Chief Of Neurology Research Articles

Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department.

Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care.The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.

Altered mental status predicts length of stay but not death in a community-based cohort of hospitalized COVID-19 patients

IntroductionAltered Mental Status (AMS) is a common neurological complication in patients hospitalized with the diagnosis of COVID-19 (Umapathi et al., 2020; Liotta et al., 2020). Studies show that AMS is associated with death and prolonged hospital stay. In addition to respiratory insufficiency, COVID-19 causes multi-organ failure and multiple metabolic derangements, which can cause AMS, and the multi-system involvement could account for the prolonged hospital stay and increased mortality. In this study, we built on our previous publication (Chachkhiani et al., 2020) using a new, larger cohort to investigate whether we could reproduce our previous findings while addressing some of the prior study’s limitations. Most notably, we sought to determine whether AMS still predicted prolonged hospital stay and increased mortality after controlling for systemic complications such as sepsis, liver failure, kidney failure, and electrolyte abnormalities. ObjectivesThe primary purpose was to document the frequency of AMS in patients with COVID-19 at the time of presentation to the emergency room. Secondary aims were to determine: 1) if AMS at presentation was associated with worse outcomes as measured by prolonged hospitalization and death; and 2) if AMS remained a predictor of worse outcome after adjusting for concomitant organ failure and metabolic derangements. ResultsOut of 367 patients, 95 (26%) had AMS as a main or one of the presenting symptoms. Our sample has a higher representation of African Americans (53%) than the US average and a high frequency of comorbidities, such as obesity (average BMI 29.1), hypertension (53%), and diabetes (30%). Similar to our previous report, AMS was the most frequent neurological chief complaint. At their admission, out of 95 patients with AMS, 83 (88%) had organ failure or one of the systemic problems that could have caused AMS. However, a similar proportion (86%) of patients without AMS had one or more of these same problems. Age, race, and ethnicity were the main demographic predictors. African Americans had shorter hospital stay [HR1.3(1.0,1.7),p = 0.02] than Caucasians. Hispanics also had shorter hospital stay than non-Hispanics [HR1.6(1.2,2.1), p = 0.001]. Hypoxia, liver failure, hypernatremia, and kidney failure were also predictors of prolonged hospital stay. In the multivariate model, hypoxia, liver failure, and acute kidney injury were the remaining predictors of longer hospital stay, as well as people with AMS at baseline [HR0.7(0.6,0.9), p < 0.02] after adjusting for the demographic characteristics and clinical predictors. AMS at baseline predicted death, but not after adjusting for demographics and clinical variables in the multivariate model. Hypoxia and hyperglycemia at baseline were the strongest predictors of death. ConclusionAltered mental status is an independent predictor of prolonged hospital stay, but not death. Further studies are needed to evaluate the causes of AMS in patients with COVID-19.

ANA Webinars: Clinical and basic research resilience during COVID-19.

ANA Webinars: Clinical and basic research resilience during COVID-19.

Neurological complications in a predominantly African American sample of COVID-19 predict worse outcomes during hospitalization

People with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, COVID-19, can have neurological problems including headache, anosmia, dysgeusia, altered mental status (AMS), ischemic stroke with or without large vessel occlusion, and Guillen-Barre Syndrome. Louisiana was one of the states hit hardest by the pandemic with just over 57,000 laboratory-confirmed cases of COVID-19 by the end of June 2020.We reviewed the electronic medical records (EMR) of patients hospitalized during the peak of the pandemic, March 1st through March 31st, to document the type and frequency of neurological problems seen in patients with COVID-19 at presentation to the emergency room. Secondary aims were to determine: 1) the frequency of neurological complaints during the hospital stay; 2) whether the presence of any neurological complaint at presentation or any of the individual types of neurological complaints at admission predicted three separate outcomes: death, length of hospital stay, or the need for intubation; and 3) if the presence of any neurological complaint or any of the individual types of neurological complaints developed during hospital stay predicted the previous three outcomes.A large proportion of our sample (80 %) was African American and had hypertension (79 %). Out of 250 patients, 56 (22 %) patients died, and 72 (29 %) patients required intubation. Thirty-four (14 %) had a neurological chief complaint at presentation; the most common neurological chief complaints in the entire sample were altered mental status (AMS) (8 %), headache (2 %), and syncope (2 %). We used a competing risk model to determine whether neurological symptoms at presentation or during hospital stay were predictors of prolonged hospital stay and death. To establish whether neurological symptoms were associated with higher odds of intubation, we used logistic regression. Age was the only significant demographic predictor of death and hospital stay. The HR (95 %CI) for remaining in the hospital for a ten-year increase in age was 1.2, (1.1, 1.3, p < 0.0001), and for death was 1.3, (1.1, 1.5, p < 0.01).There were no demographic characteristics, including age or comorbidities predictive of intubation. Adjusting for age, patients who at presentation had neurological issues as their chief complaint were at significantly increased risk for remaining in the hospital, HR = 1.7, (1.1,2.5, p = 0.0001), and dying, HR = 2.1(1.1,3.8, p = 0.02), compared to patients without any neurological complaint. Of the individual admission complaints, AMS was associated with a significantly prolonged hospital stay, HR = 1.8, (1.0–3.3, p = 0.05). Patients that required dialysis or intubation or had AMS during hospitalization had more extended hospital stays. After adjusting for age, dialysis, and intubation, patients with AMS during hospital stay had a HR of 1.6, (1.1, 2.5, p = 0.01) for remaining in the hospital. Patients who had statistically significant higher odds of requiring intubation were those who presented with any neurological chief complaint, OR = 2.8 (1.3,5.8, p = 0.01), or with headaches OR = 13.3 (2.1,257.0, p = 0.008). Patients with AMS during the hospital stay, as well as those who had seizures, were more likely to need intubation. In the multivariate model, dialysis, OR = 4.9 (2.6,9.4, p < 0.0001), and AMS, OR = 8.8 (3.9,21.2, p < 0.0001), were the only independent predictors of intubation.Neurological complaints at presentation and during the hospital stay are associated with a higher risk of death, prolonged hospital stay, and intubation. More work is needed to determine whether the cause of the neurological complaints was direct CNS involvement by the virus or the other systemic complications of the virus.

Wallace William Tourtellotte, MD, PhD (1924–2019)

Wallace William Tourtellotte was born in Great Falls, Montana, on September 13, 1924, to winter wheat farmers Nathanial Mills and Victoria Frances (Charlton) Tourtellotte. Wallace became interested in science in high school as an Eagle Scout. He went to The University of Chicago on a full scholarship and graduated in 1945. He attended medical school at the University of Chicago with a full scholarship in one of the first MD/PhD programs in the nation. After graduating in 1951, he did his internship at The University of Rochester, followed by deployment as lieutenant at the Bethesda Naval hospital from 1952 to 1954. During those years, he met his wife to be, Dr. Jean Esther Toncray, graduate of the University of Michigan School of Medicine. They were married on Valentine's day, February 14, 1953, and had 4 sons, Wallace William, Jr., Georges Mills, James Millard, and Warren Gerard. The family moved to Ann Arbor, MI, where Wallace received residency training in neurology (1954–1957) and joined the Department of Neurology as Assistant Professor (1957–1959), Associate Professor (1959–1966), and Professor (1966–1971). He was Visiting Professor in Pharmacology at Washington University, 1963–1964. In 1971, he moved to Los Angeles, CA, where he became Professor and Vice Chair of Neurology at UCLA and Chief of Neurology at the VA in West Los Angeles. At the VA, he became founding director of the Neurology Residency Training Program and created the first of its kind fellowship program in Multiple Sclerosis (MS). In 1998, he became emeritus vice chair of Neurology and emeritus Chief of Neurology at the VA. He remained on the medical staff as neurologist and neuroscientist until 2011.

Fletcher H. McDowell 1923-2017.

Fletcher H. McDowell, MD, died at his home in New York City on April 23, 2017. He was 93 years old. Fletcher graduated from Dartmouth College and then from Cornell Medical School in 1947. He continued training in medicine there and at Stanford, returning to neurology residency with Harold Wolff at Cornell. He then joined the Army Medical Corps and was chief of neurology at army hospitals in Bad Kanstadt and Landstuhl, Germany, for 2 years. After discharge, he went to Queen’s Square for a year and returned to New York in the mid 50s. Wolff appointed him chief of the Cornell Neurological Service at Bellevue Hospital. There he became involved with studies of stroke diagnosis and prevention and also with new treatments for Parkinson’s disease. When the Bellevue service folded into one academic line, he returned to Cornell and became the director of the Burke Rehabilitation Hospital. This brief appreciation mentions some pillars in a life of achievement, but only partly describes the man. He was a founding editor of this journal, Stroke . With Clarke Milliken and Irving Wright in 1971 and a cast of neurological and neurosurgical luminaries from the Stroke Council of the American Heart Association, he particularly appreciated the need for a new outlet that would consolidate stroke manuscripts for a growing focused group of investigators. Thanks in large part to Milliken’s efforts, when Fletcher took over in 1978, the “child had …

In Memoriam: John F. Kurtzke, MD (1926-2015): A Founding Father of Neuroepidemiology and Pioneer of Modern Clinical Trial Design.

On December 1, 2015, we lost one of the most influential contributors to the field of medical epidemiology, and in particular the man who is credited for performing the most systematic exploration of the geographic distribution patterns for the most common disabling neurologic disorder of young people, multiple sclerosis (MS). John F. Kurtzke, MD, graduated from the Cornell Medical College in 1952, and by 1956 he had ascended to the position of chief of neurology for the Veterans Administration in Coatesville, Pennsylvania. He would later serve as professor of neurology at Georgetown University from 1963 to 1995, during which time he conducted some of the most seminal investigations that collectively helped to establish the field of neuroepidemiology. The role of one ormore environmental factors, including infections, as a critical factor in thepathogenesis ofMS is now widely recognized. It was Kurtzke’s pioneering work that brought forth some of the most persuasive evidence to date supporting a putative role for an infectious agent as a contributing factor in MS. When the presence of the disorder was nearly unheard of on the remote Faeroe Islands and in Iceland, the recording of many cases of MS following the occupation of these territories by the British troops during World War II fostered Kurtzke’s exploration into the infectious etiologic hypothesis as a contributing factor in the development of MS.1-8 The contemporary framework for thepathobiological underpinnings ofMS is nowmost consistentwith that of an epigenetic disorder predicatedongenetic, environmental, nutritional, and behavioral factors, in conjunction with a factor acting as a trigger or “ignition switch.” Kurtzke’s observations and interpretive conclusions resonate with contemporary thinking, particularly given his hypothesis that a modifying etiological factor for developing MS appeared to be influenced by the location, with respect to equatorial latitude, of early life development,withmounting evidence that corroborates thepostulated role of vitaminDas a criticalmitigating influence potentially linked to its relationship to immune regulatorynetworks and thederivative achievement of self-tolerance. Kurtzke’s secondmajor accomplishmentwas thedevelopment of the disability status scale score, which catapulted the clinical assessment within clinical trials from the reporting of the assessor’s subjective impressions to the establishment of anobjective, reproducible, andstereotypedgold-standardneurological examination and status ascertainment.9,10 This formidable contribution to the field of medical therapeutics resulted in the transformation of clinical trial design for MS in particular and set forth objective standards for the characterization of clinical outcomes to be emulated for disabling neurologic disorders in general. Originally proposed in 1955 and 1961, Kurtzke formulated anordinal scale for the application inMSdrug trials (initially for the assessment of isoniazid as a treatment forMS) as a means to objectify the effects of putative therapies on the clinical disposition of neurologic disability in MS.9 Initially conceived as a scale from0 (no evidence of signs, symptoms, or report of disabling changes in neurologic functioning or status) to 10 (death due toMSor its complications), the scale was later transformed into 0.5-point steps (the Expanded Disability Status Scale score) to account for the functional integrity of eachof the functional systemscales such as abnormalities affiliated with each of the components of the neurological examination: vision, brainstem functions, pyramidal functions (strength, reflexes, tone), cerebellar functions, sensory functions, bowel-bladder-sexual functions, cerebral functions (depression, euphoria, reduced mentation), and ambulation.10 The scale is an ordinal scale, heavily weighted on the impact anddeterioration inwalking, othermotor functions, and, toadegree, sensoryandvisual functions.Notwithstanding the ordinal nature of the scale, theheavybias on ambulation, and John F. Kurtzke, MD

Sidney Schulman, MD (1923–2014)

Sidney Schulman, MD, former Chief of Neurology at the Pritzker School of Medicine of the University of Chicago, died in Chicago on January 31, 2014, in his 90th year. He was born and educated at the University of Chicago and its medical school. He is survived by 3 children and many grandchildren; his wife Mary died in 2011. After his army service at the close of World War II, he became a neurologist and neuropathologist under the tutelage of Dr. Richard B. Richter, who founded the University of Chicago's Division of Neurology within the Department of Medicine in 1936. There was one trainee each year, and it was not until the 1970s that the number increased to 2. As residents in the 1960s, we worked with a faculty of 6 in a remarkably intimate way, arranging our own schedules and working as junior colleagues with memorable independence and responsibility.

Standardizing Neurological Assessments

Evaluation of neurological status is imperative to patient assessment. Multiple assessment tools are readily available for clinicians to diagnose and report changes in neurological condition. Some of these tools include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale, the Canadian Neurological Scale, and the Four Score. Although assessment tools are beneficial to help standardize the assessment and communication of findings, they are at times cumbersome, leaving bedside clinicians with questions concerning which tool is appropriate for a given patient population. This initiative began as a means to standardize assessments and communication for neuroscience patients. As success was met, the project was moved forward locally at our hospital campus and later extended to the entire health system. With the support of the chief of neurology, the neuroscience patient care services director, the stroke coordinator, and the neuroscience clinical educator, three different neurological examinations were developed. They were defined as the Basic Neurological Check, the Coma Neurological Check, and the National Institutes of Health Stroke Scale/Stroke Neurological Check. The neurological examinations would address the assessment needs of patients with acute stroke, general neurosurgery/neurology patients, and patients in coma.

H. Royden Jones, Jr., MD (1936–2013)

H. Royden Jones Jr., MD, died of pancreatic cancer on June 4, 2013. He was 76 years old. A native of New Jersey, he graduated from Tufts University and received his medical degree in 1962 from Northwestern University Medical School. This was followed by residency training in internal medicine and neurology at the Mayo Clinic. After service in the US Army Medical Corps as Chief of Neurology at the 5th General Hospital in Bad Cannstatt, Germany, he returned to the Mayo Clinic for fellowship training in clinical neurophysiology. He spent the greater part of his career at the Lahey Clinic, which he joined in 1972, and where he was appointed to the Jaime Ortiz-Patino Chair in Neurology in 1996. He was also a clinical professor of neurology at Harvard Medical School. Dr. Jones was an outstanding physician who was much loved by his patients, an extraordinarily influential clinical educator, and a well-known clinical investigator.

Sheldon Kapen, MD (1935–2012)

Sheldon Kapen, MD, a pioneer in sleep medicine, long-standing member of the Department of Neurology at Wayne State University School of Medicine, and recently retired Chief of Neurology at the John D. Dingell Veterans Administration Medical Center in Detroit, died on November 22, 2012. He had recently been diagnosed with acute myeloid leukemia.

Editorial introductions

Current Opinion in Neurology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of neurology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Editors and Section Editors for this issue. SECTION EDITORS Jean-Marc LégerJean-Marc LégerDr Léger started his career in neurology at the University Hospital Pitié-Salpêtrière and University Pierre et Marie Curie (Paris VI), France, in 1980, where he trained in general neurology and clinical neurophysiology. He was then nominated as full-time senior neurologist in 1987 in the Department of Neurology, University Hospital Pitié-Salpêtrière, and received his post-graduate degree (Habilitation à diriger des Recherches) from University Paris VI in 1991. He is currently coordinator, together with Dr Eymard, of the National Referral Center for rare neuromuscular diseases, that was built up in the Department of Neurology of University Hospital Pitié-Salpêtrière in 2004. Dr Léger's clinical and research interests are in the field of peripheral neuropathy and in particular chronic immune-mediated neuropathy. He has authored and co-authored more than 150 articles in peer-reviewed journals, and contributed more than 30 chapters to books on neurology, mainly in the field of diagnostic features and therapeutic trials in vasculitic neuropathy, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal motor neuropathy and paraproteinaemic neuropathies. He served as Editor-in-Chief of the Revue Neurologique for 8 years and as member of the Editorial Board of Brain for 5 years, and is currently member of the Board of the European Journal of Neurology and Associate Editor of the Journal of the Peripheral Nervous System. Dr Léger is currently President of the Société Française de Neurologie, in which he served as Secretary General for 8 years. He serves as officer of the Management Committee of the European Federation of Neurological Societies (EFNS) and as chairman of the Training and Education Committee of the EFNS. He is also member of the Board of the Peripheral Nerve Society and will organize its biennal meeting in Saint-Malo, France, in July 2013. He is Corresponding Fellow of the American Academy of Neurology, and Corresponding Member of the American Neurological Association. He was elected as Corresponding Member of the Académie Nationale de Médecine, France, in 2009. Tom RandoTom RandoThomas Rando is Professor of Neurology and Neurological Sciences at the Stanford University School of Medicine, USA. He received his A.B. degree in biochemistry from Harvard College and he received his MD and PhD (cell and developmental biology) degrees from Harvard University, USA. He completed his clinical training in neurology at the University of California San Francisco, USA, and he completed his postdoctoral training in the Department of Molecular Pharmacology at Stanford University where he was a Howard Hughes Physician Postdoctoral Scholar. Dr Rando's laboratory has been focused on the role of tissue-specific stem cells in muscle homeostasis and repair, as well as on the mechanisms by which those cells fail to sustain muscle either in the setting of muscular dystrophies, or during the process of age-related muscle atrophy (sarcopenia). Groundbreaking work from his laboratory showed that the age-related decline in stem cell function is due primarily to influences of the aged environmental, rather than to intrinsic aging of stem cells themselves. In addition, his laboratory focuses on the pathogenesis and treatment of the muscular dystrophies, with particular emphasis on cell and gene therapy. Dr Rando is Chief of Neurology at the VA Palo Alto Health Care System, USA, where he is Director of the Rehabilitation Research & Development Center of Excellence whose focus is the emerging field of regenerative medicine, particularly in neuromuscular disorders. He is also Director of the Glenn Laboratories for the Biology of Aging at the Stanford University School of Medicine. Dr Rando has received numerous awards and has been recognized by academic and professional societies for his work. He is a past recipient of a Junior Faculty Research Award from the American Academy of Neurology, and in 2007 he was honored to deliver the F.L. McNaughton Lecture at the Montreal Neurological Institute. He received a Paul Beeson Physician Faculty Scholar in Aging from the American Federation for Aging Research, an Ellison Medical Foundation Senior Scholar Award, and a “Breakthroughs in Gerontology” (BIG) Award from the American Federation for Aging Research. In 2005 he received an NIH Director's Pioneer Award for his work at the interface between stem cell biology and the biology of aging.

Dr. Joseph Foley - Case Western Reserve's Living Legend (P04.005)

Background Dr. Joseph Foley, Professor Emeritus and former Chief of Neurology at Western Reserve University in Cleveland, Ohio, is a living legend. Raised in a strict Irish-Catholic household during the Great Depression, he was influenced early in life by colorful Boston politicians and a classic literary training. After earning scholarships to Holy Cross and Harvard Medical School, he treated the wounded on the beaches of Normandy. In 1948, Foley joined Derek Denny-Brown at Boston City Hospital and in 1951 became the Director of the Mallory Pathological Institute. Over the next decade, Foley described benign fasciculation syndrome (Denny-Brown-Foley Disease), the vascular supply of hypothalamus, and with Raymond Adams, coined the term “asterixis” and triphasic waves of hepatic encephalopathy. In 1961, Foley was recruited to Cleveland. Two years later he recruited his former resident Maurice Victor. In contrast to beurecratic chiefs of his time, Foley was constantly visible in wards and clinics, spreading humor, which earned him the reputation as the “silver tongued Irish doctor from Boston”. He could recite poetry of Homer, Yeats, and Joyce ad lib. He once said, “For an Irishman to be listening when he could be talking is a form of perversity”. Yet he set strict academic standards for his well-attired, well-spoken young doctors. From 1963-1965, he served as president of the AAN and from 1974-1975, president of the ANA, retiring in 1980. Joseph Foley, at age of 95, remains a cheerful personality, present at most conferences, and frequently seen at local coffee shops. During a Cleveland local radio interview, when asked of advice, Dr. Foley simply stated, “Make sure you continue to love people and behave in a way that you can be loved”. Dr. Foley lived by his own advice, and let love of humanity guide his practice in neurology and medicine. Disclosure: Dr. Shams has nothing to disclose. Dr. Ashraf has nothing to disclose. Dr. DeGeorgia has received personal compensation for activities with Osram Medical Incorporated as a consultant.

Elliott M. Marcus, MD (1932–2011)

Elliott M. Marcus, Professor Emeritus of Neurology at the University of Massachusetts, and former Chief of Neurology at St. Vincent Hospital, Worcester, died on July 25, 2011, from complications related to non-Hodgkin lymphoma. Elliott M. Marcus, MD Elliott was born in Connecticut and attended schools in Danbury, where he worked summers milking cows and delivering milk for the Marcus Dairy, which is still serving the area after more than 100 years. He attended public schools there, and was valedictorian of his high school class. He received a scholarship to attend Yale, where he graduated Magna Cum Laude; he then studied medicine at Tufts Medical School, where he was elected to the Alpha Omega Alpha …

Med Schools Urged to Offer Better Health Care Coverage

Back to table of contents Previous article Next article Professional NewsFull AccessMed Schools Urged to Offer Better Health Care CoverageAaron LevinAaron LevinSearch for more papers by this authorPublished Online:4 Nov 2011https://doi.org/10.1176/pn.46.21.psychnews_46_21_8_1AbstractTo the surprise of no one who has attended medical school, the experience can induce distress in some students and psychiatric symptoms in a few. Yet insurance policies offered by many medical schools to their students often impose visit or dollar limits on mental health or substance abuse care and require cost sharing that may dissuade students from seeking needed care, according to a research letter published in the September 7 Journal of the American Medical Association.Rachel Nardin, M.D., an assistant professor of neurology at Harvard Medical School and chief of neurology at Cambridge Health Alliance in Massachusetts, and colleagues compiled data from 115 of 129 U.S. medical schools during 2010. All the schools offered policies with coverage for outpatient mental health care, although six did not provide inpatient mental health or substance abuse coverage."Medical schools should consider improving student insurance coverage for mental health and substance use disorders," Nardin emphasized. Between 29 percent and 43 percent of the 115 responding schools provided unlimited coverage of some combination of inpatient or outpatient care for mental health and/or substance abuse, they noted. Median annual maximum dollar amounts of the policies offered to students varied from $3,000 for outpatient mental health treatment and $3,919 for outpatient substance abuse treatment to $62,500 for inpatient mental health treatment and $20,000 for inpatient substance abuse treatment."Medical students probably face no greater concerns about insurance than students in other professional schools," said pediatrician Samuel Parrish, M.D., senior associate dean for student affairs and admissions at Drexel University's College of Medicine in Philadelphia, in an interview with Psychiatric News.Most schools are forced to strike a balance between the cost of premiums and the amount or quality of coverage they can offer at a given price, said Parrish, who was coauthor of a report on medical student mental health and services for the Association of American Medical Colleges. However, even modest copayments can affect a medical student's willingness to seek treatment, said Parrish."Medical students aren't making a salary yet." he said. "In reality, they are poor people living on loans."Parrish said he had never encountered a student who reached the maximum of the coverage provided, although one or two in each year's medical school class of 260 at Drexel apply for a leave of absence.In a talk to incoming students each year, former APA President Michelle Riba, M.D., a clinical professor of psychiatry at the University of Michigan, discusses the stresses they will face and how to minimize the problems those stresses may cause; she also encourages the students to seek help when they feel overwhelmed. At Michigan, medical students can turn to a psychiatrist on the staff whose job it is to help them specifically, she told Psychiatric News.Nardin's survey covered insurance plans offered by medical schools, but Riba noted that some medical students may be insured through other plans. Some students under age 26 may still be covered by their parents' policies or may have other sources of insurance, which may be better or worse than the university plan. Confidentiality is another concern beyond costs and coverage, said Riba. Some students worry that seeking help may affect later matters such as the cost of purchasing life insurance.In some states, at least in the past, licensing bodies may have noted that a physician applicant had experienced a mental health problem while in medical school and required an evaluation by a clinician to determine that the problem would not affect the individual's ability to practice, said Riba.Finally, noted Parrish, some psychiatric diagnoses frequently make their first appearance in early adulthood, which may account for service usage during college or medical school.However, one major change in recent years is that professors and administrators at every level of higher education are seeing students who have received mental health services beginning in middle school.Parrish sees that as a positive sign. "It shows that treatment works.""U.S. Medical Students' Health Insurance Coverage for Mental Health and Substance Abuse Treatment" is posted at <http://jama.ama-assn.org/content/306/9/931.2.full>. ISSUES NewArchived

Headache in the emergency room: the role of immigrant background on the frequency of serious causes and diagnostic procedures

Headache is the most frequent neurological chief complaint in the emergency room (ER). During diagnostic workup, accurate history taking still is the mainstay for identification of patients with a serious underlying disorder. However, in patients with an immigrant background, language problems and cultural influences on pain perception and pain-associated behavior can pose serious challenges for physicians. Here, we have evaluated the epidemiological characteristics of the chief complaint headache in ER patients with a probable immigrant background. We performed a retrospective study on 4,132 consecutive neurological ER patients. Identification of patients with probable immigrant background was done by a name based algorithm. Epidemiological characteristics of ER headache patients with and without probable immigrant background were evaluated. Patients with a probable immigrant background had a higher frequency of headache as chief complaint compared to age- and sex-matched control patients (32 vs. 21%). In addition, headache patients with a probable immigrant background had a lower frequency of serious causes (5.2 vs. 16%). Approximately eight cranial imaging procedures and three lumbar punctures were performed for one serious diagnosis in patients with a probable immigrant background. In control patients, these ratios were three and one, respectively. Taken together, our data suggest that socio-cultural factors such as migrational status significantly affect pain-associated behavior of headache patients as well as the clinical workup in an ER. Culturally competent care may be optimized by interpreters, standardized headache questionnaires and easy access to cranial imaging when a benign etiology cannot be firmly established.

Dizziness in the Emergency Room: Diagnoses and Misdiagnoses

Background: Dizziness is among the most frequent neurological chief complaints in emergency room (ER) patients. Although the majority of underlying disorders are benign, serious causes that require immediate in-hospital treatment may occur that are difficult to identify clinically. Methods: Retrospective study of 475 consecutive ER neurological consultations with dizziness as the chief complaint. Results: Of all ER dizziness patients, 73% were initially assigned to benign and 27% to serious diagnoses. The two most frequent disorders were benign paroxysmal positional vertigo (22%) and stroke (20%). On follow-up (available in 124 patients), 43% of all ER diagnoses were corrected: 6% of benign ER diagnoses were corrected to serious diagnoses, 23% of serious ER diagnoses were revised to benign. The most frequent corrections concerned patients with an ER diagnosis of stroke or vestibular neuronitis. Conclusions: In the patient sample studied here, serious causes of dizziness were more prevalent than can be expected from population-based surveys or data from specialized outpatient departments. However, inappropriate assignment of dizziness patients to benign diagnoses still occurred in a relevant proportion of patients. ER clinical pathways, planning of imaging resources and follow-up of patients in- and outside the hospital must take these points into consideration.

Neurologische Leitsymptome in einer Notaufnahme

Neurological chief complaints often lead patients into the emergency room. In order to establish standard emergency workups it is important to know the frequency of neurological chief complaints. Therefore, we performed a retrospective study on 4,132 consecutive neurological patients in the emergency room over a 1-year period. The most frequent chief complaint was headache (20%) followed by motor deficit (13%), vertigo (12%) and epileptic seizure (11%). In conclusion, the neurological workup in the emergency room can be optimized by establishing clinical decision-making rules for the four most frequent chief complaints.

Personal reflections on the neuropathology of kuru

My involvement with kuru began towards the end of 1963 while I was a Fellow at the Massachusetts General Hospital (MGH). During the autumn of that year I was contacted by Dr Michael Alpers, who was on his way to Boston from the National Institutes of Health (NIH) in Bethesda, Maryland with a carload

Milton Gene Ettinger, MD, FAAN (1930–2008)

Milton G. Ettinger, long-time Chief of Neurology at Hennepin County Medical Center (HCMC) in Minneapolis, Minnesota, died May 2, 2008, of meningitis. Milt struggled with several medical problems in recent months, but he was clear-headed and forward-looking until his final brief illness. Milt was raised in St. Paul and earned baccalaureate and doctoral degrees from the University of Minnesota, graduating from Medical School in 1954. After internship in Los Angeles, Milt returned to the University to train in neurology under A.B. Baker. Milt completed his residency in 1958 and an air force stint in 1960. In those years, Minneapolis …