The Duke Neurology residency class of 2020 held their graduation virtually this week, celebrating the completion of their four years of training and contributions to our Department amidst departmental growth, a continuing global pandemic, and numerous other challenges.

Our graduating class of residents will complete their neurology training in fellowships across the field of neurology, both at Duke and in other leading academic institutions across the country.

Congratulations to you all. Youre an amazing class of residents and truly phenomenal doctors. Make yourselves proud of yourselves as we are of you, said Assistant Professor Shreyansh Shah, MD, who shared hosting duties for the graduation. Thanks for selecting us and letting Duke Neurology be a part of your training.

Our graduating residents have selected the following fellowship programs for next year:

The ceremony included a homemade blues song by Associate Professor Emeritus Marvin Rozear, MD, who has been a mainstay of the Neurology Residency program for four decades.

Graduation closed with the presentation of awards to faculty and residents, with winners selected by this years graduating class. Assistant Professor Scott Le, DO, received the 2020 Marvin Rozear Common Sense Award. Assistant Professor Scott Strine, DO, received the 2020 Eun-Lyu Lee Excellence in Teaching Award. Graduating resident Abhi Kapuria, MD, received both the E. Wayne Massey Teaching Award and the Chief Resident Research Award for 2020.

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Duke Neurology congratulates the graduating residency class of 2020 | Duke Department of Neurology - Duke Department of Neurology

Peripheral neuropathy is frequently seen in patients with Parkinsons disease (PD) and may increase the functional disability in these individuals. A review article published in Neurological Sciences discussed the etiology of peripheral neuropathy in the context of PD.

Previous studies have shown that peripheral neuropathy can adversely affect the lives of patients with PD. As limited data are available on small fiber neuropathy (SFN) and effective treatments for peripheral neuropathy in PD, the current review focused on the etiology, pathological mechanisms, subtypes, and management of the neurological problem in PD.

The exact pathogenic mechanism of neuropathy in PD is not entirely clear and there are many potential factors involved in the disease process, including medication, mitochondrial dysfunction, oxidative stress, and genetic susceptibility.

Diagnosis

The diagnosis is based on clinical findings along with nerve conduction studies and electromyography. As some neuropathies may present with normal findings on peripheral nerves testing, a thorough patient history is vital.

The initial investigation of peripheral neuropathy often includes glucose tolerance testing, fasting glucose levels, measurement of vitamin B12, methylmalonic acid (MMA), homocysteine (Hcy), and serum protein electrophoresis.

The diagnosis of SFN is commonly difficult to be made on the basis of peripheral nerve testing and clinical criteria are more important. Intraepidermal nerve fiber density in skin biopsy or analysis of quantitative sensory testing can help in establishing the diagnosis.

Additional tools that may aid in the diagnosis and severity assessment of SFN include autonomic testing utilizing a variety of reflex tests, intraepidermal electrical stimulation tests, corneal confocal microscopy, and microneurography.

Parkinson Disease Treatment and Neuropathy

Levodopa, the gold standard treatment for PD, may play an important role in the development of peripheral neuropathy . Long-term use of levodopa can lead to increased levels of Hcy and MMA which have been linked to neuropathy, as well as increased risk for cardiovascular diseases, neurodegenerative diseases, and neural tube defects. While many studies have pointed at B12 deficiency as the potential cause for levodopa-associated neuropathy, others suggested that folate deficiency is a more important cause.

As not all patients taking levodopa develop neuropathy, experts have suggested there may be a genetic susceptibility for the development of neuropathy in some patients. Potential candidate genes involved in PN with PD may be the parkin or MTHFR genes.

Levodopa-carbidopa intestinal gel (LCIG) are additional treatment options that were found to be associated with peripheral neuropathy. Studies have suggested a higher incidence of neuropathy in PD patients treated with duodopa or LCIG. While limited data exist on the risk for SFN, there are reports suggesting an association between LCIG treatment with neuropathy of small fibers.

Administration of catechol-O-methyltransferase (COMT) inhibitors may attenuate the levodopa-induced increase in plasma Hcy and MMA levels. However, due to the limited available data, more studies are required to better understand the efficacy of COMT inhibitors in preventing peripheral neuropathy.

Treatments of Peripheral Neuropathy

The data on treatment of peripheral neuropathy in PD remain limited and additional studies are needed to explore the benefits of cobalamin injections with folate supplements and COMT inhibitors, especially in levodopa-treated patients. Novel treatment options include electromagnetic and laser therapy.

At this point in time, COMT inhibitors, such as entacapone, are the main treatment options for peripheral neuropathy. One study has shown that the addition of COMT inhibitors may improve levodopa-associated neuropathy. However, as COMT inhibitors were not found to be effective against peripheral neuropathy secondary to causes other than levodopa exposure, other therapeutic options are needed.

Combination of vitamin B12 and methylcobalamin is recommended by some experts in the field and there are reports this may improve pain and paresthesia, but most of the data are based on studies in patients with diabetic neuropathy.

Several enzymes and genetic markers were suggested as therapeutic targets for peripheral neuropathy and have shown promising results. Furthermore, monoclonal antibodies may prove to be useful, as there are reports from patients with malignant tumors in which the combination of bendamustine-rituximab was found to alleviate immune-mediated neuropathies. Early reports have suggested a potential role for ultrasound guided vitamin B12 injections.

Future studies should investigate the toxic effects of elevated Hcy and MMA levels in patients with PD along with viable treatment options that include vitamin B12 and folate therapy. Large scale studies are required in order to understand the role and efficacy of COMT-Is along with other IPD interventions in [peripheral neuropathy], concluded the investigators.

Reference

Paul DA, Qureshi ARM, Rana AQ. Peripheral neuropathy in Parkinsons disease [published online May 1, 2020]. Neurol Sci. doi:10.1007/s10072-020-04407-4

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Therapeutic Options for Peripheral Neuropathy in Parkinson Disease - Neurology Advisor

Article In Brief

Disparities in access to health care, WiFi services, comorbidities, and even clean running water have led to a disproportionate number of COVID-19 cases among Native American populations. Neurologists who serve the Navajo Nation discuss the conditions that have led to those increases.

The novel coronavirus has hit Native American communities in the United States at such an alarming rate that Doctors Without Borders has sent teams of medical professionals to the American Southwest to help the Navajo Nation, which as of May 12 had more than 3,100 cases of COVID-19 and more than 100 deaths among its population of roughly 175,000 people.

If the Navajo Nation's reservation, which spreads across New Mexico, Arizona, and a corner of Utah, were a state, as of May 11, it would have the second-highest per capita rate of confirmed coronavirus cases in the countrybehind only New York. And as of May 14, 60 percent of the people who had died from COVID-19 in New Mexico were Native American, although they make up only 11 percent of the state's population.

Neurologists who work with the Navajo Nation and other Native communities told Neurology Today that the situation dramatically illustrates the historical inequities in access to health care, infrastructure and services affecting these communities, noting that many people who do not live in the area do not understand the difficulties of life on the reservation.

The Navajo Nation covers some 27,000 square miles, with about six people per square mile. There's a lot of space and not a whole lot of people, so you would think it would be easy to socially distance, says David M. Labiner, MD, professor and head of the department of neurology at the University of Arizona in Tucson.

But more than 30 percent of Navajos don't have running water at home. They have to haul water in on a truck every few days, which means there isn't the opportunity to wash hands as frequently and for as long as necessary. And to get their water supplies from water stations, or to get food from small general stores, people often have to break social distancing guidelines.

Amazon Fresh and Instacart don't deliver to remote areas of Arizona and New Mexico where you can drive for miles on unpaved roads without seeing a house. A lot of my patients don't have electricity in their homes, or necessarily reliable access to mail or phone or internet, said Mike Stitzer, MD, director of the Native American Neurology Service at Winslow Indian Health Care Center in Arizona, who has been a member of AAN's Diversity Leadership Program and its Health Care Disparities Task Force. Dr. Stitzer is also an enrolled member of the Enterprise Rancheria Estom Yumeka Maidu tribe.

There is also a lot of intergenerational living, with multiple generations of families living either in the same house or right next to each other, sharing food and water. It may be 20 or 30 miles to your nearest neighbor, but if a case makes it to one person in a family group, there's a high chance it will spread to everybody.

Access to health care can also be challenging. There are seven sites that serve the Navajo Nation: Chinle Comprehensive Health Care Center (60 beds), Tuba City Regional Health Care (73 beds), Northern Navajo Medical Center (69 beds), Gallup Indian Medical Center (99 beds), including six ICU beds), Tshootsoo Medical Center (56 beds, including ICU beds), Crownpoint Health Care Facility ( 32 beds), and Sage Memorial Hospital (25 beds), Dr. Labiner said.

But even though the network of facilities is very capable of providing care, when conditions become serious, people have to travel a long way for access to specialists, said Dr. Labiner.

It's not that Native communities are not working to stem the spread of the coronavirusin fact, precisely the opposite. The Navajo Nation has actually been significantly more proactive in addressing the risks of COVID-19 than many other states and governments, said Dr. Stitzer.

The first cases here appeared probably in early March. There had been a religious gathering in Chilchinbito, in the eastern part of Arizona, that drew hundreds of people from all over the Nation, and one person at that gathering later turned out to have tested positive. Within a week or two, we started seeing cases trickling out and as soon as that happened, the Nation began talking about social distancing and shelter in place for anything but essential servicesweeks before anyone else in Arizona was doing it.

The Nation also put out orders for residents to wear cloth masks in public in late March and enacted a nightly curfew on March 30, followed by complete weekend curfews. They have police on the road issuing citations, and there are thousand-dollar fines for violations, said Dr. Stitzer. We've also been very proactive at our health center, with a dedicated screening protocol and separate waiting rooms for anyone with any possible respiratory symptoms by the end of February.

The per capita testing rate for COVID-19 is also much higher among the Navajo Nation than in the surrounding region, Dr. Stitzer said. As of May 14, the Nation had conducted conducted 19,441 tests for its population of 175,000, compared with 175,455 for the state of Arizona (population approximately 7.3 million)which comes out to approximately 111 tests per 1,000 people in the Navajo Nation and 24 tests per 1,000 people in Arizona.

Despite these extraordinary efforts, a disproportionate burden continues to fall on Native peoplesand on the health care systems that serve them.

The pandemic is only magnifying the health care disparities faced by Native Americans, said Cumara O'Carroll, MD, MPH, an assistant professor of neurology at the Mayo Clinic in Scottsdale, AZ, who provides stroke services to patients at Tuba City Regional Health Care through a telestroke network. Dr. O'Carroll was also a participant in the AAN's Diversity Leadership Program.

We know that there are a number of factors contributing to the high rates of infection in the Navajo Nation, and some of that is increased susceptibility from pre-existing underlying medical conditions like diabetes, hypertension, coronary artery disease, and obesitymany of which are the same risk factors for stroke, of course. In this country, we have barriers to care that fall across racial and ethnic lines, and those barriers and disparities are exacerbated and accelerated in a pandemic like this one.

Health care systems serving the Native community, such as Tuba City, are struggling to get access to medical supplies, personal protective equipment, and other resources, Dr. O'Carroll said. What we are seeing and hearing is that they are being expected to provide the same level of services that they have always provided, but with fewer resources. Their system is being overwhelmed by more and more patients, and the patients who are coming in are critically ill.

As an example, she described a recent telestroke call with some physicians in Tuba City. We have algorithms and systems in place when someone comes in with stroke symptoms, and they are fine-tuned through many years of work, she said.

But because clinicians and staff are being spread so thin, these systems are breaking down. In this case, we had a patient with clear stroke symptoms who needed a CT scan immediately. They said to me, Doctor, we understand, but it can't be done immediately because we have a long line of critical patients waiting for care. This is a facility that usually runs very smoothly with a superior caliber of physicians. They're very resourceful. They can do it all. You could sense their frustration and stress. This pandemic is resulting, at times, in delays in care for acute stroke interventions. People are still getting treatment, but not in the timeline we are accustomed to pre-pandemic.

The Navajo Area Indian Health Service (IHS) does not have many hospital beds. There are just over 400 beds for the entire Navajo Nation. I don't know how many are ICU beds, but it's not more than a handful, and the same goes for ventilators, Dr. Stitzer said.

For comparison, the major tertiary care center for northern Arizona, Flagstaff Medical Center, has approximately 300 beds, of which about 55 are ICU. While none of the major hospitals in Arizona has been overwhelmed like New York and New Jersey have, the IHS hospitals in the eastern portion of the Navajo Nation have been very busy.

By mid-May, the state's hospitals have been hovering at only about 21 percent of ICU beds free, while it had been approximately 30 percent or so for March and the first half of April, Dr. Stitzer added.

Beds in use have slowly crept up over the second half of April. The cases per week in the state also continue to increase. With Arizona starting to roll back distancing measures, I am nervous that this will result in a spike of new cases. That would both make it harder to transfer the very ill patients out of the IHS hospitals to locations with more ICU beds, and also increase the chances of more cases coming from Arizona into the Navajo Nation.

To ease the burden on health care facilities in any outbreak areas, patients with non-emergent conditions are being urged to take advantage of newly expanded telehealth optionsbut the digital divide in Native communities means that this option, too, is less accessible to them.

Federal funding was given to the Navajo Nation several years ago to improve rural broadband and cellular service, and most of our patients do have cellphones at this point and many have smartphones, said Dr. Stitzer. But data are not yet reliable or fast enough for most people to do video chats. We have been able to do some successful video telemedicine visits, but my clinic often has been relying on telephone visits. However, patients may not have enough minutes to make all the calls they need.

Dr. Stitzer hopes that the response to COVID-19 will help start the spark of long term change needed to correct the massive, historical institutional challenges to improving health outcomes for Native Americans, such as the rate of poverty and issues associated with that, such as food deserts.

We need the rest of the country to understand the lack of resources that many of our patients have, and what this pandemic has meant to them. The fact COVID-19 is much more deadly in the elderly population is especially tough as they have a special place in Din society. They hold the traditions, language, etc. and pass it down to the younger generations. So a family and community losing someone is this group is hit particularly hard. It's not exactly equivalent, but my small tribe in Northern California, Estom Yumeka Maidu, has almost lost our spoken language as the elders are passing on. It's only minimally recorded and written down, so once it's gone it's gone. I have some understanding of what the loss of each elder to the tribe's culture is like, and it can be really difficult.

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Neurologists on the Front Lines: The Burden of COVID-19 on... : Neurology Today - LWW Journals

A young couple from Stroud have joined forces with their family in Spain to take part in the Marvel Superhero at Home challenge to raise awareness for the rare and often unheard about neurological condition ataxia.

Thomas and Samantha will undertake a triathlon with Thomas's dad Brian to raise awareness of the condition which effects three members of their family, including Brian who lives in Spain.

Brian, along with his brother Nigel and sister Susan all suffer with ataxia.

Nigel was first diagnosed in his late teens in the 1980s, and then Brian and Susan were diagnosed.

Brian said: "At the time of diagnosis ataxia was virtually unheard of, now it's a little better but the vast majority of people have never heard of it hence the need to raise awareness."

Brian and his siblings are all from Stroud, although he now lives in Spain, while his sister Susan lives in New Zealand and his brother lives on Stamford.

Thomas and Laura, Brian's children, still live in Stroud.

The rare condition predominantly impacts mobility, co-ordination and speech.

People with ataxia are often wrongly perceived to be drunk because of their strange gait, lack of mobility and slurred speech.

Brian said:"It is a life limiting degenerative condition where from diagnosis the only certainty is that it will get worse.

"It is ageless, impacting adults and children alike, and in the UK there are only around 10,000 adults and 500 children with ataxia."

The superhero challenge means the family will have to complete a 20km distance between June 15 and July 15 that can be completed anywhere and in any way.

Brian, his son Thomas and Thomas's wife Samantha have all decided to undertake the 'triathlon' challenge between them by swimming, cycling and walking.

The challenge will raise money for Ataxia UK and the family have already exceeded their sponsorship target.

To donate visit: bit.ly/2UYrXeO

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Stroud family to take part in 20km challenge for rare neurological condition - Stroud News and Journal

Additional analyses examine the impact of migraine in France, Spain and the United Kingdom

Teva Pharmaceutical Industries Ltd. (NYSE and TASE: TEVA) presented a wide range of important new data on AJOVY (fremanezumab) and the societal and economic impact of migraine in Europe at the 6th Congress of the European Academy of Neurology (EAN). This years EAN congress was a virtual meeting due to the global coronavirus pandemic.

The fremanezumab data included pooled analyses of the AJOVY Phase 3 clinical trials (FOCUS, HALO-episodic migraine (EM) and HALO-chronic migraine (CM)) which focused on the safety, efficacy and improved quality-of-life for patients experiencing difficult-to-treat migraine. Post-hoc analyses were also evaluated in patients who may experience challenges when managing their migraine due to comorbidities.

Migraine creates a significant disease and economic burden. With more than one billion people impacted globallyi, migraine is the second leading global cause of years lived with disabilityii and annual costs of the disease in the U.S. and EU are $200 billion.iii,iv

"Migraine imposes physical, emotional and societal burdens worldwide and yet available treatment options are often unsatisfactory for many patients," said Joshua M. Cohen, MD, MPH, FAHS, Senior Director, Global Medical Affairs Therapeutic Area Lead Migraine & Headache, Teva. "As a leader in neurology and migraine treatment, Tevas goal is to continue evaluating the impact of AJOVY across various patient populations to ensure that reliable and relevant information is available to healthcare professionals when considering treatment options."

Pooled Analysis Shows Impact of AJOVY in Patients with Migraine

Pooled analyses of the Phase 3 FOCUS, HALO-EM and HALO-CM clinical trials in patients 60 years of age or older with EM or CM, examined treatment with fremanezumab versus placebo over 12 weeks. Reductions from baseline in monthly migraine days, headache days of at least moderate severity, and days with acute headache medication use over 12 weeks were significantly greater with quarterly and monthly fremanezumab versus placebo (all P0.0103).

The analyses also examined early onset of efficacy and improved headache-related disability, health-related quality-of-life, productivity, and satisfaction in this patient population. Additionally, the analyses looked at cardiovascular adverse events in fremanezumab and placebo treated patients in this group, regardless of whether or not they had a cardiovascular medical history.

Cardiovascular Safety of AJOVY

Additional pooled analyses of the Phase 3 trials were also conducted to examine cardiovascular safety across all patients. The analyses were performed in migraine patients with cardiovascular/cerebrovascular risk factors (e.g., diabetes mellitus, hyperlipidemia, obesity, hypertension, hormonal birth control pill use) (n=499). The overall incidence of cardiovascular adverse events in these patients were low and comparable between fremanezumab and placebo treated groups. An increase in the number of risk factors did not seem to correlate with an increase in frequency of cardiac and vascular adverse events. Additionally, the analyses examined patients with migraine using cardiovascular medications at baseline (n=280), and patients using concomitant triptans (n=1,123) with those who did not use triptans. Similar to the overall trial populations, the most common adverse events reported in all of these subgroups were injection site reactions.

Disease and Economic Burden of Migraine in Europe

Two analyses evaluated the economic and disease burden of migraine across patients in the United Kingdom, France and Spain. The first analysis found that CM patients experienced greater disability caused by migraine versus EM patients. CM patients also reported lower health status than EM patients for their most recent migraine. The second evaluation, which included examining electronic medical records from 84,266 adult patients with EM and CM, found CM patients had more migraine-related consultations with their general practitioners than EM patients. Additionally, average quarterly treatment costs were higher for CM patients in all three countries.

These results point to substantial migraine disability and unmet treatment needs across the three countries. They also associate migraine with a significant healthcare and economic burden that includes higher costs for CM patients.

Story continues

Accessing Teva EAN Presentations

The ePresentations and ePosters shared by Teva at EAN can be accessed by healthcare professionals through the EAN conference website. The sessions will be available at no cost and will also be on-demand for EAN members from 27 May onward.

Additional resources on migraine, including articles, videos, publications summaries, podcasts and webinars can be accessed on Neurologybytes. Neurologybytes is a platform published by Teva to support neurologists in accessing timely, bite-sized content on the latest research developments and clinical care perspectives in the world of migraine and multiple sclerosis (MS).

Information for Europe about AJOVYcan be found here.

Adverse events should be reported.

This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events. Reporting forms and information can be found at https://www.hpra.ie. Adverse events should also be reported to Teva please refer to local numbers.

About Teva

Teva Pharmaceutical Industries Ltd. (NYSE and TASE: TEVA) has been developing and producing medicines to improve peoples lives for more than a century. We are a global leader in generic and specialty medicines with a portfolio consisting of over 3,500 products in nearly every therapeutic area. Around 200 million people around the world take a Teva medicine every day and are served by one of the largest and most complex supply chains in the pharmaceutical industry. Along with our established presence in generics, we have significant innovative research and operations supporting our growing portfolio of specialty and biopharmaceutical products. Learn more at http://www.tevapharm.com.

Cautionary Note Regarding Forward-Looking Statements

This press release contains forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 regarding new analysis of fremanezumab Injection which are based on managements current beliefs and expectations and are subject to substantial risks and uncertainties, both known and unknown, that could cause our future results, performance or achievements to differ significantly from that expressed or implied by such forward-looking statements. Important factors that could cause or contribute to such differences include risks relating to:

and other factors discussed in our Quarterly Report on Form 10-Q for the first quarter of 2020 and our Annual Report on Form 10-K for the year ended December 31, 2019, including in the sections captioned "Risk Factors" and "Forward Looking Statements." Forward-looking statements speak only as of the date on which they are made, and we assume no obligation to update or revise any forward-looking statements or other information contained herein, whether as a result of new information, future events or otherwise. You are cautioned not to put undue reliance on these forward-looking statements.

i Global Burden of Disease 2016 Disease and Injury Incidence and Prevalence Collaborators. Lancet 2017;390:121159.

ii Saylor D, Steiner TJ. The Global Burden of Headache. Semin Neurol 2018 Apr;38(2):182-190.

iii Gooch CL, et al. Ann Neurol 2017;81:47984.

iv Linde M, et al. Eur J Neurol 2012;19:70311.

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Contacts

IR Contacts United States Kevin C. Mannix (215) 591-8912Ran Meir 972 (3) 926-7516

PR Contacts United States Doris Li (973) 265-3752Israel Yonatan Beker 972 (54) 888 5898

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Teva Presented New Data at the European Academy of Neurology Congress Evaluating the AJOVY (fremanezumab) Experience in Populations with...

Use in treatment-nave patients drives recent growth of Biogen's Tecfidera and Genzyme's Aubagio in Canada, as reported switch share has remained flat over the past year - reflecting the continued shift in using established oral agents earlier in the multiple sclerosis treatment algorithm

EXTON, Pa., May 27, 2020 /PRNewswire/ -- The COVID-19 pandemic has (at least temporarily) transformed neurology practices and multiple sclerosis (MS) patient management patterns across Canada, according to the most recent report included in Spherix's RealTime Dynamix: Multiple Sclerosis (Canada) service. The report, which collected the responses of 50 Canadian neurologists surveyed between April 6th and May 2nd, found that 90% of respondents indicate the novel coronavirus outbreak has had a high impact on their practice. While preference for induction versus escalation treatment was clearly on the rise prior to the pandemic, new data suggest a potentially transient reversion to more conservative disease-modifying therapy (DMT) treatment patterns.

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Neurologists express hesitation to prescribe or re-dose patients with immunosuppressive DMTs, namely Roche's Ocrevus, Sanofi Genzyme's Lemtrada, and EMD Serono's Mavenclad, due to increased risk of complications or death among MS patients infected with the novel coronavirus. One surveyed neurologist states "becoming more aggressive in [the] treatment of highly active MS" prior to the COVID-19 pandemic, which has now resulted in "more caution with immune-suppressing therapies." This mindset has resulted in a leveling off of reported shares for the immunosuppressant DMTs.

Along with the trajectory of COVID-19 spread, the permanency of COVID-19-related impacts on high-efficacy DMT use remains uncertain. Neurologists anticipate Mavenclad and Ocrevus use to rebound over the next six months, suggesting optimism that MS patient management may soon return to normal. Conversely, Lemtrada share has declined and is projected to remain depressed in the future, bringing into question whether COVID-19 has simply hastened shrinking use of the DMT that may have already occurred as a result of new reports of vascular and immune-related safety concerns.

Regardless, strong preference for Ocrevus, as well as continued uptake among patients recently started on or switched to a new DMT, hints at potential resiliency to COVID-19-related disruption for Roche's brand. The DMT has now established a clear lead within the recently switched segment, following a 60% increase in reported share of recent switches compared to one year ago. Moreover, Ocrevus use among recent new starts has also grown over the same time period, despite caution in early-line DMT treatment paradigms with respect to DMTs that could impact immune response.

Among DMTs considered to be less/not immunosuppressive, uptake of Biogen's Tecfidera and Sanofi Genzyme's Aubagio for MS patients starting on their first DMT has propelled overall oral DMT class share of first-line prescribing to more than twice that of the interferon, glatiramer acetate (GA), and monoclonal antibody (mAb) DMT classes. Aubagio and Tecfidera alone currently account for more than half of recent DMT initiations. In fact, neurologists are more likely to prefer Aubagio than other agents for treatment-nave patients diagnosed with relapsing remitting MS (RRMS) presenting with less active disease. Amid considerable success within the new start patient segment, shares for Aubagio and Tecfidera among recently switched patients have remained relatively stable, resulting in moderate overall growth in use of these established oral DMTs which is being driven by a shift to earlier use in the treatment algorithm.

Story continues

While COVID-19 remains a concern, neurologist conservatism may limit uptake of any new DMTs. Nearly two thirds of respondents claim they are currently less likely than normal to prescribe any DMT recently approved or that may be approved in the coming months. Novartis' Mayzent, which received Health Canada approval in March, may be somewhat insulated from this apprehension as the first non-injectable DMT indicated to treat active secondary progressive MS (SPMS). Neurologists agree that Mayzent could become their preferred option in active SPMS, and some already say they would choose the agent over other DMTs for patients with active SPMS or disease transitioning from RRMS to SPMS. Nevertheless, with many neurologists believing that DMTs approved for RRMS are also effective in SPMS, the new market entrant will face considerable competition from high-efficacy DMTs indicated for RRMS, especially Ocrevus, upon expansion of market access and provincial formulary coverage.

Bristol Myers Squibb's Zeposia (ozanimod) and Janssen's ponesimod, late-stage pipeline S1P receptor modulators, will most likely be classified as immunomodulators that may impact immune response. Thus, as with Novartis' Gilenya and Mayzent, both agents, if approved, may face a suboptimal environment upon launch depending upon the length of the COVID-19 pandemic. Few neurologists express high interest in either Zeposia or ponesimod compared to other assessed pre-market DMTs, even those with immunosuppressive mode of action, such as Novartis' ofatumumab.

The next wave of the RealTime Dynamix series will continue to closely track Mayzent's launch, as well as provide a prelaunch assessment of ofatumumab. Spherix's assessment of unmet needs, along with analysis of DMT preferences by MS subtype, will further illustrate which pre-market DMTs have the most potential and likely confirm Aubagio's dominance in early RRMS and Ocrevus' sway in primary progressive MS.

About RealTime DynamixRealTime Dynamix: Multiple Sclerosis (Canada)is an independent service providing strategic guidance through rapid and comprehensive semiannual reports, which include market trending, launch tracking, and a fresh infusion of unique content with each wave. The next semiannual report publishes in November.

About Spherix Global InsightsSpherix Global Insights is a hyper-focused market intelligence firm that leverages our own independent data and expertise to provide strategic guidance, so biopharma stakeholders make decisions with confidence. We specialize in select immunology, nephrology, and neurology markets.

All company, brand or product names in this document are trademarks of their respective holders.

For more information contact:Meg Stabb, Neurology Insights DirectorEmail:info@spherixglobalinsights.comwww.spherixglobalinsights.com

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Amid the COVID-19 Pandemic, Neurologists in Canada Report Pulling Back from EMD Serono's Mavenclad and Sanofi Genzyme's Lemtrada, While Roche's...

Neuromodulatory systems in the brain heavily influence behavioral and cognitive processes. Understanding how these systems modulate perceptual behavior is a crucial steppingstone toward unraveling their roles in brain functions.

One particular neuromodulatory system is the noradrenergic system. Dysfunction of this system is linked to several neurological disorders, such as attention deficit hyperactivity disorder and post-traumatic stress disorder, and is a main target of current drug-administered treatments. But how these drugs work is not well understood.

In a paper published in the journal Neuropharmacology, UC Riversides Hongdian Yang and colleagues provide evidence that activating and suppressing the noradrenergic system in mice affects behavior and motivation in different but not opposite directions, laying the groundwork for understanding why some drugs work while others fail in treating neurological disorders.

We found that using drugs, commonly given to humans, to perturb the noradrenergic system in mice causally affects their motivational state and behavior, said Yang, an assistant professor of molecular, cell and systems biology, whose research focuses on neural circuit mechanisms underlying sensory perception, with potential applications in addressing anxiety and stress-related neurological disorders. Systemic activation and local activation of this system have different effects on behavior and motivation. Since drugs are administered in humans in a systemic manner, their possible off-target effects need to be considered in future work on drug design, drug effects, animal work, and interpreting results.

The researchers found that both localized and systemic suppression of the noradrenergic system impaired tactile detection in mice by reducing motivation. They were surprised to find that while locally activating the system enabled the mice to perform in a near-optimal regime, systemic activation of the system impaired their behavior by promoting impulsivity.

The research paper is the first from the Yang lab since he joined UCR in 2016. Yang received his bachelor's degree in physics from China's Nanjing University, and his doctorate in biophysics from the University of Maryland, College Park. He did postdoctoral research at Johns Hopkins University.

Yang was joined in the research by Jim McBurney-Lin, Yina Sun, Lucas S. Tortorelli, Quynh Anh Nguyen, and Sachiko Haga-Yamanaka of UCR.

The research was supported by UCR startup funds, a UC Regents Faculty Fellowship, a Klingenstein-Simons Fellowship Award in Neuroscience, and grants from the National Institute of Neurological Disorders and Stroke to Yang.

The research paper is titled Bidirectional pharmacological perturbations of the noradrenergic system differentially affect tactile detection.

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Why some drugs work and others don't in treating neurological disorders - UC Riverside

Article In Brief

Neurologists who work in hospital settings discuss the changes their institutions have made to address the surge in COVID-19 patients.

When a longtime patient developed worrisome neurological symptoms in March, W. David Freeman, MD, FAAN, a neurointensivist at Mayo Clinic in Jacksonville, FL, interfaced with him via telemedicine. The virtual visit averted a trip to a hospital emergency room teeming with potentially contagious patients during the COVID-19 pandemic.

Dr. Freeman's patient, who had had a brain aneurysm before age 40 several years ago, had slurred speech and numbness and weakness on one side of his body. To arrange a virtual consultation, Mayo Clinic's Connected care team guided the patient, a former Florida resident who now lives in another state, in how to access telehealth software on his home computer and connect with Dr. Freeman.

With those symptoms, first, we're always thinking about transient ischemic attack, a precursor to a severe stroke, said Dr. Freeman, professor of neurology and neurosurgery at Mayo Clinic, where he is medical director of the neurosciences intensive care unit. Seizure can be another mimic.

Before the virtual visit, symptoms had resolved, Dr. Freeman advised the patient to check in via telemedicine as needed and to schedule an in-person visit a few months later.

On the hospital side, Dr. Freeman was one of the first physicians at Mayo Clinic in Flordia to use a telemedicine robot positioned in the emergency department to examine acute stroke patients remotely for administration of intravenous recombinant tissue plasminogen activators.

Nowadays, these telepresense robots can be equipped with a stethoscope and ultrasound port, which may enable a nurse, respiratory therapist, and physician to listen to the lungs from another location.

Such a telemedicine robot enabled Lelie V. Simon, DO, an emergency medicine physician and department chair, to develop a process that led to the first virtual diagnosis of COVID-19 at the Jacksonville Mayo Clinic, with minimal use of personal protective equipment and exposure to staff, Dr. Freeman said.

Respiratory distress can be seen on observation by using the visual camera on the telemedicine robot if a patient is breathing heavily or in distress, without the stethoscope, Dr. Freeman explained. However, he said, not all patients can be examined this way, if they are uncooperative or already on a breathing tube and require a proxy examiner such as a nurse in personal protective equipment.

COVID-19 has also forced us to rethink and consolidate nursing and medical staff trips into an admitted patient's room, he noted, administering medications every four to eight hours, if possible, instead of spacing them out every one to two hours.

As the coronavirus pandemic continues to strain the resources of health care systems across the country, neurologists are turning to telemedicine to triage patients remotely. With sophisticated technologies, they can replicate much of a traditional doctor's visit by observing and communicating with patients without risking a life-threatening infection.

Limiting the number of in-person interactions by using telemedicine and other methods also preserves the limited supply of personal protective equipment for front-line workers and enables them to carry out their job duties as safely as possible.

We're in a crisis, said Jana Wold, MD, associate professor of neurology and director of the Veterans' Affairs stroke program at the University of Utah Clinical Neurosciences Center in Salt Lake City. We're trying to keep our workforce well and as minimally exposed as possible. Otherwise, we won't have a workforce.

Despite having to expend additional time and effort setting up the camera and other equipment for telemedicine, nurses and other staff recognize that these are unique and unprecedented times, added Dr. Wold, who is also director of the adult neurology residency program. Health care workers are fully aware that this is the time to be innovative and to use technology in ways that we haven't before.

Telemedicine isn't a new phenomenon for many academic medical centers, including the University of Utah School of Medicine, which operates a broad telestroke network with 27 sites in the traditional hub-spoke model.

But this is a first for us to use it in our own emergency department, as we would normally just see these patients in person, she said.

At New York-Presbyterian/Weill Cornell Medical College, situated at the epicenter of the US coronavirus outbreak, most neurologists with outpatient office hours have converted those appointments to telemedicine visits, said Louise M. Klebanoff, MD, vice chair of clinical operations in the department of neurology.

In her experience, video-based visits are more suited for established patients. She is more comfortable using telemedicine for patients she previously examined and found to be stable with a baseline abnormality.

For new patients, however, those types of visits are not as straightforward for Dr. Klebanoff, a general neurologist who welcomes diagnostic challenges that present with the management of headaches and migraines, neck and back pain, pinched nerves, dizziness, and vertigo.

Without actually examining the patient, it is really difficult to do the type of evaluation I need to do, she said. When assessing a patient for dizziness, the physical examination allows me to determine if they have low blood pressure causing light-headedness, trouble walking, or benign positional vertigo.

For truly urgent medical needs, Dr. Klebanoff said, patients should still visit the hospital emergency room. A coronavirus isolation protocol has been instituted at New York-Presbyterian/Weill Cornell Medical College.

At this time, our ED is separating COVID-19 patients from non-COVID patients, she said. We have assigned attending physicians who are usually doing outpatient appointments to rotate through the ED to care for these patients.

At least one attending physician in every subspecialty is available for telephone consultations on an as-needed basis. Patient assessments in the emergency department will be followed with office appointments once that becomes a possibility. Hospitalists, as well as attending physicians specializing in stroke and critical care, are working as part of inpatient teams treating COVID-19 patients, Dr. Klebanoff said.

The mounting difficulties facing neurology peers on the country's east coast are on the mind of S. Andrew Josephson, MD, FAAN, professor and chair of neurology at the University of California, San Francisco.

As a neurohospitalist, Dr. Josephson is preparing for a large surge in his region, just in case, by planning and changing workflows to be a step ahead of the acceleration in growth of coronavirus cases.

On the outpatient side, providers are conducting very few in-person visits, except for the most urgent cases. We are almost purely telehealth at this point, Dr. Josephson said.

He noted that a shelter-in-place order in San Francisco, coupled with many patients watching young children at home during school closures, have made virtual visits much more convenient for faculty, staff, and patients while also halting spread of the virus.

Around hospitalized patients, clinical teams are more conscious than ever of the need to wear personal protective equipment while tending to those who have endured a stroke, complications from epilepsy, and other neurological emergencies during the pandemic. Amid a widespread US shortage of masks and gowns, Dr. Josephson said, one clinician is typically tasked with performing a hands-on patient exam in a room of the intensive care unit while other providers observe through a glass window.

In addition, within the hospital, we have expanded our ability to do video visits, he added.

Only one provider may be in the room with a patient, but the rest of them, including trainees, and a multidisciplinary teamfor instance, a respiratory therapist, social worker, and chaplaincould be beaming in via telemedicine to participate in the visit. This approach saves the available personal protective equipment for first responders directly seeing patients while also preventing the virus from infecting patients and staff, Dr. Josephson said.

For the very few patients seated in outpatient waiting rooms, the medical center is helping them maintain social distancing by rearranging chairs far apart and cleaning the areas more frequently. Even before patients and employees enter, Dr. Josephson said, they must answer questions about symptoms potentially suspicious for coronavirus, such as fever and cough. Those with symptoms are directed to respiratory screening clinics to determine whether they need to undergo further testing.

Conducting departmental meetings virtually from his office, he has been able to interact with his colleagues remotely, most of whom are working from home.

We also want to make sure that we're preserving our workforce, he said, foreseeing backup plans to substitute for faculty and residents who may become ill.

At EvergreenHealth Neuroscience Institute and Medicine Hospitalists in Kirkland, Washington, care coordination has ramped up since the first US cases of coronavirus were confirmed at its facility on February 28, said David Likosky, MD, FAAN, executive medical director of the EvergreenHealth Neuroscience Institute.

Close collaboration with various area hospitals, the health department, and other governmental agencies has helped plan the allocation of resources to where they are most in demand. No one hospital can do it all alone without reliance on others in a public health emergency of this magnitude, said Dr. Likosky, who is also director of stroke and neurohospitalist programs.

Within the hospital setting, pulmonary critical care specialists may align with neurohospitalists in taking care of an individual who has suffered a stroke. You can see how this cascades out in a tier fashion to meet the needs of our patients, Dr. Likosky said. So far, he added, Evergreen Health has had enough ventilators to serve patients, as well as a sufficient supply of nurses, with some volunteering to work additional shifts.

For surge planning in the hospital setting, neurointensivists help back up pulmonary critical care specialists; neurohospitalist back up the neurointensivists, and clinic neurologists (who may have lighter schedules) back up the neurohospitalists.

You can see how this cascades out in a tiered fashion to meet the needs of our patients, Dr. Likosky said. So far, he added, EvergreenHealthalong with Washington state's aggressive and early social distancing and cancellation of elective surgeries and visitshas flattened the resources needed curve enough that, while there has been a significant strain, patients have not gone without ventilators or appropriate nursing care.

At Cleveland Clinic, telemedicine visits have also become the norm during the pandemic for evaluating neurological conditions and titrating medications for previously examined patients. In addition, there are ongoing preparations for the possibility that neurologists may need to help with the shortage of providers to care for critically ill patients, said Marisa McGinley, DO, a neurologist and assistant professor of medicine in the Cleveland Clinic Lerner College of Medicine.

The current plan for redeployment would be for neurologists to aid with caring for non-ICU patients, Dr. McGinley said. In order to prepare neurologists for these types of duties, educational sessions are being designed to provide useful information about potential situations they may encounter.

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In and Out of the Hospital, Neurohospitalists Shift Course... : Neurology Today - LWW Journals

The guideline subcommittee of the American Academy of Neurology (AAN) has updated practice recommendations on secondary stroke prevention and the management of patients with patent foramen ovale (PFO). The update was published in Neurology.

Current Evidence as the Basis for Recommendations

The guideline served as an update to the AANs practice advisory released in 2016, which provided clinical practice recommendations for secondary stroke prevention in patients with PFO. The AAN guideline subcommittee comprised a team of neurologists, internists, and cardiologists with experience and expertise in stroke and PFO. A systematic literature review was performed to identify new evidence that answered 2 key clinical questions.

The first question pertained to the role of percutaneous PFO closure in reducing stroke recurrence risk vs medical therapy only in patients with PFO who have had an otherwise cryptogenic ischemic stroke. The second question pertained to the role of anticoagulation in reducing stroke recurrence risk compared with antiplatelet therapy in this same patient population.

Based on current evidence, the guideline subcommittee suggests that percutaneous PFO closure likely reduces stroke recurrence in patients with cryptogenic stroke and PFO. The AAN subcommittee states that anticoagulation and antiplatelet medications could be equally effective in reducing recurrent stroke in these patients, according to available evidence.

Recommendation 1 Statements

In their first clinical recommendation statement, the AAN wrote that clinicians should thoroughly evaluate of patients who are being considered for PFO closure. This evaluation would help rule out alternative stroke mechanisms. The subcommittee also recommends that clinicians perform brain imaging to confirm stroke size, distribution, and the potential presence of either an embolic pattern or lacunar infarct. Complete vascular imaging should also be obtained in patients who are being considered for PFO closure. The ANN notes that vascular imaging, either MR angiography or CT angiography, should be performed on the cervical and intracranial vessels to identify dissection, atherosclerosis, or vasculopathy.

The subcommittee also recommends prolonged cardiac monitoring for 28 days or longer in patients being considered for PFO closure and who may be at risk of atrial fibrillation (AF). A baseline ECG can be used to screen for AF in these patients. A clinician who is experienced in treating stroke should perform a complete examination of the patient prior to PFO closure to ensure that PFO is the most plausible stroke mechanism. Clinicians should recommend against PFO closure if a higher-risk alternative stroke mechanism is identified.

Additionally, the guideline recommends that clinicians should assess for cardioembolic sources with transthoracic echocardiography and transesophageal echocardiography (TEE) assessment. The use of TEE would be appropriate if the first study fails to identify a high-risk stroke mechanism.

Recommendation 2 Statements

In their second series of recommendation statements, the AAN provided practice suggestions for patients over 60 years of age. The guideline states that a closure is recommended for patients in this age group who have a PFO and an embolic-appearing infarct with no other identified stroke mechanism, as long as the clinician discusses the potential benefits of the procedure. The guideline also recommends offering PFO closure in other populations, including patients between the ages of 60 to 65 years who have very few traditional vascular risk factors and no other identified stroke mechanism.

Younger patients, including those less than 30 years of age, can also receive PFO closure under the guideline recommendations if they have: a single, small; deep stroke less than 1.5 cm; a large shunt; and no evidence of vascular risk factors that would cause intrinsic small-vessel disease. The subcommittee also recommended a shared decision-making approach between patients and clinicians.

Recommendation 3 Statements

In the third series of statements, the AAN recommends the use of either antiplatelet medications or anticoagulation therapy in patients who choose to take medical therapy alone instead of PFO closure. For patients who are good candidates for PFO closure and require long-term anticoagulation because of either proven or suspected hypercoagulability, the AAN recommends that physicians counsel the patient on how the efficacy of closure and anticoagulation cannot be confirmed or discredited.

Call for Future Research

In their guideline, the AAN subcommittee wrote that additional research, including long-term and large-scale safety registries for patients who have received PFO closure are needed to assess the risk of device erosion, fracture, embolization, and thrombotic and endocarditis risks and the effect of residual shunts and incidence of AF.

Reference

Mess SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the guideline subcommittee of the American Academy of Neurology [published online April 29, 2020]. Neurology. doi: 10.1212/WNL.0000000000009443

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AAN: Updated Practice Recommendations on PFO and Secondary Stroke Prevention - Neurology Advisor

A University of Pittsburgh physician is leading an international effort to learn more about the link between COVID-19 and neurological symptoms, including stroke.

Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery, said reports have come in from all over the world that some COVID-19 patients are suffering strokes.

In some cases, people are reporting that folks are coming in primarily with a neurological disorder, and then later on, because of some degree of suspicion, they tested them for COVID and found them to be positive, Chou said. Of course, as a medical community, we're both interested and concerned.

Last week,the New England Journal of Medicine published a reportsummarizing the cases of five patients at Mt. Sinai Health System in New York City. All were under 50 years old, tested positive for COVID-19 and suffered large-vessel strokes within the same two-week period.

At least one Allegheny Health Network patient died after a COVID-related stroke. Sixty-four-year-old Mark Ramutis was riding out his symptoms at home when he awoke one morning unable to speak. At Allegheny General Hospital, a brain scan showed multiple clots and swelling in his brain. He died two days later.

What we have is sort of a fragmented picture where there are some examples of very young people without risk factors having stroke, said Dr. Ashis Tayal, a neurologist who directs stroke services at AHN. There are other examples of older adults with risk factors, also having severe forms of COVID, so it's difficult to reconcile those easily at this point."

Chou and her co-authors are seeking to determinewhether COVID-19 is a cause of stroke and other neurological symptoms, and if so, by what mechanism. She said it is unclear whether the novel coronavirus itself is causing the blood clots that are leading to strokes, or if the strokes are a secondary result of multiple organ failure among very sick patients.

The cases of the five Mt. Sinai patients complicate the latter theory, because their COVID-19 symptoms were not particularly severe. However, Chou cautioned that in areas such as New York City, where the virus has become endemic, it is possible that the fact that these patients had both strokes and COVID-19 could be coincidental.

My gut feeling will be theyre probably related, and thats what everybody's gut feeling is saying, Chou said. But as medical professionals and scientists, a gut feeling is not good enough.

More than 70 sites in 17 countries have registered through theNeurocritical Care Society websiteto collect patient data. Its difficult to launch a new study during a pandemic, said Chou, and the contagiousness of the novel coronavirus makes it particularly challenging. That means, for now, theyre focusing on the most basic data that providers are already collecting at patients bedsides, including age, symptom severity, underlying conditions, the results of basic blood tests and general neurological function. In later phases of the study, Chou and her colleagues hope to collect data from more advanced diagnostic tests, such as MRIs.

Its not clear how prevalent stroke and other neurological symptoms are in Covid-19 patients; thats one of the primary questions driving Chous research.

In order to know prevalence, we need to know how many people out there [have been infected with COVID-19], and from that we figure out what percentage or proportion of that population have this problem, Chou said. Because of the limited testing we still have we don't really know how much COVID there is in the community.

Chou expects the first results from the study to be available in late summer.

WESA receives funding from the University of Pittsburgh.

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Pitt Researcher Studying Link Between COVID-19 And Stroke - 90.5 WESA

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Researchers at the University of Pittsburgh have found a way to observe how misbehaving mitochondria can lead to neurological problems resembling neurodegenerative diseases in humans.

The study, publishedrecently in eLife,uses genetically-modified zebrafish larvae, whose see-through bodies give researchers a chance to watch whats happening inside their nervous system when mitochondria break down, such as during Parkinsons, Alzheimers, Huntingtons and chronic traumatic encephalopathy (CTE).

Edward Burton, M.D., Ph.D., associate professor of neurology at Pitt, UPMC Endowed Chair of Movement Disorders and neurologist at UPMC, and colleagues caused mitochondrial damage in specific compartments of zebrafish neurons, using technology developed by Marcel Bruchez, Ph.D., at Carnegie Mellon University.

Normal mitochondria (left, green) and light-damaged mitochondria (right)

Burton and colleaguesgenetically-modified zebrafish to express a protein called dL5 in the mitochondria of their neurons. The dL5 protein acts as a receptor that binds fluorescent molecules, which emit harmful oxygen molecules when exposed to red light, causing oxidative damage to the mitochondria.

The really big first here is that weve got a way of targeting a one micrometer component of specific cells in a whole animal, with absolute precision in terms of where and when the damage happens and how much damage there is, Burton said. Compare that to coarser techniques, such as adding chemicals to the zebrafishs water theres no way to control which cells get damaged.

Zebrafish with damaged mitochondria in their nervous systems (left) dont move around like normal zebrafish (right).

The researchers found that zebrafish with damaged mitochondria in their nervous system had no motor responses to stimulation. The mitochondria of affected zebrafish were swollen, losing many of their signature folds, in which ATP production the main energy units used by cells takes place. Without ATP, the neurons lost their membrane stability and started to die about a day after the initial light-evoked damage.

Zebrafish and human brains share many of the same structures and neuronal populations affected in neurodegeneration, such as dopamine-producing neurons that die in Parkinsons disease. By causing damage to the mitochondria of living zebrafish and observing what happened next, Burton and his team were able to glean insights into what might happen in humans with damaged mitochondria.

I look after Parkinsons disease patients clinically at UPMC, and from a clinicians point of view its very frustrating because we can only treat their symptoms, Burton said. We know they have damaged mitochondria. What I really need is a treatment that targets downstream events, to prevent the pathogenic cascade and arrest or slow the progression of clinical symptoms.

Burton and his lab have now restricted the expression of dL5 to only dopaminergic neurons in the brains of their zebrafish. Over the next one to two years, they expect to create a timeline of the biochemical events underlying cell death that mimics the one found in human patients.

Continued here:
Study Illuminates the Role of Mitochondria in Neurodegeneration - UPMC

The research report offers a comprehensive Coronavirus COVID-19 impact analysis of the Global Neurology Software Market, emphasizing on the key factors impacting the growth of the market. The factors affecting the growth of the market have been studied thoroughly and valuation of the market has been provided in the report. This report provides accurate information about various aspects, such as production chain, manufacturing capacity, and industry policies impacting the Global Neurology Software Market It analyzes the competitive landscape of this market and examined geographical distribution at length.

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Potential Impact of COVID-19 on Neurology Software Market Overview By New Technology, Demand And Scope 2020 To 2026 - Cole of Duty

MAY 03, 2020 --Daniella Sisniega, MD, a neurology resident at Mt. Sinai Medical Center in New York City, recently dusted off her stethoscope and headed for the frontlines of the COVID-19 pandemic.

She announced her intentions on twitter, saying she is happy to do her part.

Sisniega joins other neurology attendings, fellows, and residents across the globe who are joining the ranks of their critical care and emergency medicine colleagues to provide them with much-needed back up.

Sisniega had always planned to volunteer in some way. Then she learned from her program director that the ED at Elmhurst Hospital in Queens, New York, was understaffed and needed extra hands. She signed up.

"I am currently working on the side of the emergency department that sees the COVID patients that do not require NIPPV [nasal intermittent positive pressure ventilation] or intubation," she told Medscape Medical News.

"As a resident, I see and staff new patients, but if needed I also check all patient oxygen saturations, make sure to titrate oxygen supplementation, refill oxygen tanks or whatever else is needed. It's all-hands-on-deck."

Emergency care differs from neurology in multiple ways, Sisniega said. COVID-19 patients require acute treatment, a contrast to the long-term, follow-up care required by neurology patients.

"To say the least, working in the ED in the middle of a pandemic is very different from a normal day in neurology, but it makes me appreciate what my ED colleagues do."

Sisniega also worked with an ophthalmologist and two volunteer physician assistants to come up with an innovative solution when the hospital temporarily ran out of a type of essential mask, a success she also shared on Twitter:

A Global Effort

Sisniega is not the only one redeploying during the pandemic. Physicians from across the globe are stepping up to help. Tim Wilkinson, MD, a neurology resident in Edinburgh, Scotland, also saw the need and acted:

"It's still early days, but I've been enjoying the switch. It was daunting at first, but the respiratory team were very welcoming, and it didn't take me long to find my feet. I'd like to think they have accepted me as one of their own," Wilkinson told Medscape Medical News.

Wilkinson recommends that neurologists looking to join multidisciplinary COVID-19 efforts should review the acute patient management and best practices for prescribing palliative care. "These are the two main aspects of working on a COVID-19 ward," he said.

Neurologists in northern Italy, the epicenter of the COVID-19 outbreak in Europe, have also left their usual posts to help during the pandemic.

Anna Bersano, MD, PhD, at the cerebrovascular unit at Fondazione Istituto Neurologico Carlo Besta in Milan, told Medscape Medical News that many of her colleagues have redeployed to teams at other facilities, especially in Bergamo and Brescia.

"Other neurologists at bigger hospitals were reallocated to emergency wards or internal medicine wards," she said.

Although Bersano was willing to help out, she contracted the virus at the end of February. "I was not redeployed. I was fortunate enough only to have a long fever, muscle pain, and ageusia. Now I'm recovering," she said.

Neurosurgeons have also answered the call to help, especially those who find they have more time on their hands because of the large volume of canceled elective surgeries at their institutions.

"We are supporting the frontlines as we can, deploying to emergency room and ICU where we can be helpful," Martina Stippler, MD, a neurosurgeon at Beth Israel Deaconess Medical Center, Boston, Massachusetts, told Medscape Medical News.

Waiting in the Wings

The intensity of COVID-19 outbreaks in different regions varies widely, but neurologists are ready and willing to switch specialties should the local infection rate and caseload spike.

"There has definitely been an effect of COVID. While we have not experienced a surge, the hospital has a steady influx of COVID patients," said Shyam Prabhakaran, MD, professor and chair of neurology at the University of Chicago Biological Sciences, Illinois.

Neurologists remain ready to redeploy as needed. Not content to wait, some neurology faculty are volunteering for shifts in the ED to help triage patients for admission, he added.

"The ED faces staff shortages in dealing with the increase in patients with ILI [influenza-like illness]."

The pandemic has also changed the number of people coming to his institution for stroke care, Prabhakaran added.

"Stroke admissions and EMS transports are down compared to pre-COVID," he lamented. "This indirect public health aspect of the pandemic is a major concern as we fear stroke patients are delaying care or staying home altogether."

The faculty and trainees in the neurology department at the University of Miami School of Medicine have not yet had to redeploy either, Ralph Sacco, MD, chief of neurology, told Medscape Medical News. "We may be faced with this when we see a Florida surge in the future."

It's the same scenario in Seattle. David Tirschwell, MD, professor of neurology and medical director of Comprehensive Stroke Care, University of Washington, said his hospital, Harborview Medical Center, "did incredible planning" for COVID-19 but, so far, there's been no surge in cases.

He praised King County in Washington State for "a remarkable job at flattening the curve."

For this reason, he and other neurologists have not had to redeploy.

"We're right about at our peak hospital usage, and we have not filled our ICU beds with these patients," he noted. "We had a multistep plan we never had to fully implement because the massive surge like we're hearing about in NYC just hasn't materialized here."

"Be Kind"

Back in NYC, Sisniega said the diverse backgrounds and expertise of her new team members surprised her.

"We have volunteers from all specialties including dermatology, psychiatry, ophthalmology, and of course from all areas of the country," she said.

"No matter what their previous roles were attending, RN, resident everyone is ready to contribute in whatever way is necessary," she added. "Just today I met an ophthalmology attending whose role was to keep stock of the number of ventilators in the building."

Sisniega's neurology skills have come in handy. "As neurology residents we often respond to stroke codes and we're comfortable with sick patients whose medical history we're not familiar with," she said.

Neurologists are accustomed to acting quickly when patients suddenly decompensate. "Unfortunately, COVID patients can also decompensate unexpectedly," Sisniega said.

Her words of advice for other neurologists considering redeployment to help with COVID-19: "The patients are very scared and anxious. Be kind. You may be the only conversation they had that day."

References

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Neurologists Dust Off Their Stethoscopes, Join COVID Frontlines - MedicineNet

Sir, Amidst the appropriate, radical and urgent restructuring of our healthcare services in Ireland and internationally to deal with the global Covid-19 pandemic, it is also essential that patients with other urgent high-risk conditions are diagnosed, investigated and treated urgently.

Stroke is the most common cause of acquired physical disability and the second or third most common cause of death in adults in middle-high income countries. Most strokes are due to reduced blood supply to the brain and are called ischaemic strokes.

Some are preceded by a transient ischaemic attack (TIA), which is sometimes referred to as a warning stroke by patients, and this provides patients and doctors with an extremely important window of opportunity for urgent stroke prevention.

Symptoms last for less than 24 hours with a TIA (usually minutes) and for 24 hours with a stroke, but the symptoms are the same. TIAs cause the S symptoms: sight (blurring or loss of vision or double vision); speech (impaired expression, understanding or slurring); swallowing (less common than with stroke); strength (weakness of the face, arm and/or leg), sensation (usually numbness or reduced sensation and less commonly pins and needles on the face, arm and/or leg), or stability (sudden unsteadiness or a sensation of movement called vertigo).

In addition to our other work at Tallaght University Hospital, we continue to run a daily one-stop rapid access stroke prevention (Rasp) service which is co-ordinated by the vascular neurology and age-related healthcare and stroke medicine consultants on alternate weeks, in close collaboration with our colleagues in vascular surgery, cardiology, phlebotomy, medical administration and radiology.

We accept email referrals from our local GPs, emergency department physicians and hospital consultant colleagues via our local e-referral pathway, with a view to assessing all patients with suspected TIAs within 24 hours or on the same day if they have higher-risk clinical symptoms.

Since the start of the Covid-19 pandemic, we are concerned that local referrals to our vascular neurology Rasp outpatient service have decreased by at least 50 to 80 per cent over a three-week period compared with a similar time period in 2019.

Anecdotally, a trend towards reduced referrals and attendances with suspected TIAs is also happening in other parts of the country and is also occurring internationally. The same has happened with stroke.

Some patients might be having difficulty getting through to their own GPs due to their GPs extremely busy workloads, but we suspect some patients may simply be afraid to present to their GPs or emergency department with symptoms of suspected TIAs, or are dismissing such symptoms because of fear of contracting Covid-19 if they attend hospital.

Busy doctors are never looking for more work, but if patients have had symptoms suggestive of a TIA, we advise that they must make urgent contact with their GP, or attend their local emergency department if they cannot access their GP, or if symptoms occur outside of normal working hours, for immediate assessment. GPs or emergency department staff can then refer patients for urgent vascular neurology and stroke specialist assessment at their local service Rasp service if a TIA is suspected.

Practices vary through the country, but in our own hospital we have maintained access to expedited outpatient specialised blood tests and neurovascular investigations, with face-to-face assessments in appropriate personal protective equipment by a consultant with expertise in TIA and stroke care to establish an accurate diagnosis and begin urgent treatment to optimally prevent a potentially disabling stroke on the same day.

We also advise selected patients if a brief inpatient stay for other urgent investigations or treatment is necessary.

With this expedited approach, international studies indicate that one can prevent more than 80 per cent of strokes following a TIA if we are given the opportunity to do so.

Therefore, the message is to stay safe and follow all HSE guidelines on Covid-19 regarding social distancing, self-isolation and cocooning, etc, but please do not ignore your symptoms and do not stay at home if you have had a suspected TIA which needs urgent medical assessment and treatment. Yours, etc,

Prof DOMINICK

McCABE,

Dr ALLAN

McCARTHY,

Consultant Neurologists,

Tallaght University

Hospital.

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Stroke prevention during the pandemic - The Irish Times

Interim analysis of erenumab (Aimovig; Novartis) from the TELESCOPE study confirmed the monoclonal antibodys real-world and long-term safety and benefit in patients with episodic and chronic migraine.1,2

Data included 109 patients from Germany, and showed an average reduction of 8 migraine days with erenumab therapy. Additionally, 80% of the patients felt a reduction of intensity and 92% of patients had a reduction of frequency of their attacks. Using global impression scores, treating physicians noted 80% of the patients were rated as much improved or very much improved after receiving erenumab.

These data from TELESCOPE were accepted to the American Academy of Neurology (AAN) 2020 Annual Meeting. Erenumab, the first-in-class fully human monoclonal antibody against calcitonin-gene-related-peptide (CGRP) was approved by the FDA in May 2018 for the prevention of migraine after it showed significant improvement in 3 different clinical trials.

In addition to the aforementioned reduction of migraine days, treatment with erenumab triggered a first response in 75% of patients after their first injection.

These newly shared data reinforce Novartiss commitment to reimagine migraine care and add to the growing body of real world and long-term evidence demonstrating the efficacy of Aimovig for migraine prevention across the migraine spectrum, Estelle Vester-Blokland, MD, global head, Neuroscience Medical Affairs, Novartis Pharmaceuticals, said in a statement.

The TELESCOPE study included data from 70 headache centers from July 2019 to December 2019, and initially aimed to characterize the use of erenumab with regard to therapy decision, patient profiles, and quality of life from the treating patients perspective. Following that evaluation, each center documented the treatment effects and satisfaction of treatment outcomes in 1020 individual and consecutive patients with episodic and chronic migraine already into 3 months of erenumab treatment.

Novartis also announced interim results from the real-world PERISCOPE study, which included 91 patients who received erenumab with an overall mean disease duration of 18 years. Data showed that 85% of patients who received erenumab could cope better with daily activities and 83% lost fewer days to migraine since the start of their treatment.2

Long-term data results from a 4.5-year interim analysis of the open-label treatment phase of the phase 2 clinical trial demonstrated sustained reductions in monthly migraine days in patients with episodic migraine who received erenumab. An average of 5.8 fewer monthly migraine days were observed in patients who switched from 70 mg to 140 mg and remained on 140-mg erenumab for >4 years.

Novartis and Amgen are proud to lead the way based on the vast breadth of experience with Aimovig in showing how patients can take their life back from this highly debilitating disease, Vester-Blokland continued.

References:

REFERENCES1. Straube A, Stude P, Gaul C, Koch M, Schuh K. First one-year real world evidence data with the monoclonal antibody erenumab in Germany. Neurology. 2020;94 (15 Suppl). 18732. Novartis announces data in Neurology reinforcing the real-world and long-term effectiveness and safety of Aimovig as a preventive treatment across the full spectrium of migraine [news release]. Basel, Switzerland: Novartis; Published April 16, 2020. Accessed April 22, 2020. novartis.com/news/media-releases/novartis-announces-data-neurology-reinforcing-real-world-and-long-term-effectiveness-and-safety-aimovig-preventive-treatment-across-full-spectrum-migraine.

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Erenumab Improves Daily Functioning and Quality of Life - Neurology Times

With some pivotal trials on hold, the COVID-19 pandemic is slowing the pace of research in Alzheimer's disease (AD), stroke, and multiple sclerosis (MS).

However, researchers remain determined to forge ahead with many redesigning their studies, at least in part to optimize the safety of their participants and research staff.

Keeping people engaged while protocols are on hold; expanding normal safety considerations; and re-enlisting statisticians to keep their findings as significant as possible are just some of study survival strategies underway.

The pandemic is having a significant impact on Alzheimer's research, and medical research in general, says Heather Snyder, PhD, vice president, Medical & Scientific Relations at theAlzheimer's Association.

"Many clinical trials worldwide are pausing, changing, or halting the testing of the drug or the intervention," she told Medscape Medical News. "How the teams have adapted depends on the study," she added. "As you can imagine, things are changing on a daily basis."

The US Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER) trial, for example, is on hold until at least May 31. The Alzheimer's Association is helping to implement and fund the study along with Wake Forest University Medical Center.

"We're not randomizing participants at this point in time and the intervention which is based on a team meeting, and there is a social aspect to that has been paused," Snyder said.

Another pivotal study underway is the Anti-Amyloid Treatment in Asymptomatic Alzheimers study (the A4 Study). Investigators are evaluating if an anti-amyloid antibody, solanezumab (Eli Lilly and Co), can slow memory loss among people with amyloid on imaging but no symptoms of cognitive decline at baseline.

"The A4 Study is definitely continuing. However, in an effort tominimize risk to participants, site staff and study integrity, we have implemented an optional study hiatus for both the double-blind andopen-label extension phases," lead investigator Reisa Anne Sperling, MD, told Medscape Medical News.

"We wanted to prioritize the safety of our participants as well as theability of participants to remain in the studydespitedisruptions from the COVID-19 pandemic," said Sperling, who is professor of neurology at Harvard Medical School and director of the Center forAlzheimer Research andTreatment at Brigham and Women'sHospital andMassachusetts GeneralHospital in Boston.

The ultimate goal is for A4 participants to receive the full number of planned infusions and assessments, even if it takes longer, she added.

Many AD researchers outside the United States face similar challenges. "As you probably are well aware, Spain is now in a complete lockdown. This has affected research centers like ours, Barcelonaeta Brain Research Center, and the way we work," Jos Lus Molinuevo Guix, MD, PhD, told Medscape Medical News.

All participants in observational studies like the ALFA+ study and EPAD initiatives, as well as those in trials including PENSA and AB1601, "are not allowed, by law, to come in, hence from a safety perspective we are on good grounds," added Molinuevo Guix, who directs the Alzheimer's disease and other cognitive disorders unit at the Hospital Clinic de Barcelona.

The investigators are creating protocols for communicating with participants during the pandemic and for restarting visits safely after the lockdown has ended.

A similar situation is occurring in stroke trials. Stroke is "obviously an acute disease, as well as a disease that requires secondary prevention," Mitchell Elkind, MD, president-elect of the American Heart Association, told Medscape Medical News.

"One could argue that patients with stroke are going to be in the hospital anyway why not enroll them in a study? They're not incurring any additional risk," he said. "But the staff have to come in to see them, and we're really trying to avoid exposure."

One ongoing trial, the AtRial Cardiopathy and Antithrombotic Drugs In Prevention After Cryptogenic Stroke (ARCADIA), stopped randomly assigning new participants to secondary prevention with apixaban or aspirin because of COVID-19. However, Elkind and colleagues plan to provide medication to the 440 people already in the trial.

"Wherever possible, the study coordinators are shipping the drug to people and doing follow-up visits by phone or video," said Elkind, chief of the Division of Neurology Clinical Outcomes Research and Population Sciences at Columbia University in New York City.

Protecting patients, staff, and ultimately society is a "major driving force in stopping the randomizations," he stressed.

ARCADIA is part of the StrokeNet prevention trials network, run by the NIH's National Institute of Neurologic Disorders and Stroke (NINDS). Additional pivotal trials include the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) and the Multi-arm Optimization of Stroke Thrombolysis (MOST) studies, he said.

Joseph Broderick, MD, director of the national NIH StrokeNet, agreed that safety comes first. "It was the decision of the StrokeNet leadership and the principal investigators of the trials that we needed to hold recruitment of new patients while we worked on adapting processes of enrollment to ensure the safety of both patients and researchers interacting with study patients," he told Medscape Medical News.

Potential risks vary based on the study intervention and the need for in-person interactions. Trials that include stimulation devices or physical therapy, for example, might be most affected, added Broderick, professor and director of the UC Gardner Neuroscience Institute at the University of Cincinnati in Ohio.

Nevertheless, "there are potential waysto move as much as possible toward telemedicine and digital interactions during this time."

At the national level, the COVID-19 pandemic has had an "unprecedented impact on almost all the clinical trials funded by NINDS," said Clinton Wright, MD, director of the Division of Clinical Research at NINDS. "Investigators have had to adapt quickly."

Supplementing existing grants with money to conduct research on COVID-19 and pursuing research opportunities from different institutes are "some of the creative approaches [that] have come from the NIH [National Institutes of Health] itself," Wright said. "Other creative approaches have come from investigators trying to keep their studies and trials going during the pandemic."

In clinical trials, "everything from electronic consent to in-home research drug delivery is being brought to bear."

"A few ongoing trials have been able to modify their protocols to obtain consent and carry out evaluations remotely by telephone or videoconferencing," Wright said. "This is especially critical for trials that involve medical management of specific risk factors or conditions, where suspension of the trial could itself have adverse consequences due to reduced engagement with research participants."

For participants already in MS studies, "each upcoming visit is assessed for whether it's critical or could be done virtually or just skipped. If a person needs a treatment that cannot be postponed or skipped, they come in," Jeffrey Cohen, MD, director of the Experimental Therapeutics Program at theMellen Center for Multiple Sclerosis Treatment and Researchat the Cleveland Clinic, Ohio, told Medscape Medical News.

New study enrollment is largely on hold and study visits for existing participants are limited, said Cohen, who is also president of the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).

Some of the major ongoing trials in MS are "looking at very fundamental questions in the field," Cohen said. The Determining the Effectiveness of earLy Intensive Versus Escalation Approaches for RRMS (DELIVER-MS) and Traditional Versus Early Aggressive Therapy for Multiple Sclerosis (TREAT-MS) trials, for example, evaluate whether treatment should be initiated with one of the less efficacious agents with escalation as needed, or whether treatment should begin with a high-efficacy agent.

Both trials are currently on hold because of the pandemic, as is the Best Available Therapy Versus Autologous Hematopoietic Stem Cell Transplant for Multiple Sclerosis (BEAT-MS) study.

"There has been a lot of interest in hematopoietic stem cell transplants and where they fit into our overall treatment strategy, and this is intended to provide a more definitive answer," Cohen said.

"The pandemic has been challenging" in terms of ongoing MS research, said Benjamin M. Segal, MD, chair of the Department of Neurology and director of the Neuroscience Research Institute at The Ohio State University Wexner Medical Center, Columbus.

"With regard to the lab, our animal model experiments have been placed on hold.We have stopped collecting samples from clinical subjects for biomarker studies.

"However, my research team has been taking advantage of the time that has been freed up from bench work by analyzing data sets that had been placed aside, delving more deeply into the literature, and writing new grant proposals and articles," he added.

Two of Segal's traineesare writing review articles on the immunopathogenesis of MS and its treatment. Another postdoctoral candidate is writing a grant proposal to investigate how coinfection with a coronavirus modulates CNS pathology and the clinical course of an animal model of MS.

"I am asking my trainees to plan out experiments further in advance than they ever have before, so they are as prepared as possible to resume their research agendas once we are up and running again," Segal said.

Confronting current challenges while planning for a future less disrupted by the pandemic is a common theme that emerges.

"The duration of this [pandemic] will dictate how we analyze the data at the end [for the US POINTER study]. There is a large group of statisticians working on this," Snyder said.

Harvard Medical School's Sperling also remains undeterred.

"This is definitely a challenging time, as we must not allow the COVID-19 to interfere with our essential mission to find a successful treatment to prevent cognitive decline in AD. We do need, however, to be asflexible as possible to protect our participants and minimize the impact to our overall study integrity," she said.

Molinuevo Guix, of the Barcelonaeta Brain Research Center, is also determined to continue his AD research.

"I am aware that after the crisis, there will be less [risk] but still a COVID-19 infection risk, so apart from trying to generate part of our visits virtually, we want to make sure we have all necessary safety measures in place. We remain very active to preserve the work we have done to keep up the fight against Alzheimer's and dementia," he said

Such forward thinking also applies to major stroke trials, said University of Cincinnati's Broderick.

"As soon as we shut down enrollment in stroke trials, we immediately began to make plans about how and when we can restart our stroke trials," he explained. "One of our trials can do every step of the trial process remotely without direct in-person interactions and will be able to restart soon."

An individualized approach is needed, Broderick added.

"For trials involving necessary in-person and hands-on assessments, we will need to consider how best to use protective equipment and expanded testing that will likely match the ongoing clinical care and requirements at a given institution.

"Even if a trial officially reopens enrollment, the decision to enroll locally will need to follow local institutional environment and guidelines. Thus, restart of trial enrollment will not likely be uniform, similar to how trials often start in the first place," Broderick added.

The NIH published uniform standards for researchers across its institutes to help guide them during the pandemic.

Future contingency plans also are underway at the NINDS.

"As the pandemic wanes and in-person research activities restart, it will be important to have in place safety measures that prevent a resurgence of the virus, such as proper personal protective equipment for staff and research participants, said Wright, the clinical research director at NINDS.

For clinical trials, NINDS is prepared to provide supplemental funds to trial investigators to help support additional activities undertaken as a result of the pandemic.

"This has been an instructive experience.The pandemic will end, and we will resume much of our old patterns of behavior," said Ohio State's Segal."But some of the strategies that we have employed to get through this time will continue to influence the way we communicate information, plan experiments, and prioritize research activities in the future, to good effect."

Snyder, Sperling, Molinuevo Guix, Elkind, Broderick, Wright, Cohen, and Segal have disclosed no relevant disclosures.

Follow Damian McNamara on Twitter: @MedReporter. For more Medscape Neurology news, join us on Facebook and Twitter.

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Trials and Tribulations: Neurology Research During COVID-19 - Medscape

Article In Brief

The AAN, the American Neurological Association, and the American Epilepsy Society have responded to the call for action to address systemic racismwith initiatives that look specifically at what the field of neurology can do.

The American Academy of Neurology and other neurology organizations, like many other medical organizations, are grappling with the problem of systemic racism in health care and in their own organizations. And they have committed to taking sustained and specific actions to become genuinely anti-racist organizations.

Strong public statements are important, but we have to put action behind them, AAN President James C. Stevens, MD, FAAN, a specialist in sleep disorders medicine at the Fort Wayne Neurological Center in Indiana, told Neurology Today in a telephone interview.

Beginning in 2014, the AAN created its Diversity Leadership Program, and since then a variety of other task forces and leadership groups have worked on addressing issues of inequity, diversity, and inclusion within neurology and in the Academy.

In the fall of 2018, the Joint Coordinating Council on Equity, Diversity, Inclusion, and Disparities was established to ensure that recommendations from these groups, including the Diversity Leadership Program, Gender Disparities Task Force, and the Health Care Disparities Task Force, would be implemented across the entire organization.

But although a lot of work has been done, events of the past few months, including the heinous murder of George Floyd in Minneapolis, the home of AAN headquarters, have rightly focused people's attention on these injustices, and demonstrated that we must do much more, Dr. Stevens said.

So in early June, the Academy announced the creation of a special commission to recommend specific short-term and long-term action steps for the AAN to take toward becoming an anti-racist organization.

The AAN commits to enact sustained change for our members and patients, Dr. Stevens said in a statement released at the time. In this historic moment, we are resolved to pursue bold action beyond rhetoric and stand with the communities we serve to eliminate inequities that are antithetical to our values and the pursuit of our vision and mission.

These action steps will be presented to the AAN Board of Directors for review and approval by late summer.

What we need is not a knee-jerk, one-time response, but a sustained change in the way the organization approaches these issues, said Jeffrey McClean II, MD, FAAN, chair of the AAN Equity, Diversity, and Inclusion Joint Coordinating Council. That's why we created this special commission, to take a deep dive into the organization and the field and look comprehensively at what changes need to be made, both now and in the future, to sustainably move toward that ideal of being a fully inclusive and anti-racist organization.

The AAN Board charged the special commission to address two broad areas of focus: (1) the AAN itselfboth its structural composition and its programmatic workand changes necessary to achieve anti-racist goals; and (2) disparities in care, particularly within neurology and the neurosciences, and how the Academy can use its influence, resources, and expertise to mitigate and reduce these disparities.

The special commission includes chairs or vice chairs of all the major AAN committees, as well as chairs or editors-in-chief of all other major entities in the Academy, including its publications.

We have expertise about how the organization works and what it does from top to bottom, said Dr. McClean. We have combined that expertise and influence with a number of at-large members who have spent a lot of time working on issues related to equity, diversity, inclusion, anti-racism, and social justice.

Since early June, the special commission has conducted several large group meetings and small group breakouts (all virtual), and researched organizations in multiple different fields that have pursued organizational change to become anti-racistmost of them outside medicine.

We've used those lessons to inform us as we evaluate where the Academy is now, and what concrete steps to take toward becoming an anti-racist organization, Dr. McClean said.

Groundwork for the commission's work was also laid by a powerful presentation from members of the AAN's Emerging Leaders Program, who had been charged in October of 2019 with researching the question of how the Academy could become a fully inclusive society.

They were detailed in their recommendations and gave us a vision for the Academy moving forward, which really formed the foundation for the special commission as we looked into specific things to recommend to the Board of Directors, Dr. McClean said.

The special commission recently finalized its report for review, first by the Equity, Diversity and Inclusion Joint Coordinating Council and then by the AAN Board of Directors. The report and recommendations will be released publicly in the fall.

Even as the special commission conducted its work, further actions to pursue anti-racist goals were already underway at the AAN. In July, the AAN and Neurology Today hosted a webcast on health care disparities in the time of COVID-19, featuring Richard S. Isaacson, MD, FAAN, founder and director of the Alzheimer's Prevention Clinic at NewYork-Presbyterian/Weill Cornell Medical Center and Richard T. Benson, MD, PhD, director of the Office of Global Health and Health Disparities in the Division of Clinical Research at the National Institute of Neurologic Disorders and Stroke.

The broadcast focused on what AAN members can do to reduce disparities within their institution, how NIH and NINDS are working to address health care disparities across the country, and the importance of developing a diverse pipeline.

And on July 22, the AAN announced the establishment of a new Underrepresented in Neurology section, formed by leaders from the Society of Black Neurologists (SBN).

SBN was created about 18 months ago, explained Jimmy V. Berthaud, MD, MPH, an assistant professor in the department of neurology at the University of Michigan Medical School. At the time, there was really no overarching group for underrepresented minorities in the field of neurology to come together, so a small group of us decided to form a society on Facebook.

After SBN had reached more than 100 membersit now has more than 200Dr. Berthaud and other group leaders approached Dr. McClean about creating an official AAN Section. Less than a month after its founding in July 2020, the new section already had more than 50 members.

And in June, the SBN authored a powerful message on Neurology's blog site. Many of us have had the unfortunate experience of being called Ngger and other derogatory words by patients and colleagues. We are often mistaken for other health care workerscommonly janitors, maids, food service workers, and nurseseven while wearing our white coats and identification badges, wrote Dr. Berthaud and colleagues, including Ima Ebong, MD; Aaron Anderson, MD; Shaun Smart, MD; Uzo Ugochukwu, MD; and Andrew Spector, MD.

If not wearing our white coats, we are often not recognized by our colleagues in the hallways of our hospitals and clinics. We endure daily microaggressions regarding our physical appearances, including chosen styles of hair, and choice of attire. Yet we still pride ourselves to provide the best unbiased care possible to patients of all races, regardless of their perceptions of us as Black people.

The SBN and the section's immediate goals are to significantly increase their numbers and help to grow the pipeline of people of color coming into the field. Only about 2 to 3 percent of practicing neurologists are Black, and we want to increase those numbers, Dr. Berthaud told Neurology Today. For example, we recently held a Zoom forum for current medical students on how to apply for neurology residency positions, which had about 25 to 30 participants.

Like the AAN, the American Neurological Association (ANA), which represents academic neurologists and neuroscientists, is undergoing a similar self-examination on issues of race.

We first had to accept the fact that for the 143 years of our existence, we have been a relatively exclusionary society, says ANA President Justin C. McArthur, MBBS, FAAN, FANA, chair and professor of neurology at Johns Hopkins and founding director the of the Johns Hopkins/National Institute of Mental Health Research Center for Novel Therapeutics of HIV-associated Cognitive Disorders.

Until 15 years ago you could only get into the ANA by being nominated and selected. Those rules were changed with the intent of making the ANA more diverse, younger and more forward-looking, but in terms of social justice and equity, we know that the ANA has to take concrete steps to move us from where we were as an organization toward where we want to be.

The organization has created a new task force on Inclusion, Diversity, Equity, Anti-Racism and Social Justice (IDEAS) to address the diversity of its membership and representational leadership and fund health care disparities research. IDEAS has established an endowed lectureship in the name of Audrey Penn, MD, the first and only Black woman president of the ANA, who will help the organization select its first speaker for 2021.

The ANA has also developed a social justice Zoom series in partnership with Johns Hopkins, with sessions every Thursday from July into early September. We will have a series of speakers educating our members about systemic racism, implicit bias, and structural elements in our society that have led to health care disparities, said Dr. McArthur. Nearly 200 participants joined the first session, which featured Maya R. Cummings, PhD, former chair of the Maryland Democratic Party and the widow of Congressman Elijah Cummings (D-MD).

In October, the ANA will host a four-hour social justice symposium as part of its virtual Annual Meeting, which will include the presentation of a member survey on diversity and equity and a keynote address from Valencia Walker, MD, assistant dean for equity and diversity inclusion at the David Geffen School of Medicine at UCLA.

We are committed to making this a durable response, one that is self-sustaining, said Dr. McArthur. We have to be accountable for our outcomes and will use the social justice symposium at the ANA annual meeting to help us set those metrics. It's not a six-week feel-good campaign. We have been heavily influenced by some of our members of color who have courageously spoken up to candidly tell us that some of them do not feel welcome in our organization. That's a tough thing to say and we owe it to them to take change very seriously.

At the subspecialty society level, one organization that is planning significant, specific changes is the American Epilepsy Society (AES).

We have had an ongoing effort focused on diversity for the last several years, including a special task force on diversity in gender, and we had been working toward efforts on racial equity when the killings of George Floyd, Ahmaud Arbery and Breonna Taylor brought this issue to the forefront, said AES President William D. Gaillard, MD, FAAN, chief of the divisions of child neurology, epilepsy and neurophysiology at Children's National Hospital.

In response, we have created a Diversity, Equity and Inclusion Task Force, which will report to our board in September on goals and actions to embed in our new strategic plan.

Dr. Gaillard promises that the AES will embed within that strategic plan an ongoing process of addressing all levels of diversity, inclusion and equity, including the creation of a senior-level committee with ongoing responsibilities related to equity, diversity and anti-racism. The AES is also expanding on three existing efforts: These include prioritization of diversity, equity, and inclusion in the AES Fellows Program; an annual poster session at the AES Annual Meeting Better Patient Outcomes through Diversity; and governance that focuses on addressing diversity in appointments to serve on AES committees.

We view this as a long-term process, understanding that it requires constant effort, he said. This is one of those moments where I think it's possible to implement change because there is interest, enthusiasm, and a will to do things better.

While awaiting the release of the AAN special commission's recommendations in the fall, all neurologists can take action, starting with recommendations from the SBN's blog post.

Start with listening and most importantly believing when you hear what life is like for Black Americans, the SBN authors of the blog post wrote. The stories are not exaggerated. Take time to educate yourself with books like How to Be an Antiracist by Prof. Ibram X. Kendi, Black Man in a White Coat by Dr. Damon Tweedy, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present by Harriet Washington, or any of a number of similar resources. It is every physician's responsibility to learn what we can about a problem that is killing so many people.

Given the history of race and racism in our country, our society and in health care, the continuation of the effects of race and racism does not require that people actively perpetuate that system, said Dr. McClean. It has become self-perpetuating and it won't resolve on its own with time or even with increased diversity. It requires purposeful, proactive, and sustained action in order to reverse these things that have plagued our society for hundreds of years.

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More Than Words: Neurologic Societies Take Action On... : Neurology Today - LWW Journals

Receiving a diagnosis in 2020 at least one made at a medical center outfitted with the latest clinical gadgetry might include a scan that divides your body into a bread loaf of high-resolution digital slices. Your DNA might be fed through a gene sequencer that spits out your mortal code in a matter of hours. Even your smartphone is being used to uncover health problems and could maybe even help in detecting COVID-19 symptoms.

Yet nearly 130 years since its inception, after decades of science has mapped out our neuronal pathways, a simple knob of rubber with a metal handle remains one of medicine's most essential tools. I'm referring to the cheap, portable, easy-to-use reflex hammer.

This unassuming device can be invaluable in diagnosing nervous and muscular disorders, and in determining whether a patient's pathology lies in the brain or elsewhere in the body. It can also help curtail healthcare spending by preventing unnecessary, often expensive testing. Yet like so many major medical and scientific discoveries, the reflex hammer has humble origins in this case, the basement of a Viennese hotel.

The inn was run by the father of Leopold Auenbrugger, an 18th century doctor who is considered to be among the founders of modern medicine. To gauge how much wine was left for customers, hotel employees would thump casks with their hands and listen for a dull thud or hollow tympany. Auenbrugger realized that the same technique, now called "percussing," could be applied to the human torso to, say, determine how much fluid had built up around a diseased heart. He wrote as much in his 1761 paper "New invention to detect diseases hidden deep within the chest."

Leopold Auenbrugger (here with his wife, Marianne) is regarded as one of the founders of modern medicine, having applied the idea of detecting disease by sound.

Thought to be more accurate than the human hand, it wasn't long before percussion hammers were being designed to more precisely diagnose disease. Competition ensued.

Scottish physician Sir David Barry's model, released in the 1820s, was the first. German doctor Max A. Wintrich's came shortly after and was more popular but was not without its critics: "[Wintrich's hammer] is inconvenient to hold, it is rigid ... it required education to use it, and even then it does not fulfill its purposes," a rival inventor commented.

As neurologist Douglas J. Lanska wrote in a 1989 paper on the many types of reflex hammers, "Some were T-shaped or L-shaped, others resembled battle axes, tomahawks, or even magic wands." He adds that no material was off-limits: wood, ebony, whale bone, brass, lead, even "velvet-covered worsted" (a type of yarn).

As percussion hammer warfare waged on, doctors and scientists were also beginning to understand the concept of reflexes, or involuntary, near-immediate responses to stimuli that occur before any sensory information reaches the brain. Muscular jerks. Blinking. Sneezing. Gagging. All of these are automatic feedback loops between sensory and motor neurons that help us navigate our environment and protect us from danger.

In 1875, German neurologists Heinrich Erb and Carl Friedrich Otto Westphal were among the first to realize that eliciting a reflex by briskly tapping the tendons of major muscles might be useful. They felt that the knee jerk or "patellar-tendon" reflex in particular could help assess nerve function.

Anton Wintrich introduced this percussion hammer model in 1841.

Hammers specifically suited to test reflexes were soon developed, the first of which had the now classic shape we're accustomed to, a thin metal handle with a triangular rubber head. Designed by American physician John Madison Taylor in Philadelphia in 1888 and modified ever since by many the simple device was heavy enough to elicit reflexes and had round edges to ease impact. An entry-level model runs just $6.99 on Amazon.

The Krauss hammer, developed by German-American physician William Christopher Krauss, was designed around the same time. It had two rounded heads: a large one for knees and a smaller one for biceps. Dr Ernst L.O. Trmner's did too, but it tapered to a thin end to assess skin reflexes. There were also the Queen Square hammer, the Babinski hammer, the Buck hammer, and the Berliner hammer. The Stookey hammer flaunted a camel hair brush to get a better sense of touch sensation. The list goes on.

Daniella C. Sisniega is a neurology resident at Mt. Sinai Medical Center. At the 2017 American Academy of Neurology annual meeting, while still a medical student, she presented a poster explicating the reflex hammer's past. "I'm fascinated by how the reflex hammer started out as a percussion hammer but was [then] adapted to elicit reflexes and has been in every neurologist's tool box ever since," she says.

"I also did not know that the little rubber triangle was the first reflex hammer. I feel like I owe it an apology!" she joked, referring to the often lackluster quality of the inexpensive Taylors.

"The little tomahawk is included in the kit everyone receives when they enter medical school," she recalls. "The rubber is cheap and very light, while the other hammers are heavier on the head so that you can use the 'swing' of the hammer as opposed to the strength of the strike to test the reflex."

While welcoming technological advances in medicine, Mt. Sinai School of Medicine neurologist and multiple sclerosis expert Stephen Krieger doesnt hedge on the role of the reflex hammer in modern medical diagnosis.

"We could argue about the nuances of the hammer the Queen Square, the Tomahawk, plastic handle, metal handle, weighted, flexible or rigid but the hammer itself is always in the hand. Reflexes tell the story of neurologic diseases of all sorts," he says.

Krieger explains how disorders of the brain, like a stroke or brain tumor, result in hyperactive reflexes, while conditions affecting muscles and peripheral nerves usually result in reduced or nonexistent reflexes. Reduced reflexes, for example, are a common symptom of back pain due to degenerative disk disease.

Dr Andrew Wilner, a long-time Medscape contributor and staff neurologist at a county hospital in Memphis, Tennessee, recounts the story of one of his patients, who had back pain, weakness, and numbness of the legs. Wilner was leaning toward a diagnosis of either Guillain-Barr syndrome (GBS) an autoimmune disorder of peripheral nerves or a myelopathy, an injury of some kind to the spinal cord. Both conditions can lead to medical emergencies, but each requires drastically different treatment.

"The reflex hammer was arguably our most important tool in narrowing down the differential diagnosis," he says. "Had we found diminished or absent deep tendon reflexes, GBS would have been more likely. As it turned out, the patient had brisk pathological knee jerks, pointing to a lesion in the brain or spinal cord."

On the basis of these findings, Wilner ordered an imaging study of the patient's spinal cord, where a lesion was found as opposed to pursuing the costly tests involved in a GBS diagnosis.

Wilner feels that the simple art of interviewing and examining a patient can get overshadowed by the myriad new diagnostic technologies. When it comes to clinical tools, he feels that sometimes basic is better.

"Technology is glorious," admits Krieger, "and [it] will teach us things about patients that we could never have known or imagined. But the simple, elegant, inexpensive, almost plebeian swing of the reflex hammer has a cost-benefit ratio that I think no advanced technology will likely ever match."

This article originally appeared on Shots, NPR's health blog.

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Newswise The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) is honoring Vinay Chaudhry, MD, with the 2020 AANEM Distinguished Researcher Award for his many years of dedicated research and outstanding clinical care of patients with neuromuscular (NM) diseases.

Dr. Chaudhry has made significant contributions to research throughout his career. He has received more than 40 research grants, and is currently participating in 15 ongoing NM clinical trials. He has also been an author on over 80 peer-reviewed publications, over 20 book chapters, as well as more than 75 published abstracts. He has been in the forefront of defining clinical, electrophysiological, and IVIG responsiveness of multifocal motor neuropathy (MMN), a disease close to his heart.He has published extensively on chemotherapy-induced polyneuropathies (CIPN) from taxol, vincristine, suramin, thalidomide, and bortezomib. These papers have emphasized the dose-dependent nature of neuropathy and patterns of length-dependent distal symmetric neuropathy versus the nonlength dependent neuropathy.

"I continue to be involved in trials of myasthenia gravis, amyotrophic lateral sclerosis (ALS), and amyloid neuropathy. Electrophysiology remains the cornerstone of all my research and I have worked on several projects including motor unit estimates, motor unit number index, neuronal excitability studies, and electrophysiological methodological studies in ALS," Dr. Chaudhry said.

Dr. Chaudhry has been active in the AANEM for many years. He served as chair for both the AANEM CME Advisory Committee and the Journal Committee. He was a member of the Neuromuscular Vision Task Force, Membership & Ethics committee, and has served on the Muscle & Nerve Editorial Board. Dr. Chaudhry was also actively involved with ABEM, serving as an examiner for the ABEM certification exams in 2002, 2003, and 2007- 2013 and as the ABEM Secretary. AANEM is important to Dr. Chaudhry.

AANEM is a special organization of the physicians, by the physicians, and for the physicians practicing neuromuscular and electrodiagnostic medicine, said Dr. Chaudhry. AANEM meetings make me feel completely at home, providing the perfect opportunity to lean on, teach and interact with colleagues practicing in your field."

Dr. Chaudhry is currently a Professor of Neurology at John Hopkins University School of Medicine and Director of Neurology EMG Laboratory at the John Hopkins Hospital. At Johns Hopkins, he has also served as the Vice Chair of Clinical Affairs and Director of the Neurology Outpatient Center (2002-2013), and Director of Clinical Neurophysiology/Neuromuscular Fellowships (1996-2005), and Director of Neuromuscular Division (2001-2004). Dr. Chaudhry has been a member of AANEM since 1989 and has presented at over 20 sessions and symposiums at AANEM Annual Meetings since 1997. Dr. Chaudhry received his medical degree from the All-India Institute of Medical Services in New Delhi, India. He became house officer in internal medicine at Preston Hospital & Tynemouth Victoria Jubilee Infirmary in North Shields, England and senior house officer in internal medicine at Llanelli Hospital in Wales, United Kingdom. He obtained membership in the Royal College of Physicians (M.R.C.P.), equivalent to board certification in internal medicine. He went on to complete a residency in neurology at the University of Tennessee Center for Health Sciences and the University of Alabama in Birmingham. He was the chief resident during his last year of training. He then trained at Johns Hopkins, receiving subspecialty training in clinical and research aspects of neuromuscular diseases. Dr. Chaudhry has also been active with the American Academy of Neurology (AAN) serving on the board of directors from 2007 to 2011 and the chair of NM section of AAN (2001-2005). It was under his leadership that the Accreditation Council for Graduate Medical Education (ACGME) subspecialty NM examination was created.

About the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM)

Based in Rochester, Minnesota, the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) is the premier nonprofit membership association dedicated to the advancement of neuromuscular (NM), musculoskeletal and electrodiagnostic (EDX) medicine. The organization and its members work to improve the quality of patient care and advance the science of NM diseases and EDX medicine by serving physicians and allied health professionals who care for those with muscle and nerve disorders.

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Dr. Vinay Chaudhry Receives Distinguished Researcher Award - Newswise

Other pharmaceutical news is on orphan drugs, ALS trials, Theranos and more.

ABC News:For Company Behind Coronavirus Drug, Sharp Questions Over Pricing, Potentially Cheaper OptionAfter initial excitement about the discovery of a promising treatment for some coronavirus patients, executives with Gilead Sciences are now facing harsh criticism over the initial business decisions theyve made in the midst of a pandemic. In recent days, state leaders and a government watchdog group have leveled complaints against the company for the price point it set for its antiviral drug remdesivir, a promising treatment shown to diminish recovery time in hospitalized coronavirus patients, and for allegedly not more quickly pursing a potentially cheaper alternative. Gilead holds exclusive manufacturing rights for remdesivir. (Bruggeman, 8/13)

Stat:A Long-Awaited Report On Orphan Drugs In Europe Suggests Incentives To Pharma Need ChangeAfter being kept under wraps for a year, an expansive review of European regulations designed to spur development of drugs for rare diseases and children found the number of medicines has increased. But at the same time, drug makers often did not address some of the most urgent needs. Instead, the pharmaceutical industry sometimes targeted more profitable therapeutic areas, raising questions about whether incentives offered to the pharmaceutical industry should be changed, according to the long-awaited report from the European Commission. As in the U.S., these incentives include market exclusivity for a period of time. (Silverman, 8/12)

Boston Globe:'Were Going To Keep Going': A New Clinical Trials For ALS Gives Patients HopeAs a cardiologist, Dr. Marc Litt has plenty of arrows in his quiver for patients with heart disease: Medications that thin blood. Drug-coated stents that widen blocked arteries. Implants that replace damaged valves in minimally invasive surgery. But when the 63-year-old physician was diagnosed with ALS in March 2019 at Massachusetts General Hospital, he was dismayed to see how little medicine had to offer him. (Saltzman, 8/12)

In other pharmaceutical industry news

San Jose Mercury News:Theranos Founder Elizabeth Holmes Twice-Delayed Trial To Start In March: JudgeAfter being delayed twice by the coronavirus pandemic, the criminal trial of Theranos founder Elizabeth Holmes has been scheduled to start in March. Holmes, a Stanford University dropout who founded her now-defunct Palo Alto blood-testing startup in 2003, is charged with a dozen felony counts of fraud, and has denied federal government allegations that she and her co-accused, former company president Sunny Balwani, misled doctors and patients and bilked investors out of hundreds of millions of dollars. (Baron, 8/11)

Stat:4 Questions For Neurology Startups As Investment SurgesAs pharmaceutical companies stepped back from developing new drugs for neurological conditions, venture capitalists took a big step forward. Venture investors have poured more than $500 million into early-stage neurology startups this year, according to a recent health care venture capital report from Silicon Valley Bank more than six times as much money that was invested in the same over the first six months of last year. (Sheridan, 8/12)

CNN:CEO Does 180 Zoom Calls In Three Days To Help Take Company PublicBeing in charge of a health care company during a pandemic is a ton of work just ask Eric Hobbs, CEO of Berkeley Lights, who met with 180 investors over Zoom over three and a half days and lost 10 pounds over the process. You don't have to go on a virtual roadshow to work tirelessly in the drug business nowadays. Major drug companies are racing to develop a Covid-19 vaccine. But Hobbs says it won't be easy to come up with one that works right off the bat. (La Monica, 8/12)

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Gilead, Maker Of Remdesivir, Criticized As 'Taking Advantage Of The Situation' - Kaiser Health News