Neurological Practice Research Articles

Blurred boundaries of the brain-1 (Aide-memoire for patient narrative)

Background: This is a case series of clinical cases presenting to our Neuropsychiatry Center, who were either referred by physicians or approached to seek treatment on their own. They were receiving treatment since few years. No improvement in symptom were primary reason for referral and consultation with our team. Re-evaluation in realms of Neurology and Psychiatry depicted the missed link in diagnostic and therapeutic approaches exercised previously. The intent to reflect upon novel findings is not to undermine the effort applied in clinical evaluation by prior physicians, but to reflect few observations which may have been inadvertently missed during routine assessment. This serves as as an aide-memoire to history taking and suggestions to remain well informed and updated in our approach to service seekers. Abstract: Symptom overlap and comorbidities are commonly encountered in clinical practice of Psychiatry or Neurology. Many neurologic disorders have psychiatric symptoms (e.g., depression in patients following a stroke or with multiple sclerosis or Parkinson’s disease), and many psychiatric disorders have been associated with neurologic symptoms (e.g., movement disorders in schizophrenia). This overlap occurs mostly because brain is the source common for both neurological and psychiatric illness and on multiple occasion it becomes difficult to delineate the boundary, leading to diagnostic dilemmas, followed by inappropriate management strategies. Patients and family members suffer for long periods of time in trying to understand the disease phenomenon and prognosis. In this case series, we present 3 cases of clinical interest across different framework of clinical presentation and assessment for e.g, neurological illness being managed as psychiatric illness or scenarios where both neurological and psychiatric illness coexisted but only one aspect was addressed. Re-assessment and work up by a team of neurologists and psychiatrist lead to clarification of the boundaries (at least in these cases who underwent prolonged sufferings owing to lack in clarity of pathology) with precise diagnosis generating improved outcomes in functionality and satisfaction. The diagnosis of neuropsychiatric disorders is performed by psychiatrists through diagnostic interviews, and categorization of patients based on diagnostic and classification manual (ICD-10, DSM-5) which are syndrome/symptom based. Although this has been a standard practice, often error may occur in diagnosing illnesses falling under the wider realm of neurology and psychiatry. Some presenting symptoms may be assumed being part of neurological illness or of functional origin, or mixed states and many may be overlooked during routine clinical assessment.

Depressive disorders and their pharmacotherapy in routine clinical practice

Depression is one of the most common medical causes of disability and mortality in patients of all ages. Depressive disorders are common in the practice of physicians of a variety of specialties, including psychiatrists, neurologists, and physicians. This paper provides a summary review of the literature on modern ideas about the epidemiology, classification, and clinical picture of depression. Current approaches to the diagnosis and treatment of depressive disorders in neurological and psychiatric practice are discussed. Modern pharmacotherapeutic strategies for the treatment of depression in various patient populations are described in detail. Current clinical practice indicates the high importance of an interdisciplinary approach in the diagnosis and management of patients with depressive symptoms in Russia. The paper suggests organizational and educational strategies that can be recommended to improve the effectiveness of medical care for patients with depressive disorders.

A multi-task learning model with reinforcement optimization for ASD comorbidity discrimination

How to discriminate the comorbidities in autism spectrum disorder (ASD) population has long been an intriguing and challenging issue in neuroscience and neurology practices. Taking attention deficit hyperactivity disorder (ADHD) for example, electroencephalogram (EEG) analysis has alleviated the problem caused by the task of evaluation of similar behaviors of subjects with ASD, ADHD and ASD+ADHD, which requires a very high expertise to reach any concrete conclusions. However, the performance of ASD comorbidity discrimination is still limited by two major difficulties 1) crucial EEG features regarding ASD and ASD+ADHD largely overlap, and 2) reliable data for model training are routinely insufficient.This study proposes a multi-task learning method with “reinforcement optimization” (namely RO-MLT) working in a two-fold manner: 1)Modeling for Discrimination: a multi-task CNN model maintains the target discrimination task (ASD vs. ASD+ADHD) with the aid of the auxiliary task (ASD vs. Typically Developed (TD)), which is designed to mitigate the aforementioned difficulties on model training; and 2) Reinforcement Optimization: a reinforcement learning algorithm enhances the model's feature extraction and fusion capabilities by optimizing its shared structure.Experimental results based on resting-state EEG that collected from 150 ASD, ASD+ADHD or TD children with the RO-MLT method against the state-of-the-art counterparts indicate that RO-MLT is far superior in terms of all performance indicators (e.g., accuracy). Ablation experiments also show that introduction of multi-task learning and reinforcement optimization can achieve a performance boost-up by 11.07%, a gain even higher than the sums of introduction of two individual techniques to the model design.

The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline: A Comparison With the 2010 and 2011 Guidelines.

In collaboration with the American Academy of Pediatrics, Child Neurology Society, and Society for Critical Care Medicine, the American Academy of Neurology formulated an updated, evidence-informed consensus-based guideline for pediatric and adult brain death/death by neurologic criteria (BD/DNC) determination. In comparison with the prior guidelines, the revisions and additions in this guideline, which are summarized in this review, are intended to (1) ensure recommendations are conservative, yet practical, and emphasize circumstances in which BD/DNC determination should be delayed or deferred, so as to minimize the risk of a false-positive BD/DNC determination; and (2) provide guidance about aspects of BD/DNC determination that clinicians find challenging and/or controversial. We hope that clinicians throughout the United States will use this information to revise their hospital BD/DNC determination policies to conform to the standardized process for BD/DNC determination described in the new guideline, to ensure that every BD/DNC evaluation is consistent and accurate.

Feasibility and Usability of a Mobile App-Based Interactive Care Plan for Migraine in a Community Neurology Practice: Development and Pilot Implementation Study.

Migraine is a common and major cause of disability, poor quality of life, and high health care use. Access to evidence-based migraine care is limited and projected to worsen. Novel mobile health app-based tools may effectively deliver migraine patient education to support self-management, facilitate remote monitoring and treatment, and improve access to care. The risk that such an intervention may increase the care team workload is a potential implementation barrier. This study aims to describe a novel electronic health record-integrated mobile app-based Migraine Interactive Care Plan (MICP) and evaluate its feasibility, usability, and impact on care teams in a community neurology practice. Consecutive enrollees between September 1, 2020, and February 16, 2022, were assessed in a single-arm observational study of usability, defined by 74.3% (127/171) completing ≥1 assigned task. Task response rates, rate and type of care team escalations, and patient-reported outcomes were summarized. Patients were prospectively recruited and randomly assigned to routine care with or without the MICP from September 1, 2020, to September 1, 2021. Feasibility was defined by equal to or fewer downstream face-to-face visits, telephone contacts, and electronic messages in the MICP cohort. The Wilcoxon rank-sum test was used to compare continuous variables, and the chi-square test was used for categorical variables for those with at least 3 months of follow-up. A total of 171 patients were enrolled, and of these, 127 (74.3%) patients completed ≥1 MICP-assigned task. Mean escalations per patient per month was 0.9 (SD 0.37; range 0-1.7). Patient-confirmed understanding of the educational materials ranged from 26.6% (45/169) to 56.2% (95/169). Initial mean headache days per week was 4.54 (SD 2.06) days and declined to 2.86 (SD 1.87) days at week 26. The percentage of patients reporting favorable satisfaction increased from a baseline of 35% (20/57) to 83% (15/18; response rate of 42/136, 30.9% to 28/68, 41%) over the first 6 months. A total of 121 patients with MICP were compared with 62 patients in the control group. No differences were observed in the rate of telephone contacts or electronic messages. Fewer face-to-face visits were observed in the MICP cohort (13/121, 10.7%) compared with controls (26/62, 42%; P<.001). We describe the successful implementation of an electronic health record-integrated mobile app-based care plan for migraine in a community neurology practice. We observed fewer downstream face-to-face visits without increasing telephone calls, medication refills, or electronic messages. Our findings suggest that the MICP has the potential to improve patient access without increasing care team workload and the need for patient input from diverse populations to improve and sustain patient engagement. Additional studies are needed to assess its impact in primary care.

Does GPT-4 have neurophobia? Localization and diagnostic accuracy of an artificial intelligence-powered chatbot in clinical vignettes

Background and Objectives: This is an observational study of the performance of an artificial intelligence-powered chatbot tasked with solving unknown neurologic case vignettes. The primary objective of the study is to assess the current capabilities of widely-accessible artificial intelligence within the field of clinical neurology in order to determine how this technology can be deployed in clinical practice, and what insights can be learned from its performance and translated to clinical education. Methods: This observational study tested the accuracy of GPT-4, an artificial intelligence-powered chatbot, at appropriately localizing and generating a differential diagnosis for a series of 29 clinical case vignettes. The cases were from previously published educational material prepared for learners. No cases required more than text input, a current limitation of GPT-4. The primary outcome measures were ranked accuracy of localization and differential diagnosis based on clinical history and exam alone and after ancillary clinical data was provided. Secondary outcome measures included a comparison of accuracy by case difficulty. Results: GPT-4 identified the correct localization less than 50% of the time and performed worse when provided ancillary testing. GPT-4 was more accurate with localization and diagnosis of easier versus harder cases. Diagnostic accuracy was independent of its ability to localize the lesion. Discussion: GPT-4 did not perform as well on neurology clinical vignettes as compared to reported accuracy when provided other medical clinical vignettes. Incorporation of an AI chatbot into the practice of clinical neurology will require neurology-focused teaching.

Anxiety disorders in neurology practice

Anxiety disorders are often encountered in the practice of a neurologist. These disorders are in various relationships with a neurological disease, based on which three groups of pathologies can be distinguished: anxiety disorders, manifested by somatic neurological symptoms arising from dysfunction the autonomic nervous system; anxiety disorders associated with major neurological diseases, such as epilepsy, migraine, and stroke; anxiety disorders resulting from side effects of therapy for the underlying somatic disease, including neurological one. In the first case, a neurologist must differentiate an anxiety disorder from a true nervous pathology, which is necessary in order to prescribe the correct therapy. In the second case, it is the responsibility of a neurologist to differentiate the symptoms of an anxiety disorder that occurs against the background of an underlying neurological disease from a progressive disease of the nervous system and prescribe specific therapy for a comorbid anxiety disorder. In the third case, a neurologist should take a detailed patient’s history to identify the relationship between the onset/intensification of manifestations and therapy. To assess the level of anxiety and its dynamics, it is necessary to use psychometric scales and symptomatic questionnaires. Therapy of anxiety disorders includes two areas: psychotherapy and psychopharmacotherapy; in order to achieve the maximum effect in severe cases of anxiety disorders, it is possible to combine these components. The preferred method of psychotherapy is cognitive behavioral therapy. Psychopharmacotherapy is represented by two lines. The first-line includes drugs from the group of selective serotonin reuptake inhibitors, while the second-line therapy involves increasing the dose of the drug or changing to serotonin and norepinephrine reuptake inhibitors.

Clinical Neurology in Practice: The Tongue (part 2).

The tongue is an essential organ for the development of certain crucial functions such as swallowing and speech. The examination of the tongue can be very useful in neurology, as the various types of lingual alterations can lead to certain specific diagnoses, the tongue being a kind of 'mirror' of some neurological function. To discuss the elements of clinical examination of the tongue in relation to neurological disorders. After reviewing the different superficial lesions of the tongue, we deal with various movement disorders of the tongue (fasciculations/myokimia, orolingual tremor, choreic movements of the tongue, dystonia of the tongue, lingual myoclonus, and psychogenic movements), disorders of taste and lingual sensitivity and lingual pain. Examination of the tongue should not be limited to studying its motility and trophicity. It is equally important to check the sensory function and understand how to interpret abnormal movements involving the tongue. This study also aimed to demonstrate the importance of nonmotor tongue function in neurological practice.

A Comparison of Patients' and Neurologists' Assessments of their Teleneurology Encounter: A Cross-Sectional Analysis.

Background and Objectives: To better understand patients' and neurologists' assessments of their experiences regarding effectiveness of teleneurology encounters. Methods: Following an audio-video telehealth visit, neurologists asked patients to participate in a survey-based research study about the encounter, and then, the neurologists also recorded their own evaluations. Data were analyzed using standard quantitative and qualitative techniques for dichotomous and ordered-category survey responses in this cross-sectional analysis. Results: The study included unique encounters between 187 patients and 11 general neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of the patients (66.8%, 125/187) were female. One third (33.2%; 62) were patients new to the NYU Langone Health neurology practices. The most common patient chief complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Most patients (94.7%, 177/187) reported that the teleneurology encounter satisfied their needs. Patients and their neurologists agreed that the experience was effective in 91% (162/178) of encounters, regardless of whether the visit was for a new or established patient visit. Discussion: More than 90% of new and established patients and their neurologists agreed that teleneurology encounters were effective despite some limitations of the examination, the occasional need for patient assistance, and technical difficulties. Our results provide further evidence to justify and to expand the clinical use of teleneurology.

Electronic health record (EHR)-based PROMIS measures among neurology clinic decedents and survivors: a retrospective cohort analysis

BackgroundIn addition to their standard use to assess real-time symptom burden, patient-reported outcomes (PROs), such as the Patient-Reported Outcomes Measurement Information System (PROMIS), measures offer a potential opportunity to understand when patients are experiencing meaningful clinical decline. If PROs can be used to assess decline, such information can be used for informing medical decision making and determining patient-centered treatment pathways. We sought to use clinically implemented PROMIS measures to retrospectively characterize the final PROMIS report among all patients who completed at least one PROMIS assessment from December 2017-March 2020 in one large health system, stratified by decedents vs. survivors. We conducted a retrospective cohort analysis of decedents (N = 1,499) who received care from outpatient neurology clinical practice within a single, large health system as part of usual care. We also compared decedents to survivors (360 + days before death; N = 49,602) on PROMIS domains and PROMIS-Preference (PROPr) score, along with demographics and clinical characteristics. We used electronic health record (EHR) data with built-in PROMIS measures. Linear regressions assessed differences in PROMIS domains and aggregate PROPr score by days before death of the final PROMIS completion for each patient.ResultsAmong decedents in our sample, in multivariable regression, only fatigue (range 54.48–59.38, p < 0.0029) and physical function (range 33.22–38.38, p < 0.0001) demonstrated clinically meaningful differences across time before death. The overall PROPr score also demonstrated statistically significant difference comparing survivors (0.19) to PROPr scores obtained 0–29 days before death (0.29, p < 0.0001).ConclusionsAlthough clinic completion of PROMIS measures was near universal, very few patients had more than one instance of PROMIS measures reported, limiting longitudinal analyses. Therefore, patient-reported outcomes in clinical practice may not yet be robust enough for incorporation in prediction models and assessment of trajectories of decline, as evidenced in these specialty clinics in one health system. PROMIS measures can be used to effectively identify symptoms and needs in real time, and robust incorporation into EHRs can improve patient-level outcomes, but further work is needed for them to offer meaningful inputs for defining patient trajectories near the end of life.Plain English SummaryAssessing symptom burden provides an opportunity to understand clinical decline, particularly as people approach the end of life. We sought to understand whether symptoms reported by patients can be used to assess decline in health. Such information can inform decision-making about care and treatments. Of eight symptoms that we assessed, patient reports of fatigue and physical function were associated with clinical decline, as was an overall score of symptom burden. Because few symptoms were associated with decline, patient-reported outcomes in clinical practice may not yet be robust enough for incorporation in prediction models and assessment of trajectories of decline.

Augenblickdiagnose in neurology: Revisiting 'diagnosis in the blink of an eye'.

The art of diagnosis in clinical neurology requires attentive listening and careful observation. In certain situations, a fragment of the history or a physical sign may be so distinctive that it allows clinicians to evoke a specific diagnosis. This quick mental process was previously referred to as 'Augenblickdiagnose' ('diagnosis in the blink of an eye') in a seminal paper by Dr. William Campbell in 1998. We aimed to revisit this concept by providing additional clinical vignettes. The authors wrote clinical vignettes using examples from their own clinical practice and performed a non-systematic review of influential neurology textbooks using the words 'pathognomonic' and 'highly suggestive'. Twenty examples from various fields of neurology are presented in a table, stratified by major fields of neurology. A short educational reflection is provided for each diagnosis considered. 'Augenblickdiagnose' is an engaging teaching resource that also contributes to 'neurophilia', that is, a fascination for neurology, perhaps increasingly in today's modern neurology practice. However, multiple cognitive biases underlying mental shortcuts may lead to an incorrect diagnosis. It is important to stress that good clinical practice in neurology requires taking a thorough history and performing a careful neurological examination.

Neuromuscular disease genetics in under-represented populations: increasing data diversity.

Neuromuscular diseases (NMDs) affect ∼15 million people globally. In high income settings DNA-based diagnosis has transformed care pathways and led to gene-specific therapies. However, most affected families are in low-to-middle income countries (LMICs) with limited access to DNA-based diagnosis. Most (86%) published genetic data is derived from European ancestry. This marked genetic data inequality hampers understanding of genetic diversity and hinders accurate genetic diagnosis in all income settings. We developed a cloud-based transcontinental partnership to build diverse, deeply-phenotyped and genetically characterized cohorts to improve genetic architecture knowledge, and potentially advance diagnosis and clinical management. We connected 18 centres in Brazil, India, South Africa, Turkey, Zambia, Netherlands and the UK. We co-developed a cloud-based data solution and trained 17 international neurology fellows in clinical genomic data interpretation. Single gene and whole exome data were analysed via a bespoke bioinformatics pipeline and reviewed alongside clinical and phenotypic data in global webinars to inform genetic outcome decisions. We recruited 6001 participants in the first 43 months. Initial genetic analyses 'solved' or 'possibly solved' ∼56% probands overall. In-depth genetic data review of the four commonest clinical categories (limb girdle muscular dystrophy, inherited peripheral neuropathies, congenital myopathy/muscular dystrophies and Duchenne/Becker muscular dystrophy) delivered a ∼59% 'solved' and ∼13% 'possibly solved' outcome. Almost 29% of disease causing variants were novel, increasing diverse pathogenic variant knowledge. Unsolved participants represent a new discovery cohort. The dataset provides a large resource from under-represented populations for genetic and translational research. In conclusion, we established a remote transcontinental partnership to assess genetic architecture of NMDs across diverse populations. It supported DNA-based diagnosis, potentially enabling genetic counselling, care pathways and eligibility for gene-specific trials. Similar virtual partnerships could be adopted by other areas of global genomic neurological practice to reduce genetic data inequality and benefit patients globally.

Examining the National Representativeness of the Axon Registry: A Neurology-Specific Patient Registry.

The objective of this study was to determine the external validity of the Axon Registry by comparing the 2019 calendar year data with 2 nationally representative, publicly available data sources, specifically the National Ambulatory Medical Care Survey (NAMCS) and the Medical Expenditure Panel Survey (MEPS). The Axon Registry is the American Academy of Neurology's neurology-focused qualified clinical data registry that reports and analyzes electronic health record data from participating US neurology providers. Its key function is to support quality improvement within ambulatory neurology practices while also promoting high-quality evidence-based care in clinical neurology. We compared demographics of patients who had an outpatient or office visit with a neurologist along with prevalence of selected neurologic conditions and neurologic procedures across the 3 data sets. We performed a cross-sectional, retrospective comparison of 3 data sets: NAMCS (2012-2016), MEPS (2013-2017, 2019), and Axon Registry (2019). We obtained patient demographics (age, birth sex, race, ethnicity), patient neurologic conditions (headache, epilepsy, cerebrovascular disease, multiple sclerosis, parkinsonism, dementia, spinal pain, and polyneuropathy), provider location, and neurologic procedures (neurology visits, MR/CT neuroimaging studies and EEG/EMG neurophysiologic studies). Parameter estimates from the pooled 5-year samples of the 2 public data sets, calculated at the visit level, were compared descriptively with those of the Axon Registry. We calculated Cohen h and performed Wald tests (α = 0.05) to conduct person-level statistical comparisons between MEPS 2019 and Axon Registry 2019 data. The Axon Registry recorded 1.3 M annual neurology visits (NAMCS, 11 M; MEPS, 22 M) and 645 K people with neurologic conditions (MEPS, 10 M). Compared with the pooled national surveys, the Axon Registry has similar patient demographics, neurologic condition prevalence, neuroimaging and neurophysiologic utilization, and provider location. In direct comparison with MEPS 2019, the Axon Registry 2019 had fewer children (2% vs 7%), more elderly persons (21% vs 16%), fewer non-Black and non-White race persons (5% vs 8%), less number of patients with epilepsy (10% vs 13%), more patients with dementia (8% vs 6%), more patients with cerebrovascular disease (11% vs 8%), and a greater predominance of neurology providers in the Midwest (25% vs 20%). The only difference with a non-negligible effect size was the proportion of people younger than 15 years (Cohen h = 0.25). The Axon Registry demonstrates high concordance with 2 nationally representative surveys. Recruiting more and diverse neurology providers will further improve the volume, representativeness, and value of the Axon Registry.

The 2022 European postgraduate (residency) programme in neurology in a historical and international perspective.

Neurology residency programmes, which were first established at the beginning of the 20th century, have become mandatory all over Europe in the last 40-50 years. The first European Training Requirements in Neurology (ETRN) were published in 2005 and first updated in 2016. This paper reports the most recent revisions of the ETRN. Members of the EAN board performed an in depth revision of the ETNR 2016-version, which was reviewed by members of the European Board and Section of Neurology of the UEMS, the Education and Scientific Panels, the Resident and Research Fellow Section and the Board of the EAN, as well as the presidents of the 47 European National Societies. The new (2022) ETRN suggest a 5-year training subdivided in three phases: a first phase (2 years) of general neurology training, a second phase (2 years) of training in neurophysiology/neurological subspecialties and a third phase (1 year) to expand clinical training (e.g., in other neurodisciplines) or for research (path for clinical neuroscientist). The necessary theoretical and clinical competences as well as learning objectives in diagnostic tests have been updated, are newly organized in four levels and include 19 neurological subspecialties. Finally, the new ETRN require, in addition to a programme director, a team of clinician-educators who regularly review the resident's progress. The 2022 update of the ETRN reflects emerging requirements for the practice of neurology and contributes to the international standardization of training necessary for the increasing needs of residents and specialists across Europe.

Benefits of a 12-Week Non-Drug "Brain Fitness Program" for Patients with Attention-Deficit/Hyperactive Disorder, Post-Concussion Syndrome, or Memory Loss.

Non-pharmacologic interventions can potentially improve cognitive function, sleep, and/or mood in patients with attention-deficit/hyperactive disorder (ADHD), post-concussion syndrome (PCS), or memory loss. We evaluated the benefits of a brain rehabilitation program in an outpatient neurology practice that consists of targeted cognitive training, lifestyle coaching, and electroencephalography (EEG)-based neurofeedback, twice weekly (90 minutes each), for 12 weeks. 223 child and adult patients were included: 71 patients with ADHD, 88 with PCS, and 64 with memory loss (mild cognitive impairment or subjective cognitive decline). Patients underwent a complete neurocognitive evaluation, including tests for Verbal Memory, Complex Attention, Processing Speed, Executive Functioning, and Neurocognition Index. They completed questionnaires about sleep, mood, diet, exercise, anxiety levels, and depression-as well as underwent quantitative EEG-at the beginning and the end of the program. Pre-post test score comparison demonstrated that all patient subgroups experienced statistically significant improvements on most measures, especially the PCS subgroup, which experienced significant score improvement on all measures tested (p≤0.0011; dz≥0.36). After completing the program, 60% to 90% of patients scored higher on cognitive tests and reported having fewer cognitive and emotional symptoms. The largest effect size for pre-post score change was improved executive functioning in all subgroups (ADHD dz= 0.86; PCS dz= 0.83; memory dz= 1.09). This study demonstrates that a multimodal brain rehabilitation program can have benefits for patients with ADHD, PCS, or memory loss and supports further clinical trials in this field.

Current methods of modeling depression in animals and approaches to the study of their efficiency in biomedical research (review of the problem)

Depressive disorders are one of the leading problems of modern health care. Their prevalence in the world ranges from 4.4 to 20 % of the population, and in Russia the incidence of depression reaches 20 %. The study of depressive disorders is relevant not only from the point of view of psychiatry and behavioral therapy, but also occupies a leading place in neurological practice, since more than a quarter of the population with chronic neurological diseases suffer from depression. Currently, most basic biomedical research on depressive disorders is carried out using laboratory animals. However, the protocols for experimental modeling and analysis of behavioral patterns are very diverse, which creates certain difficulties in planning research. This review is aimed at describing, analyzing, comparing and systematizing possible approaches to creating experimental models of depression in animals, and also contains criteria for model validation and a description of behavioral tests to assess anxiety-depressive disorders.

Association Between Anti-CD20 Therapies and COVID-19 Severity Among Patients With Relapsing-Remitting and Progressive Multiple Sclerosis

In patients with multiple sclerosis (MS), factors associated with severe COVID-19 include anti-CD20 therapies and neurologic disability, but it is still unclear whether these 2 variables are independently associated with severe COVID-19 or whether the association depends on MS clinical course. To assess the association between anti-CD20 therapies and COVID-19 severity in patients with relapsing-remitting MS (RRMS) and progressive MS (PMS). This multicenter, retrospective cohort study used data from the COVISEP study, which included patients with MS and COVID-19 from February 1, 2020, to June 30, 2022, at 46 French MS expert centers, general hospitals, and private neurology practices. Eligible patients with RRMS were those treated with high-efficacy MS therapy (ie, anti-CD20, fingolimod, or natalizumab), and eligible patients with PMS were those younger than 70 years with an Expanded Disability Status Scale (EDSS) score of 8 or lower. Patients were monitored from COVID-19 symptom onset until recovery or death. Current anti-CD20 therapy (ocrelizumab or rituximab). The main outcome was severe COVID-19 (ie, hospitalization with any mode of oxygenation or death). All analyses were conducted separately in patients with RRMS and PMS using propensity score-weighted logistic regression. Subgroup analyses were performed according to COVID-19 vaccine status, sex, EDSS score, and age. A total of 1400 patients, 971 with RRMS (median age, 39.14 years [IQR, 31.38-46.80 years]; 737 [76.1%] female) and 429 with PMS (median age, 54.21 years [IQR, 48.42-60.14 years]; 250 [58.3%] female) were included in the study. A total of 418 patients with RRMS (43.0%) and 226 with PMS (52.7%) were treated with anti-CD20 therapies. In weighted analysis, 13.4% and 2.9% of patients with RRMS treated and not treated with anti-CD20 had severe COVID-19, respectively, and anti-CD20 treatment was associated with increased risk of severe COVID-19 (odds ratio [OR], 5.20; 95% CI, 2.78-9.71); this association persisted among vaccinated patients (7.0% vs 0.9%; OR, 8.85; 95% CI, 1.26-62.12). Among patients with PMS, 19.0% and 15.5% of patients treated and not treated with anti-CD20 had severe COVID-19, respectively, and there was no association between anti-CD20 treatment and severe COVID-19 (OR, 1.28; 95% CI, 0.76-2.16). In PMS subgroup analysis, anti-CD20 exposure interacted negatively with EDSS score (P = .009 for interaction) and age (P = .03 for interaction); anti-CD20 therapies were associated with risk of severe COVID-19 only in patients with less neurologic disability and younger patients with PMS. In this cohort study, risk of severe COVID-19 was higher in patients with PMS than in those with RRMS. Use of anti-CD20 therapies was associated with an increased risk of severe COVID-19 among patients with RRMS. In patients with PMS, there was no association between anti-CD20 therapies and risk of severe COVID-19.

Percutaneous Spinal Interventions for Chronic Pain Management.

Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.

Education on neuromuscular electrodiagnosis and neurological symptomatology

AbstractNeurological symptomatology is a crucial component of neurological expertise. The committee for fostering board‐certified neurologists in the Japanese Society of Neurology (JSN) has hosted an educational activity for residents before the board examination, “The seminar for fostering board‐certified neurologists” since 2004. In particular, the autumn seminar has been characterized by small group hands‐on of neurological examinations and the evaluations of higher brain function. Besides this, hands‐on seminar of neurological examinations by regional branches has been promoted by the JSN. In the Kanto Ko‐shin‐etsu branch, “The first hands‐on seminar of neurological examinations” started in 2023 after a 3‐year‐suspension due to COVID‐19. The most important educational activities in neuromuscular electrodiagnosis (EDx) is the “Neuromuscular diagnostics seminar” hosted since 2004 by the Japanese Society of Clinical Neurophysiology (JSCN). The majority of tutors and participants are neurologists. This seminar is also characterized by small‐group, hands‐on workshops. We have also run the overseas seminar, “Tokyo Super EMG hands‐on,” since 2013. These have undoubtedly contributed to enhancing the level of neuromuscular electrodiagnosis not only in Japan but also in other Asian countries. I have conducted studies on neurological symptomatology and neuromuscular electrodiagnosis, which are directly linked to enhancing clinical practice of neurologists through educational activities such as review articles or lectures. Due to the fact that symptomatology is crucial in neurological expertise, neurology is a basic specialty around the world except in Japan. In 2018, the JSN decided to aim to make neurology a basic specialty and continues to make efforts to attain this goal.

Enfoque holístico al paciente neurológico: el aporte de Oliver Sacks

La obra de Oliver Sacks es bien conocida y muy destacada en la literatura de divulgación médica y ha contribuido al conocimiento de la enfermedad neurológica por el público en general. Desde el punto de vista de la neurología literaria sus escritos han sido analizados por muchos autores. El presente artículo examina desde la perspectiva de un neurólogo clínico algunos elementos de la obra de Oliver Sacks que podrían ser de gran beneficio en el abordaje diagnóstico y terapéutico del paciente neurológico y un valioso aporte a la práctica clínica de la neurología. Se exploran también algunas nuevas contribuciones hechas por la investigación en neurociencias y por la psicología cognitiva al abordaje holístico del paciente en medicina y se discuten los beneficios de este abordaje en la recuperación de la enfermedad neurológica.