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Neurology

To advance care for patients with brain metastases: Reject five myths

Brain • • Cancer • • NeurologyJun 25 14

To advance care for patients with brain metastases: Reject five myths

A blue-ribbon team of national experts on brain cancer says that professional pessimism and out-of-date “myths,” rather than current science, are guiding - and compromising - the care of patients with cancers that spread to the brain.

In a special article published in the July issue of Neurosurgery, the team, led by an NYU Langone Medical Center neurosurgeon, argues that many past, key clinical trials were designed with out-of-date assumptions and the tendency of some physicians to “lump together” brain metastases of diverse kinds of cancer, often results in less than optimal care for individual patients. Furthermore, payers question the best care when it deviates from these misconceptions, the authors conclude.

“It’s time to abandon this unjustifiable nihilism and think carefully about more individualized care,” says lead author of the article, Douglas S. Kondziolka, M.D., MSc, FRCSC, Vice Chair of Clinical Research and Director of the Gamma Knife Program in the Department of Neurosurgery at NYU Langone. The authors - who also say medical insurers help perpetuate the myths by denying coverage that deviates from them - identify five leading misconceptions that often lead to poorer care:

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Study Explains How High Blood Pressure in Middle Age Affects Memory in Old Age

Brain • • NeurologyJun 06 14

Study Explains How High Blood Pressure in Middle Age Affects Memory in Old Age

High blood pressure in middle age plays a critical role in whether blood pressure in old age may affect memory and thinking, according to a study published in the online edition of the journal Neurology.

“Our findings bring new insight into the relationship between a history of high blood pressure, blood pressure in old age, the effects of blood pressure on brain structure, and memory and thinking,” said study author Lenore J. Launer, PhD, National Institute on Aging, part of the National Institutes of Health (NIH), Bethesda, Maryland.

For the study, 4,057 older participants free of dementia had their blood pressure measured in middle-age (mean age, 50 years). In late life (mean age, 76 years) their blood pressure was re-measured and participants underwent magnetic resonance imaging (MRI) scans that looked at structure and damage to the small vessels in the brain. They also took tests that measured their memory and thinking ability.

The study found that the association of blood pressure in old age to brain measures depended on a history of blood pressure in middle age. Higher systolic and diastolic blood pressure was associated with increased risk of brain lesions and tiny brain bleeds. This was most noticeable in people without a history of high blood pressure in middle age. For example, people with no history of high blood pressure in middle age who had high diastolic blood pressure in old age were 50% more likely to have severe brain lesions than people with low diastolic blood pressure in old age.

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Study reveals workings of working memory

Brain • • NeurologyFeb 19 14

Study reveals workings of working memory

Keep this in mind: Scientists say they’ve learned how your brain plucks information out of working memory when you decide to act.

Say you’re a busy mom trying to wrap up a work call now that you’ve arrived home. While you converse on your Bluetooth headset, one kid begs for an unspecified snack, another asks where his homework project has gone, and just then an urgent e-mail from your boss buzzes the phone in your purse. During the call’s last few minutes these urgent requests - snack, homework, boss - wait in your working memory. When you hang up, you’ll pick one and act.

When you do that, according to Brown University psychology researchers whose findings appear in the journal Neuron, you’ll employ brain circuitry that links a specific chunk of the striatum called the caudate and a chunk of the prefrontal cortex centered on the dorsal anterior premotor cortex. Selecting from working memory, it turns out, uses similar circuits to those involved in planning motion.

In lab experiments with 22 adult volunteers, the researchers used magnetic resonance imaging to track brain activity during a carefully designed working memory task. They also measured how quickly the subjects could choose from working memory - a phenomenon the scientists called “output gating.”

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Family problems experienced in childhood and adolescence affect brain development

Brain • • NeurologyFeb 19 14

Family problems experienced in childhood and adolescence affect brain development

The study led by Dr Nicholas Walsh, lecturer in developmental psychology at the University of East Anglia, used brain imaging technology to scan teenagers aged 17-19. It found that those who experienced mild to moderate family difficulties between birth and 11 years of age had developed a smaller cerebellum, an area of the brain associated with skill learning, stress regulation and sensory-motor control. The researchers also suggest that a smaller cerebellum may be a risk indicator of psychiatric disease later in life, as it is consistently found to be smaller in virtually all psychiatric illnesses.

Previous studies have focused on the effects of severe neglect, abuse and maltreatment in childhood on brain development. However the aim of this research was to determine the impact, in currently healthy teenagers, of exposure to more common but relatively chronic forms of ‘family-focused’ problems. These could include significant arguments or tension between parents, physical or emotional abuse, lack of affection or communication between family members, and events which had a practical impact on daily family life and might have resulted in health, housing or school problems.

Dr Walsh, from UEA’s School of Psychology, said: “These findings are important because exposure to adversities in childhood and adolescence is the biggest risk factor for later psychiatric disease. Also, psychiatric illnesses are a huge public health problem and the biggest cause of disability in the world.

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Researchers find retrieval practice improves memory in severe traumatic brain injury

Brain • • NeurologyFeb 01 14

Kessler Foundation researchers find retrieval practice improves memory in severe traumatic brain injury

Kessler Foundation researchers find retrieval practice improves memory in severe traumatic brain injury

Robust results indicate that retrieval practice would improve memory in memory-impaired persons with severe TBI in real-life settings

West Orange, NJ. January 30, 2014. Kessler Foundation researchers have shown that retrieval practice can improve memory in individuals with severe traumatic brain injury (TBI). “Retrieval Practice Improves Memory in Survivors of Severe Traumatic Brain Injury,” was published as a brief report in the current issue of Archives of Physical Medicine & Rehabilitation Volume 95, Issue 2 (390-396) February 2014. The article is authored by James Sumowski, PhD, Julia Coyne, PhD, Amanda Cohen, BA, and John DeLuca, PhD, of Kessler Foundation.

“Despite the small sample size, it was clear that retrieval practice (RP) was superior to other learning strategies in this group of memory-impaired individuals with severe TBI,” explained Dr. Sumowski.

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Study finds axon regeneration after Schwann cell graft to injured spinal cord

Neurology • • TraumaDec 24 13

Study finds axon regeneration after Schwann cell graft to injured spinal cord

A study carried out at the University of Miami Miller School of Medicine for “The Miami Project to Cure Paralysis” has found that transplanting self-donated Schwann cells (SCs, the principal ensheathing cells of the nervous system) that are elongated so as to bridge scar tissue in the injured spinal cord, aids hind limb functional recovery in rats modeled with spinal cord injury.

The study will be published in a future issue of Cell Transplantation but is currently freely available on-line as an unedited early e-pub at: http://www.ingentaconnect.com/content/cog/ct/pre-prints/content-ct1074Williams.

“Injury to the spinal cord results in scar and cavity formation at the lesion site,” explains study corresponding author Dr. Mary Bartlett Bunge of the University of Miami Miller School of Medicine. “Although numerous cell transplantation strategies have been developed to nullify the lesion environment, scar tissue - in basil lamina sheets - wall off the lesion to prevent further injury and, also, at the interface, scar tissue impedes axon regeneration into and out of the grafts, limiting functional recovery.”

The researchers determined that the properties of a spinal cord/Schwann cell bridge interface enable regenerated and elongated brainstem axons to cross the bridge and potentially lead to an improvement in hind limb movement of rats with spinal cord injury.

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Recurring memory traces boost long-lasting memories

Brain • • NeurologyDec 06 13

Recurring memory traces boost long-lasting memories

Bonn, Germany, December 5th, 2013 - While the human brain is in a resting state, patterns of neuronal activity which are associated to specific memories may spontaneously reappear. Such recurrences contribute to memory consolidation - i.e. to the stabilization of memory contents. Scientists of the DZNE and the University of Bonn are reporting these findings in the current issue of The Journal of Neuroscience. The researchers headed by Nikolai Axmacher performed a memory test on a series of persons while monitoring their brain activity by functional magnetic resonance imaging (fMRI). The experimental setup comprised several resting states including a nap inside a neuroimaging scanner. The study indicates that resting periods can generally promote memory performance.

Depending on one’s mood and activity different regions are active in the human brain. Perceptions and thoughts also influence this condition and this results in a pattern of neuronal activity which is linked to the experienced situation. When it is recalled, similar patterns, which are slumbering in the brain, are reactivated. How this happens, is still largely unknown.

The prevalent theory of memory formation assumes that memories are stored in a gradual manner. At first, the brain stores new information only temporarily. For memories to remain in the long term, a further step is required. „We call it consolidation“, Dr. Nikolai Axmacher explains, who is a researcher at the Department of Epileptology of the University of Bonn and at the Bonn site of the DZNE. “We do not know exactly how this happens. However, studies suggest that a process we call reactivation is of importance. When this occurs, the brain replays activity patterns associated with a particular memory. In principle, this is a familiar concept. It is a fact that things that are actively repeated and practiced are better memorized. However, we assume that a reactivation of memory contents may also happen spontaneously without there being an external trigger.”

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TB Vaccine May Work Against Multiple Sclerosis

Drug News • • Infections • • Tuberculosis • • NeurologyDec 05 13

TB Vaccine May Work Against Multiple ScleRosis

A vaccine normally used to thwart the respiratory illness tuberculosis also might help prevent the development of multiple sclerosis, a disease of the central nervous system, a new study suggests.

In people who had a first episode of symptoms that indicated they might develop multiple sclerosis (MS), an injection of the tuberculosis vaccine lowered the odds of developing MS, Italian researchers report.

“It is possible that a safe, handy and cheap approach will be available immediately following the first [episode of symptoms suggesting MS],” said study lead author Dr. Giovanni Ristori, of the Center for Experimental Neurological Therapies at Sant’Andrea Hospital in Rome.

But, the study authors cautioned that much more research is needed before the tuberculosis vaccine could possibly be used against multiple sclerosis.

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Discovery of gatekeeper nerve cells explains the effect of nicotine on learning and memory

Brain • • NeurologyOct 08 12

Swedish researchers at Uppsala University have, together with Brazilian collaborators, discovered a new group of nerve cells that regulate processes of learning and memory. These cells act as gatekeepers and carry a receptor for nicotine, which can explain our ability to remember and sort information.

The discovery of the gatekeeper cells, which are part of a memory network together with several other nerve cells in the hippocampus, reveal new fundamental knowledge about learning and memory. The study is published today in Nature Neuroscience.

The hippocampus is an area of the brain that is important for consolidation of information into memories and helps us to learn new things. The newly discovered gatekeeper nerve cells, also called OLM-alpha2 cells, provide an explanation to how the flow of information is controlled in the hippocampus.

“It is known that nicotine improves cognitive processes including learning and memory, but this is the first time that an identified nerve cell population is linked to the effects of nicotine”, says Professor Klas Kullander at Scilifelab and Uppsala University.

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Increasing care needs for children with neurological impairment

Children's Health • • NeurologyJan 18 12

In this week’s PLoS Medicine, Jay Berry of Harvard Medical School, USA and colleagues report findings from an analysis of hospitalization data in the United States, examining the proportion of inpatient resources attributable to care for children with neurological impairment (NI). Their results indicate that children with NI account for a substantial proportion of inpatient resources and that the impact of these children is growing within children’s hospitals, necessitating adequate clinical care and a coordination of efforts to ensure that the needs of children with NI are met.

The authors state: “We must ensure that the current health care system is staffed, educated, and equipped to serve, with efficiency and quality, this growing segment of vulnerable children.”

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Funding: AP was supported by the Harvard Medical School Eleanor & Miles Shore Scholar/Children’s Hospital Boston Junior Faculty Career Development Fellowship. RS and JGB were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development career development awards K23 HD052553 and K23 HD58092-02, respectively. JLB was supported by NIH K08 DA024753. This project was supported in part by the Children’s Health Research Center at the University of Utah and Primary Children’s Medical Center Foundation. The funders and sponsors were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

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Neurologically impaired children dependent on children’s hospitals

Children's Health • • NeurologyJan 18 12

Because of care advances, more infants and children with previously lethal health problems are surviving. Many, however, are left with lifelong neurologic impairment. A Children’s Hospital Boston study of more than 25 million pediatric hospitalizations in the U.S. now shows that neurologically impaired children, though still a relatively small part of the overall population, account for increasing hospital resources, particularly within children’s hospitals. Their analysis, based on data from the Agency for Healthcare Research and Quality Kids’ Inpatient Database (KID), was published online January 17th in PLoS Medicine.

The researchers analyzed KID data from 1997, 2000, 2003 and 2006, encompassing 25.7 million hospitalizations of children age 0 to 18. Of these, 1.3 million hospitalizations were for children with neurologic conditions, primarily cerebral palsy and epilepsy.

During the 10-year period, children with neurologic diagnoses were admitted more to children’s hospitals and less to community hospitals. At non-children’s hospitals, they made up a falling share of admissions (from 3 percent in 1997 to 2.5 percent in 2006); at children’s hospitals, they made up a rising share (from 11.7 percent of admissions in 1997 to 13.5 percent in 2006).

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What you want versus how you get it

NeurologyOct 21 11

New research reveals how we make decisions. Birds choosing between berry bushes and investors trading stocks are faced with the same fundamental challenge - making optimal choices in an environment featuring varying costs and benefits. A neuroeconomics study from the Montreal Neurological Institute and Hospital – The Neuro, McGill University, shows that the brain employs two separate regions and two distinct processes in valuing ‘stimuli’ i.e. ‘goods’ (for example, berry bushes), as opposed to valuing the ‘actions,’ needed to obtain the desired option (for example flight paths to the berry bushes). The findings, published in the most recent issue of the Journal of Neuroscience and funded by the Canadian Institutes of Health Research, are vital not only for improving knowledge of brain function, but also for treating and understanding the effects of frontal lobe damage, which can be a feature of common neurological conditions ranging from stroke to traumatic brain injury to dementia.

Decision making - selecting the most valuable option, typically by taking an action - requires value comparisons, but there has been debate about how these comparisons occur in the brain:  is value linked to the object itself , or to the action required to get that object. Are choices made between the things we want, or between the actions we take? The dominant model of decision making proposes that value comparisons occur in series, with stimulus value information feeding into actions (the body’s motor system). “So, in this study we wanted to understand how the brain uses value information to make decisions between different actions, and between different objects,” said the study’s lead investigator Dr. Lesley Fellows, neurologist and researcher at The Neuro. “The surprising and novel finding is that in fact these two mechanisms of choice are independent of one another. There are distinct processes in the brain by which value information guides decisions, depending on whether the choice is between objects or between actions.” Dr. Fellows often sees patients with damage to the frontal lobe, where decision making areas of the brain are located.  “This finding gives me more insight into what is happening in the brain of my patients, and may lead to new treatments and new ways to care for them and manage their symptoms.”

“Despite the ubiquity and importance of decision making, we have had, until now, a limited understanding of its basis in the brain,” said Fellows. “Psychologists, economists, and ecologists have studied decision making for decades, but it has only recently become a focus for neuroscientists.

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Neurologist Develops New Educational Tool

NeurologyJul 13 11

With a new application developed by a U-M neurologist, better understanding of the anatomy of the peripheral nervous system can be found right on your iPhone.

Nerve Whiz is a free application for medical professionals interested in learning the complex anatomy of nerve roots, plexuses, and peripheral nerves. It can work on Apple personal devices such as iPhones, iPads and iPods, and will soon be available for Android devices.

The application goes beyond simple nerve charts to help medical professionals interpret clinical examinations. Users select which muscles are weak or point to where the patient has sensory loss and the application provides a differential diagnosis, complete with relevant pictures and diagrams.

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A better way to remember

Brain • • NeurologyJun 20 11

Scientists and educators alike have long known that cramming is not an effective way to remember things. With their latest findings, researchers at the RIKEN Brain Science Institute in Japan, studying eye movement response in trained mice, have elucidated the neurological mechanism explaining why this is so. Published in the Journal of Neuroscience, their results suggest that protein synthesis in the cerebellum plays a key role in memory consolidation, shedding light on the fundamental neurological processes governing how we remember.

The “spacing effect”, first discovered over a century ago, describes the observation that humans and animals are able to remember things more effectively if learning is distributed over a long period of time rather than performed all at once. The effect is believed to be closely connected to the process of memory consolidation, whereby short-term memories are stabilized into long-term ones, yet the underlying neural mechanism involved has long remained unclear.

To clarify this mechanism, the researchers developed a technique based around the phenomenon of horizontal optokinetic response (HOKR), a compensatory eye movement which can be used to quantify the effects of motor learning. Studying HOKR in mice, they found that the long-term effects of learning are strongly dependent on whether training is performed all at once (“massed training”), or in spaced intervals (“spaced training”): whereas gains incurred in massed training disappeared within 24 hours, those gained in spaced training were sustained longer.

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Researchers discover potential cause of chronic painful skin

Neurology • • PainJun 08 11

A new study may explain why only 50% of patients experiencing chronic nerve pain achieve even partial relief from existing therapeutics. The study, published in the June 6 online version of the international research journal PAIN, reveals that certain types of chronic pain may be caused by signals from the skin itself, rather than damage to nerves within the skin, as previously thought.

A Medical Mystery
For years, researchers have known that increased amounts of a molecule called Calcitonin Gene-Related Peptide (CGRP) is found in the skin of chronic pain patients. The source of the increased CGRP was thought to be certain types of sensory nerve fibers in the skin that normally make and release a type or “isoform” called CGRP-alpha. Curiously, however, the authors of the current study found that nerve fibers containing CGRP-alpha are actually reduced under painful conditions – leading them to investigate where the increased CGRP in the skin came from.

The answer, surprisingly, was that the skin cells themselves generate increased amounts of a lesser-known “beta” isoform of CGRP. This skin cell-derived CGRP-beta is increased in painful conditions and may be sending pain signals to remaining sensory nerve fibers in the skin. The discovery of CGRP-beta as a therapeutic target presents a potentially important new treatment approach.

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