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It is unknown if patients with neuromuscular diseases prefer in-person or virtual telemedicine visits. We studied patient opinions and preference on virtual versus in-person visits, and the factors influencing such preferences.Telephone surveys, consisting of 11 questions, of patients from 10 neuromuscular centers were completed.Five hundred and twenty surveys were completed. Twenty-six percent of respondents preferred virtual visits, while 50% preferred in-person visits. Sixty-four percent reported physical interaction as "very important." For receiving a new diagnosis, 55% preferred in-person vs 35% reporting no preference. Forty percent were concerned about a lack of physical examination vs 20% who were concerned about evaluating vital signs. Eighty four percent reported virtual visits were sufficiently private. Sixty eight percent did not consider expenses a factor in their preference. Although 92% were comfortable with virtual communication technology, 55% preferred video communications, and 19% preferred phone calls. Visit preference was not significantly associated with gender, diagnosis, disease severity, or symptom management. Patients who were concerned about a lack of physical exam or assessment of vitals had significantly higher odds of selecting in-person visits than no preference.Although neither technology, privacy, nor finance burdened patients in our study, more patients preferred in-person visits than virtual visits and 40% were concerned about a lack of physical examination. Interactions that occur with in-person encounters had high importance for patients, reflecting differences in the perception of the patient-physician relationship between virtual and in-person visits.

Objective: To assess the prevalence and clinical implications of variant sciatic nerve anatomy in relation to the piriformis muscle on magnetic resonance neurography (MRN), in patients with lumbosacral neuropathic symptoms. Materials and Methods: In this retrospective single-center study, 254 sciatic nerves, from 127 patients with clinical and imaging findings compatible with extra-spinal sciatica on MRN between 2003 and 2013, were evaluated for the presence and type of variant sciatic nerves, split sciatic nerve, abnormal T2-signal hyperintensity, asymmetric piriformis size and increased nerve caliber, and summarized using descriptive statistics. Two-tailed chi-square tests were performed to compare the anatomical variant type and clinical symptoms between imaging and clinical characteristics. Results: Sixty-four variant sciatic nerves were identified with an equal number of right and left variants. Bilateral variants were noted in 15 cases. Abnormal T2-signal hyperintensity was seen significantly more often in variant compared to conventional anatomy (40/64 vs. 82/190; p = 0.01). A sciatic nerve split was seen significantly more often in variant compared to conventional anatomy (56/64 vs. 20/190; p < 0.0001). Increased nerve caliber, abnormal T2-signal hyperintensity, and asymmetric piriformis size were significantly associated with the clinically symptomatic side compared to the asymptomatic side (98:2, 98:2, and 97:3, respectively; p < 0.0001 for all). Clinical symptoms were correlated with variant compared to conventional sciatic nerve anatomy (64% vs. 46%; p = 0.01). Conclusion: Variant sciatic nerve anatomy, in relation to the piriformis muscle, is frequently identified with MRN and is more likely to be associated with nerve signal changes and symptomatology.

Mismatch between whole-brain death criteria embedded in statutes and accepted tests physicians use to diagnose brain death have clinical and ethical implications that could undermine public trust in death pronouncements. We consider merits and drawbacks of 4 ways to address this problem.

Background and ObjectivesPeripheral nerve impairments and dementia are common among older adults and share risk factors. However, few studies have examined whether peripheral nerve function and dementia are associated. We evaluated whether lower extremity peripheral nerve impairments were associated with higher incidence of dementia and whether associations differed by comorbidity subgroups (diabetes, low vitamin B12, and APOE ε4 allele carriers).MethodsWe studied Black and White Health, Aging, and Body Composition Study participants 70 to 79 years of age and without dementia at enrollment. Lower extremity sensory and motor peripheral nerve function was measured at year 4 (the analytic baseline of this study). Sensory nerve impairments were measured with monofilament (1.4 g, 10 g) and vibration threshold of the toe. Monofilament insensitivity was defined as unable to detect monofilament (3 of 4 touches), and vibration detection impairment was defined as >130 μm. Fibular motor impairments were defined as ResultsAmong 2,174 participants (52% women, 35% Black), 45% could not detect monofilament 1.4 g, 9% could not detect monofilament 10 g, 6% could not feel vibration, 10% had low CMAP amplitude, and 24% had slow conduction velocity. Monofilament 10 g (hazard ratio [HR] 1.35, 95% CI 0.99–1.84) and vibration detection insensitivity (HR 1.73, 95% CI 1.24–2.40) were associated/borderline associated with a higher risk of dementia after covariate adjustment. Estimates were elevated but not significant for monofilament 1.4 g, CMAP amplitude, and conduction velocity (p > 0.05). Increasing number of peripheral nerve impairments was associated with higher risk of dementia in a graded fashion; for ≥3 impairments, the HR was 2.37 (95% CI 1.29–4.38). In subgroup analyses, effect estimates were generally higher among those with diabetes, low vitamin B12, and APOE ε4 allele except for vibration detection.DiscussionPeripheral nerve impairments, especially sensory, were associated with a higher risk of dementia even after adjustment for age and other health factors. These associations may represent a shared susceptibility to nervous system degeneration.

Black people living in the United States suffer disproportionate morbidity and mortality across a wide range of neurologic conditions. Despite common conceptions to the contrary, “race” is a socially defined construct with little genetic validity. Therefore, racial health inequities in neurology (“neurodisparities”) are not a consequence of biologic differences between races. Instead, racism and associated social determinants of health are the root of neurodisparities. To date, many neurologists have neglected racism as a root cause of neurologic disease, further perpetuating the problem. Structural racism, largely ignored in current neurologic practice and policy, drives neurodisparities through mediators such as excessive poverty, inferior health insurance, and poorer access to neurologic and preventative care. Interpersonal racism (implicit or explicit) and associated discriminatory practices in neurologic research, workforce advancement, and medical education also exacerbate neurodisparities. Neurologists cannot fulfill their professional and ethical responsibility to care for Black patients without understanding how racism, not biologic race, drives neurodisparities. In our review of race, racism, and race-based disparities in neurology, we highlight the current literature on neurodisparities across a wide range of neurologic conditions and focus on racism as the root cause. We discuss why all neurologists are ethically and professionally obligated to actively promote measures to counteract racism. We conclude with a call for actions that should be implemented by individual neurologists and professional neurologic organizations to mitigate racism and work towards health equity in neurology.

OBJECTIVES HIV-associated neurocognitive disorders (HAND) remain prevalent in people living with HIV (PLWH) despite widespread use of combined antiretroviral therapy (ART). Vascular disease contributes to the pathogenesis of HAND, but traditional vascular risk factors do not fully explain the relation between vascular disease and HAND. A more direct measure of vascular dysfunction is needed. This cross-sectional study tested whether the cardio-ankle vascular index (CAVI), a novel method to assess arterial stiffness, is associated with HAND among PLWH. METHODS Participants included 75 non-diabetic adults with well-controlled HIV from an outpatient HIV clinic. We assessed the relation between CAVI and neurocognitive impairment (NCI). The latter was primarily characterized by the Frascati criteria and secondarily (post hoc) using the Global Deficit Score (GDS). Logistic regression models tested whether high CAVI (≥ 8) was independently associated with NCI when controlling for potential confounders. RESULTS Participants (Mage = 45.6 ± 8.3 years; 30.1% male) had few traditional cardiovascular disease (CVD) risk factors (hypertension, n = 7; dyslipidaemia, n = 34; body mass index ≥ 25 kg/m2 , n = 12; smoking history, n = 13; 2.2% mean 10-year risk of CVD or stroke). Twelve (16%) participants had high CAVI, which was independently associated with meeting Frascati criteria for NCI [n = 39, odds ratio (OR) = 7.6, p = 0.04], accounting for age, education, gender, income, CD4 nadir, recent CD4 and traditional CVD risk factors. High CAVI was also associated with NCI as reflected by higher GDS (OR = 17.4, p = 0.02). CONCLUSIONS Cardio-ankle vascular index is a promising measure of vascular dysfunction that may be independently associated with NCI in relatively healthy PLWH. Larger studies should test the utility of CAVI in predicting NCI/decline in PLWH.

There is a growing need for brief screening measures for HIV Associated Neurocognitive Disorders (HAND). We compared two commonly used measures (the Montreal Cognitive Assessment [MoCA] and the International HIV Dementia Scale [IHDS]) in their ability to identify asymptomatic HAND (i.e., asymptomatic neurocognitive impairment [ANI]). Participants included 74 Thai PLWH: 38 met Frascati criteria for ANI and 36 were cognitively normal (CN). Participants completed Thai language versions of the MoCA (MoCA-T) and IHDS, and a validated neurocognitive battery. We examined between-group differences for MoCA-T and IHDS total scores, and scale subcomponents. We also conducted receiver operating characteristic (ROC) analyses to determine the ability of the MoCA-T and IHDS to discriminate between CN and ANI groups, and compared their area under the curve (AUC) values. Results revealed lower MoCA-T total score, as well as the Visuospatial/Executive and Delayed Recall subtask scores, in the ANI relative to CN group. Groups did not differ on the IHDS. For ROC analyses, the MoCA-T, but not the IHDS, significantly differentiated the ANI from CN group, and there was a significant difference in AUC values between the MoCA-T (AUC = .71) and IHDS (AUC = .56). Sensitivity and specificity statistics were poor for both screening measures. These data indicate while the MoCA-T functions better than the IHDS in detecting Thai PLWH with ANI, the mildest form of HAND, neither cognitive screener, showed strong utility. Our findings reflect the limited efficacy of common screening measures in detecting subtler cognitive deficits among Thai PLWH, and highlight the need for better screening tools.

ObjectiveTo detail the scope, nature, and disclosure of financial conflicts of interest (COI) between the pharmaceutical and medical device industries (Industry) and authors in high-impact clinical neurology journals.MethodsUsing the Centers for Medicare and Medicaid Services Open Payments Database (OPD), we retrieved information on payments from Industry to 2,000 authors from randomly selected 2016 articles in 5 journals. We categorized payments by type (research, general, and associated research/institutional), sponsoring entity, and year (from 2013 to 2016). Each author's self-disclosures were compared to OPD-listed Industry relationships to measure discordance. Payments were manually reviewed to identify those from manufacturers of products that were directly tested or discussed in the article. We also quantified the prevalence and value of these nondisclosed, relevant COI.ResultsTwo hundred authors from 158 articles had at least 1 OPD payment. Median/mean annual payments per author were $4,229/$19,586 (general); $1,702/$5,966 (research); and $67,512/$362,102 (associated research). Most neurologists received 10% of authors) received more than $10,000 per year, and several received over $1 million. Of 3,013 payments deemed directly relevant to the article, 50.9% were not self-disclosed by the authors, totaling $5,782,197 ($1,665,603 general; $25,532 research; $4,091,062 associated research).ConclusionIndustry-related financial relationships are prevalent among United States–based physicians publishing in major neurology journals, and incomplete self-disclosure is common. As a profession, academic and other neurologists must work to establish firm rules to ensure and manage disclosure of financial COI.

Organ donation after the circulatory determination of death (DCDD) accounts for a growing percentage of deceased organ donations. Although hospital DCDD protocols stipulate donor death determination, some do not adhere to national guidelines that require mechanical, not electrical, asystole. Surrogate decisions to withdraw life-sustaining therapy should be separated from decisions to donate organs. Donor families should be given sufficient information about the DCDD protocol and its impact on the dying process to provide informed consent, and donors should be given proper palliative care during dying. An unresolved ethical question is whether and how donor consent should be seen as authorizing manipulation of a living donor during the dying process solely for to benefit of the organ recipient.

Background Minorities have historically been underrepresented in clinical research trials despite having comparatively poor health indicators. Recognizing the dual inequalities of increased disease burden and decreased research participation, the National Institute of Health (NIH) Revitalization Act of 1993 mandated the inclusion and reporting of women and minorities in NIH-funded research. While progress has been made in the subsequent decades, this underrepresentation of minorities in research trials persists and has been documented in multiple disciplines. However, the extent of adequate representation and reporting of minority inclusion in clinical trials for migraine remains unknown. Objectives In this systematic review and study, we review the literature examining the representation of women and minorities in migraine clinical research trials Methods First we searched PubMed for pertinent articles examining the inclusion of women and minorities in migraine clinical research trials. Second, we identified controlled-trials for migraine published since 2011 in major neurology, headache, and general medicine journals using the terms “migraine randomized controlled trial.” We then reviewed the results manually and excluded pilot studies and those with fewer than 50 participants. We next determined (a) how frequently representation of minorities and women were reported in these major trials; (b) what factors correlated with reporting; and (c) whether women and minority inclusion comprised their ratios in the general population. Results We identified 128 relevant clinical trials, of which 36 met our inclusion criteria. All 36 trials (100%) reported gender frequency, and 25 of 36 (69.4%) reported ethnicity or race. Among all studies, women and Whites represented 84.2 and 82.9% of participants (mean), respectively. Studies conducted in the United States and funded by a private company were more likely to report race than studies conducted exclusively outside of the U.S. or with a public sponsor. No studies stratified efficacy or safety by ethnicity or gender. Men and non-Whites in the U.S. were statistically underrepresented. Conclusions Most recent headache studies comply with the NIH mandate to include women and minorities in research trials, particularly U.S.-based and industry-funded studies. Whites are overrepresented compared to both the general population and the population of migraineurs. Future studies should strive to increase minority participation and investigate race-based differences in migraine expression, treatment response, and medication toxicity.

To detail the scope and nature of financial conflicts of interest (COIs) between neurologists and the pharmaceutical and medical device industries (Industry) using the Centers for Medicare and Medicaid Services Open Payments (OP) database, with a focus on trends from 2013 to 2016.Payments from Industry to US neurologists were categorized into research payments, general (nonresearch) payments, and value of ownership in Industry. We performed descriptive analyses to detail the scope and nature of these relationships and trends over time.At least 9,505 neurologists received at least one payment from Industry each year. From 2013 to 2016, 1.6 million payments totaled $354 million, of which 99.5% of payments and 85.6% of payment value were for general/nonresearch-related payments. Most neurologists (between 65% and 80%) received less than $1,000 per year, but over 200 neurologists each received more than $100,000 during some years. Several received over $1 million. General payments are increasing, research payments are steady, and neurologists' ownership and investments are decreasing.Neurologists have extensive financial relationships with Industry, though this is driven by a well-paid minority. As a profession, we must work to establish firm rules to manage these potential COIs, ensuring that relationships with Industry yield synergistic advances while minimizing bias and maintaining public trust.

Drs. Ahlawat and Narayanaswami1 detailed the extent of industry-related financial interests among neurologists captured in the Open Payments (OP) database. Industry-related conflicts of interests (COIs) widely influence neurologic education, research, and clinical practice.2 Industry-funded trials often reach different conclusions than non-industry-funded trials,3 and even small gifts to physicians can influence their prescribing practices.4 Despite the OP database's shortcomings,5 it is an important step for 2 reasons. First, disclosure only mitigates COI if the disclosed information is widely and publicly available. Patients are generally not aware of their doctors' financial relationships.6 We hope OP will improve transparency. Second, the resulting social pressure from this transparency could lead to divestment from financial COI. Full disclosure is an important step towards mitigating COI, but does not redress subconscious biases that nearly invariably accompany financial relationships2; COI avoidance is often preferable. To investigate OP's effects on divestiture, we reviewed all neurologists in OP from 2013 to 2016. Of 9,505 neurologists in 2013 (OP's first year), 13 (0.07%) had ownership or investment interests totaling $26,610,645 (mean $2,800; median $65,975; maximum $24,949,811. In 2016, 16 of 11,105 neurologists had ownership and investment interest (0.09%) totaling $2,103,947 (mean $191; median $41,497; maximum $700,521). Perhaps OP is having an effect, but more research is required.

Objectives To compare outcomes between two models of acute ischemic stroke care. Namely 1) “drip-and-stay”, i.e. IV tissue plasminogen activator (tPA) administered at a spoke hospital in a telestroke network, with the patient remaining at the spoke, versus 2) “drip-and-ship”, i.e. tPA administered at a spoke hospital with subsequent patient transfer to a hub hospital, and 3) “hub”, i.e. tPA and subsequent treatment at a hub hospital. Materials and Methods We performed a systematic review and meta-analysis according to PRISMA guidelines. Literature searches of MEDLINE, Embase, and Cochrane from inception-October 2019 included randomized control trials and observational cohort studies comparing the drip-and-stay model to hub and drip-and-ship models. Outcomes of interest were functional independence (modified Rankin Scale ≤ 1), symptomatic intracranial hemorrhage (sICH), mortality, and length of stay. Pooled effect estimates were calculated using a fixed-effects meta-analysis and random-effects Bayesian meta-analysis. Non-inferiority was calculated using a fixed-margin method. Results Of 2806 unique records identified, 10 studies, totaling 4,164 patients, fulfilled the eligibility criteria. Meta-analysis found no significant difference in functional outcomes (mRS0-1) (6 studies, RR=1.09, 95%CI 0.98–1.22, p=0.123), sICH (8 studies, RR=0.98, 95%CI 0.64–1.51, p=0.942), or 90-day mortality (5 studies, RR=0.98, 95%CI 0.73–1.32, p=0.911, respectively) between patients treated in a drip-and-stay model compared to patients treated in drip-and-ship or hub models. There was no significant heterogeneity in these outcomes. Drip-and-stay outcomes (mRS 0–1, sICH) were non-inferior when compared to the combined group. Conclusions Our findings indicate that drip-and-stay is non-inferior to current models of drip-and-ship or hub stroke care, and may be as safe and as effective as either.

Magnetic resonance neurography (MRN) is an important tool to detect abnormalities of peripheral nerves. This pictorial review demonstrates the MRN features of a variety of neuropathies affecting the lumbosacral plexus (LSP) and lower extremity nerves, drawn from over 1200 MRNs from our institution and supplemented by the literature. Abnormalities can be due to spinal compression, extraspinal compression, malignancy, musculoskeletal disease, iatrogenesis, inflammation, infection, and idiopathic disorders. We discuss indications and limitations of MRN in diagnosing LSP neuropathies. As MRN becomes more widely used, physicians must become familiar with the differential diagnosis of abnormalities detectable with MRN of the LSP.

Psychogenic nonepileptic seizures (PNES) are relatively common, accounting for 5-40% of visits to tertiary epilepsy centers. Inpatient video-electroencephalogram (vEEG) monitoring is the gold standard for diagnosis, but additional positive predictive tools are necessary given vEEG's relatively scarce availability. In this study, we investigated if the number of patient-reported allergies distinguishes between PNES and epilepsy. Excessive allergy-reporting, like PNES, may reflect somatization. Using electronic medical records, ICD-9 codes, and text-identification algorithms to search EEG reports, we identified 905 cases of confirmed PNES and 5187 controls with epilepsy but no PNES. Patients with PNES averaged more self-reported allergies than patients with epilepsy alone (1.93 vs. 1.00, p

A conflict of interest (COI) exists when a physician's professional responsibilities are compromised by personal or financial relationships. COIs between physicians and the pharmaceutical or medical device industry (Industry) are common. Collaborations with Industry have many potential benefits, but also raise potential ethical pitfalls. Industry-related COIs have widespread influence on medical education, research, and clinical practice, and therefore have profound implications for the integrity of the field of medicine. Full disclosure is an important step toward mitigating COI but does not redress subconscious accompanying biases. I review the spectrum of potential COI faced by physicians, with a focus on the ethics surrounding the relationship between neurologists and Industry. Other financial and nonfinancial COIs that influence neurologists and nonindividual entities, such as academic institutions, medical journals, and professional societies, are also discussed. Solutions ranging from disclosure to avoidance and recusal are briefly considered.

Dementia is a common condition that impacts the patient, the family, and society. Currently, a diagnosis of dementia evokes hopelessness in the afflicted, and society provides few resources or systematic support for caregivers or for demented patients. In this commentary, we discuss the origins of hopelessness in dementia, the World Health Organization's six-stage framework of dementia care, and barriers to "normalizing" the experience of dementia in order to provide beneficent and humane care for patients with dementia. We also offer recommendations for clinicians who care for patients who feel that a life with dementia is not worth living.

Reduced delivery of glucose and oxygen during brain ischemia can cause energy failure (ATP depletion), which can in turn trigger processes leading to cell death. Glucose can support glycolytic ATP production even in the absence of oxygen, and it would seem to follow that increased glucose in the residual blood flow to ischemic brain should increase cell survival. This was tested experimentally in a rat model of ischemia/reperfusion by Pulsinelli et al1 several decades ago. Glucose had a striking effect, but in the direction opposite to what might be expected: rats in which circulating blood glucose was increased by intravenous infusion had far more extensive brain injury and mortality compared with normoglycemic rats. This experiment has subsequently been revisited dozens of times, using different animal species, stroke models, glucose concentrations, timing of glucose elevations, and permutations of these factors. The net result is one of the most robust in all of stroke research: hyperglycemia almost always exacerbates brain injury.2,3 Clinical experience mirrors the animal literature in these respects, because both retrospective studies and patient registries show a striking correlation between elevated admission glucose concentrations and poor outcomes.4 Hyperglycemia is similarly associated with increased hemorrhage formation and poor outcome in patients treated with tissue plasminogen activator.5–7 Random blood glucose levels are ≈4.4 to 6.1 mmol/L in both humans and rodents, with rodents being the species most commonly used for experimental stroke. The definition of hyperglycemia varies somewhat in stroke studies, ranging from 6.1 to >10 mmol/L glucose. Using these definitions, hyperglycemia is found at presentation in 30% to 60% of all patients with stroke.8,9 Some of these patients are diabetic, but acute, poststroke hyperglycemia is a sympathomimetic stress response in most. Despite the frequency of hyperglycemia in stroke and >30 …

Context Chronic pain remains prevalent in HIV+ adults despite widespread antiretroviral use. Pain continues to be underrecognized and undertreated in this population. In Thailand, similar to the West, HIV care is transitioning toward chronic disease management. Despite the importance of pain management in chronic HIV, the prevalence of pain and adequacy of pain management is unknown in HIV+ adults in Thailand. Objectives This cross-sectional study aimed to determine the prevalence of chronic pain, the burden of inadequate analgesia, and risk factors for chronic pain in HIV+ adults in Thailand. Methods A total of 254 HIV+ adults were recruited from an outpatient clinic in Thailand. Interviewers obtained information on demographics, clinical data, and pain characteristics. The burden of inadequate analgesia was assessed using the Brief Pain Inventory. Risk factors were identified with logistic regression analysis. Results Frequent pain was reported by 27% of participants; 22% reported chronic pain. Pain was significantly associated with education less than primary school, a positive depression screen, and the number of years on combined antiretroviral therapy. Eighty-six percent of patients with frequent pain were inadequately treated. Of 34 patients with moderate or severe pain, none received adequate analgesia. Inadequate analgesia was a significant risk factor for poorer quality of life. Conclusion Despite widespread antiretroviral use, pain remains common and undertreated in HIV+ adults in Thailand. Undertreated pain negatively impacts quality of life. It is imperative that policy makers and HIV caregivers address this treatment gap to advance the care of people living with HIV in Thailand.

Background Legionella pneumophila is a common cause of community-acquired pneumonia. Central nervous system dysfunction is common, and diagnosis in the absence of pulmonary symptoms can be challenging. Here we describe an atypical clinical presentation of Legionella infection in a patient with HIV who was found to have an unusual neuroradiologic lesion that further served to obscure the diagnosis. This is the first such description in a patient with Legionellosis and HIV coinfection. Case presentation A 43 year-old HIV positive man presented to our hospital with dysarthria, fevers, headache, and altered mental status. Initial work-up revealed pneumonia and a lesion of the splenium of the corpus callosum on magnetic resonance imaging. He was subsequently diagnosed with Legionella pneumonia and treated with complete symptom resolution. Conclusions Neurologic abnormalities are frequent in Legionellosis, but the diagnosis may be difficult in the absence of overt respiratory symptoms and in the presence of HIV coinfection. A high index of suspicion and early initiation of empiric antibiotics is imperative since early treatment may help prevent long-term sequelae. Neuroimaging abnormalities, though rare, can help the physician narrow down the diagnosis and avoid unnecessary invasive testing. Future studies should aim to elucidate the as yet unknown role of neuroimaging in the diagnoses and prognostication of Legionellosis, as well as the interaction between Legionella infection and HIV.