Need For Neurologists Research Articles

Postural orthostatic tachycardia syndrome during pregnancy, labor, and post-delivery: A case series

Postural orthostatic tachycardia syndrome (POTS) is an autonomic condition characterized by the presence of a >30 bpm increase in heart rate, accompanied by orthostatic symptoms, including heart palpitations, light-headedness, weakness, blurred vision, nausea, and headache. Females are commonly affected by POTS at childbearing age. This case series aims to compare the clinical presentations, autonomic dysfunction management, and pregnancy outcomes of four women with POTS. In our autonomic neurology clinic, the goal for our patients is consistent blood pressure during pregnancy. The patients were all interviewed retrospectively to determine pregnancy outcomes. Our study indicates the need for neurologists to collaborate with a team of maternal-fetal medicine specialists with advanced training in high-risk pregnancies to optimize autonomic function throughout the course of pregnancy. In addition, our results suggest that reducing medications to minimize harm can be achieved through regular monitoring at 1 – 3 month intervals during pregnancy, with a 6-week postpartum evaluation.

Monkeypox-Associated Central Nervous System Disease: A Case Series and Review.

Monkeypox virus (MPXV) disease has been declared a public health emergency by the World Health Organization, creating an urgent need for neurologists to be able to recognize, diagnosis, and treat MPXV-associated neurologic disease. Three cases of MPXV-associated central nervous system (CNS) disease occurring during the 2022 outbreak, and their associated imaging findings are presented, with 2 cases previously published in a limited capacity in a public health bulletin. Three previously healthy immunocompetent gay men in their 30s developed a febrile illness followed by progressive neurologic symptoms with presence of a vesiculopustular rash. MPXV nucleic acid was detected by polymerase chain reaction (PCR) from skin lesions of 2 patients, with the third patient having indeterminate testing but an epidemiologic link to a confirmed MPXV disease case. Cerebrospinal fluid demonstrated a lymphocytic pleocytosis, elevated protein, and negative MPXV-specific PCR. In 2 patients, magnetic resonance imaging of the brain and spine demonstrated partially enhancing, longitudinally extensive central spinal cord lesions with multifocal subcortical, basal ganglia, thalamic, cerebellar, and/or brainstem lesions. The third patient had thalamic and basal ganglia lesions. All patients received 14 days of tecovirimat, and 2 patients also received multiple forms of immunotherapy, including intravenous immunoglobulin, pulsed high-dose steroids, plasmapheresis, and/or rituximab. Good neurologic recovery was observed in all cases. MPXV can be associated with CNS disease. It is unclear whether this is from a parainfectious immune-mediated injury or direct CNS viral invasion. ANN NEUROL 2023;93:893-905.

Current Situation and Issues in the Transition from Pediatric to Adult Health Care: A Neurologist's Perspective

Our hospital provides medical care and rehabilitation for individuals with disabilities. In our hospital, both neurologists and pediatricians have been working on the transition from pediatric to adult healthcare. We used a transition readiness checklist and pediatrician-neurologist transition consultation. We aimed to promote appropriate medical care, community-based healthcare coordination, and welfare services through interprofessional care with other health professionals. We assisted patients and their families in improving self-management and discussed patient issues with their best interests in mind through a shared decision-making process. Recently, the need for neurologists in transitioning patients from pediatric to adult healthcare has been increasing.

A Shortage of Neurologists - We Must Act Now: A Report From the AAN 2019 Transforming Leaders Program.

In nearly every US state, a large mismatch exists between the need for neurologists and neurologic services and the availability of neurologists to provide these services. Patients with neurologic disorders are rising in prevalence and require access to high-level care to reduce disability. The current neurology mismatch reduces access to care, worsens patient outcomes, and erodes career satisfaction and quality of life for neurologists as they face increasingly insurmountable demands. As a community, we must address this mismatch in the demand and supply of neurologic care in an aggressive and sustained manner to ensure the future health of our patients and our specialty. The American Academy of Neurology has multiple ongoing initiatives to help reduce and resolve the existing mismatch. With the intent of raising awareness and widening the debate nationally, we present a strategic plan that the Academy could implement to coordinate and expand existing efforts. We characterize the suggested strategies as shaping the demand, enhancing the workforce, and advocating for neurologist value. The proposed framework is based on available data and expert opinion when data were lacking. Prioritization of strategies will vary by geography, practice setting, and local resources. The time to act is now to allow concerted effort and targeted interventions to avert this looming public health crisis.

Vestibular vertigo in stroke and vestibular neuronitis

The article discusses two main causes of acute vestibular dizziness - vertebrobasilar ischemic stroke and vestibular neuritis. The features of acute vestibular syndrome depending on the localization of cerebral infarction - in the territory of the posterior inferior, anterior inferior and superior cerebellar arteries, as well as in the brain stem are presented. Detailed clinical characteristics of vestibular neuritis is given. The issues of differential diagnosis of diseases, including the features of nystagmus and head impulse test, are discussed. The approaches to the treatment of acute vestibular syndrome depending on its etiology are considered. The authors present a treatment and diagnostic algorithm and consider features of clinical practice in acute dizziness. Fundamental differences in the treatment of vestibular neuritis and vertebrobasilar stroke dictate the need for neurologists of vascular departments to master the skills of otoneurological examination, which is the key to differential diagnosis. When choosing a treatment method, the most individualized approach is required.

Editors' note: Reducing birth defects in women with epilepsy: Research leading to results

In “Reducing birth defects in women with epilepsy: research leading to results,” Pennell and Meador discuss: (1) the need for neurologists to carefully consider selection of antiepileptic drugs (AEDs) in women of childbearing age and (2) the impact of EURAP—a prospective registry of women on AEDs in 42 countries—on facilitating further understanding of the risks of congenital malformations and neurodevelopmental abnormalities associated with AEDs. Braillon and Bewley comment that (1) increased advocacy is needed to ensure whether EURAP's findings affect practice expediently and (2) to make the results more meaningful, EURAP should include detailed data on other risk factors for congenital malformations and neurodevelopmental abnormalities. Finally, the findings of EURAP should have influence on regulatory agencies to improve drug safety. Sethi further notes that it is particularly important for steps to be taken to ensure whether EURAP's findings be used to improve AED prescribing practices in low- and middle-income countries. Pennell and Meador respond that it is challenging to change practice, but partnership with governmental and regulatory organizations and performance of meta-analyses can help disseminate information about medications associated with of congenital malformations and neurodevelopmental abnormalities. Pennell further notes that the International League against Epilepsy is working to facilitate education of all specialists who care for women with epilepsy using knowledge acquired from EURAP in an effort to decrease the frequency of congenital malformations and neurodevelopmental abnormalities in patients on AEDs. In “Reducing birth defects in women with epilepsy: research leading to results,” Pennell and Meador discuss: (1) the need for neurologists to carefully consider selection of antiepileptic drugs (AEDs) in women of childbearing age and (2) the impact of EURAP—a prospective registry of women on AEDs in 42 countries—on facilitating further understanding of the risks of congenital malformations and neurodevelopmental abnormalities associated with AEDs. Braillon and Bewley comment that (1) increased advocacy is needed to ensure whether EURAP's findings affect practice expediently and (2) to make the results more meaningful, EURAP should include detailed data on other risk factors for congenital malformations and neurodevelopmental abnormalities. Finally, the findings of EURAP should have influence on regulatory agencies to improve drug safety. Sethi further notes that it is particularly important for steps to be taken to ensure whether EURAP's findings be used to improve AED prescribing practices in low- and middle-income countries. Pennell and Meador respond that it is challenging to change practice, but partnership with governmental and regulatory organizations and performance of meta-analyses can help disseminate information about medications associated with of congenital malformations and neurodevelopmental abnormalities. Pennell further notes that the International League against Epilepsy is working to facilitate education of all specialists who care for women with epilepsy using knowledge acquired from EURAP in an effort to decrease the frequency of congenital malformations and neurodevelopmental abnormalities in patients on AEDs.

Neurological manifestations of dengue fever

Dengue fever is a highly endemic mosquito-borne viral infection with a wide range of neurological manifestations including encephalitis, neuromuscular and neuro-ophthalmic involvement. To explore the pleiotropic effects of dengue virus infection on the nervous system. Effect of the dengue virus on nervous system is pleiotropic. Direct central nervous system invasion by dengue virus is implicated in encephalitis whereas immune mediated release of cytokines may involve peripheral nerve constituents (myelin/axon), muscle fibres leading to myositis, and damage omnipause cells in the brainstem causing ocular flutter. Five patients of serologically confirmed Dengue fever (NS1 Antigen and Immunoglobulin M antibody positive) were included, who presented with the following uncommon neurological manifestations. Recently emerging evidence of neurotropism and neurovirulence by dengue virus emphasizes the need for neurologists to look for these associations while dealing with dengue infection. It also emphasizes the need for specific immunomodulation in addition to supportive measures for causing neurological recovery.

Teleneurology Network to Improve Access to Neurologists for Patients in Rural Areas: A Real-World Experience.

Background: The need for neurologists has been steadily increasing over the past few years. The implementation of teleneurology networks could serve as a potential solution to this need. Methods: A retrospective review of the Medical University of South Carolina (MUSC) Teleneurology records for all consults performed between August 2014 and July 2018 was conducted. Collected data included number of consults, baseline characteristics, final diagnosis, and number of providers and hospitals over the study period. Results: A total of 4,542 Teleneurology consults were performed during the study period. The most common diagnosis was cerebrovascular disease, followed by seizure disorders. The number of consults per month increased throughout the study period from three in August 2014 to 257 in July 2018. The number of community hospitals covered has increased from 3 hospitals in August 2014 to 14 hospitals throughout the state of South Carolina in July 2018. Conclusion: Over 4 years, the MUSC teleneurology program has evolved into a robust partnership with 14 partner hospitals, and is now delivering more than 250 expert neurology consultations monthly to patients throughout the state of South Carolina.

Promoting Careers in Neurology: Mentorship of Medical Students.

Research in neurological disorders is expanding at a phenomenal pace, and the need for neurologists is increasing as the population ages. This results in a critical requirement for medical students entering the neurology pipeline. Mentoring, whether formal or informal, ensures that students are inspired and supported to enter the field of neurology. Students should also receive structured mentoring throughout their longitudinal curriculum. Informal mentoring programs enable expanded opportunities for collaborations in education, research, and outreach. Faculty, residents, fellow medical students, and other health professionals all participate in medical student mentoring. Each relationship offers unique aspects to individual growth and development. Specific programmatic guidance and mentoring qualities are presented in this paper.

Update on Palliative Care for Pediatric Neurology.

It has long been recognized that patients with neurological conditions, and particularly pediatric neurology patients, are well suited for palliative care because they frequently have a high symptom burden and variable prognoses. In 1996, the American Academy of neurology formally recognized a need for neurologists to "understand and apply the principles of palliative medicine." Subsequently, some reviews have proposed a simultaneous care model in which palliative care is integrated for all neurology patients from the time of diagnosis. This article will review the current status of palliative care in pediatric neurology and discuss barriers to its integration.

Everything you always wanted to know about sex and Neurology: neurological disability and sexuality.

Chronic neurological disorders generate disabilities affecting multiple aspects of life, including sexuality. To describe the presence of sexual dysfunction and comorbidities in a population with chronic neurological disorders. To analyze the relationship between disability and sexual dysfunction. A cross-sectional case-control study was carried out. Patients with amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson's disease (PD), and stroke of at least one year since the onset of symptoms were included, and compared with controls with no neurological disease, matched by age and sex. We included 71 participants: 29 controls, with a mean age of 49.4 years, and 42 patients with a mean age of 53.8 years. Sexual dysfunction was present in 22.5% of the controls and 77.5% of the patients. A statistically significant relationship between sexual dysfunction and disability was found in the logistic regression analysis (OR = 20.38, 95%CI: 2.5 -165.86). Disability proved to be the main variable related to the presence of sexual dysfunction. Patients with ALS had the worst rates of sexual dysfunction. Patients with MS were similar to the control group. As for the PD group, no patient had normal sexuality. Finally, in stroke patients, the presence of comorbidities and their treatment may have negatively influenced sexuality. These findings showed that patients with chronic neurological diseases have sexual dysfunction and underscore the need for neurologists to know and address this problem.

A Comparison of Clinical Presentation and MRI Findings in Neuromyelitis optica Spectrum Disorder and Spinal Cord Infarct in Complex Patients with Multiple Co-Morbidities

Neuromyelitis optica spectrum disorder (NMOSD) can be difficult to differentiate from other causes of longitudinally extensive transverse my elites (LETM), such as spinal cord infarct (SCI), especially when patients are complex and have multiple co-morbidities. It is therefore of utility to compare the MRI findings in such cases in order to further distil the key characteristics associated with each condition and improve diagnostic accuracy while predicting variability. This case comparison examines two patients with acute LETM that were followed by a single provider. Each patient’s clinical history, cervical and thoracic MRI, CSF studies, AQP4-Ab serology and co morbidities are compared, ultimately leading to the final diagnosis of NMOSD and SCI in each patient respectively. In these patients, clinical history differed in time to nadir and precipitating factor of hypotension. Etiology specific features on MRI were found to be unreliable but associated features helped to synthesize the clinical picture. These difficult cases underscore the need for neurologists to be familiar with the differential diagnosis of LETM and to use key distinguishing findings on MRI to help differentiate NMOSD from other diseases such as SCI.

Emerging Subspecialties in Neurology: Telestroke and teleneurology.

In 2013, Dall et al.1 projected that by 2025, the societal need for neurologists will exceed availability by 19%. This number failed to account for the disproportionate number of neurologists practicing in urban and academic centers, likely underestimating the gap in rural populations. In a recent effort to improve access to neurologic services in these areas, telestroke and teleneurology networks have being championed as the solution. With the emergence of these networks come unique challenges and opportunities in the distribution and breadth of neurologic care that fellows and residents will need to understand to optimally incorporate this tool into their future practices.

Nationwide evaluation of German university teaching methods in neurology

Germany is confronted with a lack of medical doctors and an increasing need for neurologists in particular. In order to recruit future doctors in neurology it is essential to attract young students when still at university. This article presents the first German national survey of medical students' acceptance of teaching methods in neurology. The participants evaluated teaching methods and examination formats and were asked about their preferences. The survey was based on a questionnaire distributed to 22 German medical schools and 1245 participating students. Interactive teaching methods, especially courses in practical examinations, clinical internships and bedside teaching were highly rated among the students. In contrast, multiple choice tests, as one of the most widespread examination methods, were poorly rated compared to practical and oral examinations. For most of the students it was not decisive, in which semester teaching of neurology took place, while the majority asked for additional and more intensive neurological education. The data give an overview of teaching of neurology in Germany and students' assessment of various approaches. The results should be utilized towards reorientation of future curricula that should aim at innovative and even more practically oriented teaching.

Advantages and limitations of teleneurology.

The growing disparity between the demand for neurological services and the need for neurologists requires new and innovative strategies for delivering care. Teleneurology allows neurological expertise to be delivered to remote locations to supplement or replace in-person neurological care. To summarize the current status of teleneurology. Applications of teleneurology include acute care, outpatient teleneurology, and teleconsultations. Existing barriers to further expansion of teleneurology are also discussed. Published studies pertaining to teleneurology were reviewed. Practical experience with telemedicine in neurological practice contributed to the conclusions. Outcomes after intravenous tissue plasminogen activator treatment via telemedicine (telestroke) are similar to those achieved with in-person evaluations. Other aspects of teleneurology are less established but have demonstrated feasibility, high patient satisfaction, and, in some cases, cost savings. Teleneurology provides neurological expertise to rural areas with limited availability of neurologists and improves care for patients with difficulty traveling owing to neurological disease. It is likely that use of teleneurology will continue to grow and become incorporated into many aspects of neurological practice. Understanding the advantages and limitations of teleneurology is vital to delivering optimal clinical care for patients with neurological disease regardless of the setting.

Pseudo pre-excitation ECG changes in a patient with anti-GAD mediated autoimmune limbic encephalitis

We report the case of a 30-year-old male patient presenting with complex partial seizures and amnesia and diagnosed with anti-glutamic acid decarboxylase (anti-GAD) mediated autoimmune limbic encephalitis. New onset ECG changes consistent with pre-excitation were co-existent and resolved entirely with immunotherapy. This association has not been previously reported in the literature. Pre-excitation is usually attributable to an accessory cardiac pathway, the presence of which was excluded in the case. Instead, we posit a potential deleterious, reversible effect of anti-GAD antibodies on cardiac membrane stability. Given the risk of sudden cardiac death associated with such ECG profiles, we highlight the need for neurologists to be aware of this potential association and of the possible benefits of specialist cardiological involvement. Further work should be undertaken to elucidate the nature of this association, and clinicians should be mindful of the potentially adverse consequences thereof.

Quality improvement in neurology: AAN Parkinson disease quality measures: report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology.

Measuring the quality of health care is a fundamental step toward improving health care and is increasingly used in pay-for-performance initiatives and maintenance of certification requirements. Measure development to date has focused on primary care and common conditions such as diabetes; thus, the number of measures that apply to neurologic care is limited. The American Academy of Neurology (AAN) identified the need for neurologists to develop measures of neurologic care and to establish a process to accomplish this. To adapt and test the feasibility of a process for independent development by the AAN of measures for neurologic conditions for national measurement programs. A process that has been used nationally for measure development was adapted for use by the AAN. Topics for measure development are chosen based upon national priorities, available evidence base from a systematic literature search, gaps in care, and the potential impact for quality improvement. A panel composed of subject matter and measure development methodology experts oversees the development of the measures. Recommendation statements and their corresponding level of evidence are reviewed and considered for development into draft candidate measures. The candidate measures are refined by the expert panel during a 30-day public comment period and by review by the American Medical Association for Current Procedural Terminology (CPT) II codes. All final AAN measures are approved by the AAN Board of Directors. Parkinson disease (PD) was chosen for measure development. A review of the medical literature identified 258 relevant recommendation statements. A 28-member panel approved 10 quality measures for PD that included full specifications and CPT II codes. The AAN has adapted a measure development process that is suitable for national measurement programs and has demonstrated its capability to independently develop quality measures.

Advocacy training in neurology: scope and impact

In this Training Matters article, the authors highlight the need for neurologists to develop advocacy skills that they can use to promote high-priority issues facing the practice of neurology. The authors describe a training program that teaches participants to identify issues related to clinical practice, develop an action plan for dealing with these problems, and apply strategies to improve their communication skills.

Reply from the Authors

Reply from the Authors: We appreciate the opportunity to address the responses to our article proposing a principal'' or primary'' care plan for patients with neurologic diseases. Although we will comment on the main issues raised by each correspondent, we will do so in the spirit in which we offered our proposal. We leave to the journal's readership to judge the motives that brought us to propose that neurologists provide principal'' or primary'' care for patients with primary neurologic diseases. [1] The comments of Drs. Fielder, Jaffe, and Menken can be grouped into three areas: the competence of neurologists to provide primary care, the education of generalists in neurology, and the projected need for neurologists in a changing health care delivery system. Drs. Fielder and Jaffe question whether neurologists have the training to function as primary care physicians. We would suggest that well-trained neurologists are competent to provide primary care for patients with diseases of the nervous system. Neurologists are better equipped than generalists also to understand and care for the complications of neurologic disease. Fielder and Jaffe suggest they would not wish to have their non-neurologic problems managed by a neurologist. Jaffe cites the example of stroke in the context of diabetes and hypertension. As all neurologists are aware, management of blood pressure and serum glucose, inter alia, during the acute stages of stroke is essential for the best outcome. Do we stop managing these problems when patients enter the chronic stage of their neurologic disease? We think not. Dr. Fielder's example allows us to address a second …

Clinical audit and neurology.

Medical audit has been defined as "a systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome for the patient". In Britain, recent reforms of the Health Service increase the need for neurologists to undertake audit. The basic principles of audit in relation to the management of common conditions such as headache and epilepsy are described. Audit must consider not only efficiency but also effectiveness, but the difficulty of developing valid outcome measures should not be underestimated, especially in chronic disabling conditions.