – LWW Journals

Posted on December 10, 2019 by Danzig

Article In Brief

The Physician Fee Schedule for 2020 brought better news this year, as neurologists and other cognitive specialists will be able to bill for more of their time for E/M codes, among other changes.

What a difference a year makes!

In the summer of 2018, the Centers for Medicare and Medicaid Services (CMS) issued proposed changes to the Medicare Physician Fee Schedule that would have collapsed the existing five-tier Evaluation and Management (E/M) code structure, with blended payment rates for office and outpatient visits billed at the second through fifth levels.

Clinicians practicing in a number of specialties stood to lose reimbursement dollars under the proposal, but neurologists would have taken one of the worst hits.

A study published in JAMA Neurology calculated that neurologists would lose a median of $3,226 annually and cardiologists would lose a median of $3,203, while dermatologists and orthopedists would get an annual median boost of $16,655 and $6,239, respectively.

A veritable blizzard of comments and advocacy from neurologists and other physicians practicing in cognitively-focused specialtiesmuch of it led by the AANconvinced the CMS to delay and re-evaluate their proposal. And then, on July 29, 2019, the agency unveiled a new plan, designed to align its E/M coding with changes laid out by the American Medical Association (AMA)'s CPT Editorial Panel for office/outpatient E/M visits.

The Final Rule, officially released on November 1 for implementation in 2021, maintains the existing five levels of coding for established patients and reduces the number of levels for new patients to four, by eliminating the code 99201.

The proposed changes also allow clinicians to choose E/M visit levels using either medical decision-making or time. CMS also proposed the addition of an add-on code (15-minute increment) for prolonged service time, and a separate add-on code to recognize the complexity inherent to E/M services that are part of ongoing care related to a patient's single, serious, or complex chronic condition.

What does that mean for practicing neurologists? It's a swing of $150 million a year annually in the positive direction, Daniel Spirn, AAN's senior regulatory counsel told Neurology Today. Documentation guidelines have also been simplified, news that every practicing neurologist will likely welcome. This really is one of our biggest advocacy wins ever, he said.

It's a major landmark success, agrees Brad C. Klein, MD, MBA, FAAN, a neurologist in private practice at Abington Neurological Associates in Willow Grove, Pennsylvania and clinical associate professor of neurology at Thomas Jefferson University who is a member of the AAN Board of Directors and chair of the Medical Economics and Practice Committee.

For years it's felt like our reimbursement for cognitive care has continued to drop at the expense of other more procedural specialties, and this is a major turnaround. That face-to-face time we spend with patients can really change a person's life.

Last year's proposal posed a major threat to neurologists' time with patients, said Kara Stavros, MD, a neurologist at Rhode Island Hospital and assistant professor of neurology at The Warren Alpert Medical School of Brown University, and a member of the AAN Advocacy Committee.

E/M services are so important for what we do as neurologiststhe time we spend with patients to make the diagnosis, counsel, and manage the condition. For example, I'm a neuromuscular specialist treating patients with very complex conditions like muscular dystrophy or ALS, and if I can't spend an appropriate amount of time with them, their care will suffer. It's gratifying to see that the intensity of what we do is valued by CMS, and that they recognize the importance of the time we spend with our patients.

Advocacy by the AAN and its members across the country played a critical role in CMS' about-face, Spirn says. We quickly and aggressively responded to last year's proposed fee schedule. In the last half of 2018 alone, we had five different meetings with staffers at the Department of Health and Human Services and 54 meetings on Capitol Hill, all pushing CMS not to collapse the E/M codes. And over 700 AAN members contacted their Members of Congress in response to our advocacy alerts.

A January 2019 letter to the AAN from Deputy Secretary of Health and Human Services Eric Hargan praised the organization's efforts, saying We appreciated the input of Dr. [Marc] Raphaelson [a member of the AAN Health Policy Subcommittee and AAN RVS Update Committee (RUC) Representative] and Mr. Spirn, who highlighted for us the challenges faced by neurologists in today's reimbursement environment and the advantages of using time as a variable in coding E&M visits.

The Academy also received the American Association of Medical Society Executives (AAMSE) Profiles of Excellence award for its regulatory advocacy pushing back against the proposed changes. This truly was a full court press and the AAN pulled it off, said the AAMSE award judge.

And the AAN didn't rest on its laurels after the 2018 success. In March 2019, AAN members and staff met with CMS leadership, stating the case for the value of E/M services and their critical importance to neurologists. The Academy also participated in all the meetings of the AMA's E/M workgroup, setting the groundwork for what CMS ultimately proposed and finalized this year in the November Final Rule for 2021 implementation.

Even after the proposal came out in July, we have been actively involved in making sure that CMS would finalize these very positive reimbursement trends for neurology, Spirn said.

These efforts included a 41-page comment letter to CMS and an editorial from AAN President James C. Stevens, MD, FAAN, and the president of the American College of Rheumatology published in Fierce Healthcare, both supplementing the AAN's previous meetings with CMS on the subject. In the end, CMS did finalize the proposal as we wanted to see it, Spirn said.

Although the rule is titled 2020 Medicare Physician Fee Schedule, that name is misleadingthe new codes won't go into effect until January 1, 2021.

Dr. Klein said that the AAN will offer a host of educational programming over the next year to help members prepare for the new fee schedule, beginning with a webinar on December 12 and including extensive offerings at the 2020 Annual Meeting in Toronto in April. (See the website at http://www.aan.com for further details and updates.)

Not all the news about reimbursement for next year is good. CMS has also established a new coding structure for reporting long-term EEG monitoring services beginning in 2020 that likely will have a negative financial impact on some neurologists.

These changes had been in the works since November 2016, when CMS identified CPT Code 95951 (long-term EEG monitoring with video) as a high-volume service, as growth in Medicare claims exceeded 10,000 and increased by at least 100% from 2009 -2014.

The problem with this code is that it was really intended for a monitored service in the inpatient setting, but the description is left open to interpretation such that it could be done in an unattended outpatient setting, not requiring much expense, and generate a lot of income, said Dr. Klein. In short, CMS felt it was being reimbursed too much.

Among the changes in the revision:

These changes will lead to a significant decrease in reimbursement for some neurologists and institutions, particularly given that physician work RVUs (wRVUs) are lower than for the current codes, reflecting efficiencies that have developed in EEG monitoring over the past two decades.

But it could have been worse. Medicare's original proposal rejected the RVU valuations for four of the ten physician work proposed by the AMA's RVS Update Committee (RUC) based on surveys of neurologists across the country.

In response, the AAN engaged in a major advocacy effort in partnership with the American Epilepsy Society, the National Association of Epilepsy Centers, and the American Clinical Neurophysiology Society, to educate Medicare that the devaluation of these four RUC values was not fair or accurate, said Dr. Klein. Ultimately, CMS agreed to bring those code values back up to the level recommended by the RUC. Even though this represents a financial loss to neurologists, there were a lot of steps along the way where it could have been a lot worse.

In another new wrinkle, Medicare elected not to establish national values for the technical component codes. Instead, rates will be set by each Medicare Administrative Contractor (MAC), for their geographic jurisdiction. Private health care insurers will also set their own payment rates and are subject to independent negotiations with health care providers, as is the case with any existing service.

This is something physicians rarely considered, said Dr. Klein. Previously, we always had a global value for the work involved in EEG services. Now, we will see a value of zero for the technical components. To find out our payment rates for these codes, we have to take the extra step and reach out to our local MACs, and these rates will be non-negotiable. However, we will also have to reach out to our commercial payers, where these rates may be up for discussion. Regardless, these changes are going to have an impact on decisions like buying new equipment, staffing, and what services will be provided. Whether in an academic center or private practice, providers will need to understand these nuances to make the right decisions for their practice.

Unlike the physician fee schedule, the EEG changes officially go into effect on January 1, 2020. We are working to help our members who do a lot of EEG work transition to the new codes, said Elaine C. Jones, MD, FAAN, a member of the AAN's Board of Directors who has chaired the AAN's Government Relations Committee and currently chairs the Coding and Payment Policy Subcommittee.

We will also be working with the insurers on the payment decisions that are being pushed back to the regional MAC carriers regarding what is appropriate reimbursement and monitoring how that rolls out going forward as well.

Dr. Jones also urged members to pay attention to changes in chronic care management codes, which include new and enhanced care management services and even two new codes for Principal Care Management.

When the original codes initially came out, they were rather difficult for neurologists to use because of excessive documentation requirements, and because it was unclear whether or not they could be billed by multiple providerssuch as discharge monitoring and transitions of care for a patient who has visits with both a primary care provider and a neurologist, she says.

Now, I think these changes mean we will be able to incorporate them a little more easily. We're already doing this kind of care management now, and it's less difficult to bill for than it was, so this represents revenue we can start picking up.

This is a real opportunity for those who can take advantage of these codes, said Joel M. Kaufman, MD, FAAN, chair of the Care Delivery Subcommittee of the AAN's Medical Economics & Practice Committee.

It's true that procedures like long-term EEG monitoring have been an incredibly useful tool in neurology, but with these changes, there's an opportunity to balance the need to do procedures with the importance of managing patients with chronic conditions.

Overall, said Spirn, these developments underscore the AAN's growing role as a thought leader in healthcare policy. There used to be a time when we could only hope CMS and HHS leaders would meet with us. Now, we often meet several times a year, and agency leadership takes time to write us letters thanking us for our feedback and involvement. That's an incredible shift in how they see the AANas a resource they can go to when making policy.

That shift can be credited to the AAN's approach to advocacy. It's not about protecting the physicians' pocketbooks or making more money; it's about the right thing for the patients, Dr. Jones said.

We feel that we do better by making our care better and improving our patients lives. That's what the AAN focuses on, and as a result, it has really become recognized as a fair and thoughtful voice out there for the right way to do health care.

Dr. Klein has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Allergan, Amgen, Biohaven, Depomed/Assertio, Eli Lilly and Company, Teva, US WorldMeds, Promius, Eagalet, and the AAN. Dr. Klein has received compensation for serving on the board of directors of Appsbydocs, LLC, and Makers of P-Cog. Dr. Klein has received research support from Allergan, Alder Pharmaceuticals, and Eli Lilly and Company. Dr. Jones has been reimbursed for travel and lectures for MER, a CME company.

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Neurologists and Neurologic Care to Benefit from... : Neurology Today - LWW Journals

Closed-Loop Spinal Cord Stimulation for the Management of Chronic Back and Leg Pain [Part 1] – Neurology Advisor

Posted on January 13, 2020 by Danzig

Spinalcord stimulation (SCS) with a closed-loop system that uses recorded evokedcompound action potentials (ECAPs) is superior to a fixed-output, open-loopsystem for patients with chronic back and leg pain, according to study resultspublished in Lancet Neurology.

While SCS has been a well-established treatment for chronic pain for more than 50 years, the results are suboptimal. The major challenge in SCS is the changing distance between the stimulating electrodes and their spinal cord target, because while the spinal cord changes position within the cerebrospinal fluid with every movement, the electrode is fixed in the epidural space.

Theavailable SCS systems are open-loop systems and do not measure or adjust forchanges in the electrical field strength reaching the spinal cord, leading tounpredictable inhibition of pain-processing pathways. An ECAP-controlled,closed-loop system can change the stimulation output current as needed.

Thegoal of the current double-blind, randomized-controlled study was to comparethe safety and efficacy of ECAP-controlled, closed loop SCS with that of fixed-output,open-loop SCS for patients with chronic back and leg pain.

Thestudy included patients with chronic intractable pain of the back and legs whowere refractory to conservative therapy and on stable medications. Theparticipants were randomly assigned to receive ECAP-controlled closed-loop SCSor fixed-output, open-loop SCS.

Theprimary objective was to show noninferiority, and then to test the superiority,of closed-loop SCS compared with open-loop SCS. The primary outcome, tested at3 and 12 months after the permanent implant, was a composite outcome thatincluded the proportion of patients who responded to SCS with a 50% reductionin overall back and leg pain as determined by visual analog scale score, withno increase in analgesics.

Thestudy enrolled 134 participants: 67 were assigned to closed-loop(investigational) group and 67 to open-loop (control) group.

Inthe intent-to-treat population, the percentage of responders with 50% reductionin overall back and leg pain and no increase in pain medications at 3 monthswas 82.3% (51 of 62 patients) in the closed-loop group vs 60.3% (38 of 63 patients)in the open-loop group. At 12 months the response rates were 83.1% (49 of 59patients) and 61.0% (36 of 59 patients), respectively. Noninferiority was demonstratedat 3 months (P <.0001) and 12 months (P <.0001), as wassuperiority (3 months, P =.0052; 12 months, P =.0060).

Thetype, nature, and severity of adverse events were similar between treatmentgroups. There were 23 adverse events in 13 patients (19%) in the closed-loopgroup and 11 adverse events in 11 patients (16%) in the open-loop group. Themost common study-related adverse events were lead migration, implantable pulsegenerator pocket pain and muscle spasm or cramps.

LawrencePoree, MD, MPH, PhD, Director of Neuromodulation Service, Division of PainMedicine at University of California, San Francisco and the senior author ofthe study commented that these are impressive clinical outcomes forcomprehensively managing patients pain effectively over the long term. Themore than 50 percent of closed-loop patients who reached high responder statusof greater than or equal to 80% reduction in overall pain also demonstratedclinically meaningful changes in secondary patient-reported outcomes,emphasizing the value of achieving this high threshold.

Closed-loopspinal cord stimulation provided greater levels of spinal cord activation,within the therapeutic window, which suggests a mechanistic explanation for thesuperior results. Although preliminary, we believe this is the first step inthe field of neuromodulation, moving towards a mechanism-based, personalisedtherapy founded on an objective outcome measure, concluded theresearchers.

Disclosure: This clinical trial was supported by Saluda Medical. Please see the original reference for a full list of authors disclosures.

Reference

Mekhail N, Levy RM, Deer TR, et al. Long-term safety and efficacy of closed-loop spinal cord stimulation to treat chronic back and leg pain (Evoke): a double-blind, randomised, controlled trial [published online ahead of print, 2019 Dec 20]. Lancet Neurol. 2019;S1474-4422(19)30414-4. doi:10.1016/S1474-4422(19)30414-4

This is part 1 of a 2 part feature. In part 2 Neurology Advisor interviews Nagy Mekhail, MD, PhD, Professor at the Cleveland Clinic Lerner College of Medicine, Director of Evidence-Based Pain Medicine Research and Education in the Department of Pain Management at the Cleveland Clinic, and first author of this study.

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Closed-Loop Spinal Cord Stimulation for the Management of Chronic Back and Leg Pain [Part 1] - Neurology Advisor

The Role that Fragmented Sleep Plays in Cognition : Neurology Today – LWW Journals

Posted on January 14, 2020 by Danzig

By Jamie Talan January 9, 2020

A new study suggests that disrupted sleep throughout older age is accompanied by microglial cells that age faster and become overly active, potentially contributing to cognitive impairment.

Older adults who had experienced greater fragmented sleep showed higher levels of a gene signature suggestive of aged microglia, and they performed worse on annual cognitive tests.

The findingswhich were based on data from two prospective, observational, community-based studies of older persons who had donated their brains and medical records for research purposesunderscore the role that poor sleep can play in late life and cognition.

These findings add more evidence that fragmented sleep is bad for the brain, said Andrew S.P. Lim, MD, associate professor of neurology at University of Toronto and senior investigator of the study, published December 11 in Science Advances. It means that sleep problems in older people need to be taken seriously.

More research is needed to test whether modifying sleep can reverse these changes, and to figure out how much sleep fragmentation is enough to trigger activated microglia or other changes in the brain's innate immune cells that regulate inflammation and other immune system functions, Dr. Lim said.

There is growing evidence that microglia play a role in Alzheimer's disease (AD) and in sleep. Understanding microglia biology could ultimately allow us to target pathways in the brain that can reverse these problems, said Dr. Lim, a sleep neurologist.

Dr. Lim and his colleagues drew data from the Rush Memory and Aging Project and the Religious Orders Study. At the time of this assessment, 685 adults, 65-years-old or older265 with AD and 420 withoutwere enrolled in the study. A subset of study participants agreed to an annual test to measure movement during sleep. Results from this wristwatch-like accelerometer were paired with their yearly cognitive test scores. In subsets of participants, the autopsied tissue was also tested in two ways: first, neocortical microglial gene expression was quantified by RNA sequencing and then, neocortical microglial density and morphologic activation was assessed by immunohistochemistry.

The researchers reported that people who had more sleep fragmentation had higher expression of marker genes characteristic of aged microglia, an increased level of activated microglia, and worse cognition before they died. The problems with sleep fragmentation and its relationship to expression of genes related to aging microglia, and worsening scores on cognitive tests were present in patients with AD, as well as people who were not diagnosed with AD, said Dr. Lim.

The transcriptional changes were independent of chronological age, density of microglia, and dementia-related brain pathologies and were not completely accounted for by the increased density of morphologically activated microglia, the study authors wrote. ...These findings raise the possibility that microglial aging and activation may be a consequence of sleep fragmentation and may link sleep fragmentation to poor cognition in older adults.

The researchers are still not sure whether microglial aging or activated microglia leads to sleep fragmentation or whether waking up throughout the night triggers microglial aging and activation, and how this contributes to dementia pathologies.

It is possible that both processes play a role in what Dr. Lim and his colleagues called a two-hit model.

They wrote that it is also possible that greater sleep fragmentation is associated with higher expression of genes characteristic of aged microglia, irrespective of the presence or absence of AD pathology, but the subsequent impact of microglial transcriptional aging on cognition is greatest in those who also have AD pathology, in whom microglial transcriptional aging amplifies the cognitive impact of AD pathology.

The scientists said that they need to study sleep fragmentation in middle-aged people to understand how long the problem exists before it leads to changes in gene expression and activated microglia.

This is an exciting and interesting paper linking sleep fragmentation to microglial function that could open the door to new insights into how sleep protects the brain, said Erik S. Musiek, MD, PhD, associate professor of neurology at Washington University School of Medicine in St. Louis.

There are a number of studies suggesting that sleep disruption can increase inflammation in the periphery, and some animal studies show a relationship between sleep loss and inflammation in the brain. This study supports those previous findings and adds a new wrinklesleep fragmentation. This method to measure sleep fragmentation is quite powerful and has previously been used to correlate sleep fragmentation and risk of incident dementia. The participants in the study had their sleep measured on average about 1.5 years before they died, and there are correlations between sleep fragmentation and microglial gene expression.

In general, Dr. Musiek added, microglia gene expression patterns suggest aging and microglial activation, indicative of inflammation, in people with sleep fragmentation. Sleep fragmentation and microglial changes were also correlated with poor memory performance. This suggests that sleep fragmentation may contribute to brain inflammation via microglial activation in aging.

He added that some caveats include the fact that all of the findings are correlational, and further experiments would be needed to show true causality. Also, the use of post-mortem tissue can be a problem, as death and postmortem interval may alter microglial gene expression. Confirmation of these finding using CSF biomarkers in living people would be an important next step. Finally, sleep fragmentation may result from disruption of the circadian clock, which has also been implicated in regulation of neuroinflammation.

This is another study that supports the importance of sleep for cognition, added Rachel Marie E. Salas, MD, FAAN, associate professor of neurology at Johns Hopkins Medicine and assistant medical director for the Johns Hopkins Center for Sleep.

Fragmented sleep is so common with older adults for many reasons. It is very important to address and optimize your sleep environment or it can have negative consequences. Sleep is a basic human need and we tell our patients that only they can make it a priority. Not only do we need enough sleep but it has to be quality sleep.

Although the pathways linking sleep and circadian rhythms with neurologic health are likely multifactorialincluding alterations in interstitial and CSF flow dynamics, neuronal metabolism, and oxidative stressrecent evidence in animals indicate that alterations in microglial function, together with microglial activation and neuro-inflammation are potential common pathways, added Phyllis C. Zee, MD, PhD, professor of neurology and director of the Center for Circadian and Sleep Medicine at Northwestern University Feinberg School of Medicine.

Although the causal role of sleep fragmentation and alterations in microglial aging was not directly addressable in the study, we now have further insight into accelerated microglial aging as a potential mechanism linking sleep disturbance and neurodegeneration in humans.

Dr. Zee added: The results from the current study are clinically significant because they highlight the importance of sleep and circadian health for successful brain aging, but also point to the potential of sleep and circadianbased approaches as a component for disease modification therapies in age-related cognitive decline and dementia.

Drs. Lim, Musiek, Salas, and Zee had no competing interests.

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