Read the most current news on neurologic diseases here! And we want your input. Leave your comments at the end of each article.
Friday, March 07, 2014
Bullets and Brains (2013), by Andrew Nathan Wilner, M.D., is a collection of more than 100 of the author’s interesting essays on neurology-related topics from Medscape.com. An epilepsy specialist and neurohospitalist, Dr. Wilner is also a medical journalist and member of the American Academy of Neurology. [Disclosure: he has written for Neurology Now.] His previous books include Epilepsy: 199 Answers and Epilepsy in Clinical Practice—both written for medical professionals.
Although Bullets and Brains is also written for a professional audience, the book avoids jargon and should be accessible to many Neurology Now readers, particularly those looking for more information on epilepsy. Dr. Wilner covers a range of topics in the epilepsy section: new drug treatments and causes of epilepsy, seizure-detection devices, various forms of stimulation (vagus nerve, trigeminal nerve), the continuing impact of stigma, and more.
If you have a subscription to Medscape.com, you can find the book’s content online. Perhaps one advantage of the print version is that related content is organized by topic instead of date, so that you don’t have to search for all of the TBI chapters, for example. However, section introductions would have been a useful addition and an opportunity to reflect on the information in the chapters from the perspective of the present, as many of the posts were written prior to 2013.
Nevertheless, the book is filled with solid coverage from someone who has been on the front lines of neurology. The chapters looking at study results are especially informative. In them, Dr. Wilner explains the methods and results of a large number of studies, points out strengths and weaknesses, and discusses the implications of findings in the context of related research.
Bullets and Brains is available on Amazon.com in paperback and Kindle.
For a full collection of Neurology Now articles on epilepsy, go to http://bit.ly/L2KnVM
Monday, March 03, 2014
by Olga Rukovets
For Jeffrey Kutcher, MD, the journey to the 2014 Sochi Winter Olympic Games began more than two years ago, when he was first approached by the medical director of the US Ski and Snowboard Association (USSA). The USSA was looking to update concussion management to reflect changes in the understanding of brain injury—and they wanted a neurologist on board.
Fortunately, Dr. Kutcher—director of the Michigan Neurosport Program, associate professor of neurology at the University of Michigan School of Medicine, and team physician with the Michigan Athletic Department—was just the man for that job. In addition to his impressive credentials as a sports neurologist and concussion specialist, Dr. Kutcher also knew his way around the slopes and the hockey rink.
Now, as the first full-time sports neurologist to attend the Olympics on behalf of Team USA, Dr. Kutcher is the official head neurologist for the USSA and all National Hockey League (NHL) players—regardless of their country; he is also a consultant for the entire US Olympic team in cases of concussions or brain injuries. “I see my involvement reflecting the overall evolution of the neurologist’s increasing role in sports medicine,” he says.
In an e-mail correspondence with Neurology Today, Dr. Kutcher described what life and medicine really look like in the Olympic Village.
HOW MANY PHYSICIANS DOES THE US OLYMPIC TEAM HAVE IN SOCHI?
Every specific team or sport representing the US does it a little differently and has a different set of needs. The US Olympic Committee has its own medical staff as well to provide another layer. I would imagine we have 30-35 physicians in Sochi, but that’s only a guess! In addition, we have an incredibly skilled staff of athletic trainers, physical therapists, and other clinicians. We have easily over 100 medical providers here for Team USA.
WHAT HAVE THE US OLYMPIC TEAM AND NHL ASKED YOU SPECIFICALLY TO DO?
My first responsibility is for the skiers and snowboarders, so I’m stationed in the mountain village. It’s an amazing experience to live with athletes and staff from so many countries! Essentially, every day I go from one event or training session to another, providing care on site—on course, if needed—and in our medical clinic in the village. In addition, being the only neurologist in Sochi for the US, I’m also available to care for any of our athletes, from any sport—from ice-dancing to curling—with any type of neurological problem. The NHL has also asked me to serve as a neurological consultant for any NHL player participating in the games, regardless of country.
HOW DID YOU HAVE TO PREPARE FOR COVERING THIS EVENT AS PART OF THE MEDICAL TEAM? HAVE YOU HAD ANY DEALINGS WITH MEMBERS OF THE OLYMPICS TEAM?
I’ve been dedicating time over the past two years getting to know the sports, athletes, and particular challenges that come along with the venues. Also, every December the USSA has a course for team physicians in Beaver Creek, CO where we practice our on-course emergency response. I’ve truly been amazed at how different these sports are from what I’m used to (team sports like football and hockey). I’ve also spent some time out in Park City, UT at the USSA Center of Excellence, getting to know the staff.
WHAT WOULD YOU EXPECT TO BE UNIQUE ABOUT COVERING THESE OLYMPIC GAMES? SOCHI?
So far, from a work perspective, I’ve been struck with how similar it feels to other sports I’ve covered and other venues. In the end, it’s all about caring for the athletes, so you need to focus on that. The rest of it then becomes background noise. As for Sochi and Russia, it’s been fantastic. It’s definitely a unique place with such amazing mountains so close to the sea. Every day has brought a little quirk here and there, unexpected things that amuse, but nothing too troublesome. One has to be careful not to get stuck on a gondola, however.
WHAT DOES YOUR PACKING LIST LOOK LIKE? ANY PARTICULAR TOOLS YOU EXPECT TO USE WHEN EVALUATING CONCUSSION ON THE SLOPES/ICE AT SOCHI?
All of our USSA athletes have gone through baseline testing and we can repeat those tests very simply in the clinic. Other than being on skis and carrying a radio to communicate with the medical and coaching staffs, I carry the usual neurological examination tools. Additionally, whenever any of our athletes are on course, whether in training or competition, one of us will also be carrying a (rather heavy) trauma pack.
I'VE READ THAT YOU SKI AND PLAY HOCKEY. ANY SPECIAL ADVICE OR TACTICS YOU HAVE FOR THE ATHLETES TO AVOID INJURY?
The number one piece of equipment for injury prevention is between your ears. Be aware, know your limits, and remained focused. Practice is also incredibly important, or course. Helmets should be in good condition and fit properly. After that, the biggest thing is to respond appropriately to injury. Get evaluated quickly and take your recovery seriously.
See Neurology Today's previous articles on Dr. Kutcher’s work in sports-related brain injury: http://bit.ly/1b2zUVI. Also, browse Neurology Now's collection of stories on brain injury and concussion: http://bit.ly/1g4WcCo.
Tuesday, February 25, 2014
by Richard Robinson
It is still a long ways away, but a truly bionic hand may be one step closer, according to a new study that demonstrated that when tactile sensation is delivered from an artificial hand to intact peripheral nerves, motor function improves. During the course of this 30-day trial, the subject using the prosthetic reported that the new artificial hand began to feel like a part of his own body. A description of this approach was published in the Feb. 5 issue of Science Translational Medicine.
The value of sensory feedback for control of an artificial limb has been understood for a long time, Paolo Maria Rossini, MD, PhD, co-leader of the study and director of the Institute of Neurology at Catholic University of The Sacred Heart in Rome, Italy, told Neurology Today. Current state-of-the-art hand prostheses rely on so-called “open-loop” control, in which the subject must use visual feedback to control the movement and position of the fingers of the hand. Visual feedback is useful, he said, but without tactile input, the hand may operate at only 25 percent efficiency in the natural environment. Many tasks, such as those requiring a delicate and graded grasp, may be impossible to perform.
The ideal prosthesis would instead employ “closed-loop” control, in which the hand’s actions generated sensory information to the brain, exploiting the pre-existing tight connection between tactile input and motor output. But that requires three key things, said study co-leader Silvestro Micera, PhD, director of the Translational Neural Engineering Laboratory at the Center for Neuroprosthetics, part of the Swiss Federal Institute of Technology in Lausanne, Switzerland.
FULLY ARTICULATED MECHANICAL HAND
Five years of developing those key features led to “LifeHand 2,” a fully articulated mechanical hand whose fingertips are covered in a pliable polymer. Pressure sensors are embedded in the tips of the index and little fingers. Wires lead from its base to an external computer, which in turn powers a set of multichannel electrodes. The electrodes are embedded in the remaining limb stump, where they contact the median and ulnar nerves.
The subject in this first-ever trial was a Danish man who, nine years earlier, had lost his left hand in a fireworks accident. The electrodes, thinner than a human hair, were implanted under general anesthesia, and two days later connected to the computer. Over several days, the researchers tested combinations of contacts and stimulation settings, eliminating those that registered as pain or temperature, while fine-tuning those that were sensed as pressure originating from the index and little finger.
“At the end of this mapping procedure, we retained a number of contacts, from which the subject was receiving stable sensation, very precisely localized in the missing hand,” Dr. Rossini said. “Next, we connected the hand. At this point, we had a system which was theoretically able to dispatch sensory information from distinct parts of the fingers, that the subject could localize quite precisely.”
Regulatory permission for the implant was limited to only 30 days, so it is not yet known how far this device might go to restoring daily function. Dr. Rossini referred to the subject as a “hero,” willing to undergo two major surgeries despite knowing he had nothing to gain in the end. “He worked with us, to help make a small step towards a solution for millions of people suffering from limb amputation.”
The team is already at work on a new iteration, with a goal of a fully wearable system than can be implanted for much longer periods.
For the extended discussion on the implications of this study for the future of bionic prosthetics, see the March 6 issue of Neurology Today. For previous coverage of similar devices, browse Neurology Now’s archives: http://bit.ly/1ljwxgE.
Friday, February 14, 2014
by Olga Rukovets
The concept of death by neurologic criteria — the irreversible loss of the clinical function of the whole brain, commonly known as brain death — is at the center of a very public ethical debate after two tragic stories-turned-legal-battles took the media by storm in January.
The first case involves 13-year-old Jahi McMath, who was declared brain dead after complications from a sleep apnea surgery, and whose family took Children’s Hospital Oakland in California to court for the right to move Jahi to a private facility that agreed to keep her on the ventilator despite the declaration. The second case of a 33-year-old paramedic, Marlise Muñoz, who was declared brain death while pregnant, had the family and hospital at odds for entirely different reasons — with the hospital refusing to follow the family’s wishes to take Marlise off the machines because of a misinterpreted Texas law.
The cases, albeit different, may reflect the gaps in public understanding of brain death and the continued uncertainty about the role that families of loved ones with disorders of consciousness should play in determining their fate and care, neurologists and neuroethicists interviewed for this article told Neurology Today.
Brain death can be a difficult concept for family members and the public to understand, but all 50 states recognize it as a form of death by either case or statutory law, said James Russell, DO, vice chair of the neurology department at Lahey Hospital and Medical Center and clinical professor of neurology at Tufts University School of Medicine. “It’s a generally well-accepted and documented concept, and no court has ever overturned a brain death diagnosis — although they have allowed religious exception in NY and NJ,” added Dr. Russell, who is also the vice chair of the Ethics, Law, and Humanities committee of the AAN.
“Whether the recent cases in the news reflect a broader public misunderstanding of the idea or a mistrust of the medical profession in general, I don’t know. But I worry about it,” Daniel Larriviere, MD, JD, acting chair of the Ochsner Neuroscience Institute in New Orleans, told Neurology Today.
Referring to the case involving the 13-year-old Jahi McMath, Dr. Larriviere, chair of the AAN Ethics, Law, and Humanities Committee, and member of the Neurology Today editorial advisory board, said he did not understand “the legal reasoning that would support a decision to let the family transport a dead body across the country for further ‘care,’” or issue a restraining order that kept the hospital from removing the girl’s ventilator.
Dr. Larriviere is concerned, as well, about the impact these case decisions could have on clinicians and other health care personnel who will be essentially [in the case of Jahi McMath] providing care for a dead body. Treating physicians may feel the effects “emotionally and psychologically, in their roles as healers as well as in terms of using scarce resources for a deceased person,” he said.
Stay tuned for the extended discussion from neuroethicists in the Mar. 20 issue of Neurology Today.
For now, see Neurology Now’s collection of stories on brain death: http://bit.ly/1f1UoNZ.
Friday, February 07, 2014
Is there a link between pesticide exposure and Parkinson’s disease (PD)? The question of association between environmental contaminants and neurological disorders is certainly not a novel one; and now, an epidemiological study published in the Feb. 4 print issue of Neurology adds to the growing body of evidence. UCLA researchers found that an individual's genetic makeup was a significant contributing factor in the strength of the pesticide and PD association; in the most exposed populations, individuals had a two- to six-fold increased risk of developing PD.
Led by Arthur G. Fitzmaurice, PhD, of the department of neurology at the David Geffen School of Medicine at University of California, Los Angeles, the authors of the paper had previously reported that a fungicide (benomyl) was associated with increased PD risk and damaged dopaminergic neurons by inhibiting in vitro and in vivo aldehyde dehydrogenase (ALDH) enzyme activity. For the Neurology paper, they set out to study whether environmental and genetic changes to neuronal ALDH enzymes increased risk of PD.
For the Neurology study, Dr. Fitzmaurice and colleagues developed an ex vivo assay to identify pesticides that could inhibit ALDH activity. These assays were then investigated for an association with PD within a population-based, case-control study called the Parkinson’s Environment & Genes Study. The study has been enrolling incident PD cases diagnosed no longer than 3 years before recruitment and population controls from 3 rural California counties (Fresno, Tulare, Kern) since 2001. The current study compared 360 patients with Parkinson's with 816 people from the same counties who did not have Parkinson's.
Of the 26 pesticides tested for their effects on neuronal ALDH activity, all of the metal-coordinating dithiocarbamates tested (e.g., maneb, ziram), two imidazoles (benomyl, triflumizole), two dicarboxymides (captan, folpet), and one organochlorine (dieldrin) inhibited ALDH activity, potentially via metabolic byproducts (e.g., carbon disulfide, thiophosgene), the authors reported. However, 15 screened pesticides did not inhibit ALDH.
Exposure to an ALDH-inhibiting pesticide was associated with two- to 6-fold increase in PD risk; genetic variation in ALDH2 exacerbated PD risk in subjects exposed to ALDH-inhibiting pesticides. Effect estimates for exposure at workplace addresses alone were smaller, but when there was also a genetic variation in ALDH2, this exacerbated PD risk in subjects exposed to ALDH-inhibiting pesticides.
Dr. Fitzmaurice and co-authors concluded that ALDH inhibition plays a role in PD pathogenesis, and certain pesticides should be avoided to reduce the risk of developing PD. The findings also suggest “that therapies modulating ALDH enzyme activity or otherwise eliminating toxic aldehydes should be developed and tested to potentially reduce PD occurrence or slow or reverse its progression particularly for patients exposed to pesticides.”
See Neurology Today's previous coverage of the association between pesticide exposure and Parkinson’s risk: http://bit.ly/LLSqX4. Browse Neurology Now's collection of articles on PD: http://bit.ly/172YIHY.