Future of Neurology & Technology

With machine learning, jobs ranging from caring for the elderly to identifying abnormalities on radiological images may soon lie in the hands of robots or artificial intelligence, as Dr. Siddartha Mukherjee has pointed out in his essay, A.I. Versus M.D., for The New Yorker. How will advances in technology, like seizure alert devices, impact the field of neurology? What aspects of our profession will become automated, if any? How should we prepare for the future?

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Starting antiepileptic medication after a first unprovoked seizure

While 10% of the population will have a single seizure in their lifetime, the challenge is determining for which patients the risk and repercussions of recurrent seizure are great enough to warrant starting antiepileptic therapy. Although immediate treatment after a first unprovoked seizure may decrease seizure risk over the next few years, there is no evidence that early treatment improves longer-term prognosis.

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Another recipe for improving global neurology for US trainees—this time with a dash of ACGME-flavored core competencies

An anthropologist-friend some years ago described the average international student elective as “an experience of inflicting the unprepared upon the unsuspecting.” Thankfully, as US global health programs have expanded in number with many becoming formally incorporated into existing training programs, a growing body of knowledge and academic thought about what should be included in a global neurology curriculum is starting to emerge.1-4

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In response to Establishment of Epilepsy Surgery in Peru

I read with some interest the description of the recent development of not one, but two epilepsy surgery programs in Peru. There are certainly laudable aspects of the work including that, as described, it represents a true transfer of technical and medical capacity and not a “mission trip” with external experts dropping in briefly to declare victory over disease.

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Where do monoclonal antibodies against the CGRP receptors fit into the treatment algorithm for patients with migraine?

VanderPluym et al report post-hoc analyses from 2 clinical trials to evaluate the effects of fremanezumab on patient’s functional status on their headache free days1. Neurology characterizes the evidence as level 2 that fremanezumab increases normal functional performance on headache free days. The results were robust to multiple functional measures and to both migraine subsets, episodic (8-14 days of headache per month) and chronic (>15 days of headache per month). The authors rightfully describe their findings as exploratory given that these results were not the pre-specified outcomes of these trials. They also point out that the increase in functional performance on headache free days might be just because of the increase in headache free days overall rather than any additional effect on function.

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The World Health Organization’s First Edition Essential Diagnostics List: More aspirational than feasible

In May 2018, the World Health Organization (WHO) published its first edition of a “Model List of Essential in Vitro Diagnostics” (EDL) in which they detail those clinical diagnostic tests which should be (ideally?) available and at which level of healthcare facility. Clearly, developing this list was no small undertaking and WHO is careful to state that the EDL is “not intended to be prescriptive…rather country programmes should make the ultimate decision about [EDLs] selected”. Nonetheless, there are some paradoxical recommendations hard to reconcile with realities. For example, the primary health care facility is delineated as:

“Primary health care: Health centres, doctors’ offices, health posts, outreach clinics. Typically, self-testing and rapid diagnostics tests are available, but there are either no laboratories, or small laboratories with trained health”

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Did consolidating acute stroke services in Denmark help?

Getting acute stroke patients to appropriate clinical care setting as fast as possible is very important. Hastrup et al report results of an initiative to centralize stroke care in 2012 in the Central Denmark Region (CDR). CDR has a population of 1.3million and area of 5040 square miles1. The purpose of the centralization was a) to ensure all stroke patients would receive care in designated areas and b) to reduce overall costs. The design of the study was pre/post with contemporaneous comparisons to the rest of Denmark. The centralization involved consolidating acute stroke care to 2 designated hospitals from a total of 6 hospitals in the region. These hospitals both offered thrombolysis, but endovascular therapy was only offered at one. A neurologist was on call 24 hours a day for calls from outside the acute stroke units. In addition, an outpatient clinic was established for minor stroke and TIA.

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Publons – A useful resource for residents and fellows to become experienced reviewers, and get recognized for it.

The Neurology journal has recently become an official partner of Publons. Publons (publons.com), is a relatively new company founded in 2012 to help recognize reviewers for their contributions and train the next generation of reviewers. It currently boasts over 400,000+ users and the number is rapidly growing. Publons’ website has many resources that residents and fellows may find helpful in their early career development.

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