Is this the end of office visits to the neurologist, more evidence for medical marijuana, and other neuro updates

As the holidays creep up on us, the struggle has never been more real for holiday shopping. You may be left wondering what to buy the doc who has everything. But, worry not! Here’s our gift to you, a holiday shopping cheat sheet.

Just cause it’s the holidays doesn’t mean you should fall behind on what’s going on in your field: One trend we’ve seen over the past decade is that, as technology changes, so too does the world of medicine. But, the question becomes, with new tech, will office visits to the neurologist become a thing of the past? We’ll let you answer that one. Other updates this week include studies linking the gut to more, serious brain disorders, new, significant benefits of medical marijuana, a novel treatment for infantile brain tumors, and many more. So, kick back, relax, and catch up with a week’s worth of neuro news. Just don’t be surprised if you end up prescribing yourself a round of monopoly, it may save your brain.

Neuro Flashback

Your very own GPS system? At this time 14 years ago, the husband-and-wife team of May-Britt and Edvard Moser discovered that the brain has its very own built-in GPS system—in the form of grid cell. While observing rats running around in boxes, they found that certain cells fired in a grid-like pattern, always updating the rats’ location. These grid cells work in tandem with place cells to “tell” animals where they are. Humans also have these grid cells. The Mosers have since spent their time studying these cells and how they interact with other neurons to form a complete navigational system in animals that lets them know where they have been and where they are going. This dynamic duo received the 2014 Nobel Prize in Physiology and Medicine for their discovery. While it’s good to know we each have a built-in GPS system, don’t delete your Google Maps just yet…

In the News

A gut feeling. The gut-brain connection just got another boost, as a recent study demonstrated that the gut may play a role in the development of multiple sclerosis (MS). In a preclinical model, researchers demonstrated that the Smad7 protein can mobilize the immune cells in the intestines, thus triggering inflammation in the central nervous system (CNS). Findings were validated in humans with MS.

In the mice, researchers watched for the development of opticospinal encephalomyelitis—a sort of mouse version of human MS. Those with increased Smad7 levels in their intestinal T-cells had the most pronounced MS-like symptoms. These little guys also had intestinal T-cells that were more frequently activated and migrated into the CNS, triggering inflammation. Interestingly, their T-cell “yin and yang” also changed: the ratio of protective, regulatory T-cells to autoreactive, pathogenic T-cells became altered. This didn’t happen in mice without the Smad7 protein.

The Smad7 protein is already being studied in patients with Crohn and other inflammatory bowel diseases, and now, it may become a target in fighting MS. Talk about a two-for-one.

Don’t forget the US. In the United States, the number of cases of Alzheimer disease (AD) has declined, according to an analysisof a 5% random sample of Medicare beneficiaries 65 years and older. It’s great news that from 2007 to 2014, there was a decrease of 1.53%, a trend similar in most regions of the country. The fly in the ointment is that in 2014, the incidence of AD started to vary a lot from region to region—from 0% to over 3%—with the highest rates in the Midwest and the South. So, researchers concluded that these regional trends need to be considered and studied to improve the management of Americans with AD.

Monopoly anyone? This is probably something we’ve all suspected but have never known for sure: Board games are really good for your brain, and a study published in The Journals of Gerontology has just proven it. Researchers used 14 standardized cognitive tests to evaluate the mental and cognitive capacities of 1,091 study participants born in 1936, starting at 11 years of age, and then again at ages 70, 73, 76, and 79. They found that those who played more board games in their 70s had less cognitive decline from the age of 11 years until 70 years, and again, between ages 70 and 79 years. They now plan to study whether some of these non-digital, almost archaic games may be better than others for cognition as we age. So, dust off that Monopoly board, drag out those old Parcheesi and backgammon sets, and get playing!

Weekly Trivia

Broca’s area is in the left hemisphere in the third frontal convolution, anterior to the Sylvian fissure, a region responsible for most language functions. Broca’s aphasia is characterized by partial loss of a person’s ability to produce spoken, manual, or written language, with language comprehension generally remaining intact.

Novel Diagnostics

The future of neurology? While the field of neurology continues to change with the coming of new drugs and diagnostic tools, one necessity has always remained a constant: the neurologist. Sad to say, not all patients have easy access to a neurologist, either because they live in a low resource area, or due to limited mobility. In comes telemedicine to save the day. But how reliable is it? And especially in a field such as neurology? A recent evidence review from the American Academy of Neurology examined 101 studies documenting patient care for traumatic brain injury, dementia, epilepsy, MS, neuromuscular conditions, concussion, general neurological conditions, and others. They found that patient diagnosis through video consultations to be just as effective as in-person visits. The cherry on top is that telemedicine extended accessibility to patients with epilepsy, and mobility issue from neurological disorders, such as MS. But don’t close those office doors just yet. Unfortunately, the researchers found that few studies examining the use of telemedicine to deliver neurological care exist outside of stroke care. Sounds like these researchers have their work cut out for them.

Kicking in your sleep? Do you know which of your patients with restless legs syndrome (RLS) would do better with iron treatment? Quantitative transcranial sonography (TCS) of the substantia nigra—according to new research—may help identify changes caused by IV iron therapy in these patients, and predict which ones will do better.

Iron deficiency is an important component of RLS and iron therapy is the only disease-modifying treatment for RLS. Unfortunately, though, 40% to 50% of patients don’t respond to it. In this study, researchers measured changes in iron deposits in the substantia nigra (as reflected by substantia nigra echogenicity indices [SNEI]) before and after IV iron treatment in 30 patients with RLS. Patients were divided into two groups—those with lower baseline SNEI (the severely hypoechogenic [HE] group) and those with higher baseline SNEI (the moderately HE group). They found a mean 13% increase in SNEI after infusion. Infusion also brought about a mean decrease in patients’ total daily dopaminergic requirement of 28.04%, with reductions of better than 30% in over one-third of patients. And, in treated patients, International RLS Rating Scale scores also decreased by an average of 5.93 points—a full 21% reduction from baseline. Both of these improvements were significantly greater in the severely HE group. TCS seems to be a handy way to diagnose iron deficiency to decide which of your RLS patients would do best with iron treatment.

Novel Treatments

A new twist on an old friend…Long-term treatment with gabapentin—an anti-epileptic also commonly used for neuropathic pain—may be useful in restoring upper limb function after spinal cord injury, according to results from a preclinical study. Mice treated with gabapentin after spinal cord injury (near the top of the spine) regained about 60% of their forelimb function compared with only 30% restoration in mice treated with placebo. The mice were treated with gabapentin for 4 months, which is equivalent to about 9 years in human time.

Gabapentin blocks a protein that actually stops axonal growth when synapses are formed, in order to allow information transfer to other nerve cells. By blocking this protein, gabapentin allows for longer axonal growth, something that’s especially useful after injury.

These results are even more exciting in light of the fact that gabapentin is already clinically approved. Its use in patients with spinal cord injuries—as well as brain injuries and even stroke—may come relatively quickly. But, further pre-clinical and clinical trials are needed.

On your mark, attack! Here’s some good news for the littlest of littles: mTOR inhibitors may offer hope for the treatment of malignant infantile brain tumors. Researchers found that some of these agents can actually cross the blood—brain barrier to reach and attack these tumors at their source. The Oct4 protein and the mTOR signaling pathway have been shown to be involved in infants with brain tumors who have very poor prognoses. In their study published in Cell Stem Cell, these researchers tested drugs that could inhibit the mTOR pathway and found that the brain tumors were knocked out, and spinal cord metastasis blocked.

Headache & migraine pain, meet: Cannabis. In yet another study on the medicinal benefits of cannabis, researchers have found that inhaled cannabis may reduce the severity of headaches by 47.3%, and the severity of migraines by 49.6%. If you ask us, that’s a no-brainer (hah, get it?). This first study used data from over 1,3000 headache and 653 migraine patients using cannabis in real time. Data was collected using the Strainprint app, which was used to track their symptoms before and after using medical cannabis from Canada.

Here’s what they found: no evidence of overuse headaches. But, they did find evidence of developing a tolerance to cannabis, with patients using larger doses over time. More men reported reductions in headache pain than women (90.0% vs 89.1%, respectively). Also, cannabis concentrates seemed to produce greater reductions in headache severity ratings than cannabis flower. More studies are needed, but maybe, in the not-so-distant future, you’ll be telling your headache and migraine patients to spark one up?

Anticonvulsant showdown. Three drugs—levetiracetam, fosphenytoin, and valproate—are equally effective and safe in patients with refractory status epilepticus, according to a recent study supported by the National Institute of Neurological Disorders and Stroke. Results of the Established Status Epilepticus Treatment Trial (ESETT) were published in the New England Journal of Medicine. Researchers showed that all three drugs stopped seizures and improved responsiveness in nearly one-half of all study participants: levetiracetam in 47%, fosphenytoin in 45%, and valproate in 46%. The study was stopped early after interim analysis showed that all three agents were equally safe and effective.

New in Patient Management

Your brain on depression. Two new kinds of MRI could detect subtle brain characteristics in people with depression that could lead to a better understanding of depression and how it affects the brain. This is according to results from two recent studiespresented at the annual Radiological Society of North America (RSNA) 2019 meeting. In the first, researchers tested a newer MRI capable of showing differences in the blood—brain barrier (BBB). How, you may ask? Well, they developed this new MRI—which they call “intrinsic diffusivity encoding of arterial labeled spins (IDEALS)”—that allows scanning the movement of water across the BBB. Amazing!

And, using this, they found that BBBs in 14 patients with major depressive disorder (MDD) had reduced water permeability compared with 14 healthy controls, and—believe it or not—this difference was particularly apparent in the amygdala and the hippocampus, two regions that have been implicated in those with MDD in previous studies.

In the second study, researchers examined the connectome—or the point-to-point spatial connectivity of neural pathways in the brain. Using functional MRI (fMRI) and a multiscale neural model inversion framework—a handy new tool—they found that those with MDD exhibited different patterns of excitation and inhibition in their dorsal lateral prefrontal cortices compared with controls. The scans suggest that control functions in patients with MDD may be impaired, leading to elevated responses in the amygdala, which in turn increase anxiety and other negative moods. But, that’s not all. They also found that in patients with MDD, the thalamus had higher recurrent excitation.

Doctor said: No more monkeys jumping on the bed. Although most kids will recover fully after a concussion, 1 in 10 will have persistent symptoms. When researchers at the University of Queensland studied kids with persistent concussion symptoms, they found an association of poor sleep quality with decreases in grey matter and reduced brain function upon MRI analysis. Furthermore, fatigue and difficulties with attention in the weeks after sustaining a concussion were great predictors of which kids had persistent symptoms.

In fact, researchers could predict—with 86% accuracy—how decreases in brain function were linked to recovery at 2 months after a concussion. In the future, clinicians may be able to use simple clinical scores of sleep disturbance and fatigue to help predict which children will recover from a concussion and which will not, and perhaps better be able to steer those who won’t for targeted rehab, treatments to improve sleep, and even non-invasive brain stimulation to reduce their symptoms.

Close study of early-stage Parkinson disease. Patients with early-stage Parkinson disease (PD) may have a deficit of reactive inhibition (outright stopping) in the absence of deficiencies in proactive inhibition (shaping responses according to context). In a study published in Movement Disorders, researchers found that PD patients exhibited more impaired reactive inhibition compared with healthy controls, with no differences in proactive inhibition. When they compared left-dominant and right-dominant PD patients, however, they found no differences. They concluded, “For the first time, we found evidence for a deficit of reactive inhibition in the early‐stage PD patients in the absence of evidence for deficits in proactive inhibition. These findings have clinical relevance as they provide critical insights on the time course of the disease.”

Latest in Peer-Reviewed Studies

Some ALS patients may have higher serum formaldehyde levels

Good safety, efficacy with lacosamide for newly diagnosed epilepsy

Deep brain stimulation improves gait freezing in Parkinson patients

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Upcoming Medical Meetings

46th Annual Meeting of the Southern Clinical Neurological Society (SCNS) CME, in Naples, FL, January 18-22, 2020

13th Annual Headache Cooperative of the Pacific (HCOP) Winter Conference CME, in Ojai, CA, January 24-25, 2020

12th Annual Symposium on Neurovascular Disease CME, in Santa Monica, CA, January 25, 2020

North American Neuromodulation Society (NANS) Annual Meeting CME, in Las Vegas, NV, January 23-26, 2020

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