Annals of Neurology | American Neurological Association (ANA)

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Annals of Neurology is one of the most prestigious medical publications in the world, publishing high-impact clinical and basic research in neurology and neuroscience.

The journalpublishes articles of broad interest with potential for high impact in understanding the mechanisms and treatment of diseases of the human nervous system. All areas of clinical and basic neuroscience, including new technologies, cellular and molecular neurobiology, population sciences, and studies of behavior, addiction, and psychiatric diseases are of interest to the journal. Annals of Neurologyis particularly interested in clinical trials and other large-scale studies that inform the practice of medicine.Trials reporting negative data will be considered.

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Prolonged Space Flight Affects Human Brain Structure and… : Neurology Today – LWW Journals

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By Jamie Talan December 5, 2019

Brain MRI scans revealed cognitive and movement changes in astronauts who participated in long space flights. Researchers advise advanced neuroimaging protocols and long-term follow-up imaging in this population.

Astronauts who have participated in long space flights appear to have structural alterations in the brain that are associated with changes in measures of cognition and movement about a month after they return to Earth's atmosphere, suggests a study published online October 17 in the American Journal of Neuroradiology.

Our findings support the need for advanced neuroimaging protocols and long-term follow-up imaging of the astronaut population, the study authors wrote. Most important, understanding the influences of gravity on CSF homeostasis and brain health may provide insights into abnormalities of CSF homeostasis such as idiopathic normal pressure hydrocephalus.

In the retrospective study, Donna Roberts, MD, associate professor of radiology at the Medical University of South Carolina, and her colleagues looked at brain MRI scans from 19 NASA astronauts who had scans done before an International Space Station mission or a Space Shuttle flight and again after they returned. The scientists also had access to pre- and post-clinical assessments and tests conducted to identify cognitive and movement changes.

They found a significant 10.7 percent change in total ventricular volume in astronauts who returned from long-duration International Space Station (ISS) missions compared with no changes in ventricular volume in astronauts who returned from short-duration Space Shuttle missions.

Dr. Roberts met earlier in November with NASA scientists to discuss the findings. I believe NASA should make this a priority, she said. We need to understand what changes to brain structure and physiology are occurring during these long-duration spaceflights, whether or not these changes have any clinical consequences and, if so, then in what ways can we protect against these changes. We also don't know whether these brain changes persist after some time back in the gravity environment of Earth.

In a 2017 study in The New England Journal of Medicine, the South Carolina scientists looked at the MRI results from long-duration flights and found enlargement of the ventricles, an upshift in the brain, and a narrowing of the cerebrospinal fluid spaces at the top of the brain. The brain tissue seemed crowded, Dr. Roberts explained. With this observation in hand, she and her colleagues returned to the NASA files to obtain performance data that they could use to see if it matched with the MRI changes.

The scientists worked with data provided by the NASA Lifetime Surveillance of Astronaut Health office. They received pre-and-post flight MRI scans on 12 astronauts who spent time on the ISS and seven others who made shorter shuttle missions. Four of the astronauts on the ISS mission had spaceflight-associated neuro-ocular syndrome (SANS), which is characterized by changes to the retina that alter visual acuity and swelling of the optic nerve. These visual problems were first identified in 2005 and prompted NASA to add brain scans to a long list of tests to understand the health effects of space flight. The agency has been collecting MRI data for about a decade. Some of the astronauts had consented to a lumbar puncture, as well, that was used to measure intercranial pressure. When ISS astronauts touched down in Kazakhstan to begin their re-adaptation to the Earth's atmosphere, crew members put them through a series of tests to measure their motor skills. They assessed whether the astronauts could climb a ladder, open a hatch, get out of a seat and maneuver an easy obstacle course, and maintain their balance when carrying out these tasks.

Dr. Roberts and her team also had access to pre- and post-flight cognitive data that are now being collected on all astronauts who complete a mission. Both these post-flight functional and cognitive tests were done within a few days of re-entry. The MRI scans were also done within a few days of re-entry.

The scientists reported a 10.7 percent increase in the total ventricular volume post-flight compared with preflight in the ISS astronauts. There was no change in the shuttle astronauts. They reported that the younger astronauts were more likely to have enlarged ventricles on MRI, and the MRI findings were negatively correlated with the visual deficits of SANS, which tends to occur in older astronauts. The percentage of ventricle change was greater in those who participated in longer missions. There were no significant changes on pre- to postflight in the total volume of gray matter or white matter for either the Shuttle or ISS astronauts. The team also had access to cognitive testing data, primarily the Spaceflight Cognitive Assessment Tool for Windows (WinSCAT). This test was developed by NASA as a screening tool to monitor cognitive status during missions so flight surgeons could identify any performance issues. They analyzed data from sub-tests of the WinSCAT, including tests that measured speed and efficiency, memory, working memory, mathematical processing, and sustained attention.

They did not see a change in pre- and post-flight scores or an association between performance on the test and the length of the mission. They did find that astronauts showed a decrement in accuracy on processing speed and learning tests but showed faster reaction times on a subset of tests on sustained attention. They were also able to link it to changes in volume in three white matter regions on the scans.

The researchers found that the structural changes in the left caudate nucleus correlated with a worsening on tests of balance control. That does not mean that these volume changes caused these problems, Dr. Roberts said, and no one knows whether the structural changes persist over time.

We are trying to raise awareness so that NASA can better understand what happens to the brain in space, Dr. Roberts added. We have no idea whether these changes are a positive adaptive response to space flight, or a maladaptive consequence. As we send more astronauts into space and with the rising interest in space tourism we want to make sure we understand what is happening to the human brain in space. We will be able to develop countermeasures but we first need to understand what is happening.

There is a lot we don't know about what is happening to the brain in space, said Stephen A. McGuire, MD, FAAN, adjunct professor of neurology at the University of Texas Health Sciences Center San Antonio. It is not surprising that whatever is causing fluid shifts in the brain would be associated with changes in cognition. But you have to be careful. How much is learned behavior and remodeling of the brain and how much is environmentally-induced structural change? The ataxia that astronauts experience may just be a part of readjusting to gravity. Are these permanent changes? Astronauts are very high performers, which makes it difficult to appreciate any long-term effects. We just don't know.

Dr. McGuire has studied the effects of high altitude on U2 pilots and identified long-term deficits in cognition (following a five to 15-year period of extreme hypobaric exposure) that were correlated with white matter changes compared to Air Force pilot controls. But, he said, the effects were not clinically significant.

There are lots of unanswered questions, Dr. McGuire said. How significant are these problems in the astronauts and is this something we really need to be concerned about?

Jonathan B. Clark MD, MPH, associate professor of neurology and space medicine in the department of neurology in the Center for Space Medicine at Baylor College of Medicine, said that one of the problems in studying long-term effects of space flight on the brain is getting access to astronauts. They had small numbers but it bears further consideration and evaluation. The fact that they correlated these ventricular changes with cognitive and motor behaviors tells us that we need to keep an eye on this.

Also, he said, part of the problem with the data is that the MRI scans were generally done in the first three weeks after landing and the functional tests are done within the first few days. And during those first few days, they are landing in Kazakhstan and immediately flown to Russia and then to the United States. They are back in the US within 48-hours and you can imagine that they have the weight of gravity to contend with and the multiple flights.

It is a fascinating finding, he said. Space changes all organ systems so it would not be surprising that the brain would be affected, cautioning that they may still be in an adaptive phase. The scientists did not find any gray or white matter changes and that would be when you worry. The functional effects will generally recover after a week or two. The anatomy is arguably what will change slower.

He said that NASA is now evaluating 24 cases of SANS. This study only captured four of these cases.

Jennifer Fogarty, PhD, is the chief scientist for NASA's human research program, and oversees a portfolio of studies on astronauts during space: How their bodies change and adapt and whether the changes could create a health or performance risk. The key is interpreting the change on brain imaging scans, she said of the Medical University of South Carolina study. They identified a correlation but that doesn't tell us if it is causality.

The ataxia that astronauts experience may just be a part of readjusting to gravity. Are these permanent changes? Astronauts are very high performers, which makes it difficult to appreciate any long-term effects. We just don't know.

DR. STEPHEN MCGUIRE

She said that the agency has been trying to understand SANS and design ways to protect against it during long-term spaceflight. NASA has neurologists, neuroscientists, and neuro-ophthalmologists assessing the SANS data we collect. So far, nothing has reached a clear clinical threshold.

Dr. Fogarty said that NASA engineers are designing devices to use lower body negative pressure to pull blood volume and CSF back down. The device will be tested in 2021. There are also ongoing studies to see whether elevated CO2 levels on the Space Station help contribute to changes in the eye.

Using data like this, she said, referring to the Medical University of South Carolina study, helps us to go in different directions.

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Prolonged Space Flight Affects Human Brain Structure and... : Neurology Today - LWW Journals

Miller Fisher syndrome and Haemophilus … – n.neurology.org

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Objective: To examine the association between Miller Fisher syndrome (MFS) and antecedent Haemophilus influenzae infection.

Background: Little is known about agents in prior respiratory tract infection of MFS, whereas antecedent upper respiratory symptoms are frequent. H. influenzae is a major pathogen that can cause human respiratory tract infection.

Methods: The authors used ELISA to detect serum antibody against the bacterium in 70 consecutive patients with MFS and 110 with GuillainBarr syndrome (GBS).

Results: Serum antiH. influenzae IgG and IgM antibody activities were significantly higher in the MFS group than in age- and sex-matched patients with other neurologic diseases (n = 62) and normal control subjects (n = 82). The GBS group showed no significant increase in any class of antibody activities compared with control groups. Serologic evidence of recent infection was found in five (7%) of the patients with MFS and two (2%) of 110 patients with GBS, all of whom had a history of antecedent respiratory tract infection. They frequently showed ophthalmoplegia, but other neurologic features were not remarkable. Serum anti-GQ1b IgG antibody that had cross-reactivity with GT1a ganglioside was detected in six of these seven patients. Thin-layer chromatography with immunostaining showed that serum IgG from H. influenzaeseropositive patients with high anti-GQ1b and anti-GT1a IgG antibody titers bound to the lipopolysaccharide fraction extracted from the type b H. influenzae serostrain. These bands were also stained by anti-GT1a monoclonal antibody (GMR11), indicating that the lipopolysaccharide bears the GT1a epitope.

Conclusions: These findings point to H. influenzae being an agent associated with MFS. Epitopic overlap between H. influenzae and human nerve tissue may be involved in the development of MFS much as GBS is associated with Campylobacter jejuni enteritis.

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Education | Neurology & Neurological Sciences | Stanford …

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Adult and Child Neurology Residencies and Fellowships

The Department of Neurology & Neurological Sciencesat Stanford offers ACGME-accredited adult and child Neurology residency training programs as well as multiple adult and pediatric post-residencyfellowshiptraining programs in multiple subspecialties. A vast array of clinical and research training programs are available at the Graduate Medical Education level at Stanford.

This is a vibrant and exciting time for clinical neurosciences at Stanford. With over 130 faculty with primary appointments within the Department, Stanford is considered one of the larger programs nationally, yet still retains a close-knit and collegial training environment. Stanford Neurology faculty are among the world leaders in many areas within the clinical and basic neurosciences. Many of our subspecialty divisions and programs are the largest on the West Coast, and are at the top nationwide in terms of clinical activity, cutting-edge research, and influence within their respective fields. Every significant subspecialty within Neurology is well-represented. Certain areas are unique strengths, including our Neurology-basedneuro-oncology groupand our neuro-autonomic program. Stanford boasts a world-renownComprehensive Epilepsy Center,Movement Disorders Center,Alzheimers Disease Research Center,Udall Center of Excellence for Parkinson's Disease Research, the countrys firstComprehensive Stroke Center, the largestChild Neurologydivision of the West Coast, a large and well-developed intraoperative monitoring (IOM) program, a model multidisciplinaryHeadache (Pain) Clinic, and the pioneeringCenter for Sleep Sciences and Medicine. Our trainees have a vast array of clinical, research, and other academic opportunities available to them. Prospective applicants are invited to explore this website (and those of each subspecialty division) and its many links to gain an appreciation for the incredible scope and quality of experiences that are available at Stanford Neurology with post-graduate training in the clinical neurosciences.

Stanford Neurology attracts patients with serious and complex neurologic disorders from all over the world primarily the Western United Stated and the Pacific Rim. The tremendous population growth of the metropolitan area around Silicon Valley ensures a steady source of diverse patients with a wide range of neurological diseases.Stanford Hospital is nearly always at full capacity which leads to a dynamic and rich training environment. The volume of Neurology patients at Stanford is currently the second highest of all university hospitals in California.Similarly, Neurology outpatient volumes are tremendous, with over 60,000 annual patient visits in our multiple clinics at Stanford Healthcare, Stanford Childrens Health, Santa Clara Valley Medical Center and the VA. We have beautiful state-of-the-art facilities including two newmulti-billion dollar hospitals and the Stanford Neuroscience Health Center, a first of its kind one stop outpatient neuroscience center. This is all to say that despite the ample research and academic opportunities available (see below), our training programs remain patient focused and clinically intensive. Trainees should expect a broad exposure to a large volume of complex patients while on their clinical rotations. First and foremost, we are looking to train top-flight physicians with excellent clinical skills.

Our excellent clinical training in Neurology at Stanford is complemented by exposure to thefaculty,resources, andfacilitiesof one of the worlds leading neuroscience research institutions. Stanford sits on the cutting edge of 21stCentury neuroscience and translational research. Stanfords multidisciplinary neurosciences institute, under the direction ofDr. William Newsome, brings together clinicians and scientists in the School of Medicine and many other Stanford University Schools and Departments who share a common interest in clinical and basic neuroscience. With several hundred faculty participants dedicated to expanding the frontiers of neuroscience, the institute builds on Stanford's expertise in Medicine, Humanities and Sciences, Engineering, Law, and Business to form a world-class interdisciplinary program to provide innovative solutions to clinical medicine. This distinguished group of Stanford neuroscientists includes multiple members of the National Academy of Sciences, Institute of Medicine, and Nobel Prize laureates. Our trainees have direct access to these investigators and thought leaders as most are physically located on the School of Medicine campus. The Stanford academic community has a great tradition of innovation, along with a spirit of openness and collaboration. Along with an extensive and vigorous clinical experience, our residency program includes a neuroscience research track and Investigator Training Pipeline that allow our trainees to fully leverage this remarkable research setting Stanford also participates in the Biohub physician-scientist fellowship program for additional mentored biomedical and clinical research that does not require prior research experience. Opportunities for pushing the boundaries in neuroscience research, both basic/translational and clinical, exist at Stanford like nowhere else.

Multiple unique experiences are available at Stanford for the consideration of our Neurology trainees., in addition to the neuroscience research opportunities listed above. TheStanford biodesign program, for example, takes advantage of our exceptional institutional resources in engineering, computer science, and medical device design, as well as our long history of successful collaboration with industry in Silicon Valley. Trainees also have access to colleagues in theStanford Health Research and Policy Department, which also provides a popular master degree program in epidemiology and clinical research methodology. Fellowships and collaboration are possible with theClinical Excellence Research Center (CERC). This cutting edge program organizes research teams from multiple Stanford Schools to design and test new methods of health care delivery that substantially reduce population-wide disability and annualpercapita health spending in the near term. New initiatives in international health are available to our Neurology trainees.The Center of Innovation in Global Health(CIGH) is currently one of the most comprehensive and active in the country. Stanford neurologists have been active leaders in pioneering opportunities for residents with an interest inglobal health in Africaand beyond. Residents and clinical fellows at Stanford have access to another valuable resource in the Stanford Center for Translational Research and Education (SPECTRUM). Programs through SPECTRUM are one of many that spans major clinical departments and brings together talented residents and clinical fellows in order to train tomorrows medical leaders through scholarship and innovation, create a collaborative community, and foster mentoring opportunities between faculty and residents and between residents and medical students.The Advanced Residency Training at Stanford(ARTS) Program offers the opportunity to combine clinical training with advanced research training to complete a PhD degree during or upon completion of residency or clinical fellowship.

Stanford Neurology thrives on a culture of teaching and learning. Our faculty devote their time to educate and mentor trainees with an emphasis on career development and close faculty-trainee interactions. Our trainees graduate as leading medical educators while working closely with students from the Stanford School of Medicine, currently ranked the #3 research medical school in the United States byU.S. News and World Report. In fact, recently the Neurology Department has won the Association of University Professors of Neurology (AUPN) Successful Recruitment award two years in a row by having the highest percentage of medical students matching into Neurology of any school in the U.S. In addition, the AAMC annual survey of US medical students has identified the Stanford Neurology core rotation as the top rated core rotation at Stanford for the past 6 years and among the highest rated neurology rotations in the US. This remarkable track record is largely a testament to the dedication, enthusiasm and focus on the development of teaching and mentoring skills of our residents and fellows who interact with these excellent student on a daily basis. Professional development for trainees in medical education include novel training courses at theStanford Faculty Development Center (SFDC) for Medical Teachers, Stanford Medicine Teaching and Mentoring Academy, and Clinical Teaching Seminar Series.

Stanford is an innovator in medical education research. Trainees may earn an honors certificate in medical education after completion of a scholarly project and receive intramural grant funding to support their work. These projects may involve Stanfords cutting-edge medical simulation program, trainee-focused diversity program, or our leading wellbeing curriculum.

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Education | Neurology & Neurological Sciences | Stanford ...

West TN Neuroscience & Spine Center | West Tennessee …

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Name: Select or start typingAdetunji, Ezekiel O.Adkins, William B.Agbetoyin, Adeyinka A.Akhigbe, Kelvin O.Akin, Eric D.Alhaddad, Mohsin T.Ammons, DrewAnderson, Charles B.Anderson, MichaelAnsah, Martinson A.Appleton, Nicolas B.Arcuri, NicolasArinze, Festus N.Arnold, JohnAsmar, Salomon N.Atkinson, RobinAwan, ObaidBada, Samuel O.Baldwin, Harold S.Baldwin, Shawn A.Ball, John J.Bansal, AnkushBarrow, William CharlesBateman, Mark R.Bellor-Yeh, Pei C.Blackstock, Drew S.Blair, Kelly L.Blake, Jeremy T.Bocirnea, Ioana A. 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Love, Timothy P.Lui, Henry K.Luka, Adam K.Madduri, Nirupama S.Mah, May L.Mahajan, Natasha C.Mahalati, KamranMaley, Bruce B.Manning, James L.Mariencheck Jr., William I.Markel, Thomas O.Markham, Larry W.Marlar, Justin L.Martin, Michael J.Martindale, Michael L.Mason, Alexis T.Masterson, John P.Maynord, Patrick O.McBride, Gary L.McClinton, Ernest J.McCowan, Jon G.McCullough, Ricky J.McDaniel, Brock G.McDowell, Michael WestMcElroy, Steven J.McGuire, William L.McKnight Jr., Donald T.Menzies, Barbara E.Meriwether, John H.Micetich, Keith A.Miles, John W.Miller III, Tommy L.Miller Jr., Jesse A.Miller, Linda R.Minasyan, TatevikMisulis, Karl E.Mitchell, Christopher W.Mitchell, Gregory E.Mohamed, EmadMoore, James D.Morrison, David G.Muir, Eric W.Murphy Sr., Richard L.Murray II, Earnest L.Murray, Pamela D.Myatt, Jason A.Myers, Andrew G.Naik, Ami K.Narapareddy, Murty N.Nass, RebeccaNass, Rebecca A.Nazario, JaniceNeal, Tyler AlanNeblett Jr., John W.Neel, Sean T.Nelson, Thomas H.Nerland, RyanNicholson, GeorgeNixon, Ralph M.Noel, TamekaNord, Keith D.Norlander, Lisa M.Norsworthy, Thomas P.Nwazue, Victor C.Nwokolo, Chibuzo E.Nyenwe, Ebenezer A.O'Kelley, Ryan N.Oberg, Richard A.Obi, Patricia ReneeOdeh, Osayawe N.Odhav, Satish K.Odukoya, Adewale AdeyinkaOkewole, Simon O.Okolo, Joseph M.Oleru, Aleruchi Y.Oleru, Chima O.Osayamen, Michael O.Owens, Scott E.Palmer Jr., Edmund T.Parra, David A.Patel, Hetal D. Patel, Kandarp B.Patel, Kaushal IPatel, MihirPatel, Nirav A.Patel, Vaishali H.Payne, James A.Pearce, David A.Pechacek, AlanPedigo, Tara K.Perkins, Keith L.Perry, Heather L. Piawa, Dum L.Pickering, David E.Pierce IV, William F.Piercey, Lisa M.Pippin, Michael S. Pitt, John D. Plunk, NathanPoole, Charles T.Pope IV, John C.Preston, William A.Prewitt, Sr., Darrion JPriester, William BradProctor, Evanna S.Pucek, Kelly D.Pueschel, JordanPuzdrakiewicz, Michelle G.Quadeer, Abdul R.Qualls, Brian C.Radbill, Andrew E.Ragon Jr, William S.Ragon, Joseph L.Rainey, Debra L.Ralston, Michael D.Randolph, Fielding A.Rashid, AbdulReese Jr., Eugene P.Revelle, Michael A.Rhear, Raymond W.Rickman, Christopher E.Riley, Elly K.Rimrodt, SherylRoberts, David E.Robinson, Antwan D.Robinson, Marilyn A.Rodriquez, Juan F.Rogers, Lisa W.Rothrock, Alan C.Roy, Ryan A.Russell, Tori S.Sachan, Nitin SinghSadler, Scott M.Sarkar, ShyamalSathanandan, Sumathira T.Schmidt, Roy A.Scott, William W. 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Neurology – Ovid

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This official journal of the American Academy of Neurology features best practices, evidence-based research and articles on topics that directly affect practicing neurologists - AVAILABLE ONLY AS PART OF THE NEUROLOGY AND NEUROLOGY: CLINICAL PRACTICE BUNDLE

The leading clinical neurology journal worldwide, Neurology is directed to physicians concerned with diseases and conditions of the nervous system. The journal's purpose is to advance the field by presenting new basic and clinical research with emphasis on knowledge that will influence the way neurology is practiced.

Editorial content includes full-length Articles, Clinical/Scientific Notes, Views & Reviews (including Medical Hypothesis papers), Issues of Neurological Practice, Historical Neurology, NeuroImages, Humanities, Correspondence, Book Reviews, Software Reviews, Calendar Listings, and position papers from the American Academy of Neurology.

This journal is available only as part of the Neurology and Neurology: Clinical Practice Bundle; it is not available separately.

Subscribers to Neurology also have access to Neurology: Neuroimmunology & Neuroinflammation and Neurology: Genetics.

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Effect of aerobic exercise on cognition in … – n.neurology.org

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Yaakov Stern

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Anna MacKay-Brandt

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Seonjoo Lee

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Paula McKinley

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Kathleen McIntyre

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Qolamreza Razlighi

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Emil Agarunov

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Matthew Bartels

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

Richard P. Sloan

From the Cognitive Neuroscience Division, Department of Neurology and Taub Institute (Y.S., A.M.-B., Q.R., E.A.), Department of Biostatistics (S.L.), and Department of Psychiatry, Division of Behavioral Medicine (P.M., K.M., R.P.S.), Columbia University, New York; Division of Clinical Research (A.M.-B.), Nathan Kline Institute for Psychiatric Research, Orangeburg; Division of Biostatistics (S.L.), New York State Psychiatric Institute; and Cardiopulmonary Rehabilitation and the Human Performance Laboratory (M.B.), Columbia Presbyterian Medical Center, New York, NY.

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Effect of aerobic exercise on cognition in ... - n.neurology.org

Zika virus tied to neurological issues in adults – Chicago Tribune

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Adults infected with the Zika virus can develop a number of serious neurological conditions, a new study finds.

Until now, the most troubling Zika-related illness in adults has been Guillain-Barre syndrome, which causes muscle weakness and paralysis.

A review of 35 Zika-infected patients in Brazil with neurological symptoms found that most had Guillain-Barre. But other neurological conditions were also discovered, most often inflammation and swelling of the brain and spinal cord.

"Overall, the risk of Guillain-Barre for a person who contracts Zika is probably still very low, but it's important to know there's neurological conditions associated with Zika virus," said study co-author Dr. Jennifer Frontera, chief of neurology for NYU Lutheran Medical Center in New York City.

Frontera and other infectious disease experts said pregnant women still carry the most risk from Zika infection, since the virus can cause devastating neurological birth defects such as microcephaly.

Michael Osterholm is director of the University of Minnesota's Center for Infectious Disease Research and Policy in Minneapolis.

"Now we're realizing that adults may be impacted," he said. "There are clinical implications, as was well demonstrated in this paper."

The research team tracked patients who were referred to an academic hospital in Rio de Janeiro that specializes in treating neurological illnesses.

During the Zika epidemic in Brazil in 2015-16, admissions at this hospital for Guillain-Barre increased more than fivefold, Frontera said. On average, doctors there saw one case of Guillain-Barre a month before the outbreak; that rose to more than five a month as Zika raged through the country.

Out of a group of 40 patients, 35 tested positive for recent Zika infection. The Zika-affected group contained 27 people with Guillain-Barre syndrome, but also included five patients suffering from swelling of the brain (encephalitis) and two who had swelling of the spinal cord (transverse myelitis).

Another Zika-infected patient was diagnosed with chronic inflammatory demyelinating polyneuropathy, a condition closely related to Guillain-Barre that causes long-term nerve damage, muscle weakness and paralysis.

Nine of the patients required admission to an intensive care unit, and five had to be placed on a mechanical ventilator. Two patients died, including one with Guillain-Barre and one with encephalitis.

Dr. Amesh Adalja, a senior associate with the Johns Hopkins Center for Health Security said, "Follow-up studies will be important to determine the frequency of such complications and the associated risk factors. It will also be essential to definitely establish that Zika is involved as many related viruses circulate in the area in which this study was conducted."

Dr. Richard Temes is director of the Center for Neurocritical Care at North Shore University Hospital in Manhasset, N.Y. He said it makes sense that Guillain-Barre and these other conditions could appear following a Zika infection.

All of the neurological conditions researchers observed in Zika patients are "thought of as post-infectious syndromes, where you have a viral infection, you clear the infection by mounting an antibody response, and the antibodies actually attack parts of the central and peripheral nervous system, causing these neurological symptoms."

Zika spreads mainly through mosquito bite. So far, this year has been relatively calm in terms of Zika outbreaks, Osterholm said.

"This is characteristic of these infections," Osterholm said. "The virus infection comes and goes in the population. You can have a bad year or two, and then have a year where there's less infection and some people feel it's going away, which is not the case at all. It will come back. We have to understand we're in this for the long haul."

The study was published online in August in JAMA Neurology.

Pregnant or trying? Don't let your Zika guard down

Zika poses even greater risk for birth defects than was previously known, CDC reports

Zika can also strike eyes of adults, report reveals

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Zika virus tied to neurological issues in adults - Chicago Tribune

Neurology Associates of Arlington, P.A.

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For news and announcements please see the Bulletin Board on the home page of our patient portal.

We are a neurology group that has served Arlington, Mansfield, Grand Prairie, and surrounding areas since 1983. Our services include diagnosis, treatment, and clinical research. We use electronic medical records and provide a patient portal.

To Schedule an Appointment

To schedule an appointment call (817) 225-0410. New patients will be scheduled by our new patient scheduler.

Physician Referrals

Physicians may refer patients by telephone or facsimile.

Address and Phone

2800 E. Broad Street, Suite 504

Mansfield, TX 76063

Phone (817) 225-0410

Fax (817) 453-8866

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Monday - Friday: 8:00 - 5:00 pm.

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(817) 277-1861

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Our offices are in the professional office building on the east side of Methodist Mansfield Medical Center, at the corner of East Broad Street and North Miller Road. Parking is free.

Neurology Associates of Arlington, P.A.

Dedicated to the diagnosis and treatment of patients who have neurological disorders

Conditions We Treat

Headaches

Back and neck problems

Carpal tunnel syndrome

Sleep disorders

Restless legs

Peripheral neuropathy

Muscle diseases

Myasthenia gravis

Multiple sclerosis

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Tremor

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Other neurological disorders

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Neurology Associates of Arlington, P.A.

Ovid Therapeutics Announces Multiple Presentations at the American Academy of Neurology 2020 Annual Meeting – Yahoo Finance

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NEW YORK, March 05, 2020 (GLOBE NEWSWIRE) -- Ovid Therapeutics Inc. (OVID), a biopharmaceutical company committed to developing medicines that transform the lives of people with rare neurological diseases, today announced multiple poster presentations across its rare neurological disease platform at the American Academy of Neurology (AAN) 2020 Annual Meeting in Toronto (April 25-May 1).

We are pleased by the breadth of data selected for presentation at this years AAN conference, which underscores our efforts to find treatments for patients living with rare neurological conditions like Angelman syndrome, Fragile X syndrome and rare epilepsies, said Amit Rakhit, M.D., MBA, President and Chief Medical Officer at Ovid. We look forward to joining world-renowned neurologists and researchers attending AAN to present our findings and continue to push the envelope in the name of patients and their families, who inspire us every day.

AAN 2020 Annual Meeting Presentation Details

Presentations on OV101 (gaboxadol) in Neurodevelopmental Disorders:

Title: The adaptation and utility of the Clinical Global Impression scale for studying treatment outcomes in neurodevelopmental conditionsPoster No.: 009Poster Session 5: Research Methodology, Education, and HistoryDate and Time:Monday, April 27, 8:009:00 a.m. ET

Title: The pivotal Phase 3 NEPTUNE trial investigating gaboxadol in Angelman syndrome: Study designPoster No.: 015Poster Session 13: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Wednesday, April 29, 5:30 6:30 p.m. ET

Title: Evidence of pharmacodynamic tolerance during repeated daily gaboxadol exposure in individuals with Angelman syndrome Poster No.: 011Poster Session 13: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Wednesday, April 29, 5:30 6:30 p.m. ET

Title: Physiologically based pharmacokinetic modeling (PBPK) for gaboxadol exposure in children with Angelman syndromePoster No.: 012Poster Session 13: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Wednesday, April 29, 5:30 6:30 p.m. ET

Title: Caregiver insight on the core domains in Angelman syndromePoster No.: 013Poster Session 13: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Wednesday, April 29, 5:30 6:30 p.m. ET

Title: Quality of life in adolescent and adult individuals with Angelman syndrome: Baseline results from the Phase 2 STARS studyPoster No.: 014Poster Session 13: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Wednesday, April 29, 5:30 6:30 p.m. ET

Title: Concomitant medication in adolescent and adult individuals with Angelman syndrome: Baseline results from the Phase 2 STARS studyPoster No.: 011Poster Session 14: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Thursday, April 30, 8:00 9:00 a.m. ET

Title: The Phase 2a ROCKET trial investigating gaboxadol in adolescents and young adults with Fragile X syndrome: Study designPoster No.: 003Poster Session 14: Neuromuscular and Clinical Neurophysiology (EMG)Date and Time:Thursday, April 30, 8:00 9:00 a.m. ET

Presentations on OV935/TAK935 (soticlestat) in Rare Developmental and Epileptic Encephalopathies (DEE):

Title: Initial data from the ongoing ENDYMION open-label extension trial of soticlestat (TAK-935/OV935) in participants with developmental and/or epileptic encephalopathies (DEE)Poster No.: 007Poster Session 10: Practice, Policy, and EthicsDate and Time: Tuesday, April 28, 5:30 6:30 p.m. ET

Title: A Phase 1b/2a study of soticlestat (TAK-935/OV935) as adjunctive therapy in adults with developmental and/or epileptic encephalopathies (DEE)Poster No.: 008Poster Session 10: Practice, Policy, and EthicsDate and Time: Tuesday, April 28, 5:30 6:30 p.m. ET

About Ovid TherapeuticsOvid Therapeutics Inc. is a New York-based biopharmaceutical company using its BoldMedicine approach to develop medicines that transform the lives of patients with rare neurological disorders. Ovid has a broad pipeline of potential first-in-class medicines. The companys most advanced investigational medicine, OV101 (gaboxadol), is currently in clinical development for the treatment of Angelman syndrome and Fragile X syndrome. Ovid is also developing OV935/TAK935 (soticlestat) in collaboration with Takeda Pharmaceutical Company Limited for the potential treatment of rare developmental and epileptic encephalopathies (DEE).

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Ovid Therapeutics Announces Multiple Presentations at the American Academy of Neurology 2020 Annual Meeting - Yahoo Finance

ICH Rates Rising in the Elderly – Medscape

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A new analysis shows that rates of intracerebral hemorrhage (ICH) have not fallen during recent years, as has been seen with ischemic stroke, and rates appear to be increasing in the elderly.

"Our findings suggest we should be preparing for an increase in ICH rates with the ageing of the population," lead author Vasileios-Arsenios Lioutas, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts, told Medscape Medical News.

The researchers also discuss whether the increased use of certain medications such as anticoagulants and statins may be playing a role in ICH trends.

The analysis examined data from more than 10,000 individuals from the Framingham study. "This is the longest running population-based cohort with a follow-up period of 68 years, so gives us a unique opportunity to look at ICH trends in a large population over a long period of time," Lioutas said.

The paper was published online June 8 in JAMA Neurology.

There were 129 cases of a primary ICH incident in the study, with an incidence rate of 43 cases per 100,000 person-years. The unadjusted incidence rate increased over time, but the age-adjusted incidence rate showed a slight decrease since 1987.

An age-stratified analysis indicated a continued increase in ICH incidence among patients aged 75 years or older, reaching 176 cases per 100,000 person-years in the period 2000-2016.

"In general, there has been a stabilization of ICH rates since the mid-80s. The rates have flattened out, but we have not seen a large decline in ICH in the past 30 years as has been seen for ischemic stroke. This leads us to ask whether we could be doing better with regard to ICH," Lioutas commented.

"In particular, we saw an increase of ICH since 1985 in older people (aged over 75) whereas there was a slight decrease in those under 75. As the population is aging, we should brace ourselves for an increase in ICH," he added.

The researchers looked at the two different subtypes of ICH, deep and lobar, which are believed to represent different underlying processes.

"We have always thought that deep ICH is generally related to hypertension and lobar ICH is related to amyloid angiopathy the deposit of amyloid protein in the blood vessel walls. But our current results suggest this is not as straightforward as we may have believed," Lioutas explained.

"We found that while deep ICH is indeed related to hypertension, we also found hypertension to be a pretty robust risk factor for lobar ICH as well."

The incidence rate increased substantially with age for both the lobar and deep types of ICH.

"These results suggest we need to be even more aggressive with blood pressure control. This is the one modifiable risk factor we can absolutely act upon and make a difference," Lioutas stressed.

Many risk factors for ICH and ischemic stroke are similar, so, if ischemic stroke rates are falling, why are ICH rates not falling too? "This is the million-dollar question," Lioutas noted.

He said that the current data do not answer that question, but he put forward some suggestions including increased use of certain medications, particularly anticoagulants.

"There has been a sharp increase in the use of anticoagulants these drugs are great at reducing ischemic stroke but they do increase bleeds. The rate of use of anticoagulants has tripled since 1985. This is not a surprise," Lioutas commented.

In the study, use of anticoagulant medications increased from 4.4% in period 2 (1987-1999) to 13.9% in period 3 (2000-2016).

The researchers also discuss the increased use of statins in relation to the ICH rates seen.

"Statins have been linked to ICH but this association is not strong. The jury is out on this as the evidence is conflicting, but statin use has increased dramatically since the mid-1980s," Lioutas commented.

In the paper, the researchers write: "In our cohort, patients with deep ICH had a 4-fold higher likelihood of using statin medications compared with matched individuals in the control group despite no significant differences in cardiovascular disease prevalence. However, we approach this finding with caution given the relatively low number of exposed individuals."

Lioutas added: "We are not making a direct link between our results and the use of either anticoagulants or statins, but only to say that this may be one possible explanation for our observations."

"The beneficial effects of statins and anticoagulants in reducing ischemic events are well proven and their benefits definitely outweigh their risks when used in the right patient populations," he added. "They also probably allow people to live longer so that they may then go on to experience an ICH, but perhaps we could make sure we select patients for these medications more carefully and think about dosage and each individual's risk of hemorrhagic complications."

Commenting on the study for Medscape Medical News, Michael Szarek, PhD, professor Chair of the Department of Epidemiology and Biostatistics at the SUNY Downstate Health Sciences University, New York City, said, "The finding that hemorrhagic stroke incidence appears to be increasing in older patients over time may be explained, at least in part, by competing risks.

"Specifically, as the risk of death from vascular causes, including ischemic stroke, has decreased due to more effective treatments that modify the risk of these events, patients consequently remain at risk for non-modifiable events. Therefore, patients who would have otherwise died at a younger age from vascular causes appear to have higher rates of other negative outcomes, including hemorrhagic stroke."

On the issue of statins and ICH, Szarek points out that meta-analyses of individual patient data from randomized studies have not found statins to be associated with a significantly increased risk for ICH.

"Importantly, these analyses have consistently found substantial benefits of statin therapy in terms of vascular events including ischemic stroke, which are much more frequent than hemorrhagic stroke overall as well as in older patients," he said. "Therefore, even if statin therapy results in an increased risk of hemorrhagic stroke, the possible absolute increase in risk is small relative to the definitive absolute decrease in these other events, indicating the benefits of treatment far outweigh this potential risk."

This study was supported by grants from the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, and the National Heart, Lung, and Blood Institute.

Lioutas reported receiving grants from the National Institutes of Health and the National Institute on Aging during the conduct of the study, and personal fees from Qmetis outside the submitted work. Disclosures for other authors appear in the paper.

JAMA Neurol. 2020. Published online June 8. Abstract.

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ICH Rates Rising in the Elderly - Medscape

ICE Sued Over Treatment Of 5-Year-Old With Head Injury – KERA News

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The mother of a 5-year-old Guatemalan boy sued U.S. Immigration and Customs Enforcement over the medical care he has received in detention for a head injury suffered before the family was arrested.

The lawsuit filed late Friday in California asks a judge to order the child to be taken to a pediatric neurologist or pediatric neurosurgeon. It also seeks to prevent ICE from trying to immediately deport the family.

The boy fell out of a shopping cart in December, fractured his skull and suffered bleeding around his brain. About a month later, he and his family were detained by ICE during what they thought was a routine check-in. The boy, his 1-year-old brother and their mother were taken to ICEs family detention center at Dilley, Texas, while their father was taken to a detention center in California.

The childs relatives and advocates allege thatICE is not properly treating symptomscaused by the accident that began before he was detained. The boy has severe headaches and is hypersensitive to normal levels of sound, according to his aunt and Dr. Amy Cohen, an advocate working with the family. He is also starting to wet himself, according to his aunt. They allege the boys mother has pleaded for medical care, but has been disregarded.

ICE has defended the care the boy has received at Dilley. The agency says medical staff at the detention center conducted multiple check-ups and found no lasting neurological issues. After The Associated Press first inquired about the case on Monday, ICE took the boy to the Childrens Hospital of San Antonio on Tuesday and Wednesday, where he was found to have a normal MRI and no signs of continued bleeding in his skull.

The boy was not seen at the hospital by a pediatric neurologist, according to medical records obtained by his familys attorneys. According to the records, hospital doctors consulted the neurosurgery department and determined that no follow-up was necessary because the MRI was clear.

Cohen said the boy had an appointment to see a neurologist before the family was detained by ICE. The symptoms his family reported began before their detention and could be caused by a head injury even if the initial bleeding is gone, meaning that an MRI would not be enough, she said.

The San Antonio hospital also did not have the paperwork from the California hospital that first treated him, according to the latest records. Doctors at the first hospital determined that the boy needed a neurosurgery follow-up within four weeks.

In a statement Thursday, ICE said it was determined that no issues were present that required the need to elevate the case to another neurological specialist. It declined to comment Saturday on the lawsuit. The Childrens Hospital of San Antonio declined to comment Friday on the case.

The AP is withholding the names of the boy and his family because they fear imminent deportation to Guatemala, where the boys mother says she was threatened.

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ICE Sued Over Treatment Of 5-Year-Old With Head Injury - KERA News

Global Neurology Software Market Drivers, Key Players, Regions, Application and Forecast to 2020-2025 – News Times

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This study has articulated the Global Neurology Software Market with a detailed view of the Global Neurology Software industry including Global production sales, Global revenue, and CAGR. The report delivers core insights regarding the Neurology Software Market report with an in-depth study of market size, country-level market size, region, segmentation market growth, market share, sales analysis, value chain optimization, market players, the competitive landscape, recent developments, product launches, strategic market growth analysis, trade regulations, opportunities analysis, technological innovations, and area marketplace expanding. Moreover, it critically focuses on the application by analyzing the growth rate and consumption of every individual application.

Key vendor/manufacturers in the market:

The major players covered in Neurology Software are: Epic, Brainlab, healthfusion, Athenahealth, Practice Fusion, Nextgen, Bizmatics, Greenway Health, Allscripts, Kareo, Advanced Data Systems, NueMD, etc.

Request a sample of this report @ https://www.orbisresearch.com/contacts/request-sample/4162760

The Neurology Software Market report majorly offers an understanding about the major drivers, challenges, restraints, competitive landscape, increasing trends, market dynamics, market size, and market share, development status along with government policy, investment opportunities, and supply chains. It categorizes and analyze the segments regarding type, region, and application. This research report offers an aerial view of the Global Neurology Software Market including market share, price, revenue, growth rate, production by type.

The Global Neurology Software Market landscape and leading manufacturers offers competitive landscape and market development status including the overview of every individual market players. Furthermore, it offers productive data of vendors including the profile, specifications of product, applications, annual performance in the industry, sales, revenue, investments, acquisitions and mergers, market size, market share, and more.

The report also understand the export and import, production, and consumption of every particular region holding highest market share, market size, or CAGR. Furthermore, it provides a an potential insights regarding Porters Five Forces including substitutes, potential entrants, buyers, industry competitors, and suppliers with genuine information for understanding the Global Neurology Software Market.

Browse the complete report @ https://www.orbisresearch.com/reports/index/global-neurology-software-market-2020-by-company-regions-type-and-application-forecast-to-2025

Global Neurology Software Market By Type:

By Type, Neurology Software market has been segmented into Advanced Neurology EMR Software, Other, etc.

Global Neurology Software Market By Application:

By Application, Neurology Software has been segmented into Hospitals, College & Research Institutes, Other, etc.

Report covers detailed study about the gross margin, production, revenue, the price of the Global Neurology Software Market regarding different regions covered in particular section. It majorly focuses on manufacturing analysis including about the raw materials, cost structure, process, operations, and manufacturing cost strategies. The report introduces the industrial chain analysis, downstream buyers, and raw material sources along with the accurate insights of market dynamics. The Neurology Software Market reports delivers the knowledge about market competition between vendors through regional segmentation of markets in terms of revenue generation potential, business opportunities, demand & supply.

The report concludes with the coverage of data of big companies with information about their sales data, upcoming innovations and development, revenue margins, investments, business models, strategies, and business estimations.

Make an enquiry of this report @ https://www.orbisresearch.com/contacts/enquiry-before-buying/4162760

Major Table of Contents

1 Neurology Software Market Overview2 Company Profiles3 Market Competition, by Players4 Market Size by Regions5 North America Neurology Software Revenue by CountriesContinued

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Earlier Intervention After Concussion Linked to Faster Recovery – Medscape

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Earlier initiation of clinical care after a concussion was associated with faster recovery in a new study.

Athletes who presented for evaluation within the first week after injury recovered faster than athletes who initially presented 2 to 3 weeks post injury.

"Our results show that following a concussion, patients should seek specialty care involving a comprehensive assessment and clinical exam that allows for more targeted treatments for specific symptoms and impairments as early as possible," lead author Anthony P. Kontos, PhD, told Medscape Medical News.

Kontos, who is research director of UPMC Sports Medicine Concussion Program, University of Pittsburgh, added: "Earlier care with a trained clinician allows patients to begin behavioral management strategies involving physical and cognitive activity, sleep, nutrition, hydration, and stress management, all of which can enhance the recovery process. Patients should not wait for a week or more to seek care to see if things improve on their own; rather, they should seek care as soon as they can to enhance their recovery process."

The study was published online January 6 in JAMA Neurology.

The researchers note that most athletes who experience a concussion do not receive care beyond an initial evaluation or diagnosis at or near the time of injury and that this may result in prolonged time to recovery.

There has been general reticence among clinicians who treat patients with concussion to engage in earlier active intervention because of perceptions that it may result in a prolonged recovery, but recent research suggests that provision of care in the first few days after a concussion, especially active interventions that target specific symptoms and impairments, may play a pivotal role in influencing recovery, the researchers say.

For the current retrospective, cross-sectional study, Kontos and colleagues analyzed data on 162 young people who experienced a concussion while playing organized or recreational sports and who received treatment at a sports medicine concussion clinic.

They compared time to recovery in the 98 patients seen within the first 7 days post injury (the early group) with 64 patients seen within 8 to 20 days post injury (the late group).

The early and late groups did not differ in age (mean, 15.3 years vs 15.4 years); number of female patients (early, 52.0%; late, 62.5%), or other demographic, medical history, or injury factors. The groups were also similar with respect to symptom severity, as well as cognitive, ocular, and vestibular outcomes at the first clinic visit.

Results from a logistical regression indicated that recovery time was increased for patients in the late-treatment group (adjusted odds ratio, 5.8). Having a score >2 on an assessment of visual motion sensitivity was also associated with increased recovery time (adjusted odds ratio, 4.5).

"We found that early access to clinical care was associated with an almost six times increased likelihood of a recovery within 30 days," Kontos said.

In the early group, 52% of patients recovered within 30 days, compared with 19% of those in the late group. Mean recovery time was 51 days in the early group vs 66 days in the late group.

Kontos pointedout that concussion treatment is not just a matter of prolonged rest. "Some patients may rest for 6 months and still have symptoms, but after 1 month of vestibular therapy they are better. The brain is like any other part of the body if it is damaged and you do nothing, it doesn't always repair itself. It needs the right therapy. We used an exposed recovery model which used active targeted treatments for individual symptoms of concussion.

"Earlier care involving a comprehensive assessment and clinical exam allows for more targeted treatments for specific symptoms and impairments," he commented.

"For example, a patient with vestibular impairment would be able to begin therapy earlier and potentially accelerate their recovery simply by coming in for specialty care sooner rather than waiting. In addition, earlier care with a trained clinician allows patients to begin behavioral management strategies involving physical and cognitive activity, sleep, nutrition, hydration, and stress management, all of which can enhance the recovery process."

The researchers note that the earlier initiation of active rehabilitation strategies, including exertion progression and the opportunity to start structured physical therapies (eg, on vestibular, visual, and cervical systems), is one reasonable explanation for the shorter recovery time in the earlier group in this study.

"Further, without clinical guidance and behavioral management recommendations postinjury, athletes may have been engaging in counterproductive recovery strategies, such as strict rest or excessive physical activity," they add.

They point out that this explanation is supported by the fact that athletes recovered in a similar amount of time after the first evaluation. "It appears that all athletes had similar impairments and similar recovery time after they had received initial clinical care, highlighting the importance of clinical care as soon as possible," they conclude.

"As a parent, I would prefer my child to recover quicker from concussion symptoms, and that means accessing care sooner," Kontos added.

Commenting on the study for Medscape Medical News, Sarah Benish, MD, associate professor of neurology at the University of Minnesota, in Minneapolis, said: "I think this article adds to the growing literature that suggest early and active intervention is most likely beneficial to concussion improvement."

However, Benish pointed out that the latter group appeared to have more females, more migraine sufferers, a high rate of loss of consciousness, and a higher rate of posttraumatic amnesia, which may have had a bearing on the results.

"In addition, I would be concerned that there is a selection bias and those who had milder concussion that would self-resolve have been eliminated for the later-care group, as they would not have been seen in the clinic. The only way to truly know would be to do a prospective study where concussion athletes are assigned to an early or late appointment," she added.

"I agree the study suggests patients might benefit from improving access to care for athletes to get help for concussion, but I am not sure this is the definitive study that is needed to convince health systems to invest more money into helping access issues in an area that is historically underserved. However, it is another step towards improving care for concussion patients," she concluded.

Kontos has received grants from the National Football League, personal fees from APA Books, and other compensation from the University of Pittsburgh outside the submitted work.

JAMA Neurology. Published online January 6, 2020. Abstract

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Earlier Intervention After Concussion Linked to Faster Recovery - Medscape

Injected Nanoparticles May Provide First Real Treatment for Traumatic Brain Injury – SciTechDaily

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Reducing dangerous swelling in traumatic brain injury: Injected nanoparticles reduce swelling and secondary brain damage in preclinical research.

After a traumatic brain injury, the most harmful damage is caused by secondary swelling of the brain compressed inside the skull. There is no treatment for this.

In new research, Northwestern Medicine scientists were able to significantly reduce brain swelling and damage after a traumatic brain injury by injecting nanoparticles into the bloodstream within two hours after the injury, they report in a preclinical study.

The results are vastly better than we predicted, said Dr. Jack Kessler, professor of neurology at Northwestern University Feinberg School of Medicine and senior author on the paper. We believe this may provide the first real and practical treatment for people who have a significant traumatic brain injury.

The study will be published today (January 22, 2020) in Annals of Neurology.

The nanoparticles are made of an FDA-approved material table and could easily be loaded into a syringe and given immediately after traumatic brain injury in the field by emergency medical technicians or in the emergency room to prevent secondary damage, Kessler noted.

The scientists have begun first steps to obtain FDA approval for a clinical trial.

Traumatic brain injuries affect approximately 2.5 million people in the U.S. each year, according to a 2010 Centers for Disease Control report. However, these numbers dont account for individuals who did not receive medical care, had outpatient care or who received care at a federal facility, such as persons serving in the U.S. military. Soldiers who serve in the U.S. military are at high risk for traumatic brain injury.

After a traumatic brain injury, the body launches an inflammatory reaction that triggers a cascade of immune responses that result in brain swelling.

A patient can come into the emergency department walking and talking but then their brain swells. They immediately go downhill and can die, Kessler said. Now, the only thing a surgeon can do is open the skull up to relieve the pressure, but the brain still continues to swell.

The nanoparticles work as a decoy to distract the immune cells from charging into the brain and causing more damage. The particles, named IMPS for immune modifying nanoparticles, are merely empty shells and do not contain any drugs or cargo.

After a traumatic brain injury, a specific population of monocytes large white blood cells rush to the injury site and attempt to clean up debris from damaged brain cells and secrete inflammatory proteins that stimulate other immune cells. This immune cascade produces swelling and inflammation that inadvertently damages surrounding healthy brain tissue.

But when the scientists inject the nanoparticles into the bloodstream shortly after the injury, these monocytes are tricked into thinking the nanoparticles are invading foreign materials. They engulf the particles and usher them to the spleen for disposal. The distracted monocytes are no longer around to enter the brain and cause problems.

In the study, mice that received the nanoparticles after a traumatic brain injury had greatly reduced swelling and half the damage to brain tissue compared to those who did not receive the nanoparticles. One of the injury models mimicked a closed head traumatic brain injury common in humans. In that model, the animals motor and visual function improved after the nanoparticle injection.

We predicted there would be an effect, but the effect turned out to be quite startling. It is remarkable how well the animals do, said lead author Sripadh Sharma, a Feinberg MD-PhD student.

Sharma, who is doing his neurology rotation, sees potential for helping young and professional athletes as well as soldiers. These particles selectively knock out the damaging cells that begin infiltrating the brain within a couple of hours of the injury and reach their peak in three days. We can intervene before the secondary damage begins.

Northwestern scientist Stephen Miller originally co-developed the nanoparticles to introduce food allergens to the immune system to create tolerance in food allergies. The microparticles also were used to treat multiple sclerosis by introducing myelin to the immune system to reduce its reactivity to it.

Then, in a 2014 Science Translational Medicine paper, Miller noted the microparticles prevented death in mice infected with West Nile Encephalitis virus. That led to the work in other models of acute inflammation including heart attack, colitis, and peritonitis. Mostly recently, Miller began collaborating with Kessler, whose research focus is brain and spinal cord injury.

Reference: Intravenous Immunomodulatory Nanoparticle Treatment for Traumatic Brain Injury by Sripadh Sharma PhD; Igal Ifergan PhD; Jonathan E. Kurz MD, PhD; Robert A. Linsenmeier PhD; Dan Xu PhD; John G. Cooper PhD; Stephen D. Miller PhD and John A. Kessler MD, 10 January 2020, Annals of Neurology.DOI: 10.1002/ana.25675

Miller is the Judy Gugenheim Research Professor of Microbiology-Immunology at Feinberg.

The nanotechnology was licensed toCOUR Pharmaceuticals Co., a biotech based in Northbrook, Illinois, co-founded by Miller. Miller, who is on the COUR scientific advisory board, is a stock grantee and a paid consultant for the company. Northwestern University has a financial interest in COUR.

The research was supported by grants F31 NS105451-02 from the National Institute of Neurologic Disease and Stroke, R01 AG054429 from the National Institute on Aging and R01 EB-013198 from the National Institute of Biomedical Imaging and Engineering, all of the National Institutes of Health.

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Injected Nanoparticles May Provide First Real Treatment for Traumatic Brain Injury - SciTechDaily

2019 Report on Advanced Visualization Technologies Improving Medical Imaging and Diagnosis in Cardiology, Neurology, Surgical Planning and…

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The "Advanced Visualization Technologies Improving Medical Imaging and Diagnosis" report has been added to ResearchAndMarkets.com's offering.

This research service (RS) highlights the innovations in advanced visualization platforms, including artificial intelligence (AI)-based systems, three-dimensional (3D) imaging, and other technologies, such as augmented reality (AR), virtual reality (VR), and 3D printing.

The report showcases the application of these technologies in areas such as cardiology, neurology, and also for surgical planning and intraoperative procedure assistance. It also discusses the impact of these innovations, funding, drivers, and challenges, and future growth opportunities.

Conventional visualization methods that depend on two-dimensional (2D) medical images have been fraught with challenges such as difficulty in interpreting the information due to the static nature of the content and lack of availability of volumetric data. To address these limitations, imaging preferences of the medical community are shifting toward technologies that offer improved measurement precision, enhanced depth of imaging structures, shortened scan time, improved clinical productivity, capturing of hard to image anatomical areas and systems that provide higher diagnostic confidence.

Key Topics Covered:

1. Executive Summary

1.1 Scope of the Research

1.2 Research Methodology

1.3 Key Findings

2. Industry Overview

2.1 Changing Dynamics in Advanced Visualization

2.2 Number of CT and MRI Exams, by Major Countries

3. Technology Snapshot

3.1 Technology Segments in Advanced Visualization

3.1.1 Artificial Intelligence-based Visualization Systems for Medical Imaging

3.1.2 AI-based Visualization Systems for Cardiovascular Imaging

3.1.3 AI-based Visualization Systems for Lung Imaging

3.1.4 AI-based Visualization Systems for Neurological Imaging-Dementia Diagnosis

3.1.5 AI-based Visualization Systems for Neurological Imaging-Stroke Diagnosis

3.1.6 AI-based Visualization Systems for Breast Imaging

3.1.7 AI-based Visualization Systems for Bone Imaging

3.2 Technology Segments in Advanced Visualization

3.2.1 Improving Radiological Diagnosis and Surgical Planning through 3D Imaging

3.2.2 Enhanced Breast Specimen Visualization through 3D Imaging

3.2.3 3D Image Visualization Platforms for Faster Exam Read Times

3.3 Technology Segments in Advanced Visualization

3.3.1 Improved Understanding of Human Anatomy Variations through Other Advanced Visualization Technologies

3.3.1.1 Augmented Reality Technologies

3.3.1.2 Augmented Reality (AR) Platforms for Intraoperative Procedure Assistance

3.3.1.3 AR Platforms for Enhanced Surgical Planning

3.3.2.1 Virtual Reality Technologies

3.3.2.2 Immersive Pre-operative Planning through Virtual Reality Systems

3.3.3.1 3D Printing Platforms

3.3.3.2 Developing Anatomical Models through 3D Printing for Pre-procedural Planning

4. Impact Assessment and Analysis

4.1 Impact of Technology Accelerators and Challenges

4.1.1 Superior Specificity and Image Processing Capabilities to Aid Market Adoption

4.1.2 Cyber Security Issues and Product-associated Challenges to Impede Systems Use

4.2 Impact of Market Accelerators and Challenges

4.2.1 Expanding Therapeutic Applications and Financing Support to Drive Market Growth

4.2.2 Cumbersome Regulations and Clinicians Workforce Shortfall to hinder Systems Adoption

5. Funding Assessment and Growth Opportunity

5.1 Assessment of Federal Funding for Advanced Visualization Platforms

5.1 Assessment of Federal Funding for Advanced Visualization Platforms (continued)

5.2 AI-based Medical Imaging Platforms Receive Maximum Funding Compared to AR, and VR Visualization Systems

5.3 Assessment of Key Partnerships Involving Advanced Visualization Companies

5.4 Growth Opportunities for AI-based Visualization Platforms

5.5 Strategic Recommendations

6. Key Industry Contacts

For more information about this report visit https://www.researchandmarkets.com/r/d0t980

View source version on businesswire.com: https://www.businesswire.com/news/home/20200124005161/en/

Contacts

ResearchAndMarkets.comLaura Wood, Senior Press Managerpress@researchandmarkets.com For E.S.T Office Hours Call 1-917-300-0470For U.S./CAN Toll Free Call 1-800-526-8630For GMT Office Hours Call +353-1-416-8900

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Swimming and deep brain stimulation do not mix, researchers warn – STAT

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For people with Parkinsons disease, deep brain stimulation can calm the tremors and tame the unwanted movements that come with the progressive neurodegenerative disease. Electrodes implanted in the brain, controlled by a device placed under the skin of the chest and equipped with an on-off switch, can ease troubling symptoms and synchronize complex motions.

A new paper reports a worrying development: Nine proficient swimmers lost their ability to swim after DBS surgery for Parkinsons, even though the implant improved other movements walking, for one that require coordination of the limbs. Why swimming mastery disappeared remains a mystery, but the doctors who described the cases Wednesday in Neurology wanted to sound an alarm right away.

Patients and neurologists should be aware of the potential loss of the ability to swim following subthalamic DBS, Dr. Christian Baumann, study co-author and an associate professor of neurology and a neurologist at University Hospital Zurich, told STAT. We warn all patients to be cautious when going into deep waters.

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One patient, a 69-year-old man who owned a lakeside house, found this out in dramatic fashion. Feeling confident after DBS because of his good motor outcomes, he literally jumped into the lake, where he would have drowned if he had not been rescued by a family member, the researchers wrote.

A 61-year-old woman complained that although she was a competitive swimmer who had regularly raced across Lake Zurich, when her DBS was activated, she could swim only a little over a tenth of a mile, and only with an awkward stroke.

When three other patients switched off their DBS devices, they could immediately swim again. But their other movements and neuropsychological symptoms deteriorated so rapidly that they turned the DBS back on.

Deep brain stimulation, approved to treat Parkinsons in the U.S. in 1997, has become the standard of care for people whose tremors and motor fluctuations are no longer responding to medical treatment. After other Parkinsons drugs stop working, patients typically take levodopa, a precursor to dopamine, to restore levels of the neurotransmitter that their bodies no longer make in sufficient quantities. But levodopas effects fade, too. Doses wear off, patients sometimes freeze while walking, and they have involuntary movements.

Instead of restoring dopamine, DBS sends electrical signals from surgically implanted electrodes directly to neurons thought to be responsible for movement. Why patients could still walk but not swim made the researchers wonder if DBS affects the brain in a different way than levodopa does. Patients with DBS, which they can turn on when needed to control tremors, continue to take levodopa.

I think that imprinted synchronized activity in different brain structures, which have been learnt, may be changed by DBS, i.e. the change of activity in one network piece alters the whole network, which might explain this outcome, Baumann said. But this is hypothetical.

Dr. Michael Okun, medical director of the Parkinsons Foundation and executive director of the Norman Fixel Institute for Neurological Diseases at University of Florida Health, noted the preliminary nature of the case reports as well as changes in how much dopamine the patients were taking after DBS. He was not involved in the study.

All of the patients in their series had dopaminergic reductions in medication greater than 50% post-surgery and it is possible that this factor may have played a large role in the decline in function, he said. Proper prospective testing of the device in the on- and off-medication condition, as well as in the pre- and post-operative testing conditions, will be required to sort out the root causes of this phenomenon. In the meantime, Parkinsons patients with or without DBS should not swim without a buddy.

Other complex motor behaviors, such as skiing, playing golf, or skating, might also be affected, Baumann said. But swimming is the most worrisome not just for people with DBS, Okun warned.

One important piece of advice for all Parkinsons patients is to never swim alone, Okun said. The risk of medication wearing off and freezing has been known to be associated with drowning in Parkinsons disease regardless of whether or not a deep brain stimulator has been implanted.

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Swimming and deep brain stimulation do not mix, researchers warn - STAT

UPDATE: New neurology office opens for thousands of patients left without care in Pismo Beach – KSBY San Luis Obispo News

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Patients now have a new place to go after a Pismo Beach neurology office closed up shop.

Dignity Health has opened a new clinic at the Matthew Will Memorial Medical Center in Arroyo Grande to serve former CoastNeuro patients.

That office closed abruptly in early December after nine years in business. More than 5,000 patients were left without a doctor.

"The best thing that people need to understand is that we still have neurologists here in the community," said Dr. Scott Robertson, Pacific Central Coast Health Centers President/CEO. "Most of them are the same neurologists that have been caring for them and their families over the last decade so these services are still here, the physicians are still here, and from their point of view, other than the location, nothing should be any different."

The new clinic started seeing patients last Thursday.

We're told you can call the old CoastNeuro phone number to make an appointment.

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UPDATE: New neurology office opens for thousands of patients left without care in Pismo Beach - KSBY San Luis Obispo News

How These Neurologists and Neuroethicists Navigate the… : Neurology Today – LWW Journals

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Article In Brief

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Implications of the AHA/ASA Updated Definition of Stroke for the 21st Century – WFN News

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Note:The views expressed by the authors are their own and do not represent an official statement by the American Heart Association/American Stroke Association.

Stroke was defined by the World Health Organization (WHO) more than 40 years ago as rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.1This was a working definition created for a study assessing the prevalence and natural history of stroke, and it served its purpose at the time.

The ensuing decades have witnessed major advances in basic science, pathophysiology and neuroimaging that have dramatically improved our understanding of ischemia, infarction and haemorrhage in the central nervous system (CNS). There is little doubt that permanent injury occurs well before the 24-hour threshold, and therefore purely time-based definitions are inaccurate and obsolete. Further, neuroimaging has demonstrated that clinically transient symptoms are often associated with evidence of acute cerebral infarction and that infarction may occur without overt symptoms.

In 2009, the American Heart Association/American Stroke Association (AHA/ASA) published a scientific statement redefining transient ischemic attack (TIA) as, a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction.2This statement formally addressed only one side of the proverbial coin, but clearly implied that objective evidence of infarction should be considered as a defining feature of stroke.

In the spring of 2013, the AHA/ASA published an expert consensus document with a new definition of stroke to reflect these advances.3Authors with expertise in the fields of neurology, neurosurgery, neuroradiology, neuropathology, clinical research methods, epidemiology, biomarkers, policy and global public health were invited from within the AHA/ASA, as well as the American Academy of Neurology, the American Association of Neurological Surgeons and Congress of Neurological Surgeons, U.S. Centers for Disease Control and Prevention, the National Institute of Neurological Disorders and Stroke, the European Stroke Organization (ESO), the World Stroke Organization (WSO) and others to establish a universal definition of stroke.

The major fundamental change compared with older definitions is that the new broader definition of stroke includes any objective evidence of permanent brain, spinal cord or retinal cell death due to a vascular cause based upon pathological or imaging evidence with or without the presence of clinical symptoms. Ultimately, the leaders of the ESO and WSO withdrew from participation and declined to endorse the statement because they disagreed about the inclusion of silent cerebral infarction and silent cerebral haemorrhage within the lexicon of stroke. (See Stroke Definition in the ICD-11 at the WHO.)

The AHA/ASA defined CNS infarction based on pathological, imaging or other objective evidence of infarction. In the absence of this evidence, the persistence of symptoms of at least 24 hours or until death remained a method to define stroke.At present, imaging is not always available and also is not perfect. In much of the developing world and in rural parts of more developed regions, neither [CT or MRI] may be available in the acute setting, if at all, which limits the global applicability of an imaging-based definition of stroke.

Silent lesions have been recognized pathologically as infarctions and haemorrhages since the 1960s but were deemed of uncertain importance. However, they may not be entirely asymptomatic, as patients may have subtle cognitive, gait or other functional impairments in the absence of a typical acute presentation. To some extent, the silence of an infarction or haemorrhage depends on the eye of the beholder. Patients may not be aware of their symptoms due to neglect, denial or simply may attribute them to another cause and not seek a medical opinion. Physicians and other health care providers may vary in their ability to detect mild neurologic abnormalities, or they, too, may ascribe them to an alternative cause.

The AHA/ASA included silent CNS infarctions and haemorrhages within the broadest definition of stroke for multiple reasons.

The new tissue-based definition of CNS infarction depends on either early objective (currently neuroimaging) evidence of infarction or persistence of symptoms for at least 24 hours. If early imaging is not available, then clinicians are left with a diagnostic dilemma in those first 24 hours since the event cannot be clearly classified as stroke.

Ultimately, diagnostic techniques and/or time will help define infarct or haemorrhage based on objective imaging, or TIA in the absence of positive imaging and resolution of symptoms within 24 hours from onset. A major challenge for the future will be the achievement of access to diagnostic and treatment tools in the developing world, where a substantial portion of the global burden of stroke occurs.

The inclusion of silent infarcts and microhemorrhages within the AHA/ASA definition of stroke opens many questions for clinicians. In regions with little or no access to neuroimaging, this change in definition may prove irrelevant for many years to come. However, for those with such access, silent lesions are likely to be detected as a result of the widespread use of MRI for non-cerebrovascular symptoms such as headache or dizziness.

Updating the definition of the disease can have prominent effects on disease surveillance and assessments of public health. In the case of adding a large number of silent infarction cases to the existing number of stroke cases, this will increase the total number of stroke cases while likely decreasing the mortality rate due to the addition of a number of minor/silent cases.4Updating the definition of stroke could result in reclassification of stroke cases for incidence, prevalence, and mortality in national and international statistics, disease classification coding systems and existing health surveys. This is particularly problematic if definitions are applied differently in each region of the globe, and this is a major concern of all stroke organizations. Therefore, the AHA/ASA recommended that symptomatic and silent infarctions and haemorrhages should be counted separately to allow for valid analyses of temporal and geographic trends in stroke. Although the WSO, ESO and WHO will not include the silent lesions within the definition of stroke, they recognize their importance and are going to start counting them within the scope of cerebrovascular disorders in the ICD-11.

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At the time of print, Kasner is with the University of Pennsylvania and Sacco is with the University of Miami.

References

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Implications of the AHA/ASA Updated Definition of Stroke for the 21st Century - WFN News