Category Archives: Neurology

This study was the first structured survey of neurophobia among Chinese medical students and resident trainees, comprising 351 respondents from a tertiary teaching hospital in Beijing, China. Our results showed high difficulty and low confidence scores for neurology. This is in line with the results of prior studies in different parts of the world, including the United States, United Kingdom, Canada, South America, and Asian and African countries, revealing that neurophobia is a global issue across diverse educational systems [4,5,6,7,8, 12,13,14,15] (Table 3).

In this study, both medical students and residents agreed that neurology was the most difficult medical discipline, and they felt the least confident in dealing with patients with neurological problems, in contrast to the six other specialties in primary care settings. Two-thirds of the medical students and more than half of the resident trainees had neurophobia. This prevalence is higher than previous estimates by Jozefowcz [3] and a survey conducted in Singapore [7], indicating that neurophobia should be taken seriously in China. Over the past 30years, neurology perception has remained unchanged in contrast to the rapidly changing requirements for neurological care in an aging population. Medical education authorities and neurology educators should pay particular attention to these issues.

Consistent with previous studies [4, 6, 8], neuroanatomy was the main reason for difficulty in neurology. In the digital era, neuroanatomy education can be improved from conventional sectional images by employing innovative strategies, such as computer-based instructional 3-dimensional models, web-based neuroscience and neurology teaching videos, blended and flipped strategies, and problem-based effective teaching in neuroanatomy.

The poor integration of preclinical and clinical neurological teaching is another major complaint. Almost 80% of the medical students stated that a combination of neuroanatomy, neuroscience, and clinical neurology would be the best approach. Fragmentation in the learning of basic neuroscience with clinical neurology should be tackled by integrating basic neuroscience learning with early, effective, and multiple clinical exposures more efficiently under a neuro-mentorship program. Furthermore, introducing preclinical revision courses in areas such as neuroscience and neuroanatomy through case-based learning when students enter clinical training could be another useful approach.

In Peking Union Medical College, medical students are required to be involved in a total of 8weeks neurology attachment in the clerkship year (6th year) and internship year (7th year). The internal medicine residency training program included a 4-week rotation in the Department of Neurology at PUMCH. Some respondents suggested that the lack of rotation time and restricted exposure to neurological patients led them to consider neurology a difficult subject, which should be addressed urgently. In such a limited rotation time, multiple novel educational interventions would help students organize, re-engage, and manage their learning approaches for a deeper understanding through selfdirected, problem-based, and team-based learning.

In our study, a high proportion of the residents expected more online self-directed learning resources. Utilization of online resources in neurology teaching and its distinct success over other teaching approaches has been signified in prior studies [18,19,20,21]. Online teaching has been revealed to enhance neurology knowledge at the final clinical attachment and residency rotation stages compared to textbooks. The incorporation of video tutorials as part of the online educational approach could offer a reasonable addition to increasing patient exposure and bedside teaching for residents.

It is noteworthy that neurology is regarded as a difficult and challenging subject, but this did not reduce students interest in or enthusiasm for neurology, and a substantial number of medical students tended to pursue neurology in their future careers. However, once resident trainees begin clinical practice, they may become less neurophobic. Although there was a relatively wide range of neurophobias among medical students and young residents, a trend toward gradual improvement was observed. We speculate that ongoing neurological education and clinical exposure to overcome neurophobia will initially target medical students and then seamlessly continue via postgraduate education.

Owing to the unique, difficult, and complex nature of neurology, neurophobia has long existed worldwide, and our research reached the same conclusions. The presence of neurophobia in various medical communities around the globe raises concerns about its adverse effects on the quality of patient care and management. Researchers have presented several evidence-based recommendations for overcoming neurophobia. Neurology education curriculum reforms, a paradigm shift from a traditional knowledge-based curriculum to a student-centered, and competency-driven education [22], neuro-mentorship programs, evidence-based effective educational interventions, and problem-based and integrated learning, would be the way forward to removing neurophobia.

As China continues to grow, the need for physicians to adequately address the health needs of its population has become increasingly important. In the future, the government should provide more political support and financial investments to improve the overall capability of global cooperation and communication in neurology education, reinforce partnerships and cultures, identify differences between China and the rest of the world, propose targeted improvement measures to solve neurophobia, and ultimately provide excellent talent reserves for brain science in the twenty-first century.

This study had several limitations. This study was conducted in a single medical institution. PUMCH is a tertiary comprehensive teaching hospital in China and a national referral center offering diagnostic and therapeutic care for complex and rare disorders. Therefore, it may be difficult to generalize our findings to other Chinese medical schools and hospitals. Therefore, multi-center studies are required to confirm these conclusions. Investigations are also warranted to estimate whether intervention measures such as increased patient exposure, more online resources, and enhanced integration of neuroanatomy, neuroscience, and clinical neurology may result in better performance in neurology education.

More:
Neurophobia among medical students and resident trainees in a ... - BMC Medical Education

A. Gordon Smith, MD, FAAN

According to a new survey on neurologists in the United States, patients with generalized myasthenia gravis (gMG) who faced social determinants of health (SODH) challenges experienced health care access inequities when initiating and continuing treatment for their condition. These findings suggest the need to mitigate treatment-related disparities in gMG by assisting patients with treatment costs, transportation, and in-home infusions, as well as increasing awareness and patient advocacy.1

Among 150 neurologists who completed the survey in October 2022, respondents estimated that 33% of their patients with gMG faced care inequities and 74.7% (n = 112) reported it is more difficult for these patients to afford prescribed gMG therapies. Notably, 67.3% (n = 101) of respondents reported these patients experienced a greater difficulty in continuing gMG treatment and 60.0% (n = 90) noted these patients had a greater likelihood of experiencing exacerbation or crisis-related hospitalization.

These findings were presented at the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) meeting, held November 1-4, in Phoenix, Arizona, by senior author A. Gordon Smith, MD, FAAN, professor and chair of neurology, and Kenneth and Dianne Wright Distinguished Chair in clinical and translational research at Virginia Commonwealth University, and colleagues. Investigators conducted a 42-item online survey on healthcare access which was deployed to neurologists using email. The questions centered around demographics, diagnosis, treatment, and continuity of care in patients with gMG that were considered to be facing SDOH challenges. These challenges could pertain to any racial/ethnic minority or financial limitations.

READ MORE: Subcutaneous Efgartigimod PH20 Demonstrates Efficacy for Generalized Myasthenia Gravis in Open Label ADAPT-SC+ Trial

In comparison with other patients with gMG, respondents viewed patients who faced inequities as less receptive to infusion therapies and thymectomy and were less likely to be presented with newer therapies. In addition, these patients were reportedly less likely to receive payor approval for antibody-based biologics, IVIg, and plasmapheresis, and were more likely to have trouble traveling to infusion centers. The respondents also identified the cost of treatment/insurance and transportation issues as the biggest contributors to the difficulties in obtaining and continuing treatment for gMG.

In an additional analysis presented at AANEM 2023 by the same authors, neurologists reported that patients with gMG who faced SDOH challenges were also more likely to experience healthcare inequities when receiving diagnosis. Flexible scheduling, improved transportation options, and increased primary care education were noted as ways to address these health disparities. Approximately 84% (n = 126) of the respondents were board certified in neurology and the remainder were in neuromuscular or electrodiagnostic medicine, roughly half were university affiliated.2

About 55% of respondents (n = 82) indicated the patients who faced health inequalities also experienced longer duration between symptom onset and gMG diagnosis and 56% had a higher likelihood of diagnosis in an inpatient setting (n = 84). Similarly, 55.3% (n = 83) reported these patients had more difficulty scheduling appointments and 76.7% (n = 115) reported these patients had more difficulty attending appointments. Additionally, 72.7% (n = 109) reported these patients missed more appointments. The neurologists from the survey suggested that these disparities were because of treatment cost, challenges with appointments, transportation difficulties, being less likely to seek care, and more likely to visit an emergency room as the disease progressed.

Click here for more coverage on AANEM 2023.

The rest is here:
Treatment Inequality Issues Identified for Patients With Generalized ... - Neurology Live

Bruce Hughes, MD: Hello, and thank you for joining this Neurology Live Peers & Perspectives presentation titled, Disability Progression and Maintenance of Cognitive Function in Multiple Sclerosis. Im your host, Dr Bruce Hughes. I am the medical director of the Ruan Multiple Sclerosis and Research Center in Des Moines, Iowa. Joining me today is Dr Robert Naismith, whos an MS [multiple sclerosis] specialist and researcher at Washington University in St. Louis, [Missouri]. Today, we will be talking about how patients with multiple sclerosis acquire disability and the concept of progression independent of relapse activity or PIRRA. We will discuss current understanding of cognitive decline in multiple sclerosis and share data on how various disease modifying therapies impact PIRRA and cognitive health in multiple sclerosis. Thank you for being here today.

I think well start with how our understanding of acquiring disability has changed over the years and maybe you can make some comments on raw relapse-associated worsening vs PIRRA.

Robert Naismith, MD:Absolutely, as a neurologist and a scientist, you always try to think back to whats happening in the disease and how to translate that to the patient experience. So whenever I think about multiple sclerosis, you have these different components that are taking place and to some degree alongside each other. So, you have acute inflammation, chronic inflammation and neurodegeneration. So, like with the last iteration of the criteria, what we do in our assessments and practice is we say whether patients have a subtype of MS with or without activity, or with or without progression. And we try to relate that back to the pathogenesis of whats happening with the disease. And activity is synonymous with new MRI lesions or relapses and those represent blood-brain barrier breakdowns. We have a new lesion that forms over the course of some short period of time. It may have neurologic dysfunction that occurs with it. And then theres some resolution of that maybe due to reduction of edema, decreased inflammation in that region, and maybe even some remyelination. If you talk about with activity, then that means you have a new lesion. You may or may not have a relapse associated with that. Whereas with progression, that may be due either to chronic inflammation because we know that these acute lesions turn into these chronic lesions and those can cause damage, and then you have neurodegeneration, and thats what we refer to as progression. And neurodegeneration is the dropout of neurons and axons over time because theyre in this hostile environment thats proinflammatory, and theyre working very hard to maintain their function. So there are these big metabolic demands that are put on them.

So the patient just knows that theyre doing worse. They come in and say, Im not as good as I was last time. And as a neurologist, we have to figure out what the reason is. The patient only knows that theyre doing worse. And we have to figure out, are they having relapse activity? Are they having a pseudo exacerbation? Are they having paroxysmal symptoms? Or are they having neurodegeneration or progression? Because a lot of patients just say, I must be progressing. So we need to sort that all out.

When you think about the ways people worsen, theres RAW, [which is] relapse-associated worsening. And that refers to worsening due to acute inflammation with a new lesion within the central nervous system with the referable symptom that the patients experiencing. Whereas PIRRA is without that acute inflammation. So it could either be from the chronic inflammatory state that these lesions undergo and is actually present throughout the central nervous system or maybe because of the dropout of neurons just over time. These things are interrelated, but they dont correlate perfectly. So we know that the acute inflammation is early in the disease and this acute inflammation leads to this neurodegeneration, but its not a 1:1 correlation. A lot of our treatments are aimed to address that acute inflammation to prevent the chronic inflammation and prevent the neurodegeneration. So RAW is relapse with activity and then PIRRA is worsening of disability without that relapse or that new MRI lesion.

Transcript is AI-generated and edited for clarity and readability.

More here:
Disease Progression in Multiple Sclerosis (MS): Overview of ... - Neurology Live

New data from the phase 3 PROPEL study (NCT04138277) showed that treatment with cipaglucosidase alfa (Pombiliti)/miglustat (Opfolda), a recently approved 2-component agent, was effective in patients with late-onset pompe disease (LOPD) for up to 104 weeks. These data, presented at the 2023 American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) annual meeting, held November 1-4, in Phoenix, Arizona, highlight the longterm sustained impact of this combination approach.1

Led by Tahseen Mozaffar, MD, director of the division of neuromuscular diseases in the department of neurology at the School of Medicine at UC Irvine, 119 patients from the original double-blind trial entered the open-label extension (OLE), 91 of which were enzyme-replacement therapy (ERT)-experienced and 28 who were ERT-nave. At 104 weeks, the mean change in percentage predicted 6-minute walk distance (6MWD) change was +3.1 (SD, 8.07) for ERT-experienced patients who continued on with cipaglucosidase alfa/miglustat (cipa/mig; n = 82) vs 0.5 (SD, 7.76) for those who switched from alglucosidase alfa/placebo (alg/pbo; n = 37).

Over the same time, investigators observed changes of +8.6 (SD, 8.57) and 8.9 (SD, 11.65) for ERT-nave patients in the cipa/mig and alg/pbo groups, respectively. Forced vital capacity (FVC), a measure of lung function, was improved through treatment. At the conclusion of the analysis, mean change in percentage predicted FVC was 0.6 (SD, 7.50) for the cipa/mig group and 3.8 (SD, 6.23) for the switch group in ERT-experienced patients, and 4.8 (SD, 6.48) and 3.1 (SD, 6.66) in ERT-nave patients, respectively.

The 2-component therapy, marketed by Amicus Therapeutics, also improved biomarker levels of creative kinase and hexose tetrasaccharide over the 104-week stretch. During that time, treatment with the combination medication did not result in any new safety signals, with 3 noted patients discontinuing treatment because of infusion-associated reactions of urticaria, urticaria and hypotension, and anaphylaxis.

WATCH NOW: The Role of Biomarkers in Myasthenia Gravis Diagnosis and Treatment: Hong Sun, MD, PhD

The 52-week analysis of the study, published in Neurology in 2022, showed a mean improvement in 6MWD of 14 m with cipa/mig vs approved ERT therapy but did not reach statistical superiority (P = .072). The 2-component therapy achieved a nominally statistically significant and clinically meaningful 3% mean improvement in percentage predicted FVC for superiorirt over approved therapy (P = .023). Outcomes consistently favored cipa/mig in all subgroups for the overall and ERT-experienced populations, regardless of baseline 6MWD and percentage predicted FVC.2

Earlier this year, at the 2023 American Academy of Neurology annual meeting, Mozaffar presented data from an open-label phase 1/2 study (NCT02675465) assessing the combination agent in patients with LOPD. Also known as study ATB200-02, pooled analyses of the ERT-experienced cohorts showed improvements in 6MWD from baseline of 3.1 m (standard deviation [SD], 44.75; n = 16), 33.5 m (SD, 49.62; n = 16), 25.2 m (SD, 63.30; n = 13), and 9.8 m (SD, 85.98; n = 12), 20.7 m (SD, 101.84; n = 9), respectively, across months 6, 12, 24, and 48 of treatment. Comparatively, the ERT-nave cohort reported improvements of 36.7 m (SD, 29.08; n = 6) at 6 months, 57.0 m (29.96; n = 6) at 12 months, 54.4 m (SD, 36.18; n = 6) at 24 months, and 43.5 m (45.19; n = 5) at 36 months; and 52.2 m (SD, 46.59; n = 4) at 48 months.3

The trial enrolled 3 cohorts of adult ambulatory patients based on ERT experience: those with 2 to 6 years (n = 11; aged 18-65 years) or with 7 or more years (n = 6; aged 18-75 years) were both administered 20 mg/kg alglucosidase alfa biweekly, while those who were ERT-nave (n = 6; aged 18-65 years) were given doses of 20 mg/kg IV cipaglucosidase alfa/260 mg miglustat orally biweekly.

All told, findings showed that percent predicted sitting FVC was generally stable or improved in the ERT-experienced cohorts, with a mean change from baseline of 0.9% (SD, 8.69; n = 16), 1.2% (SD, 5.95; n = 16), 1.0% (SD, 7.65; n = 13), 0.3% (SD, 6.69; n = 10), and 1.0 (SD, 6.42, n = 6) at 6, 12, 24, 36, and 48 months, respectively. In the ERT-nave cohort, pFVC improved by 4.2% (SD, 5.04; n = 6), 3.2% (SD, 8.42; n = 6), 4.7% (SD, 5.09; n = 6), 6.2% (SD, 3.35; n = 5), and 8.3% (SD, 4.50, n = 4) at the same respective time points.

Click here for more coverage of AANEM 2023.

Read more from the original source:
Open-Label PROPEL Study Results Highlight Longterm Impact of ... - Neurology Live

Receiving a clot-busting drug in an ambulance-based mobile stroke unit (MSU) increases the likelihood of averting strokes and complete recovery compared with standard hospital emergency care, according to researchers at Weill Cornell Medicine,NewYork-Presbyterian, UTHealthHouston,Memorial Hermann-Texas Medical Center andfiveothermedical centers across the United States.

Thestudy, published online in the Annals of Neurology on Oct. 6, determined that MSU care was associated withboth increased odds of averting stroke compared with hospital emergency medical service (EMS) 18% versus 11%, respectively and a higher percentage of patients 31% versus 21% had early symptom resolution, within 24 hours after a stroke.

Patients in this study were treated with tissue plasminogen activator (t-PA), a mainstay medication delivered intravenously (IV) in stroke cases. The drug dissolves the clot in an artery that is blocking blood flow to the brain, making treatment time critical. While this is known to improve patient outcomes, how many patients fully recover afterward wasn't clear from prior research, said lead authorDr. Babak Benjamin Navi,associate professor, vice chair for hospital neurology services and chief of stroke and hospital neurology, in the neurology department at Weill Cornell Medicine. He is alsoacting medical director of theMSU, operated by NewYork-Presbyterian, in collaboration with Weill Cornell Medicine, Columbia University Irving Medical Center and the Fire Department of New York.

On average, the faster you treat someone, the more likely you are to have a good functional outcome because youre able to preserve more brain tissue, said Navi, who is alsoassociate professor of neuroscience at theFeil Family Brain and Mind Research Instituteat Weill Cornelland the medical director of the stroke center at NewYork-Presbyterian/Weill Cornell Medical Center. The brain can only sustain reduced blood flow for so long before permanent injury develops.

Using multicenter trial data from 2014 to 2020, the researchers evaluated 1,009 patients: 644 received t-PA in an MSU, and 365 received EMS care. Overall, patients received t-PA at a median interval of 87 minutes after the onset of stroke symptoms. The study found that with t-PA treatment in this time frame, about one in four patients who had a suspected stroke recovered within 24 hours and one in six averted a stroke with no demonstrable trace of brain injury on an MRI.

The outcome improved for patients treated by an MSU since the time from symptom onset to treatment was 37 minutes faster than for EMS care, meaning many more patients received vital t-PA within the crucial first hour. MSU care further increased the odds of averting a stroke with nearly one-third of patients recovering to normal within 24 hours. In addition, the researchers found other factors that contributed to better patient outcome: treatment within the first 45 minutes, younger age, being female, history of high cholesterol, lower blood pressure, lower stroke severity and no blockage of large blood vessels.

Every 40 seconds, someone in the United States has a stroke, according to the American Heart Association. This study highlights the need for optimizing stroke systems of care, Navi said. Further expediting the delivery of t-PA through MSUs should be a priority to increase the proportion of averted strokes.

Navi is also hoping that Medicare will assign MSU services a billing code in the near future so that it can be embedded within stroke systems of care and become a financially viable model.

Currently, he is working with researchers from UTHealth Houston on a study to evaluate the cost effectiveness of MSUs, which should be published next year. Such studies will hopefully lead to a shift in regulations and reimbursements, and how MSUs are led, managed and integrated within emergency medical services, he said.

Co-principal investigators for the BEST-MSU trial, which produced the data for this analysis, were Dr. James C. Grotta, director of stroke research at the Clinical Innovation and Research Institute at Memorial Hermann - Texas Medical Center and director of the Mobile Stroke Unit Consortium; and Dr. Jose-Miguel Yamal, departmentof biostatistics at UTHealth Houston School of Public Health.

Also contributing to this effort wasDr. John Volpi, director of the Eddy Scurlock Stroke CenterHouston MethodistStanley H. Appel Department of Neurology and associate professor of clinical neurology in neurology at Weill Cornell Medicine.

This study was funded by grant R-1511-33024 from the Patient-Centered Outcomes Research Institute.

Many Weill Cornell Medicine physicians and scientists maintain relationships and collaborate with external organizations to foster scientific innovation and provide expert guidance. The institution makes these disclosures public to ensure transparency. For this information, see the profiles for Dr. Babak Benjamin Navi.

Heather Lindsey is a freelance writer for Weill Cornell Medicine.

Link:
Mobile units increase odds of averting stroke | Cornell Chronicle - Cornell Chronicle

Kallol Ray Chaudhuri talks to Marika Davies about facing racial discrimination during his career and putting patients at the heart of research

After a long and arduous clinic, Kallol Ray Chaudhuri likes to take his team to the pub. I strongly believe that work should also be pleasurable and fun, he says.

Ray Chaudhuri, professor of neurology and director of the Parkinson Foundation Centre of Excellence at Kings College Hospital and Kings College London, was born in India to a medical family. His interest in neurology was sparked at a young age, sitting in on his fathers medical clinics on the ground floor of their home. I used to find it fascinating, he recalls. That concept of being in medicine and seeing patients was ingrained into me at a very early stage.

In 1984 Ray Chaudhuri graduated from Calcutta Medical College and moved to the UK to continue his training. Despite pressure to return to India to work in his fathers practice, he decided to pursue a career as a clinical academic in London, becoming a consultant neurologist in 1995 and research director at Kings College Hospital in 2018.

Ray Chaudhuri is proud of the work at the Parkinson Centre and of the feedback they get from patients. We have a plan to develop care for people based not only on medicine but on overall wellness, he explains. This has become incredibly popular and is being adopted in many different countries. Patient feedback is proof that what we do is relevant and has a tangible impact on the people we serve.

As a clinical academic Ray Chaudhuri says his research is very patient orientated. People think research is where you go to the laboratory and do cell culture stuff, but theyve forgotten about the real beauty of clinical research, he says. I love seeing patients and trying to bring innovation to the clinic by mixing education and research.

Ray Chaudhuri says that throughout his career he has encountered racial discrimination. Some consultants would refuse to talk to me directly or make derogatory comments about colleagues whose English wasnt that good. I learnt pretty early that if I was going to make a mark Id have to work really hardone of my bosses once told me I had to be twice as good as a local person to get a job, he recalls. Even after I became established and formed my own research group there was a lot of focus on trying to find errors in my work; the scrutiny was extremely high compared with colleagues who were doing the same sort of work.

Outside of work Ray Chaudhuri enjoys playing in a folk rock band and writing music. He is currently composing songs about the lived experiences of patients with Parkinsons disease. He is also active in rhinoceros conservation in South Africa, where he travels twice a year to raise money and awareness.

Ray Chaudhuri encourages his juniors to travel abroad to meetings wherever they can and to choose a career path that they enjoy. Enjoyment in work is absolutely crucial so its important that you get job satisfactionthat will often give you joy and help your work-life balance, he says.

He also tells his juniors not to be daunted by challenges that come their way. From my own experience, if I let those things into my head I wouldnt be where I am, he says. Sometimes if you have to be better than the others to be where you are, so be it.

Ray has made exceptional contributions to the field of medicine and his dedication to nurturing the next generation remains unmatched. Despite being snowed under with work and other commitments he still gives his team the attention and help they need to succeed.

He has worked to get Kings College Hospitals centre recognised as a Parkinsons Centre of Excellence, one of only two in the UK. He created the UKs first Parkinsons patient group to review all studies before we take them on, emphasising the need to have patients at the heart of our research and care. Ray sits on the equality, diversity, and inclusivity panel at our trust, working to improve representation of our communities in research.

Our career plans and projections have been shaped by Ray, and we will be forever grateful to his guidance, help, and kindness.

Mubasher A Qamar, Lucia Batzu, Silvia Rota, Valentina Leta, and Aleksandra Podlewska are fellows at the Parkinson Foundation Centre of Excellence at Kings College Hospital.

See the rest here:
Caring for the whole person: the consultant neurologist - The BMJ