MDedge Neurology

A new study from the United Kingdom provides greater clarity on how SARS-CoV-2 infection can affect cognition and memory, including novel data on how long brain fog may last after the illness resolves and which cognitive functions are most vulnerable. 

In a large community sample, researchers found that on average, people who had recovered from COVID-19 showed small cognitive deficits equivalent to a 3-point loss in IQ for up to 1 year or more after recovering from the acute illness compared with peers who never had COVID-19.

However, people who had more severe cases, requiring treatment in a hospital intensive care unit, had cognitive deficits equivalent to a 9-point drop in IQ.

“People with ongoing persistent symptoms, indicative of long COVID, had larger cognitive deficits than people whose symptoms had resolved,” first author Adam Hampshire, PhD, with Imperial College London, told this news organization. 

The largest deficits among cognitive tasks were in memory, reasoning, and executive function, he added.

“That is, people who had had COVID-19 were both slower and less accurate when performing tasks that measure those abilities,” Dr. Hampshire said. “The group with the largest cognitive deficits were patients who had been in intensive care for COVID-19.”

The study was published online in The New England Journal of Medicine. 

Lingering Brain Fog

Cognitive symptoms after SARS-CoV-2 infection are well recognized, but whether objectively measurable cognitive deficits exist and how long they persist remains unclear. 

To investigate, researchers invited 800,000 adults from the REACT study of SARS-CoV-2 transmission in England to complete an online assessment for cognitive function with eight domains.

Altogether, 141,583 participants started the cognitive battery by completing at least one task, and 112,964 completed all eight tasks.

The researchers estimated global cognitive scores among participants who had been previously infected with SARS-CoV-2 with symptoms that persisted for at least 12 weeks, whether or not resolved, and among uninfected participants. 

Compared with uninfected adults, those who had COVID-19 that resolved had a small cognitive deficit, corresponding to a 3-point loss in IQ, the researchers found. 

Adults with unresolved persistent COVID-19 symptoms had the equivalent of a 6-point loss in IQ, and those who had been admitted to the intensive care unit had the equivalent of a 9-point loss in IQ, in line with previous findings of cognitive deficits in patients hospitalized in a critical care unit, the researchers report. 

Larger cognitive deficits were evident in adults infected early in the pandemic by the original SARS-CoV-2 virus or the B.1.1.7 variant, whereas peers infected later in the pandemic (eg, in the Omicron period), showed smaller cognitive deficits. This finding is in line with other studies suggesting that the association between COVID-19–associated cognitive deficits attenuated as the pandemic progressed, the researchers noted. 

They also found that people who had COVID-19 after receiving two or more vaccinations showed better cognitive performance compared with those who had not been vaccinated. 

The memory, reasoning, and executive function tasks were among the most sensitive to COVID-19–related cognitive differences and performance on these tasks differed according to illness duration and hospitalization. 

Dr. Hampshire said that more research is needed to determine whether the cognitive deficits resolve with time. 

“The implications of longer-term persistence of cognitive deficits and their clinical relevance remain unclear and warrant ongoing surveillance,” he said. 

Larger Cognitive Deficits Likely?

These results are “a concern and the broader implications require evaluation,” wrote Ziyad Al-Aly, MD, with Washington University School of Medicine in St. Louis, and Clifford Rosen, MD, with Tufts University School of Medicine in Boston, in an accompanying editorial. 

In their view, several outstanding questions remain, including what the potential functional implications of a 3-point loss in IQ may be and whether COVID-19–related cognitive deficits predispose to a higher risk for dementia later in life. 

“A deeper understanding of the biology of cognitive dysfunction after SARS-CoV-2 infection and how best to prevent and treat it are critical for addressing the needs of affected persons and preserving the cognitive health of populations,” Drs. Al-Aly and Rosen concluded. 

Commenting on the study for this news organization, Jacqueline Becker, PhD, clinical neuropsychologist and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York City, noted that “one important caveat” is that the study used an online assessment tool for cognitive function and therefore the findings should be taken with “a grain of salt.”

“That said, this is a large sample, and the findings are generally consistent with what we’ve seen in terms of cognitive deficits post-COVID,” Dr. Becker said. 

It’s likely that this study “underestimates” the degree of cognitive deficits that would be seen on validated neuropsychological tests, she added.

In a recent study, Dr. Becker and her colleagues investigated rates of cognitive impairment in 740 COVID-19 patients who recovered and were treated in outpatient, emergency department, or inpatient hospital settings. 

Using validated neuropsychological measures, they found a relatively high frequency of cognitive impairment several months after patients contracted COVID-19. Impairments in executive functioning, processing speed, category fluency, memory encoding, and recall were predominant among hospitalized patients. 

Dr. Becker noted that in her experience, cognition typically will improve in some patients 12-18 months post-COVID. 

Support for the study was provided by the National Institute for Health and Care Research and UK Research and Innovation and by the Department of Health and Social Care in England and the Huo Family Foundation. Disclosures for authors and editorial writers are available at NEJM.org. Dr. Becker has no relevant disclosures. 

A version of this article appeared on Medscape.com.

A new study from the United Kingdom provides greater clarity on how SARS-CoV-2 infection can affect cognition and memory, including novel data on how long brain fog may last after the illness resolves and which cognitive functions are most vulnerable. 

In a large community sample, researchers found that on average, people who had recovered from COVID-19 showed small cognitive deficits equivalent to a 3-point loss in IQ for up to 1 year or more after recovering from the acute illness compared with peers who never had COVID-19.

However, people who had more severe cases, requiring treatment in a hospital intensive care unit, had cognitive deficits equivalent to a 9-point drop in IQ.

“People with ongoing persistent symptoms, indicative of long COVID, had larger cognitive deficits than people whose symptoms had resolved,” first author Adam Hampshire, PhD, with Imperial College London, told this news organization. 

The largest deficits among cognitive tasks were in memory, reasoning, and executive function, he added.

“That is, people who had had COVID-19 were both slower and less accurate when performing tasks that measure those abilities,” Dr. Hampshire said. “The group with the largest cognitive deficits were patients who had been in intensive care for COVID-19.”

The study was published online in The New England Journal of Medicine. 

Lingering Brain Fog

Cognitive symptoms after SARS-CoV-2 infection are well recognized, but whether objectively measurable cognitive deficits exist and how long they persist remains unclear. 

To investigate, researchers invited 800,000 adults from the REACT study of SARS-CoV-2 transmission in England to complete an online assessment for cognitive function with eight domains.

Altogether, 141,583 participants started the cognitive battery by completing at least one task, and 112,964 completed all eight tasks.

The researchers estimated global cognitive scores among participants who had been previously infected with SARS-CoV-2 with symptoms that persisted for at least 12 weeks, whether or not resolved, and among uninfected participants. 

Compared with uninfected adults, those who had COVID-19 that resolved had a small cognitive deficit, corresponding to a 3-point loss in IQ, the researchers found. 

Adults with unresolved persistent COVID-19 symptoms had the equivalent of a 6-point loss in IQ, and those who had been admitted to the intensive care unit had the equivalent of a 9-point loss in IQ, in line with previous findings of cognitive deficits in patients hospitalized in a critical care unit, the researchers report. 

Larger cognitive deficits were evident in adults infected early in the pandemic by the original SARS-CoV-2 virus or the B.1.1.7 variant, whereas peers infected later in the pandemic (eg, in the Omicron period), showed smaller cognitive deficits. This finding is in line with other studies suggesting that the association between COVID-19–associated cognitive deficits attenuated as the pandemic progressed, the researchers noted. 

They also found that people who had COVID-19 after receiving two or more vaccinations showed better cognitive performance compared with those who had not been vaccinated. 

The memory, reasoning, and executive function tasks were among the most sensitive to COVID-19–related cognitive differences and performance on these tasks differed according to illness duration and hospitalization. 

Dr. Hampshire said that more research is needed to determine whether the cognitive deficits resolve with time. 

“The implications of longer-term persistence of cognitive deficits and their clinical relevance remain unclear and warrant ongoing surveillance,” he said. 

Larger Cognitive Deficits Likely?

These results are “a concern and the broader implications require evaluation,” wrote Ziyad Al-Aly, MD, with Washington University School of Medicine in St. Louis, and Clifford Rosen, MD, with Tufts University School of Medicine in Boston, in an accompanying editorial. 

In their view, several outstanding questions remain, including what the potential functional implications of a 3-point loss in IQ may be and whether COVID-19–related cognitive deficits predispose to a higher risk for dementia later in life. 

“A deeper understanding of the biology of cognitive dysfunction after SARS-CoV-2 infection and how best to prevent and treat it are critical for addressing the needs of affected persons and preserving the cognitive health of populations,” Drs. Al-Aly and Rosen concluded. 

Commenting on the study for this news organization, Jacqueline Becker, PhD, clinical neuropsychologist and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York City, noted that “one important caveat” is that the study used an online assessment tool for cognitive function and therefore the findings should be taken with “a grain of salt.”

“That said, this is a large sample, and the findings are generally consistent with what we’ve seen in terms of cognitive deficits post-COVID,” Dr. Becker said. 

It’s likely that this study “underestimates” the degree of cognitive deficits that would be seen on validated neuropsychological tests, she added.

In a recent study, Dr. Becker and her colleagues investigated rates of cognitive impairment in 740 COVID-19 patients who recovered and were treated in outpatient, emergency department, or inpatient hospital settings. 

Using validated neuropsychological measures, they found a relatively high frequency of cognitive impairment several months after patients contracted COVID-19. Impairments in executive functioning, processing speed, category fluency, memory encoding, and recall were predominant among hospitalized patients. 

Dr. Becker noted that in her experience, cognition typically will improve in some patients 12-18 months post-COVID. 

Support for the study was provided by the National Institute for Health and Care Research and UK Research and Innovation and by the Department of Health and Social Care in England and the Huo Family Foundation. Disclosures for authors and editorial writers are available at NEJM.org. Dr. Becker has no relevant disclosures. 

A version of this article appeared on Medscape.com.

A new study from the United Kingdom provides greater clarity on how SARS-CoV-2 infection can affect cognition and memory, including novel data on how long brain fog may last after the illness resolves and which cognitive functions are most vulnerable. 

In a large community sample, researchers found that on average, people who had recovered from COVID-19 showed small cognitive deficits equivalent to a 3-point loss in IQ for up to 1 year or more after recovering from the acute illness compared with peers who never had COVID-19.

However, people who had more severe cases, requiring treatment in a hospital intensive care unit, had cognitive deficits equivalent to a 9-point drop in IQ.

“People with ongoing persistent symptoms, indicative of long COVID, had larger cognitive deficits than people whose symptoms had resolved,” first author Adam Hampshire, PhD, with Imperial College London, told this news organization. 

The largest deficits among cognitive tasks were in memory, reasoning, and executive function, he added.

“That is, people who had had COVID-19 were both slower and less accurate when performing tasks that measure those abilities,” Dr. Hampshire said. “The group with the largest cognitive deficits were patients who had been in intensive care for COVID-19.”

The study was published online in The New England Journal of Medicine. 

Lingering Brain Fog

Cognitive symptoms after SARS-CoV-2 infection are well recognized, but whether objectively measurable cognitive deficits exist and how long they persist remains unclear. 

To investigate, researchers invited 800,000 adults from the REACT study of SARS-CoV-2 transmission in England to complete an online assessment for cognitive function with eight domains.

Altogether, 141,583 participants started the cognitive battery by completing at least one task, and 112,964 completed all eight tasks.

The researchers estimated global cognitive scores among participants who had been previously infected with SARS-CoV-2 with symptoms that persisted for at least 12 weeks, whether or not resolved, and among uninfected participants. 

Compared with uninfected adults, those who had COVID-19 that resolved had a small cognitive deficit, corresponding to a 3-point loss in IQ, the researchers found. 

Adults with unresolved persistent COVID-19 symptoms had the equivalent of a 6-point loss in IQ, and those who had been admitted to the intensive care unit had the equivalent of a 9-point loss in IQ, in line with previous findings of cognitive deficits in patients hospitalized in a critical care unit, the researchers report. 

Larger cognitive deficits were evident in adults infected early in the pandemic by the original SARS-CoV-2 virus or the B.1.1.7 variant, whereas peers infected later in the pandemic (eg, in the Omicron period), showed smaller cognitive deficits. This finding is in line with other studies suggesting that the association between COVID-19–associated cognitive deficits attenuated as the pandemic progressed, the researchers noted. 

They also found that people who had COVID-19 after receiving two or more vaccinations showed better cognitive performance compared with those who had not been vaccinated. 

The memory, reasoning, and executive function tasks were among the most sensitive to COVID-19–related cognitive differences and performance on these tasks differed according to illness duration and hospitalization. 

Dr. Hampshire said that more research is needed to determine whether the cognitive deficits resolve with time. 

“The implications of longer-term persistence of cognitive deficits and their clinical relevance remain unclear and warrant ongoing surveillance,” he said. 

Larger Cognitive Deficits Likely?

These results are “a concern and the broader implications require evaluation,” wrote Ziyad Al-Aly, MD, with Washington University School of Medicine in St. Louis, and Clifford Rosen, MD, with Tufts University School of Medicine in Boston, in an accompanying editorial. 

In their view, several outstanding questions remain, including what the potential functional implications of a 3-point loss in IQ may be and whether COVID-19–related cognitive deficits predispose to a higher risk for dementia later in life. 

“A deeper understanding of the biology of cognitive dysfunction after SARS-CoV-2 infection and how best to prevent and treat it are critical for addressing the needs of affected persons and preserving the cognitive health of populations,” Drs. Al-Aly and Rosen concluded. 

Commenting on the study for this news organization, Jacqueline Becker, PhD, clinical neuropsychologist and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York City, noted that “one important caveat” is that the study used an online assessment tool for cognitive function and therefore the findings should be taken with “a grain of salt.”

“That said, this is a large sample, and the findings are generally consistent with what we’ve seen in terms of cognitive deficits post-COVID,” Dr. Becker said. 

It’s likely that this study “underestimates” the degree of cognitive deficits that would be seen on validated neuropsychological tests, she added.

In a recent study, Dr. Becker and her colleagues investigated rates of cognitive impairment in 740 COVID-19 patients who recovered and were treated in outpatient, emergency department, or inpatient hospital settings. 

Using validated neuropsychological measures, they found a relatively high frequency of cognitive impairment several months after patients contracted COVID-19. Impairments in executive functioning, processing speed, category fluency, memory encoding, and recall were predominant among hospitalized patients. 

Dr. Becker noted that in her experience, cognition typically will improve in some patients 12-18 months post-COVID. 

Support for the study was provided by the National Institute for Health and Care Research and UK Research and Innovation and by the Department of Health and Social Care in England and the Huo Family Foundation. Disclosures for authors and editorial writers are available at NEJM.org. Dr. Becker has no relevant disclosures. 

A version of this article appeared on Medscape.com.

TOPLINE:

Galantamine purchased as a dietary supplement may be more likely to contain bacterial contaminants and an incorrect amount of the product vs when it is prescribed as a generic drug, new research showed.

METHODOLOGY:

• Galantamine, a plant alkaloid, is approved for treating mild to moderate Alzheimer’s dementia but is also marketed as a dietary supplement for cognitive enhancement.
• In June 2023, researchers purchased all 10 galantamine dietary supplements available on Amazon.com that had a Supplement Facts panel.
• In September 2023, they acquired all 11 generic immediate-release formulations of prescription galantamine available in the United States.
• They analyzed the content of galantamine in each product using ultrahigh-performance liquid chromatography-mass spectrometry and quantified any microorganisms present.

TAKEAWAY:

• Generic galantamine drugs were found to contain 97.5%-104.2% of the labeled content, with no microbial contamination.
• Galantamine dietary supplements, however, showed a wide variance in content, ranging from less than 2% to 110% of the labeled amount, and 30% were contaminated with Bacillus cereus sensu stricto. The amount of bacteria present would not have been expected to harm consumers, according to the authors of the study.

IN PRACTICE:

“Clinicians should query patients with memory concerns about the use of dietary supplements and advise patients not to use galantamine supplements,” the researchers wrote.

SOURCE:

The corresponding author of the study was Pieter A. Cohen, MD, with Broadway Clinic, Cambridge Health Alliance, in Somerville, Massachusetts. The paper was published online as a research letter in JAMA.

LIMITATIONS:

The products were purchased at a single point in time and may not reflect current options, the researchers noted. The generalizability of the findings to other supplement ingredients or generic drugs is unknown.

DISCLOSURES:

Dr. Cohen has received grants from the Consumers Union and PEW Charitable Trust and personal fees from UpToDate and the Centers for Disease Control and Prevention. He has been sued by a supplement company in a case where the jury found in his favor.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article appeared on Medscape.com.

TOPLINE:

Galantamine purchased as a dietary supplement may be more likely to contain bacterial contaminants and an incorrect amount of the product vs when it is prescribed as a generic drug, new research showed.

METHODOLOGY:

• Galantamine, a plant alkaloid, is approved for treating mild to moderate Alzheimer’s dementia but is also marketed as a dietary supplement for cognitive enhancement.
• In June 2023, researchers purchased all 10 galantamine dietary supplements available on Amazon.com that had a Supplement Facts panel.
• In September 2023, they acquired all 11 generic immediate-release formulations of prescription galantamine available in the United States.
• They analyzed the content of galantamine in each product using ultrahigh-performance liquid chromatography-mass spectrometry and quantified any microorganisms present.

TAKEAWAY:

• Generic galantamine drugs were found to contain 97.5%-104.2% of the labeled content, with no microbial contamination.
• Galantamine dietary supplements, however, showed a wide variance in content, ranging from less than 2% to 110% of the labeled amount, and 30% were contaminated with Bacillus cereus sensu stricto. The amount of bacteria present would not have been expected to harm consumers, according to the authors of the study.

IN PRACTICE:

“Clinicians should query patients with memory concerns about the use of dietary supplements and advise patients not to use galantamine supplements,” the researchers wrote.

SOURCE:

The corresponding author of the study was Pieter A. Cohen, MD, with Broadway Clinic, Cambridge Health Alliance, in Somerville, Massachusetts. The paper was published online as a research letter in JAMA.

LIMITATIONS:

The products were purchased at a single point in time and may not reflect current options, the researchers noted. The generalizability of the findings to other supplement ingredients or generic drugs is unknown.

DISCLOSURES:

Dr. Cohen has received grants from the Consumers Union and PEW Charitable Trust and personal fees from UpToDate and the Centers for Disease Control and Prevention. He has been sued by a supplement company in a case where the jury found in his favor.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article appeared on Medscape.com.

TOPLINE:

Galantamine purchased as a dietary supplement may be more likely to contain bacterial contaminants and an incorrect amount of the product vs when it is prescribed as a generic drug, new research showed.

METHODOLOGY:

• Galantamine, a plant alkaloid, is approved for treating mild to moderate Alzheimer’s dementia but is also marketed as a dietary supplement for cognitive enhancement.
• In June 2023, researchers purchased all 10 galantamine dietary supplements available on Amazon.com that had a Supplement Facts panel.
• In September 2023, they acquired all 11 generic immediate-release formulations of prescription galantamine available in the United States.
• They analyzed the content of galantamine in each product using ultrahigh-performance liquid chromatography-mass spectrometry and quantified any microorganisms present.

TAKEAWAY:

• Generic galantamine drugs were found to contain 97.5%-104.2% of the labeled content, with no microbial contamination.
• Galantamine dietary supplements, however, showed a wide variance in content, ranging from less than 2% to 110% of the labeled amount, and 30% were contaminated with Bacillus cereus sensu stricto. The amount of bacteria present would not have been expected to harm consumers, according to the authors of the study.

IN PRACTICE:

“Clinicians should query patients with memory concerns about the use of dietary supplements and advise patients not to use galantamine supplements,” the researchers wrote.

SOURCE:

The corresponding author of the study was Pieter A. Cohen, MD, with Broadway Clinic, Cambridge Health Alliance, in Somerville, Massachusetts. The paper was published online as a research letter in JAMA.

LIMITATIONS:

The products were purchased at a single point in time and may not reflect current options, the researchers noted. The generalizability of the findings to other supplement ingredients or generic drugs is unknown.

DISCLOSURES:

Dr. Cohen has received grants from the Consumers Union and PEW Charitable Trust and personal fees from UpToDate and the Centers for Disease Control and Prevention. He has been sued by a supplement company in a case where the jury found in his favor.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article appeared on Medscape.com.

In the dynamic field of myasthenia gravis (MG) treatment, characterized by recent therapeutic advancements and a promising pipeline, Nicholas J. Silvestri, MD, advises early-career professionals to approach the whole patient, considering not only the disease manifestations but also its broader impact on their lives, including work and family.

Emphasizing the importance of tailoring therapies based on individual needs, Dr Silvestri encourages early and aggressive intervention, citing evidence supporting better long-term outcomes, and underscores the significance of treating the whole patient rather than just the disease.

In the dynamic field of myasthenia gravis (MG) treatment, characterized by recent therapeutic advancements and a promising pipeline, Nicholas J. Silvestri, MD, advises early-career professionals to approach the whole patient, considering not only the disease manifestations but also its broader impact on their lives, including work and family.

Emphasizing the importance of tailoring therapies based on individual needs, Dr Silvestri encourages early and aggressive intervention, citing evidence supporting better long-term outcomes, and underscores the significance of treating the whole patient rather than just the disease.

In the dynamic field of myasthenia gravis (MG) treatment, characterized by recent therapeutic advancements and a promising pipeline, Nicholas J. Silvestri, MD, advises early-career professionals to approach the whole patient, considering not only the disease manifestations but also its broader impact on their lives, including work and family.

Emphasizing the importance of tailoring therapies based on individual needs, Dr Silvestri encourages early and aggressive intervention, citing evidence supporting better long-term outcomes, and underscores the significance of treating the whole patient rather than just the disease.

Kelly G. Gwathmey, MD, offers three key tips for clinicians early in their careers regarding myasthenia gravis (MG): First, prioritize listening to patients, as their experiences may not always align with clinical observations. Second, advocate for shared decision-making when starting or changing treatments, considering individual patient preferences and medical conditions. Third, understand the significance of ongoing monitoring using patient-reported outcome measures and MG scales to assess treatment response and optimize care for patients with MG.

Kelly G. Gwathmey, MD, offers three key tips for clinicians early in their careers regarding myasthenia gravis (MG): First, prioritize listening to patients, as their experiences may not always align with clinical observations. Second, advocate for shared decision-making when starting or changing treatments, considering individual patient preferences and medical conditions. Third, understand the significance of ongoing monitoring using patient-reported outcome measures and MG scales to assess treatment response and optimize care for patients with MG.

Kelly G. Gwathmey, MD, offers three key tips for clinicians early in their careers regarding myasthenia gravis (MG): First, prioritize listening to patients, as their experiences may not always align with clinical observations. Second, advocate for shared decision-making when starting or changing treatments, considering individual patient preferences and medical conditions. Third, understand the significance of ongoing monitoring using patient-reported outcome measures and MG scales to assess treatment response and optimize care for patients with MG.

Nicholas J. Silvestri, MD, recounts a memorable experience with a patient with myasthenia gravis (MG) during early neurology residency, detailing the diagnostic process and initial treatment with standard therapies. Despite the patient's positive response in terms of efficacy, tolerability issues and side effects posed challenges.

Dr Silvestri highlights the evolution in MG treatment, emphasizing the availability of newer, well-tolerated options with proven efficacy, suggesting a more balanced approach between effectiveness and patient safety in contemporary MG management.

Nicholas J. Silvestri, MD, recounts a memorable experience with a patient with myasthenia gravis (MG) during early neurology residency, detailing the diagnostic process and initial treatment with standard therapies. Despite the patient's positive response in terms of efficacy, tolerability issues and side effects posed challenges.

Dr Silvestri highlights the evolution in MG treatment, emphasizing the availability of newer, well-tolerated options with proven efficacy, suggesting a more balanced approach between effectiveness and patient safety in contemporary MG management.

Nicholas J. Silvestri, MD, recounts a memorable experience with a patient with myasthenia gravis (MG) during early neurology residency, detailing the diagnostic process and initial treatment with standard therapies. Despite the patient's positive response in terms of efficacy, tolerability issues and side effects posed challenges.

Dr Silvestri highlights the evolution in MG treatment, emphasizing the availability of newer, well-tolerated options with proven efficacy, suggesting a more balanced approach between effectiveness and patient safety in contemporary MG management.

Kelly G. Gwathmey, MD, recounts shadowing a neurologist during an early phase of academic training and how witnessing examinations of patients with conditions like myasthenia gravis and amyotrophic lateral sclerosis inspired a career path in neuromuscular medicine.

Dr Gwathmey also reflects on the evolution of myasthenia gravis treatment over the past two decades, noting the introduction of new medications like eculizumab, complement inhibitors, and FcRn inhibitors — offering more targeted options and hope for patients with fewer side effects — and anticipates further advancements in treatment leading to improved disease control.

Kelly G. Gwathmey, MD, recounts shadowing a neurologist during an early phase of academic training and how witnessing examinations of patients with conditions like myasthenia gravis and amyotrophic lateral sclerosis inspired a career path in neuromuscular medicine.

Dr Gwathmey also reflects on the evolution of myasthenia gravis treatment over the past two decades, noting the introduction of new medications like eculizumab, complement inhibitors, and FcRn inhibitors — offering more targeted options and hope for patients with fewer side effects — and anticipates further advancements in treatment leading to improved disease control.

Kelly G. Gwathmey, MD, recounts shadowing a neurologist during an early phase of academic training and how witnessing examinations of patients with conditions like myasthenia gravis and amyotrophic lateral sclerosis inspired a career path in neuromuscular medicine.

Dr Gwathmey also reflects on the evolution of myasthenia gravis treatment over the past two decades, noting the introduction of new medications like eculizumab, complement inhibitors, and FcRn inhibitors — offering more targeted options and hope for patients with fewer side effects — and anticipates further advancements in treatment leading to improved disease control.

Nicholas J. Silvestri, MD, expresses gratitude for the impactful relationships and mentorship in the field of myasthenia gravis. Dr Chip Howard at the University of North Carolina is distinguished as a humble and inclusive mentor, considered influential in the field.

Dr Howard's influence goes beyond the efficacy of medications, emphasizing the importance of considering patient care comprehensively, including side effects and overall safety. This perspective has significantly shaped Dr Silvestri’s treatment approach, leading to a more holistic and patient-centered care paradigm for individuals with myasthenia gravis.

Nicholas J. Silvestri, MD, expresses gratitude for the impactful relationships and mentorship in the field of myasthenia gravis. Dr Chip Howard at the University of North Carolina is distinguished as a humble and inclusive mentor, considered influential in the field.

Dr Howard's influence goes beyond the efficacy of medications, emphasizing the importance of considering patient care comprehensively, including side effects and overall safety. This perspective has significantly shaped Dr Silvestri’s treatment approach, leading to a more holistic and patient-centered care paradigm for individuals with myasthenia gravis.

Nicholas J. Silvestri, MD, expresses gratitude for the impactful relationships and mentorship in the field of myasthenia gravis. Dr Chip Howard at the University of North Carolina is distinguished as a humble and inclusive mentor, considered influential in the field.

Dr Howard's influence goes beyond the efficacy of medications, emphasizing the importance of considering patient care comprehensively, including side effects and overall safety. This perspective has significantly shaped Dr Silvestri’s treatment approach, leading to a more holistic and patient-centered care paradigm for individuals with myasthenia gravis.

During her time in training at the University of Virginia, Kelly G. Gwathmey, MD, gained invaluable insights into myasthenia gravis (MG) care and research from the late Dr Ted Burns and Dr Larry Phillips. Dr Burns, a renowned leader in MG research, emphasized patient-centric approaches, fostering the development of crucial outcome measures like the MG composite scale and MG-QOL-15.

Burns' dedication to listening to patients' experiences shaped the development of health-related quality-of-life instruments used in MG clinical trials. For Dr Gwathmey, learning under Dr Burns underscored the significance of patient experiences in treatment decisions and highlighted the importance of incorporating patient perspectives in clinical care and research endeavors.

During her time in training at the University of Virginia, Kelly G. Gwathmey, MD, gained invaluable insights into myasthenia gravis (MG) care and research from the late Dr Ted Burns and Dr Larry Phillips. Dr Burns, a renowned leader in MG research, emphasized patient-centric approaches, fostering the development of crucial outcome measures like the MG composite scale and MG-QOL-15.

Burns' dedication to listening to patients' experiences shaped the development of health-related quality-of-life instruments used in MG clinical trials. For Dr Gwathmey, learning under Dr Burns underscored the significance of patient experiences in treatment decisions and highlighted the importance of incorporating patient perspectives in clinical care and research endeavors.

During her time in training at the University of Virginia, Kelly G. Gwathmey, MD, gained invaluable insights into myasthenia gravis (MG) care and research from the late Dr Ted Burns and Dr Larry Phillips. Dr Burns, a renowned leader in MG research, emphasized patient-centric approaches, fostering the development of crucial outcome measures like the MG composite scale and MG-QOL-15.

Burns' dedication to listening to patients' experiences shaped the development of health-related quality-of-life instruments used in MG clinical trials. For Dr Gwathmey, learning under Dr Burns underscored the significance of patient experiences in treatment decisions and highlighted the importance of incorporating patient perspectives in clinical care and research endeavors.

Moderate, severe, and penetrating traumatic brain injury (TBI) is associated with an elevated risk of developing brain cancer, new research suggested. However, mild TBI appears to confer no increased risk.

In a large cohort of post-9/11 US veterans, those who suffered moderate/severe TBI had a nearly twofold increased risk for a subsequent brain cancer diagnosis, while those with penetrating TBI had a greater than threefold increased risk.

“While the absolute number of brain cancer diagnoses was small, these diagnoses are associated with profoundly poor outcomes. Further research of this rare but devastating condition is needed to better identify those at risk and develop screening protocols,” wrote investigators led by Ian Stewart, MD, with the Uniformed Services University of Health Sciences, Bethesda, Maryland.

The study was published online on February 15 in JAMA Network Open.
 

Common War Wound

TBI is one of the most common battlefield wounds among veterans of the Iraq and Afghanistan wars. But evidence to date on the potential association of TBI with the subsequent risk for brain cancer is conflicting, the authors noted.

To investigate further, they reviewed the records of nearly 2 million mostly male US veterans of the Iraq and Afghanistan wars. A total of 449,880 people experienced TBI, which was mild in 385,848 cases, moderate/severe in 46,859 cases, and penetrating in 17,173 cases.

During a median follow-up of 7.2 years, brain cancer occurred in 318 veterans without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (0.06% or less).

There was a stepwise increase in brain cancer incidence with worse TBI severity. Crude incidence rates per 100,000 person-years were 3.06 for no TBI, 2.85 for mild TBI, 4.88 for moderate/severe TBI, and 10.34 for penetrating TBI.

In the fully adjusted model, moderate/severe TBI showed a near-doubling of brain cancer risk vs no TBI (adjusted hazard ratio [aHR], 1.90; 95% CI, 1.16-3.12), while penetrating TBI was associated with a greater than tripling of risk (aHR, 3.33; 95% CI, 1.71-6.49). There was no significantly increased risk after mild TBI.

There are plausible biological mechanisms linking TBI to brain cancer, the authors noted, including alterations in metabolism, inflammation, astrocyte proliferation, and stem cell migration and differentiation.

They caution that with few female veterans and a predominantly young cohort, the findings may not extend to the general population.
 

Meaningful New Data 

In an accompanying editorial, Elie Massaad, MD, MSc, and Ali Kiapour, PhD, MMSc, Massachusetts General Hospital, Boston, noted that federal data show glioblastoma, the most aggressive malignant brain tumor, is the third leading cause of cancer-related death among active duty personnel.

“Post-9/11 veterans deployed to Iraq, Afghanistan, and elsewhere face a 26% higher glioblastoma rate vs the general public, with an average age of onset decades earlier than in broader populations,” they wrote.

Overall, they noted this new research provides “meaningful data clarifying associations between combat-related TBI severity and subsequent brain cancer risk among post-9/11 veterans.

“Elucidating potential connections between battlefield trauma and longer-term health outcomes is imperative to inform prevention and care approaches for those who have served,” they added.

This study was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense through the Psychological Health/Traumatic Brain Injury Research Program Long-Term Impact of Military Relevant Brain Injury Consortium. The authors and editorialists had declared no relevant conflicts of interest.
 

A version of this article appeared on Medscape.com.

Moderate, severe, and penetrating traumatic brain injury (TBI) is associated with an elevated risk of developing brain cancer, new research suggested. However, mild TBI appears to confer no increased risk.

In a large cohort of post-9/11 US veterans, those who suffered moderate/severe TBI had a nearly twofold increased risk for a subsequent brain cancer diagnosis, while those with penetrating TBI had a greater than threefold increased risk.

“While the absolute number of brain cancer diagnoses was small, these diagnoses are associated with profoundly poor outcomes. Further research of this rare but devastating condition is needed to better identify those at risk and develop screening protocols,” wrote investigators led by Ian Stewart, MD, with the Uniformed Services University of Health Sciences, Bethesda, Maryland.

The study was published online on February 15 in JAMA Network Open.
 

Common War Wound

TBI is one of the most common battlefield wounds among veterans of the Iraq and Afghanistan wars. But evidence to date on the potential association of TBI with the subsequent risk for brain cancer is conflicting, the authors noted.

To investigate further, they reviewed the records of nearly 2 million mostly male US veterans of the Iraq and Afghanistan wars. A total of 449,880 people experienced TBI, which was mild in 385,848 cases, moderate/severe in 46,859 cases, and penetrating in 17,173 cases.

During a median follow-up of 7.2 years, brain cancer occurred in 318 veterans without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (0.06% or less).

There was a stepwise increase in brain cancer incidence with worse TBI severity. Crude incidence rates per 100,000 person-years were 3.06 for no TBI, 2.85 for mild TBI, 4.88 for moderate/severe TBI, and 10.34 for penetrating TBI.

In the fully adjusted model, moderate/severe TBI showed a near-doubling of brain cancer risk vs no TBI (adjusted hazard ratio [aHR], 1.90; 95% CI, 1.16-3.12), while penetrating TBI was associated with a greater than tripling of risk (aHR, 3.33; 95% CI, 1.71-6.49). There was no significantly increased risk after mild TBI.

There are plausible biological mechanisms linking TBI to brain cancer, the authors noted, including alterations in metabolism, inflammation, astrocyte proliferation, and stem cell migration and differentiation.

They caution that with few female veterans and a predominantly young cohort, the findings may not extend to the general population.
 

Meaningful New Data 

In an accompanying editorial, Elie Massaad, MD, MSc, and Ali Kiapour, PhD, MMSc, Massachusetts General Hospital, Boston, noted that federal data show glioblastoma, the most aggressive malignant brain tumor, is the third leading cause of cancer-related death among active duty personnel.

“Post-9/11 veterans deployed to Iraq, Afghanistan, and elsewhere face a 26% higher glioblastoma rate vs the general public, with an average age of onset decades earlier than in broader populations,” they wrote.

Overall, they noted this new research provides “meaningful data clarifying associations between combat-related TBI severity and subsequent brain cancer risk among post-9/11 veterans.

“Elucidating potential connections between battlefield trauma and longer-term health outcomes is imperative to inform prevention and care approaches for those who have served,” they added.

This study was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense through the Psychological Health/Traumatic Brain Injury Research Program Long-Term Impact of Military Relevant Brain Injury Consortium. The authors and editorialists had declared no relevant conflicts of interest.
 

A version of this article appeared on Medscape.com.

Moderate, severe, and penetrating traumatic brain injury (TBI) is associated with an elevated risk of developing brain cancer, new research suggested. However, mild TBI appears to confer no increased risk.

In a large cohort of post-9/11 US veterans, those who suffered moderate/severe TBI had a nearly twofold increased risk for a subsequent brain cancer diagnosis, while those with penetrating TBI had a greater than threefold increased risk.

“While the absolute number of brain cancer diagnoses was small, these diagnoses are associated with profoundly poor outcomes. Further research of this rare but devastating condition is needed to better identify those at risk and develop screening protocols,” wrote investigators led by Ian Stewart, MD, with the Uniformed Services University of Health Sciences, Bethesda, Maryland.

The study was published online on February 15 in JAMA Network Open.
 

Common War Wound

TBI is one of the most common battlefield wounds among veterans of the Iraq and Afghanistan wars. But evidence to date on the potential association of TBI with the subsequent risk for brain cancer is conflicting, the authors noted.

To investigate further, they reviewed the records of nearly 2 million mostly male US veterans of the Iraq and Afghanistan wars. A total of 449,880 people experienced TBI, which was mild in 385,848 cases, moderate/severe in 46,859 cases, and penetrating in 17,173 cases.

During a median follow-up of 7.2 years, brain cancer occurred in 318 veterans without TBI (0.02%), 80 with mild TBI (0.02%), 17 with moderate/severe TBI (0.04%), and 10 or fewer with penetrating TBI (0.06% or less).

There was a stepwise increase in brain cancer incidence with worse TBI severity. Crude incidence rates per 100,000 person-years were 3.06 for no TBI, 2.85 for mild TBI, 4.88 for moderate/severe TBI, and 10.34 for penetrating TBI.

In the fully adjusted model, moderate/severe TBI showed a near-doubling of brain cancer risk vs no TBI (adjusted hazard ratio [aHR], 1.90; 95% CI, 1.16-3.12), while penetrating TBI was associated with a greater than tripling of risk (aHR, 3.33; 95% CI, 1.71-6.49). There was no significantly increased risk after mild TBI.

There are plausible biological mechanisms linking TBI to brain cancer, the authors noted, including alterations in metabolism, inflammation, astrocyte proliferation, and stem cell migration and differentiation.

They caution that with few female veterans and a predominantly young cohort, the findings may not extend to the general population.
 

Meaningful New Data 

In an accompanying editorial, Elie Massaad, MD, MSc, and Ali Kiapour, PhD, MMSc, Massachusetts General Hospital, Boston, noted that federal data show glioblastoma, the most aggressive malignant brain tumor, is the third leading cause of cancer-related death among active duty personnel.

“Post-9/11 veterans deployed to Iraq, Afghanistan, and elsewhere face a 26% higher glioblastoma rate vs the general public, with an average age of onset decades earlier than in broader populations,” they wrote.

Overall, they noted this new research provides “meaningful data clarifying associations between combat-related TBI severity and subsequent brain cancer risk among post-9/11 veterans.

“Elucidating potential connections between battlefield trauma and longer-term health outcomes is imperative to inform prevention and care approaches for those who have served,” they added.

This study was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense through the Psychological Health/Traumatic Brain Injury Research Program Long-Term Impact of Military Relevant Brain Injury Consortium. The authors and editorialists had declared no relevant conflicts of interest.
 

A version of this article appeared on Medscape.com.

Some things are universal, or at least worldwide.

She didn’t speak a word of English, but I don’t speak any Mandarin. Fortunately, her concerned son was fluent in both.

A nice lady in her 60s, here from China to visit her son and his family for a month. The visit was going fine until she abruptly developed double vision. Through the modern miracle of email she contacted her doctor in Beijing, who told her to find a neurologist here or go to an ER.

I’d had a last minute cancellation a few minutes before her son called and so was able to see her that afternoon. Both were scared that I was going to admit her to a hospital.

Fortunately, people are wired the same no matter where they’re from. The electrical fibers of the nervous system are predictable across international borders, as are the maladies.

A history and exam made the diagnosis of a diabetic cranial nerve palsy most likely, and I was able to reassure them. I ordered the usual imaging studies (fortunately she’d bought travelers’ insurance in advance). As anticipated, they were normal.

Her son and I spoke by phone to close things out, with her in the background and him translating between us. By the time she left 2 weeks later the symptoms were resolving. I made sure she went home with copies of my notes and the MRI reports, figuring someone there would be able to translate them for her physician.

These sorts of encounters are uncommon in my little solo practice, but still drive home the point that people around the world have more in common than not. Disease prevalence varies by regions, and there are certain genetic issues one has to take into account, but the basic principles of medicine are the same.

Not to mention families. The mother traveling around the world to see her son and grandchildren. The child concerned for the welfare of his parent and helping her get care. These, too, are human universals, regardless of the language spoken. There isn’t a culture on Earth that doesn’t value family connections, nor is there one that didn’t develop (albeit in different forms) doctors.

The human population is 8 billion. Everyone is different, and yet everyone, overall, is the same. Fellow travelers on a small planet.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Some things are universal, or at least worldwide.

She didn’t speak a word of English, but I don’t speak any Mandarin. Fortunately, her concerned son was fluent in both.

A nice lady in her 60s, here from China to visit her son and his family for a month. The visit was going fine until she abruptly developed double vision. Through the modern miracle of email she contacted her doctor in Beijing, who told her to find a neurologist here or go to an ER.

I’d had a last minute cancellation a few minutes before her son called and so was able to see her that afternoon. Both were scared that I was going to admit her to a hospital.

Fortunately, people are wired the same no matter where they’re from. The electrical fibers of the nervous system are predictable across international borders, as are the maladies.

A history and exam made the diagnosis of a diabetic cranial nerve palsy most likely, and I was able to reassure them. I ordered the usual imaging studies (fortunately she’d bought travelers’ insurance in advance). As anticipated, they were normal.

Her son and I spoke by phone to close things out, with her in the background and him translating between us. By the time she left 2 weeks later the symptoms were resolving. I made sure she went home with copies of my notes and the MRI reports, figuring someone there would be able to translate them for her physician.

These sorts of encounters are uncommon in my little solo practice, but still drive home the point that people around the world have more in common than not. Disease prevalence varies by regions, and there are certain genetic issues one has to take into account, but the basic principles of medicine are the same.

Not to mention families. The mother traveling around the world to see her son and grandchildren. The child concerned for the welfare of his parent and helping her get care. These, too, are human universals, regardless of the language spoken. There isn’t a culture on Earth that doesn’t value family connections, nor is there one that didn’t develop (albeit in different forms) doctors.

The human population is 8 billion. Everyone is different, and yet everyone, overall, is the same. Fellow travelers on a small planet.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Some things are universal, or at least worldwide.

She didn’t speak a word of English, but I don’t speak any Mandarin. Fortunately, her concerned son was fluent in both.

A nice lady in her 60s, here from China to visit her son and his family for a month. The visit was going fine until she abruptly developed double vision. Through the modern miracle of email she contacted her doctor in Beijing, who told her to find a neurologist here or go to an ER.

I’d had a last minute cancellation a few minutes before her son called and so was able to see her that afternoon. Both were scared that I was going to admit her to a hospital.

Fortunately, people are wired the same no matter where they’re from. The electrical fibers of the nervous system are predictable across international borders, as are the maladies.

A history and exam made the diagnosis of a diabetic cranial nerve palsy most likely, and I was able to reassure them. I ordered the usual imaging studies (fortunately she’d bought travelers’ insurance in advance). As anticipated, they were normal.

Her son and I spoke by phone to close things out, with her in the background and him translating between us. By the time she left 2 weeks later the symptoms were resolving. I made sure she went home with copies of my notes and the MRI reports, figuring someone there would be able to translate them for her physician.

These sorts of encounters are uncommon in my little solo practice, but still drive home the point that people around the world have more in common than not. Disease prevalence varies by regions, and there are certain genetic issues one has to take into account, but the basic principles of medicine are the same.

Not to mention families. The mother traveling around the world to see her son and grandchildren. The child concerned for the welfare of his parent and helping her get care. These, too, are human universals, regardless of the language spoken. There isn’t a culture on Earth that doesn’t value family connections, nor is there one that didn’t develop (albeit in different forms) doctors.

The human population is 8 billion. Everyone is different, and yet everyone, overall, is the same. Fellow travelers on a small planet.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.