Research on telestroke (telemedicine) shows improved access and clinical care in Oregon

If you're a neurologist, you're probably in San Diego at the American Academy of Neurology’s 65th Annual Meeting. Last Friday, researchers at UPenn revealed how telemedicine programs in Oregon are pushing stroke coverage into previously uncovered, less populated areas and expanding coverage by approximately 40 percent. The study shows that, by employing telemedical systems in concert with in-person care, nearly 80 percent of residents had access to expert stroke care within one hour.

The study evaluated all hospitals in Oregon, finding that 43 percent of the population could reach a stroke center in person within 60 minutes, 76 percent had telemedical access, 40 percent had access to both, and 20 percent had no access to stroke care within an hour.

You can read the full press release here.

Speaking of telemedicine - make sure you don't miss the early bird registration deadline for the upcoming ATA (American Telemedicine Association) conference in May. Registration fees go up on April 1. You won't want to miss ATA given that there is so much happening in telemedicine right now!

Using Google Docs to gather clinical information from patients

Author: Steven Zuckerman, M.D.

The purpose of this article is to describe how I have been able to use “cloud technology” to simplify the process of getting useful clinical information from my patients. Since I am a neurologist, I have more than a passing interest in the management of patients with Parkinson’s disease. The successful management of this condition is highly dependent on the patient-physician communication regarding how their disease state is responding to their Parkinson regimen. Too much medication causes involuntary movements while inadequate dopamine stimulation results in the inability to move. Since there are several different Parkinson’s medications, all of which have different half-lives and durations of actions, the resultant clinical effectiveness is highly variable. Therefore, correlating clinical status with timing of medication ingestion is the only reliable means to make appropriate medication adjustments. Ideally, a patient log or journal should be completed at half hour intervals to capture this information. An analogous condition in Primary Care would be regulating a Diabetic. Insulin type and dosage need to be correlated with blood glucose determinations obtained throughout the day in order to optimize the Insulin regimen.

FDA approves Potiga (ezogabine) to treat seizures in adults

On June 10, Potiga (ezogabine) tablets were approved by the U.S. Food and Drug Administration for use as an add-on medication to treat seizures associated with epilepsy in adults.

Potiga was approved for the treatment of partial seizures, the most common type of seizure seen in people with epilepsy. Epilepsy is a brain disorder in which there is abnormal or excessive activity of nerve cells in the brain. Partial seizures affect only a limited or localized area of the brain, but can spread to other parts of the brain. Seizures cause a wide range of symptoms, including repetitive limb movements (spasms), unusual behavior, and generalized convulsions with loss of consciousness.

Viagra Could Reduce Multiple Sclerosis Symptoms

Universitat Autònoma de Barcelona researchers have discovered that Viagra® drastically reduces multiple sclerosis symptoms in animal models with the disease. The research, published in Acta Neuropathologica, demonstrates that a practically complete recovery occurs in 50% of the animals after eight days of treatment. Researchers are confident that clinical trials soon will be carried out in patients given that the drug is well tolerated and has been used to treat sexual dysfunction in some multiple sclerosis patients.

Generation Alzheimer's: The Defining Disease of the Baby Boomers

The first baby boomers are turning 65 this year. And while Alzheimer's is not normal aging, age is the greatest risk factor for the disease. This free report conveys the growing burden of Alzheimer's and dementia on individuals, families, government and the nation's healthcare system.

Where's the treatment? Where's the cure?

The National Institutes of Health spends over:

• $6 billion a year on cancer research
• $4 billion on heart disease research
• $3 billion on HIV/AIDS research

But it spends only $480 million on Alzheimer's research. While death rates for these diseases decline, Alzheimer's remains the only cause of death among the top 10 in America without a way to prevent, cure or even slow its progression.

Mynd gets into the minds of consumers: A breakthrough in neuromarketing

Author: Brittany Chan

NeuroFocus has created the world’s first wireless EEG sensor headset, which allows market researchers to literally get inside your mind. Using medical technology, Mynd can track eye movements and other brain activity to aid in the development of brands, products, or advertisements. The headset is reportedly extremely lightweight and comfortable. Furthermore, brainwaves can be recorded and transmitted wirelessly to a Bluetooth device.

This technology can also be used to improve the lives of people with devastating neurological disabilities such as paralysis or stroke. Researchers are exploring the possible future uses of the headset in the medical setting.

As an MD/MBA student, I find this a very fascinating intersection between business and medicine.

Unbelievable Story: A Boy Without A Cerebellum

Author: Brittany Chan

Three-year-old Chase Britton was born premature and legally blind. When he failed to achieve the appropriate developmental milestones, doctors thought he may have cerebral palsy.

What they found was that Chase has no cerebellum or pons, only fluid where these structures would have been. Yet he can take steps with help, communicate, use scissors, and play with his thirteen-year-old brother. He's also learning the alphabet.

This is truly a medical mystery! The human body never ceases to amaze me. Neurologists everywhere are now questioning what they thought they knew about the brain. Check out the full story here. Such an inspiring story and family.

A free CME/CE activity on Multiple Sclerosis (for neurologists and nurses)

Here's a free CME/CE activity on Multiple Sclerosis (for neurologists and nurses):

Managing Multiple Sclerosis: Patient-Centered Approaches to Treatment 

A new way to evaluate dyslexia

MIT News has a story about neuroscientists showing that brain scans can predict whether children’s reading ability will improve. Could brain scans predict which children with dyslexia are likely to improve their reading skills over time? Take a look at the MIT News story here.

Michael J. Fox Foundation Launches Parkinson's Progression Markers Initiative (PPMI)

Michael J. Fox Foundation Launches Parkinson's Progression Markers Initiative (PPMI)

- Landmark five-year $40-million global research study aims to identify biomarkers of Parkinson's disease progression, critical tools for drug development -

NEW YORK, Sept. 28 /PRNewswire-USNewswire/ -- The Michael J. Fox Foundation has launched the Parkinson's Progression Markers Initiative (PPMI) (www.michaeljfox.org/PPMI), the first-ever large-scale clinical study exclusively focused on identifying and validating Parkinson's disease biomarkers.

A biomarker is required to efficiently test potentially life-transforming new drugs that could slow or stop the progression of Parkinson's disease — something no PD treatment on today's market can do. A biomarker of Parkinson's has not yet been found.

Stiff-Person Syndrome

I'm always learning something new. I admit that I did not learn about Stiff-Person Syndrome during medical school (I must have missed that lecture).

According to the National Institute of Neurological Disorders and Stroke (NINDS):

Stiff-person syndrome (SPS) is a rare neurological disorder with features of an autoimmune disease.  SPS is characterized by fluctuating muscle rigidity in the trunk and limbs and a heightened sensitivity to stimuli such as noise, touch, and emotional distress, which can set off muscle spasms.  Abnormal postures, often hunched over and stiffened, are characteristic of the disorder.  People with SPS can be too disabled to walk or move, or they are afraid to leave the house because street noises, such as the sound of a horn, can trigger spasms and falls.  SPS affects twice as many women as men.   It is frequently associated with other autoimmune diseases such as diabetes, thyroiditis, vitiligo, and pernicious anemia.  Scientists don’t yet understand what causes SPS, but research indicates that it is the result of an autoimmune response gone awry in the brain and spinal cord.  The disorder is often misdiagnosed as Parkinson’s disease, multiple sclerosis, fibromyalgia, psychosomatic illness, or anxiety and phobia.  A definitive diagnosis can be made with a blood test that measures the level of glutamic acid decarboxylase (GAD) antibodies in the blood.  People with SPS have elevated levels of GAD, an antibody that works against an enzyme involved in the synthesis of an important neurotransmitter in the brain.

Why am I blogging about Stiff-Person Syndrome? I happened to see Stiff-Person Syndrome mentioned in the Tarascon Monthly Dose: August 2010 and it caught my attention.  Stiff-Person Syndrome is a true zebra in the world of medicine. If you're a medical student or resident, you may impress your residents by mentioning it. You can learn more here on the NINDS website.

FDA: Aseptic Meningitis Risk with Use of Seizure Drug Lamictal

Here's a recent warning from the FDA:

FDA: Aseptic Meningitis Risk with Use of Seizure Drug Lamictal

The U.S. Food and Drug Administration today warned that the drug Lamictal (lamotrigine), approved to treat seizures and bipolar disorder, can cause aseptic meningitis, an inflammation of the protective membranes (meninges) that cover the brain and spinal cord not caused by bacterial infection.

The agency is working with the drug’s manufacturer, GlaxoSmithKline, to update the prescribing information and patient medication guide to include this risk.

Aseptic meningitis has a number of causes including, but not limited to, viruses, toxic agents, some vaccines, autoimmune diseases, and certain medications, including Lamictal. Symptoms can include headache, fever, chills, nausea, vomiting, stiff neck and sensitivity to light. Hospitalization may be required.

Read more here.

Baxter's immune-system drug may be effective for Alzheimer's disease

Here's a snippet from the Chicago Tribune:

An immune-system drug produced by Baxter International Inc. helped preserve "thinking" abilities and reduced the rate of brain shrinkage in a small group of patients with Alzheimer's disease who have been studied for 18 months, new research released Tuesday shows.

Researchers presented this information at the American Academy of Neurology meeting in Toronto. It was a small study where 16 of 24 patients had better cognitive response and improved memory function when they were treated with Baxter's Gammagard. The patients were those who had mild to moderate Alzheimer's disease. Researchers hope that Gammagard (a biologic derived from plasma) will change the course of Alzheimer's disease. If that's the case,then it would truly be a disease-modifying therapy. The idea behind Gammagard is that it can help the body's immune system to clear the brain of amyloid, a sticky, plaque-like substance thought to be key in the development and progression of Alzheimer's. Isn't it great to see new research unfolding innovative ways to treat conditions like Alzheimer's disease?

Neuroscience for the Twitter Generation

This is a guest post by Ethan Segal, MD. If you're interested in submitting a guest post, please contact me.

I am stunned at today’s David Brooks column, “The Young and the Neuro.” The NYT’s conservative columnist, who apparently went to the Social and Affective Neuroscience Society’s conference in Lower Manhattan last weekend (who knew he liked to party with the brain-geek crowd?), talked about how instead of finding “graying professors” he found neuroscientists who were, “so damned young, hip and attractive.” These youngn’s, as Brooks notes, are barely in their twenties and thirties, seem to have a unique interdisciplinary spin to neuroscience. They are using data from fMRI (functional magnetic resonance imaging) and applying it social science questions, economics, and culture. Brooks goes on to acknowledge how one must be careful to draw broad conclusions about society and culture from such reductionistic approaches, as did the scientists at the meeting. He makes the following conclusion:

The hard sciences are interpenetrating the social sciences. This isn’t dehumanizing. It shines attention on the things poets have traditionally cared about: the power of human attachments. It may even help policy wonks someday see people as they really are.

The reader comments are interesting. Many readers seem to think Brooks is referring to the Obama administration by “policy wonks.” Although most welcome the explosion of research in the brain, with new technology such as fMRI, many disagree with his notion that there is a true way to “see people as they really are.” Im curious by my generation’s interest and take on neuroscience. It makes me think of William James, the physician and psychologist, brother of novelist Henry James, in the early twentieth century, promoter of the Pragmatism movement in academia. Follow me as I digress…

James said that in academia you could basically separate out academics into the “tough-minded” and “soft-minded” thinkers. The former were people like Hegel, Kant, Hume, who emphasized logic, reason, cause and effect; the later softies could be Emerson, Kierkegaard, Whitman, who emphasized passion, feeling, individuality. The basic premise was that ideas were as much a product of temperament of the individual as much as it was cognition.

Which brings me to my point: am I drawn to neuroscience because of my temperament, maybe the way I was raised, in a perfect storm of computers, video games, the internet, Japanese anime? Is there something about being a twenty or thirty year old in medicine or science today that seeks such reductionistic ways of describing human nature/society? Prior to medical school, I was involved in neuroimaging research with a psychiatrist at Harvard who found that the amygdala lights up on MRI scans when white subjects are shown black faces subliminally. The amygdala, being a “fear center” in the brain that is in large part subconsciously activated, could this be a biologic explanation of racism? Interestingly, the amygdala activates in african americans who are shown subliminal pictures of white faces. Like many readers of Brooks’ column have posted, it will take a long time to make sense of such data. In the meantime, Im going to sit under a tree by the Charles River and read Leaves of Grass.

This guest post was written by Ethan Segal, MD. Ethan Segal earned a BA from Amherst College and a MD from Tufts University School of Medicine. He is currently working freelance as a medical writer and applying to residency programs for July 2010. He can be reached at Ethan.Segal(at)mac.com

How the brain invents the mind

How do you differentiate the brain and the mind? Watch this great MIT video. First, Susan Hockfield (MIT President) starts this presentation by speaking about the economy and sustainable energy. Then professor Rebecca Saxe outlines her research investigating the neural basis for a Theory of Mind -- how the human mind seems geared to “glean what others are thinking and feeling.”

From her work with children and adults, Saxe has determined that there’s a very specific region of the brain -- the right temporal-parietal junction -- dedicated to thinking about how others think. This area lights up in the fMRI scanner when people read stories involving another person’s beliefs and moral judgments, but not when they digest other kinds of written material. The RTPJ develops this special function slowly (young children don’t have it), and Saxe has discovered that she can interfere with this region’s activities, altering her subjects’ sense of what constitutes morally permissible behavior. She’s exploring whether these distinct neural networks develop differently in children with autism, with the hope of finding therapies that might someday help treat the disorder.

Group Backs Telemedicine for Stroke Care

This is a guest post by Ethan Segal, MD. If you're interested in submitting a guest post, please contact me.

An article “Groups Back Telemedicine for Stroke Care” appearing in the July 1, 2009 issue of JAMA reports how the American Heart Association and the American Stroke Association in early May 2009 released a statement which demands that all facilities which lack an onsite stroke neurologist should have teleconferencing systems in place to consult expert stroke neurologists at another facility. These neurologists could then remotely evaluate an acute stroke patient possibility needing tPA treatment. The group defines teleconferencing as “the use of dedicated, high quality, interactive, bidirectional audiovisual systems coupled with teleradiology for remote review of brain images.”

The main author of the statement by the AHA is Lee H. Schwamm, MD, a pre-eminent stroke neurologist at Massachusetts General Hospital. Dr. Schwamm cites preliminary work published in Neurology, which supports the notion that using telemedicine with remote neurology consultation dramatically improves acute stroke outcomes. Dr. Schwamm also raises the issue of a scarcity of stroke neurologists available in the US to see acute stroke patients (Currently, there are only four neurologists per 100,000 people in the US and many are not experts in stroke. Compare that with 700,000 acute strokes occurring annually in the US causing 163,000 deaths).

Highly critical of the statement is Dr. Robert Solomon, MD, an ER physician, and board member on the ACEP. “The committee noted a lack of comparative assessment of telemedicine to alternatives that could also improve stroke care…” notes Dr. Solomon on the supporting studies cited by Dr. Schwamm. He continues, “There seems to be an inherent assumption that if the hospital does not have a neurologist available to come to the emergency department to see the patient at the time of initial presentation, that that situation fits the definition of ‘these people don’t know what they’re doing’ and clearly they must have telemedicine with a neurologist. That’s not the reality; there are lots of hospitals where patients are getting excellent care where the neurologist is nonexistent or cannot see the patient at the time of presentation.”

Regardless, there are many obstacles to providing telemedicine at the bedside. There remain strict guidelines by Medicare on reimbursement for telemedicine consultation, only in specifically designated rural areas. Many insurers are extremely reluctant to pay for such consultation. Furthermore, there remain problems of licensing by state medical boards that restricts the out-of-state use of the technology, and liability concerns. On April 23, a bill was introduced in the House called the Medicare Telehealth Enhancement Act, which would provide $30 million to help health facilities pay for telemedicine equipment and expand Medicare reimbursement to urban and suburban areas (HR 2068 [http://thomas.loc.gov]).

Personally, I feel there would be a more direct way to deal with the shortage of stroke specialistsincrease the number of training programs. I am currently applying to neurology residency positions in the match and it seems like the average neurology class has maybe three positions. Some have one position for the entire class. Compare that with typical residency class sizes of other advanced specialties, like anesthesiology, having two or three times as many spots. 30 million dollars a year could provide a lot of neurology residency spots and stroke fellowships. Being a current applicant, maybe this is just my bias, but it seems neurology has to do more to expand training programs in the US, especially considering the rapidly aging population. The current scarcity of neurologists could very well be due to the highly inaccurate view of neurologists as “medical nihilists,” therefore useless to the medical community. Im glad that the AHA and ASA realize the urgent need in this country for neurologists and their expertise.

Telemedicine could do wonders outside the US, in desperate areas of Africa and Asia. I was lectured, by a nephrologist, on how he used teleconferencing to teach doctors at the bedside in Africa. I regularly attended grand rounds in neurology at my own medical school, which is conducted through teleconferencing between all three Boston area hospitals that make up the program. Clearly, there are educational applications for this technology. As the population continues to age and the physician shortage becomes more apparent, telemedicine and its clinical applications in the US will no doubt continue to be a hotly debated topic.

This guest post was written by Ethan Segal, MD. Ethan Segal earned a BA from Amherst College and a MD from Tufts University School of Medicine. He is currently working freelance as a medical writer and applying to residency programs for July 2010. He can be reached at Ethan.Segal(at)mac.com

Camp Twitch and Shout

I love summer camps. However, "Camp Twitch and Shout" is not your typical summer camp. This is a camp for people who have Tourette syndrome (according to Wikipedia is also called Tourette's syndrome, Tourette's disorder, Gilles de la Tourette syndrome, GTS or, more commonly, simply Tourette's or TS). It's a neurological disorder characterized by motor and voice tics.

According to the Centers for Disease Control and Prevention, three out of every 1,000 school-age children are believed to have Tourette syndrome. The cause is unknown, but genetics appear to play a role. Most children develop the condition between 7 and 10, and if their tics are mild to moderate, they usually require no medicine to control them. Symptoms usually peak during the late teens or early 20s.

What goes on at Camp Twitch and Shout? Children with Tourette's get to have fun. It's so great to see social support groups like these camps. We have CaringBridge and other online social support sites for people who are struggling with various health conditions. When you get to meet at a camp, interact, and have fun, then I'm sure some unique friendships develop. Click here for the CNN story.

AAN is in Seattle

The American Academy of Neurology (AAN) is having its 61st annual meeting in Seattle this year. The theme this year is: "Better Practices, Better Outcomes." The meeting began over the weekend (April 25) and will run until May 2. Doctors still love to attend major national meetings to get thier continuing medical education (CME). I love Seattle. In fact, Seattle is probably one of my favorite cities because of all the outdoor activities that are available in that area. Mount Rainier is such a great park and I think I could spend weeks backpacking throughout the Cascades Range.