LIVERPOOL, ENGLAND – In biologic-experienced patients with psoriatic arthritis, the interleukin-17 inhibitor ixekizumab not only met the primary efficacy endpoint of a pivotal phase 3 trial, but also improved multiple patient-reported outcomes in doing so.

Newly-released results from the Study of Ixekizumab in Participants With Active Psoriatic Arthritis (SPIRIT-P2) showed that patients who received active treatment exhibited significantly better changes in physical function, quality of life, itch score, and work productivity compared with those given placebo.

Sara Freeman/MDedge News

Dr. Marzo-Ortega noted that the study had only been powered to show a difference between the active treatment and placebo, and not between the two doses, and that, looking at the speed of response, a difference from placebo was already being seen by week 2 “and certainly by week 4,” indicating an early effect. Data from the trial at 52 weeks are being analyzed and should be available soon, she said.

Another efficacy measure used was the percentage of patients achieving minimum disease activity at week 24. “These are stringent criteria to achieve: Five of seven criteria need to be met,” Dr. Marzo-Ortega said. “This was achieved by almost 30% of patients on the 4-weekly dose,” and by 24% on the 2-weekly dose, but by just 3% of those given placebo.

“One of the remarkable things is that nearly a third [of patients] achieved PASI [Psoriasis Area Severity Index] 100 by week 24, which is complete resolution of skin psoriasis,” she said. This is one of the first times this type of skin response has been seen in a psoriasis trial, she noted.

However, there was little difference between the active treatment and placebo arms in terms of the percentage of patients seeing a response on enthesitis, and only the dose taken every 4 weeks had a significant benefit over placebo in terms of improving dactylitis.

It is not clear why these modest results were seen in the joints, perhaps there were too few patients. While this is surprising, Dr. Marzo-Ortega noted that she “wouldn’t put too much weight on” the lack of an enthesis response; these are “fantastic drugs for the skin,” she said. “There is no doubt about it.”

Other findings from the trial included a significant improvement in itch with both ixekizumab regimens versus placebo, as shown by a greater reduction in numerical rating scale scores from baseline to week 24 (–3.4 and –3.5 vs. –1.2; P less than .001).

Significant improvements with ixekizumab versus placebo in patients’ mental and physical health were also seen when data from the Short Form–36 and EQ-5D instruments were analyzed.

There was also evidence that treatment with ixekizumab significantly improved patients’ presenteeism, work productivity, and activity impairment at work when compared against placebo. There was no difference in absenteeism, as measured by changes in Work Productivity and Activity Impairment Questionnaire–Specific Health Problem scores from baseline to week 24.

SPIRIT-P2 is one of two pivotal trials conducted with ixekizumab in patients with psoriatic arthritis; the other is SPIRIT-P1, which was conducted in biologic-naive patients (Ann Rheum Dis. 2017;76[1]:79-87). Investigators recently reported 1-year data from it (J Rheumatol. 2018;45[3]:367-77.).

Eli Lilly, which markets ixekizumab as Taltz, sponsored the study. Dr. Marzo-Ortega disclosed receiving honoraria from AbbVie, Celgene, Eli Lilly, Novartis, and UCB, and honoraria and research funding from Janssen and Pfizer. Several other authors reported disclosures with many manufacturers of biologics for psoriatic arthritis, including Eli Lilly.

SOURCE: Marzo-Ortega H et al. Rheumatology. 2018;57[Suppl. 3]:key075.185.

LIVERPOOL, ENGLAND – In biologic-experienced patients with psoriatic arthritis, the interleukin-17 inhibitor ixekizumab not only met the primary efficacy endpoint of a pivotal phase 3 trial, but also improved multiple patient-reported outcomes in doing so.

Newly-released results from the Study of Ixekizumab in Participants With Active Psoriatic Arthritis (SPIRIT-P2) showed that patients who received active treatment exhibited significantly better changes in physical function, quality of life, itch score, and work productivity compared with those given placebo.

Sara Freeman/MDedge News

Dr. Marzo-Ortega noted that the study had only been powered to show a difference between the active treatment and placebo, and not between the two doses, and that, looking at the speed of response, a difference from placebo was already being seen by week 2 “and certainly by week 4,” indicating an early effect. Data from the trial at 52 weeks are being analyzed and should be available soon, she said.

Another efficacy measure used was the percentage of patients achieving minimum disease activity at week 24. “These are stringent criteria to achieve: Five of seven criteria need to be met,” Dr. Marzo-Ortega said. “This was achieved by almost 30% of patients on the 4-weekly dose,” and by 24% on the 2-weekly dose, but by just 3% of those given placebo.

“One of the remarkable things is that nearly a third [of patients] achieved PASI [Psoriasis Area Severity Index] 100 by week 24, which is complete resolution of skin psoriasis,” she said. This is one of the first times this type of skin response has been seen in a psoriasis trial, she noted.

However, there was little difference between the active treatment and placebo arms in terms of the percentage of patients seeing a response on enthesitis, and only the dose taken every 4 weeks had a significant benefit over placebo in terms of improving dactylitis.

It is not clear why these modest results were seen in the joints, perhaps there were too few patients. While this is surprising, Dr. Marzo-Ortega noted that she “wouldn’t put too much weight on” the lack of an enthesis response; these are “fantastic drugs for the skin,” she said. “There is no doubt about it.”

Other findings from the trial included a significant improvement in itch with both ixekizumab regimens versus placebo, as shown by a greater reduction in numerical rating scale scores from baseline to week 24 (–3.4 and –3.5 vs. –1.2; P less than .001).

Significant improvements with ixekizumab versus placebo in patients’ mental and physical health were also seen when data from the Short Form–36 and EQ-5D instruments were analyzed.

There was also evidence that treatment with ixekizumab significantly improved patients’ presenteeism, work productivity, and activity impairment at work when compared against placebo. There was no difference in absenteeism, as measured by changes in Work Productivity and Activity Impairment Questionnaire–Specific Health Problem scores from baseline to week 24.

SPIRIT-P2 is one of two pivotal trials conducted with ixekizumab in patients with psoriatic arthritis; the other is SPIRIT-P1, which was conducted in biologic-naive patients (Ann Rheum Dis. 2017;76[1]:79-87). Investigators recently reported 1-year data from it (J Rheumatol. 2018;45[3]:367-77.).

Eli Lilly, which markets ixekizumab as Taltz, sponsored the study. Dr. Marzo-Ortega disclosed receiving honoraria from AbbVie, Celgene, Eli Lilly, Novartis, and UCB, and honoraria and research funding from Janssen and Pfizer. Several other authors reported disclosures with many manufacturers of biologics for psoriatic arthritis, including Eli Lilly.

SOURCE: Marzo-Ortega H et al. Rheumatology. 2018;57[Suppl. 3]:key075.185.

LIVERPOOL, ENGLAND – In biologic-experienced patients with psoriatic arthritis, the interleukin-17 inhibitor ixekizumab not only met the primary efficacy endpoint of a pivotal phase 3 trial, but also improved multiple patient-reported outcomes in doing so.

Newly-released results from the Study of Ixekizumab in Participants With Active Psoriatic Arthritis (SPIRIT-P2) showed that patients who received active treatment exhibited significantly better changes in physical function, quality of life, itch score, and work productivity compared with those given placebo.

Sara Freeman/MDedge News

Dr. Marzo-Ortega noted that the study had only been powered to show a difference between the active treatment and placebo, and not between the two doses, and that, looking at the speed of response, a difference from placebo was already being seen by week 2 “and certainly by week 4,” indicating an early effect. Data from the trial at 52 weeks are being analyzed and should be available soon, she said.

Another efficacy measure used was the percentage of patients achieving minimum disease activity at week 24. “These are stringent criteria to achieve: Five of seven criteria need to be met,” Dr. Marzo-Ortega said. “This was achieved by almost 30% of patients on the 4-weekly dose,” and by 24% on the 2-weekly dose, but by just 3% of those given placebo.

“One of the remarkable things is that nearly a third [of patients] achieved PASI [Psoriasis Area Severity Index] 100 by week 24, which is complete resolution of skin psoriasis,” she said. This is one of the first times this type of skin response has been seen in a psoriasis trial, she noted.

However, there was little difference between the active treatment and placebo arms in terms of the percentage of patients seeing a response on enthesitis, and only the dose taken every 4 weeks had a significant benefit over placebo in terms of improving dactylitis.

It is not clear why these modest results were seen in the joints, perhaps there were too few patients. While this is surprising, Dr. Marzo-Ortega noted that she “wouldn’t put too much weight on” the lack of an enthesis response; these are “fantastic drugs for the skin,” she said. “There is no doubt about it.”

Other findings from the trial included a significant improvement in itch with both ixekizumab regimens versus placebo, as shown by a greater reduction in numerical rating scale scores from baseline to week 24 (–3.4 and –3.5 vs. –1.2; P less than .001).

Significant improvements with ixekizumab versus placebo in patients’ mental and physical health were also seen when data from the Short Form–36 and EQ-5D instruments were analyzed.

There was also evidence that treatment with ixekizumab significantly improved patients’ presenteeism, work productivity, and activity impairment at work when compared against placebo. There was no difference in absenteeism, as measured by changes in Work Productivity and Activity Impairment Questionnaire–Specific Health Problem scores from baseline to week 24.

SPIRIT-P2 is one of two pivotal trials conducted with ixekizumab in patients with psoriatic arthritis; the other is SPIRIT-P1, which was conducted in biologic-naive patients (Ann Rheum Dis. 2017;76[1]:79-87). Investigators recently reported 1-year data from it (J Rheumatol. 2018;45[3]:367-77.).

Eli Lilly, which markets ixekizumab as Taltz, sponsored the study. Dr. Marzo-Ortega disclosed receiving honoraria from AbbVie, Celgene, Eli Lilly, Novartis, and UCB, and honoraria and research funding from Janssen and Pfizer. Several other authors reported disclosures with many manufacturers of biologics for psoriatic arthritis, including Eli Lilly.

SOURCE: Marzo-Ortega H et al. Rheumatology. 2018;57[Suppl. 3]:key075.185.

NEW YORK – Female physicians are at higher risk for burnout compared with their male counterparts, and the reasons and potential solutions for the problem were addressed at a symposium during the annual meeting of the American Psychiatric Association.

The work environment for women has improved over time, but lingering implicit and unconscious biases are part of the reason for the high burnout rate among women who are physicians, as are some inherent biological differences, according to Cynthia M. Stonnington, MD, of the Mayo Clinic, Phoenix.

In this video interview, Dr. Stonnington, symposium chair, discussed potential solutions, including facilitated peer mentorship and group support. She also reviewed recent data on how group support can be of benefit, and noted that “there is power in numbers.

“It is imperative that women ... band together and find a way to support each other,” she said.

Dr. Stonnington reported having no disclosures.

[email protected]

NEW YORK – Female physicians are at higher risk for burnout compared with their male counterparts, and the reasons and potential solutions for the problem were addressed at a symposium during the annual meeting of the American Psychiatric Association.

The work environment for women has improved over time, but lingering implicit and unconscious biases are part of the reason for the high burnout rate among women who are physicians, as are some inherent biological differences, according to Cynthia M. Stonnington, MD, of the Mayo Clinic, Phoenix.

In this video interview, Dr. Stonnington, symposium chair, discussed potential solutions, including facilitated peer mentorship and group support. She also reviewed recent data on how group support can be of benefit, and noted that “there is power in numbers.

“It is imperative that women ... band together and find a way to support each other,” she said.

Dr. Stonnington reported having no disclosures.

[email protected]

NEW YORK – Female physicians are at higher risk for burnout compared with their male counterparts, and the reasons and potential solutions for the problem were addressed at a symposium during the annual meeting of the American Psychiatric Association.

The work environment for women has improved over time, but lingering implicit and unconscious biases are part of the reason for the high burnout rate among women who are physicians, as are some inherent biological differences, according to Cynthia M. Stonnington, MD, of the Mayo Clinic, Phoenix.

In this video interview, Dr. Stonnington, symposium chair, discussed potential solutions, including facilitated peer mentorship and group support. She also reviewed recent data on how group support can be of benefit, and noted that “there is power in numbers.

“It is imperative that women ... band together and find a way to support each other,” she said.

Dr. Stonnington reported having no disclosures.

[email protected]

SANDESTIN, FLA. – Several drugs approved for other conditions may also have good effect in patients with systemic lupus erythematosus, Michelle Petri, MD, said in an interview at the annual Congress of Clinical Rheumatology.

The molecules target several different disease pathways, said Dr. Petri, director of the Hopkins Lupus Center at Johns Hopkins University, Baltimore.

Ustekinumab (Stelara) has accumulated the most data so far. A phase 2 study presented last fall at the annual meeting of the American College of Rheumatology found that it conferred significant benefits relative to placebo, including a 60% responder rate (29% better than placebo), a significantly lower flare rate, and improvements in musculoskeletal and mucocutaneous disease features. The rate of serious adverse events was acceptable (8.3% vs. 9.5% for placebo).

Baricitinib is also being investigated in SLE, Dr. Petri said. A phase 2 study conducted by Eli Lilly closed late last year and will be reported on June 13 at the European League Against Rheumatism’s opening plenary session (Wallace et al. EULAR 2018 abstract OP0019).

The three-armed, placebo-controlled study comprised 314 patients who were randomized to placebo or one of two baricitinib doses, given orally for 24 weeks. The primary outcome was remission of arthritis and/or rash as measured by the SLE Disease Activity Index 2000 (SLEDAI-2K). Secondary endpoints included responder rate, change from baseline in the SLEDAI-2K, change in the Global Assessment of Disease Activity score, and pharmacokinetic measures.

Dr. Petri disclosed relationships with Amgen, Boston Pharmaceuticals, Bristol-Myers Squibb, EMD Serono, Janssen, Novartis, and GlaxoSmithKline.

[email protected]

SANDESTIN, FLA. – Several drugs approved for other conditions may also have good effect in patients with systemic lupus erythematosus, Michelle Petri, MD, said in an interview at the annual Congress of Clinical Rheumatology.

The molecules target several different disease pathways, said Dr. Petri, director of the Hopkins Lupus Center at Johns Hopkins University, Baltimore.

Ustekinumab (Stelara) has accumulated the most data so far. A phase 2 study presented last fall at the annual meeting of the American College of Rheumatology found that it conferred significant benefits relative to placebo, including a 60% responder rate (29% better than placebo), a significantly lower flare rate, and improvements in musculoskeletal and mucocutaneous disease features. The rate of serious adverse events was acceptable (8.3% vs. 9.5% for placebo).

Baricitinib is also being investigated in SLE, Dr. Petri said. A phase 2 study conducted by Eli Lilly closed late last year and will be reported on June 13 at the European League Against Rheumatism’s opening plenary session (Wallace et al. EULAR 2018 abstract OP0019).

The three-armed, placebo-controlled study comprised 314 patients who were randomized to placebo or one of two baricitinib doses, given orally for 24 weeks. The primary outcome was remission of arthritis and/or rash as measured by the SLE Disease Activity Index 2000 (SLEDAI-2K). Secondary endpoints included responder rate, change from baseline in the SLEDAI-2K, change in the Global Assessment of Disease Activity score, and pharmacokinetic measures.

Dr. Petri disclosed relationships with Amgen, Boston Pharmaceuticals, Bristol-Myers Squibb, EMD Serono, Janssen, Novartis, and GlaxoSmithKline.

[email protected]

SANDESTIN, FLA. – Several drugs approved for other conditions may also have good effect in patients with systemic lupus erythematosus, Michelle Petri, MD, said in an interview at the annual Congress of Clinical Rheumatology.

The molecules target several different disease pathways, said Dr. Petri, director of the Hopkins Lupus Center at Johns Hopkins University, Baltimore.

Ustekinumab (Stelara) has accumulated the most data so far. A phase 2 study presented last fall at the annual meeting of the American College of Rheumatology found that it conferred significant benefits relative to placebo, including a 60% responder rate (29% better than placebo), a significantly lower flare rate, and improvements in musculoskeletal and mucocutaneous disease features. The rate of serious adverse events was acceptable (8.3% vs. 9.5% for placebo).

Baricitinib is also being investigated in SLE, Dr. Petri said. A phase 2 study conducted by Eli Lilly closed late last year and will be reported on June 13 at the European League Against Rheumatism’s opening plenary session (Wallace et al. EULAR 2018 abstract OP0019).

The three-armed, placebo-controlled study comprised 314 patients who were randomized to placebo or one of two baricitinib doses, given orally for 24 weeks. The primary outcome was remission of arthritis and/or rash as measured by the SLE Disease Activity Index 2000 (SLEDAI-2K). Secondary endpoints included responder rate, change from baseline in the SLEDAI-2K, change in the Global Assessment of Disease Activity score, and pharmacokinetic measures.

Dr. Petri disclosed relationships with Amgen, Boston Pharmaceuticals, Bristol-Myers Squibb, EMD Serono, Janssen, Novartis, and GlaxoSmithKline.

[email protected]

As patients with multiple sclerosis and their caregivers face various challenges in the American health care system, the Consortium of Multiple Sclerosis Centers (CMSC) is re-energizing its focus on advocacy. The 2018 annual meeting in Nashville, Tenn., will feature programming designed to teach MS professionals and researchers how to speak up and let their voices be heard.

“CMSC has re-engaged in advocacy, in a more focused and energized way, because of mounting concerns that there is inadequate advocacy pressure on some of the critical issues negatively impacting the quality and comprehensive nature of MS care required of people living with MS,” said Lisa Taylor Skutnik, a physical therapist and chief operating officer of the CMSC. “Both people living with MS and the clinicians dedicated to treating them are increasingly frustrated and powerless in attempts to facilitate the right care and resources for people living with MS. Our members are facing significant barriers and obstacles to ensure timely and seamless comprehensive care.”

As patients with multiple sclerosis and their caregivers face various challenges in the American health care system, the Consortium of Multiple Sclerosis Centers (CMSC) is re-energizing its focus on advocacy. The 2018 annual meeting in Nashville, Tenn., will feature programming designed to teach MS professionals and researchers how to speak up and let their voices be heard.

“CMSC has re-engaged in advocacy, in a more focused and energized way, because of mounting concerns that there is inadequate advocacy pressure on some of the critical issues negatively impacting the quality and comprehensive nature of MS care required of people living with MS,” said Lisa Taylor Skutnik, a physical therapist and chief operating officer of the CMSC. “Both people living with MS and the clinicians dedicated to treating them are increasingly frustrated and powerless in attempts to facilitate the right care and resources for people living with MS. Our members are facing significant barriers and obstacles to ensure timely and seamless comprehensive care.”

As patients with multiple sclerosis and their caregivers face various challenges in the American health care system, the Consortium of Multiple Sclerosis Centers (CMSC) is re-energizing its focus on advocacy. The 2018 annual meeting in Nashville, Tenn., will feature programming designed to teach MS professionals and researchers how to speak up and let their voices be heard.

“CMSC has re-engaged in advocacy, in a more focused and energized way, because of mounting concerns that there is inadequate advocacy pressure on some of the critical issues negatively impacting the quality and comprehensive nature of MS care required of people living with MS,” said Lisa Taylor Skutnik, a physical therapist and chief operating officer of the CMSC. “Both people living with MS and the clinicians dedicated to treating them are increasingly frustrated and powerless in attempts to facilitate the right care and resources for people living with MS. Our members are facing significant barriers and obstacles to ensure timely and seamless comprehensive care.”

Research shows that genes may be driving appetite differences in obesity, not adiposity. Also today, conservative early approach likely best, the true burden of nonmelanoma skin cancer and atopic eczema is linked to cardiovascular disease.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

Research shows that genes may be driving appetite differences in obesity, not adiposity. Also today, conservative early approach likely best, the true burden of nonmelanoma skin cancer and atopic eczema is linked to cardiovascular disease.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

Research shows that genes may be driving appetite differences in obesity, not adiposity. Also today, conservative early approach likely best, the true burden of nonmelanoma skin cancer and atopic eczema is linked to cardiovascular disease.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

For more than 35 years, the Nurses Organization of Veterans Affairs (NOVA) has been the voice of more than 3,000 Department of Veterans Affairs (VA) nurses caring for veterans. Speaking on behalf of its members, NOVA leaders provide an annual list of its legislative priority goals, which identifies concerns that require either legislation, funding, or implementation at the regulatory level within the VA.

At the top of this list of priorities is the ability to retain, recruit, and hire critical staff. The VA has had difficulty hiring essential staff at many levels within its health care facilities. A VA internal audit found that the need for additional doctors, nurses, and other specialty care was the highest barrier or challenge to providing access to care for veterans. Both congressional VA oversight committees have discussed this issue and included hiring provisions in their respective Choice/Community Care bills that await final action in both chambers.

In its recruitment/staffing goals, NOVA identified the 5 following areas:

• Hire additional human resources (HR) staff and review and streamline policies and procedures to improve the hiring process;
• Review thoroughly downgrades and reclassification of critical positions across the VA;
• Increase training of HR personnel on use of locality pay process in hiring;
• Revise the cap on nurse pay structures and registered nurse pay schedules and reclassification of critical positions so that VA can ensure competitive salaries; and
• Address USAJOBS website problems, including the complexity and excessive time required to complete application and inadequate applications response/feedback.

Addressing Choice/Community Integrated Health Care—Choice 2.0—is another NOVA goal. When the VA cannot provide timely care to veterans, NOVA supports the use of outside providers. A consolidated community care program implemented with clear eligibility rules and training for VA employees will end confusion for veterans using the program. The leadership of NOVA believes that the VA must remain the first point of access and coordinator of all health care for enrolled veterans. The Choice program was intended to fill gaps and be a temporary solution to access issues. Current legislation would consolidate all non-VA care and make the Choice program permanent with funding subject to appropriations.

Although NOVA supports the addition of community providers as a crucial part of an integrated network designed to provide care where there are shortages, the change has called attention to myriad problems created by outside providers, such as delays in care, the wrong care, or the veteran not being seen at all. Any final Choice/Community Care legislation must include mandatory training for both VA personnel and community providers to improve coordination and timeliness of care and services. The legislation also must hold community providers to the same high standards and quality metrics already in place at the VA.

Last, NOVA addresses information technology (IT) across VHA, which includes supporting an electronic health record for seamless transition of care between DoD and VA, proper funding for all IT stations to improve patient safety, software usability, and standardization of patient health care records across the system. As the VA continues to modernize, NOVA asks that nursing leadership be at the forefront of all strategic decision making.

As an advocate for its members and the patients they serve, NOVA will continue to share its views with Congress, the administration, and VA leadership on how they can work together toward common goals—educating the next generation of nurses, providing innovative health care solutions, or learning how veterans envision their health care. For more information about NOVA, a list of its 2018 Legislative Priority Goals, or to become a member, visit vanurse.org.

For more than 35 years, the Nurses Organization of Veterans Affairs (NOVA) has been the voice of more than 3,000 Department of Veterans Affairs (VA) nurses caring for veterans. Speaking on behalf of its members, NOVA leaders provide an annual list of its legislative priority goals, which identifies concerns that require either legislation, funding, or implementation at the regulatory level within the VA.

At the top of this list of priorities is the ability to retain, recruit, and hire critical staff. The VA has had difficulty hiring essential staff at many levels within its health care facilities. A VA internal audit found that the need for additional doctors, nurses, and other specialty care was the highest barrier or challenge to providing access to care for veterans. Both congressional VA oversight committees have discussed this issue and included hiring provisions in their respective Choice/Community Care bills that await final action in both chambers.

In its recruitment/staffing goals, NOVA identified the 5 following areas:

• Hire additional human resources (HR) staff and review and streamline policies and procedures to improve the hiring process;
• Review thoroughly downgrades and reclassification of critical positions across the VA;
• Increase training of HR personnel on use of locality pay process in hiring;
• Revise the cap on nurse pay structures and registered nurse pay schedules and reclassification of critical positions so that VA can ensure competitive salaries; and
• Address USAJOBS website problems, including the complexity and excessive time required to complete application and inadequate applications response/feedback.

Addressing Choice/Community Integrated Health Care—Choice 2.0—is another NOVA goal. When the VA cannot provide timely care to veterans, NOVA supports the use of outside providers. A consolidated community care program implemented with clear eligibility rules and training for VA employees will end confusion for veterans using the program. The leadership of NOVA believes that the VA must remain the first point of access and coordinator of all health care for enrolled veterans. The Choice program was intended to fill gaps and be a temporary solution to access issues. Current legislation would consolidate all non-VA care and make the Choice program permanent with funding subject to appropriations.

Although NOVA supports the addition of community providers as a crucial part of an integrated network designed to provide care where there are shortages, the change has called attention to myriad problems created by outside providers, such as delays in care, the wrong care, or the veteran not being seen at all. Any final Choice/Community Care legislation must include mandatory training for both VA personnel and community providers to improve coordination and timeliness of care and services. The legislation also must hold community providers to the same high standards and quality metrics already in place at the VA.

Last, NOVA addresses information technology (IT) across VHA, which includes supporting an electronic health record for seamless transition of care between DoD and VA, proper funding for all IT stations to improve patient safety, software usability, and standardization of patient health care records across the system. As the VA continues to modernize, NOVA asks that nursing leadership be at the forefront of all strategic decision making.

As an advocate for its members and the patients they serve, NOVA will continue to share its views with Congress, the administration, and VA leadership on how they can work together toward common goals—educating the next generation of nurses, providing innovative health care solutions, or learning how veterans envision their health care. For more information about NOVA, a list of its 2018 Legislative Priority Goals, or to become a member, visit vanurse.org.

For more than 35 years, the Nurses Organization of Veterans Affairs (NOVA) has been the voice of more than 3,000 Department of Veterans Affairs (VA) nurses caring for veterans. Speaking on behalf of its members, NOVA leaders provide an annual list of its legislative priority goals, which identifies concerns that require either legislation, funding, or implementation at the regulatory level within the VA.

At the top of this list of priorities is the ability to retain, recruit, and hire critical staff. The VA has had difficulty hiring essential staff at many levels within its health care facilities. A VA internal audit found that the need for additional doctors, nurses, and other specialty care was the highest barrier or challenge to providing access to care for veterans. Both congressional VA oversight committees have discussed this issue and included hiring provisions in their respective Choice/Community Care bills that await final action in both chambers.

In its recruitment/staffing goals, NOVA identified the 5 following areas:

• Hire additional human resources (HR) staff and review and streamline policies and procedures to improve the hiring process;
• Review thoroughly downgrades and reclassification of critical positions across the VA;
• Increase training of HR personnel on use of locality pay process in hiring;
• Revise the cap on nurse pay structures and registered nurse pay schedules and reclassification of critical positions so that VA can ensure competitive salaries; and
• Address USAJOBS website problems, including the complexity and excessive time required to complete application and inadequate applications response/feedback.

Addressing Choice/Community Integrated Health Care—Choice 2.0—is another NOVA goal. When the VA cannot provide timely care to veterans, NOVA supports the use of outside providers. A consolidated community care program implemented with clear eligibility rules and training for VA employees will end confusion for veterans using the program. The leadership of NOVA believes that the VA must remain the first point of access and coordinator of all health care for enrolled veterans. The Choice program was intended to fill gaps and be a temporary solution to access issues. Current legislation would consolidate all non-VA care and make the Choice program permanent with funding subject to appropriations.

Although NOVA supports the addition of community providers as a crucial part of an integrated network designed to provide care where there are shortages, the change has called attention to myriad problems created by outside providers, such as delays in care, the wrong care, or the veteran not being seen at all. Any final Choice/Community Care legislation must include mandatory training for both VA personnel and community providers to improve coordination and timeliness of care and services. The legislation also must hold community providers to the same high standards and quality metrics already in place at the VA.

Last, NOVA addresses information technology (IT) across VHA, which includes supporting an electronic health record for seamless transition of care between DoD and VA, proper funding for all IT stations to improve patient safety, software usability, and standardization of patient health care records across the system. As the VA continues to modernize, NOVA asks that nursing leadership be at the forefront of all strategic decision making.

As an advocate for its members and the patients they serve, NOVA will continue to share its views with Congress, the administration, and VA leadership on how they can work together toward common goals—educating the next generation of nurses, providing innovative health care solutions, or learning how veterans envision their health care. For more information about NOVA, a list of its 2018 Legislative Priority Goals, or to become a member, visit vanurse.org.

Starting School Later Improves Sleep Time

Delaying school start time can provide sustained benefits for sleep duration, daytime alertness, and mental well-being, according to a study published online ahead of print April 10 in Sleep. The study included 375 girls in grades 7 to 10 from a secondary school for girls. The school delayed its start time from 7:30 to 8:15 in the morning. Self-reports of sleep timing, sleepiness, and well-being were obtained at baseline before the delay and at approximately one and nine months after the delay. After one month, bedtimes on school nights were delayed by nine minutes, while rise times were delayed by 31.6 minutes, resulting in an increase in time in bed of 23.2 minutes. After nine months, the increase in time in bed was sustained, and total sleep time increased by 10 minutes.

Lo JC, Lee SM, Lee XK, et al. Sustained benefits of delaying school start time on adolescent sleep and well-being. Sleep. 2018 Apr 10 [Epub ahead of print].

Stroke Affects Social, Cognitive, and Psychologic Outcomes

Patients with ischemic stroke report symptoms in multiple domains that increase to variable degrees at higher levels of disability, according to a study published online ahead of print March 28 in Neurology. The observational cohort included 1,195 patients who completed Quality of Life in Neurological Disorders or the Patient-Reported Outcomes Measurement Information System scales as part of routine care. Participants were questioned about their physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance. Researchers also measured participants’ level of disability. Among people with stroke, scores were considerably worse than those in the general population in every area except sleep and depression. About 58% of people with stroke had scores related to satisfaction with social roles that were meaningfully worse than those of the general population.

Katzan IL, Thompson NR, Uchino K, Lapin B. The most affected health domains after ischemic stroke. Neurology. 2018 Mar 28 [Epub ahead of print].

ALS Genetic Variant Also a Risk Factor for Frontotemporal Dementia

One of the newly identified genetic variants associated with amyotrophic lateral sclerosis (ALS) also is a risk factor for frontotemporal dementia (FTD), according to a study published online ahead of print April 9 in JAMA Neurology. Researchers pooled data from previous genome-wide association studies that included genetic data from 124,876 participants. The studies included healthy controls and participants with ALS, Alzheimer’s disease, Parkinson’s disease, FTD, corticobasal degeneration, and progressive supranuclear palsy. Investigators found that a variation in a region of DNA containing the gene for tau protein was associated with elevated risk for ALS. In addition, study authors found significant genetic overlap between ALS and FTD at known ALS loci rs13302855, rs3849942, and rs4239633. They also found a genetic variation at rs538622 that is associated with ALS and FTD and affects BNIP1 production in the brain.

Karch CM, Wen N, Fan CC, et al. Selective genetic overlap between amyotrophic lateral sclerosis and diseases of the frontotemporal dementia spectrum. JAMA Neurol. 2018 Apr 9 [Epub ahead of print].

Intervention Promotes Stroke Preparedness

Hip-Hop Stroke (HHS) is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities, according to a study published in the April issue of Stroke. HHS is a three-hour, culturally tailored, theory-based, multimedia stroke literacy intervention that empowers schoolchildren to share stroke information with parents. Researchers recruited 3,070 fourth- through sixth-graders and 1,144 parents from 22 schools into a cluster-randomized trial. Schools were randomized to the HHS intervention or attentional control (ie, nutrition classes). Main outcome measures were stroke knowledge and preparedness of children and parents using validated surrogates. Among children, it was estimated that 1% of controls and 2% of the intervention group demonstrated optimal stroke preparedness at baseline, increasing to 57% immediately after the program in the intervention group.

Williams O, Leighton-Herrmann Quinn E, Teresi J, et al. Improving community stroke preparedness in the HHS (Hip-Hop Stroke) randomized clinical trial. Stroke. 2018;49(4):972-979.

Risk of Unnatural Death Is Increased in Epilepsy

People with epilepsy are at increased risk of mortality from suicide and accidents, according to a study published online ahead of print April 9 in JAMA Neurology. Researchers examined the Clinical Practice Research Datalink (CPRD) and the Secure Anonymized Information Linkage (SAIL) databank, which are linked to hospitalization and mortality records. They matched people with epilepsy on age, sex, and general practice with as many as 20 controls. In all, 44,678 people in the CPRD and 14,051 individuals in the SAIL databank were identified in the prevalent epilepsy cohorts. Furthermore, 891,429 participants from the CPRD and 279,365 people from the SAIL databank were identified as controls. People with epilepsy were significantly more likely to die of an unnatural cause, unintentional injury, poisoning, or suicide, compared with controls.

Gorton HC, Webb RT, Carr MJ, et al. Risk of unnatural mortality in people with epilepsy. JAMA Neurol. 2018 Apr 9 [Epub ahead of print].

Method to Assess Consciousness May Improve Care

The Glasgow Coma Scale-Pupil (GCS-P) score provides a way to rapidly assess levels of consciousness in people with head injuries and could improve patient care, according to a study published online ahead of print April 10 in the Journal of Neurosurgery. Investigators obtained patient-level information about early GCS scores, pupil responses, late outcomes on the Glasgow Outcome Scale, and mortality by reviewing data from the Corticosteroid Randomization After Significant Head Injury study and the International Mission for Prognosis and Clinical Trials database. GCS score and pupil response were independently related to patient outcome. Adding information about pupil response to the GCS score improved the information. The performance of the GCS-P was similar to that of methods for evaluating traumatic brain damage.

Brennan PM, Murray GD, Teasdale GM. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. J Neurosurg. 2018 Apr 10 [Epub ahead of print].

Biomarkers of Dementia Risk Identified

Researchers have identified novel biomarkers of risk for future dementia, according to a study published online ahead of print February 28 in Alzheimer’s & Dementia. Investigators analyzed metabolites in blood samples drawn from 22,623 people enrolled in eight prospective cohorts. Over 246,698 person-years, they detected 995 cases of incident dementia and 745 cases of incident Alzheimer’s disease. Isoleucine, leucine, valine, creatinine, and two VLDL-specific lipoprotein lipid subclasses were associated with lower dementia risk. One HDL and one VLDL lipoprotein lipid subclass were associated with increased dementia risk. Branched-chain amino acids also were associated with decreased Alzheimer’s disease risk, and the concentration of cholesterol esters relative to total lipids in large HDL was associated with increased Alzheimer’s disease risk.

Tynkkynen J, Chouraki V, van der Lee SJ, et al. Association of branched-chain amino acids and other circulating metabolites with risk of incident dementia and Alzheimer’s disease: a prospective study in eight cohorts. Alzheimers Dement. 2018 Feb 28 [Epub ahead of print].

Smartphone App Helps Doctors Track Parkinson’s Disease Symptoms

A smartphone app generates a score that reflects symptom severity in patients with Parkinson’s disease, according to a study published online ahead of print March 26 in JAMA Neurology. This observational study assessed people with Parkinson’s disease who remotely completed voice, finger tapping, gait, balance, and reaction time tasks on the app. Researchers generated a mobile Parkinson’s disease score (mPDS) of 0 to 100 that objectively weighed features derived from each smartphone activity. The mPDS was based on 6,148 smartphone activity assessments from 129 individuals. Gait features contributed most to the total mPDS (33.4%). The mPDS detected symptom fluctuations with a mean intraday change of 13.9 points. The mPDS improved by a mean of 16.3 points in response to dopaminergic therapy.

Zhan A, Mohan S, Tarolli C, et al. Using smartphones and machine learning to quantify Parkinson disease severity: the mobile Parkinson disease score. JAMA Neurol. 2018 Mar 26 [Epub ahead of print].

Age at Natural Menopause Linked to Memory

Entering menopause at a later age may benefit memory in women years later, according to a study published online ahead of print April 11 in Neurology. Researchers used data from 1,315 participants in the Medical Research Council National Survey of Health and Development with known age at period cessation and as many as four assessments of verbal memory and processing speed at ages 43, 53, between 60 and 64, and 69. Investigators fitted multilevel models with linear and quadratic age terms, stratified by natural or surgical menopause, and adjusted for hormone replacement therapy, BMI, smoking, occupational class, education, and childhood cognitive ability. Verbal memory increased with later age at natural menopause and with later age at surgical menopause. The association between age at natural menopause and verbal memory remained significant after data adjustment.

Kuh D, Cooper R, Moore A, et al. Age at menopause and lifetime cognition: findings from a British birth cohort study. Neurology. 2018 Apr 11 [Epub ahead of print].

Single-Pulse TMS Decreases Migraine Frequency

Single-pulse transcranial magnetic stimulation (sTMS) may be an effective, well-tolerated treatment option for migraine prevention, according to a study published online ahead of print March 4 in Cephalalgia. Researchers examined data from the eNeura SpringTMS Post-Market Observational US Study of Migraine, a multicenter, prospective, open-label, observational study. A total of 263 patients with migraine completed a one-month baseline headache diary, followed by three months of preventive (four pulses bid) and acute treatment (three pulses repeated as many as three times per attack). In all, 220 participants were eligible based on their number of headache days. The device was assigned to 217 subjects, and 132 were included in the intention-to-treat full-analysis set. Treatment reduced mean monthly headache days by 2.75. The most common adverse events were tingling, lightheadedness, and tinnitus.

Starling AJ, Tepper SJ, Marmura MJ, et al. A multicenter, prospective, single arm, open label, observational study of sTMS for migraine prevention (ESPOUSE Study). Cephalalgia. 2018 Mar 4 [Epub ahead of print].

Short Sleep Increases Risk of Obesity in the Young

Short sleep duration is a risk factor for obesity in infants, children, and adolescents, according to a study published online ahead of print February 1 in Sleep. Researchers reviewed the results of 42 population studies that included 75,499 infants, children, and adolescents ages 0 to 18. Sleep duration was assessed through methods such as questionnaires and wearable technology. The investigators classified participants as short sleepers or regular sleepers. Short sleepers were defined as having less sleep than the reference category for their age. Participants were followed up for a median of three years, and changes in BMI and incidence of overweight status and obesity were recorded. At all ages, short sleepers gained more weight and were 58% more likely to become overweight or obese.

Miller MA, Kruisbrink M, Wallace J, et al. Sleep duration and incidence of obesity in infants, children and adolescents: a systematic review and meta-analysis of prospective studies. Sleep. 2018 Feb 1 [Epub ahead of print].

—Kimberly Williams

Starting School Later Improves Sleep Time

Delaying school start time can provide sustained benefits for sleep duration, daytime alertness, and mental well-being, according to a study published online ahead of print April 10 in Sleep. The study included 375 girls in grades 7 to 10 from a secondary school for girls. The school delayed its start time from 7:30 to 8:15 in the morning. Self-reports of sleep timing, sleepiness, and well-being were obtained at baseline before the delay and at approximately one and nine months after the delay. After one month, bedtimes on school nights were delayed by nine minutes, while rise times were delayed by 31.6 minutes, resulting in an increase in time in bed of 23.2 minutes. After nine months, the increase in time in bed was sustained, and total sleep time increased by 10 minutes.

Lo JC, Lee SM, Lee XK, et al. Sustained benefits of delaying school start time on adolescent sleep and well-being. Sleep. 2018 Apr 10 [Epub ahead of print].

Stroke Affects Social, Cognitive, and Psychologic Outcomes

Patients with ischemic stroke report symptoms in multiple domains that increase to variable degrees at higher levels of disability, according to a study published online ahead of print March 28 in Neurology. The observational cohort included 1,195 patients who completed Quality of Life in Neurological Disorders or the Patient-Reported Outcomes Measurement Information System scales as part of routine care. Participants were questioned about their physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance. Researchers also measured participants’ level of disability. Among people with stroke, scores were considerably worse than those in the general population in every area except sleep and depression. About 58% of people with stroke had scores related to satisfaction with social roles that were meaningfully worse than those of the general population.

Katzan IL, Thompson NR, Uchino K, Lapin B. The most affected health domains after ischemic stroke. Neurology. 2018 Mar 28 [Epub ahead of print].

ALS Genetic Variant Also a Risk Factor for Frontotemporal Dementia

One of the newly identified genetic variants associated with amyotrophic lateral sclerosis (ALS) also is a risk factor for frontotemporal dementia (FTD), according to a study published online ahead of print April 9 in JAMA Neurology. Researchers pooled data from previous genome-wide association studies that included genetic data from 124,876 participants. The studies included healthy controls and participants with ALS, Alzheimer’s disease, Parkinson’s disease, FTD, corticobasal degeneration, and progressive supranuclear palsy. Investigators found that a variation in a region of DNA containing the gene for tau protein was associated with elevated risk for ALS. In addition, study authors found significant genetic overlap between ALS and FTD at known ALS loci rs13302855, rs3849942, and rs4239633. They also found a genetic variation at rs538622 that is associated with ALS and FTD and affects BNIP1 production in the brain.

Karch CM, Wen N, Fan CC, et al. Selective genetic overlap between amyotrophic lateral sclerosis and diseases of the frontotemporal dementia spectrum. JAMA Neurol. 2018 Apr 9 [Epub ahead of print].

Intervention Promotes Stroke Preparedness

Hip-Hop Stroke (HHS) is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities, according to a study published in the April issue of Stroke. HHS is a three-hour, culturally tailored, theory-based, multimedia stroke literacy intervention that empowers schoolchildren to share stroke information with parents. Researchers recruited 3,070 fourth- through sixth-graders and 1,144 parents from 22 schools into a cluster-randomized trial. Schools were randomized to the HHS intervention or attentional control (ie, nutrition classes). Main outcome measures were stroke knowledge and preparedness of children and parents using validated surrogates. Among children, it was estimated that 1% of controls and 2% of the intervention group demonstrated optimal stroke preparedness at baseline, increasing to 57% immediately after the program in the intervention group.

Williams O, Leighton-Herrmann Quinn E, Teresi J, et al. Improving community stroke preparedness in the HHS (Hip-Hop Stroke) randomized clinical trial. Stroke. 2018;49(4):972-979.

Risk of Unnatural Death Is Increased in Epilepsy

People with epilepsy are at increased risk of mortality from suicide and accidents, according to a study published online ahead of print April 9 in JAMA Neurology. Researchers examined the Clinical Practice Research Datalink (CPRD) and the Secure Anonymized Information Linkage (SAIL) databank, which are linked to hospitalization and mortality records. They matched people with epilepsy on age, sex, and general practice with as many as 20 controls. In all, 44,678 people in the CPRD and 14,051 individuals in the SAIL databank were identified in the prevalent epilepsy cohorts. Furthermore, 891,429 participants from the CPRD and 279,365 people from the SAIL databank were identified as controls. People with epilepsy were significantly more likely to die of an unnatural cause, unintentional injury, poisoning, or suicide, compared with controls.

Gorton HC, Webb RT, Carr MJ, et al. Risk of unnatural mortality in people with epilepsy. JAMA Neurol. 2018 Apr 9 [Epub ahead of print].

Method to Assess Consciousness May Improve Care

The Glasgow Coma Scale-Pupil (GCS-P) score provides a way to rapidly assess levels of consciousness in people with head injuries and could improve patient care, according to a study published online ahead of print April 10 in the Journal of Neurosurgery. Investigators obtained patient-level information about early GCS scores, pupil responses, late outcomes on the Glasgow Outcome Scale, and mortality by reviewing data from the Corticosteroid Randomization After Significant Head Injury study and the International Mission for Prognosis and Clinical Trials database. GCS score and pupil response were independently related to patient outcome. Adding information about pupil response to the GCS score improved the information. The performance of the GCS-P was similar to that of methods for evaluating traumatic brain damage.

Brennan PM, Murray GD, Teasdale GM. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. J Neurosurg. 2018 Apr 10 [Epub ahead of print].

Biomarkers of Dementia Risk Identified

Researchers have identified novel biomarkers of risk for future dementia, according to a study published online ahead of print February 28 in Alzheimer’s & Dementia. Investigators analyzed metabolites in blood samples drawn from 22,623 people enrolled in eight prospective cohorts. Over 246,698 person-years, they detected 995 cases of incident dementia and 745 cases of incident Alzheimer’s disease. Isoleucine, leucine, valine, creatinine, and two VLDL-specific lipoprotein lipid subclasses were associated with lower dementia risk. One HDL and one VLDL lipoprotein lipid subclass were associated with increased dementia risk. Branched-chain amino acids also were associated with decreased Alzheimer’s disease risk, and the concentration of cholesterol esters relative to total lipids in large HDL was associated with increased Alzheimer’s disease risk.

Tynkkynen J, Chouraki V, van der Lee SJ, et al. Association of branched-chain amino acids and other circulating metabolites with risk of incident dementia and Alzheimer’s disease: a prospective study in eight cohorts. Alzheimers Dement. 2018 Feb 28 [Epub ahead of print].

Smartphone App Helps Doctors Track Parkinson’s Disease Symptoms

A smartphone app generates a score that reflects symptom severity in patients with Parkinson’s disease, according to a study published online ahead of print March 26 in JAMA Neurology. This observational study assessed people with Parkinson’s disease who remotely completed voice, finger tapping, gait, balance, and reaction time tasks on the app. Researchers generated a mobile Parkinson’s disease score (mPDS) of 0 to 100 that objectively weighed features derived from each smartphone activity. The mPDS was based on 6,148 smartphone activity assessments from 129 individuals. Gait features contributed most to the total mPDS (33.4%). The mPDS detected symptom fluctuations with a mean intraday change of 13.9 points. The mPDS improved by a mean of 16.3 points in response to dopaminergic therapy.

Zhan A, Mohan S, Tarolli C, et al. Using smartphones and machine learning to quantify Parkinson disease severity: the mobile Parkinson disease score. JAMA Neurol. 2018 Mar 26 [Epub ahead of print].

Age at Natural Menopause Linked to Memory

Entering menopause at a later age may benefit memory in women years later, according to a study published online ahead of print April 11 in Neurology. Researchers used data from 1,315 participants in the Medical Research Council National Survey of Health and Development with known age at period cessation and as many as four assessments of verbal memory and processing speed at ages 43, 53, between 60 and 64, and 69. Investigators fitted multilevel models with linear and quadratic age terms, stratified by natural or surgical menopause, and adjusted for hormone replacement therapy, BMI, smoking, occupational class, education, and childhood cognitive ability. Verbal memory increased with later age at natural menopause and with later age at surgical menopause. The association between age at natural menopause and verbal memory remained significant after data adjustment.

Kuh D, Cooper R, Moore A, et al. Age at menopause and lifetime cognition: findings from a British birth cohort study. Neurology. 2018 Apr 11 [Epub ahead of print].

Single-Pulse TMS Decreases Migraine Frequency

Single-pulse transcranial magnetic stimulation (sTMS) may be an effective, well-tolerated treatment option for migraine prevention, according to a study published online ahead of print March 4 in Cephalalgia. Researchers examined data from the eNeura SpringTMS Post-Market Observational US Study of Migraine, a multicenter, prospective, open-label, observational study. A total of 263 patients with migraine completed a one-month baseline headache diary, followed by three months of preventive (four pulses bid) and acute treatment (three pulses repeated as many as three times per attack). In all, 220 participants were eligible based on their number of headache days. The device was assigned to 217 subjects, and 132 were included in the intention-to-treat full-analysis set. Treatment reduced mean monthly headache days by 2.75. The most common adverse events were tingling, lightheadedness, and tinnitus.

Starling AJ, Tepper SJ, Marmura MJ, et al. A multicenter, prospective, single arm, open label, observational study of sTMS for migraine prevention (ESPOUSE Study). Cephalalgia. 2018 Mar 4 [Epub ahead of print].

Short Sleep Increases Risk of Obesity in the Young

Short sleep duration is a risk factor for obesity in infants, children, and adolescents, according to a study published online ahead of print February 1 in Sleep. Researchers reviewed the results of 42 population studies that included 75,499 infants, children, and adolescents ages 0 to 18. Sleep duration was assessed through methods such as questionnaires and wearable technology. The investigators classified participants as short sleepers or regular sleepers. Short sleepers were defined as having less sleep than the reference category for their age. Participants were followed up for a median of three years, and changes in BMI and incidence of overweight status and obesity were recorded. At all ages, short sleepers gained more weight and were 58% more likely to become overweight or obese.

Miller MA, Kruisbrink M, Wallace J, et al. Sleep duration and incidence of obesity in infants, children and adolescents: a systematic review and meta-analysis of prospective studies. Sleep. 2018 Feb 1 [Epub ahead of print].

—Kimberly Williams

Starting School Later Improves Sleep Time

Delaying school start time can provide sustained benefits for sleep duration, daytime alertness, and mental well-being, according to a study published online ahead of print April 10 in Sleep. The study included 375 girls in grades 7 to 10 from a secondary school for girls. The school delayed its start time from 7:30 to 8:15 in the morning. Self-reports of sleep timing, sleepiness, and well-being were obtained at baseline before the delay and at approximately one and nine months after the delay. After one month, bedtimes on school nights were delayed by nine minutes, while rise times were delayed by 31.6 minutes, resulting in an increase in time in bed of 23.2 minutes. After nine months, the increase in time in bed was sustained, and total sleep time increased by 10 minutes.

Lo JC, Lee SM, Lee XK, et al. Sustained benefits of delaying school start time on adolescent sleep and well-being. Sleep. 2018 Apr 10 [Epub ahead of print].

Stroke Affects Social, Cognitive, and Psychologic Outcomes

Patients with ischemic stroke report symptoms in multiple domains that increase to variable degrees at higher levels of disability, according to a study published online ahead of print March 28 in Neurology. The observational cohort included 1,195 patients who completed Quality of Life in Neurological Disorders or the Patient-Reported Outcomes Measurement Information System scales as part of routine care. Participants were questioned about their physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance. Researchers also measured participants’ level of disability. Among people with stroke, scores were considerably worse than those in the general population in every area except sleep and depression. About 58% of people with stroke had scores related to satisfaction with social roles that were meaningfully worse than those of the general population.

Katzan IL, Thompson NR, Uchino K, Lapin B. The most affected health domains after ischemic stroke. Neurology. 2018 Mar 28 [Epub ahead of print].

ALS Genetic Variant Also a Risk Factor for Frontotemporal Dementia

One of the newly identified genetic variants associated with amyotrophic lateral sclerosis (ALS) also is a risk factor for frontotemporal dementia (FTD), according to a study published online ahead of print April 9 in JAMA Neurology. Researchers pooled data from previous genome-wide association studies that included genetic data from 124,876 participants. The studies included healthy controls and participants with ALS, Alzheimer’s disease, Parkinson’s disease, FTD, corticobasal degeneration, and progressive supranuclear palsy. Investigators found that a variation in a region of DNA containing the gene for tau protein was associated with elevated risk for ALS. In addition, study authors found significant genetic overlap between ALS and FTD at known ALS loci rs13302855, rs3849942, and rs4239633. They also found a genetic variation at rs538622 that is associated with ALS and FTD and affects BNIP1 production in the brain.

Karch CM, Wen N, Fan CC, et al. Selective genetic overlap between amyotrophic lateral sclerosis and diseases of the frontotemporal dementia spectrum. JAMA Neurol. 2018 Apr 9 [Epub ahead of print].

Intervention Promotes Stroke Preparedness

Hip-Hop Stroke (HHS) is an effective, intergenerational model for increasing stroke preparedness among economically disadvantaged minorities, according to a study published in the April issue of Stroke. HHS is a three-hour, culturally tailored, theory-based, multimedia stroke literacy intervention that empowers schoolchildren to share stroke information with parents. Researchers recruited 3,070 fourth- through sixth-graders and 1,144 parents from 22 schools into a cluster-randomized trial. Schools were randomized to the HHS intervention or attentional control (ie, nutrition classes). Main outcome measures were stroke knowledge and preparedness of children and parents using validated surrogates. Among children, it was estimated that 1% of controls and 2% of the intervention group demonstrated optimal stroke preparedness at baseline, increasing to 57% immediately after the program in the intervention group.

Williams O, Leighton-Herrmann Quinn E, Teresi J, et al. Improving community stroke preparedness in the HHS (Hip-Hop Stroke) randomized clinical trial. Stroke. 2018;49(4):972-979.

Risk of Unnatural Death Is Increased in Epilepsy

People with epilepsy are at increased risk of mortality from suicide and accidents, according to a study published online ahead of print April 9 in JAMA Neurology. Researchers examined the Clinical Practice Research Datalink (CPRD) and the Secure Anonymized Information Linkage (SAIL) databank, which are linked to hospitalization and mortality records. They matched people with epilepsy on age, sex, and general practice with as many as 20 controls. In all, 44,678 people in the CPRD and 14,051 individuals in the SAIL databank were identified in the prevalent epilepsy cohorts. Furthermore, 891,429 participants from the CPRD and 279,365 people from the SAIL databank were identified as controls. People with epilepsy were significantly more likely to die of an unnatural cause, unintentional injury, poisoning, or suicide, compared with controls.

Gorton HC, Webb RT, Carr MJ, et al. Risk of unnatural mortality in people with epilepsy. JAMA Neurol. 2018 Apr 9 [Epub ahead of print].

Method to Assess Consciousness May Improve Care

The Glasgow Coma Scale-Pupil (GCS-P) score provides a way to rapidly assess levels of consciousness in people with head injuries and could improve patient care, according to a study published online ahead of print April 10 in the Journal of Neurosurgery. Investigators obtained patient-level information about early GCS scores, pupil responses, late outcomes on the Glasgow Outcome Scale, and mortality by reviewing data from the Corticosteroid Randomization After Significant Head Injury study and the International Mission for Prognosis and Clinical Trials database. GCS score and pupil response were independently related to patient outcome. Adding information about pupil response to the GCS score improved the information. The performance of the GCS-P was similar to that of methods for evaluating traumatic brain damage.

Brennan PM, Murray GD, Teasdale GM. Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. J Neurosurg. 2018 Apr 10 [Epub ahead of print].

Biomarkers of Dementia Risk Identified

Researchers have identified novel biomarkers of risk for future dementia, according to a study published online ahead of print February 28 in Alzheimer’s & Dementia. Investigators analyzed metabolites in blood samples drawn from 22,623 people enrolled in eight prospective cohorts. Over 246,698 person-years, they detected 995 cases of incident dementia and 745 cases of incident Alzheimer’s disease. Isoleucine, leucine, valine, creatinine, and two VLDL-specific lipoprotein lipid subclasses were associated with lower dementia risk. One HDL and one VLDL lipoprotein lipid subclass were associated with increased dementia risk. Branched-chain amino acids also were associated with decreased Alzheimer’s disease risk, and the concentration of cholesterol esters relative to total lipids in large HDL was associated with increased Alzheimer’s disease risk.

Tynkkynen J, Chouraki V, van der Lee SJ, et al. Association of branched-chain amino acids and other circulating metabolites with risk of incident dementia and Alzheimer’s disease: a prospective study in eight cohorts. Alzheimers Dement. 2018 Feb 28 [Epub ahead of print].

Smartphone App Helps Doctors Track Parkinson’s Disease Symptoms

A smartphone app generates a score that reflects symptom severity in patients with Parkinson’s disease, according to a study published online ahead of print March 26 in JAMA Neurology. This observational study assessed people with Parkinson’s disease who remotely completed voice, finger tapping, gait, balance, and reaction time tasks on the app. Researchers generated a mobile Parkinson’s disease score (mPDS) of 0 to 100 that objectively weighed features derived from each smartphone activity. The mPDS was based on 6,148 smartphone activity assessments from 129 individuals. Gait features contributed most to the total mPDS (33.4%). The mPDS detected symptom fluctuations with a mean intraday change of 13.9 points. The mPDS improved by a mean of 16.3 points in response to dopaminergic therapy.

Zhan A, Mohan S, Tarolli C, et al. Using smartphones and machine learning to quantify Parkinson disease severity: the mobile Parkinson disease score. JAMA Neurol. 2018 Mar 26 [Epub ahead of print].

Age at Natural Menopause Linked to Memory

Entering menopause at a later age may benefit memory in women years later, according to a study published online ahead of print April 11 in Neurology. Researchers used data from 1,315 participants in the Medical Research Council National Survey of Health and Development with known age at period cessation and as many as four assessments of verbal memory and processing speed at ages 43, 53, between 60 and 64, and 69. Investigators fitted multilevel models with linear and quadratic age terms, stratified by natural or surgical menopause, and adjusted for hormone replacement therapy, BMI, smoking, occupational class, education, and childhood cognitive ability. Verbal memory increased with later age at natural menopause and with later age at surgical menopause. The association between age at natural menopause and verbal memory remained significant after data adjustment.

Kuh D, Cooper R, Moore A, et al. Age at menopause and lifetime cognition: findings from a British birth cohort study. Neurology. 2018 Apr 11 [Epub ahead of print].

Single-Pulse TMS Decreases Migraine Frequency

Single-pulse transcranial magnetic stimulation (sTMS) may be an effective, well-tolerated treatment option for migraine prevention, according to a study published online ahead of print March 4 in Cephalalgia. Researchers examined data from the eNeura SpringTMS Post-Market Observational US Study of Migraine, a multicenter, prospective, open-label, observational study. A total of 263 patients with migraine completed a one-month baseline headache diary, followed by three months of preventive (four pulses bid) and acute treatment (three pulses repeated as many as three times per attack). In all, 220 participants were eligible based on their number of headache days. The device was assigned to 217 subjects, and 132 were included in the intention-to-treat full-analysis set. Treatment reduced mean monthly headache days by 2.75. The most common adverse events were tingling, lightheadedness, and tinnitus.

Starling AJ, Tepper SJ, Marmura MJ, et al. A multicenter, prospective, single arm, open label, observational study of sTMS for migraine prevention (ESPOUSE Study). Cephalalgia. 2018 Mar 4 [Epub ahead of print].

Short Sleep Increases Risk of Obesity in the Young

Short sleep duration is a risk factor for obesity in infants, children, and adolescents, according to a study published online ahead of print February 1 in Sleep. Researchers reviewed the results of 42 population studies that included 75,499 infants, children, and adolescents ages 0 to 18. Sleep duration was assessed through methods such as questionnaires and wearable technology. The investigators classified participants as short sleepers or regular sleepers. Short sleepers were defined as having less sleep than the reference category for their age. Participants were followed up for a median of three years, and changes in BMI and incidence of overweight status and obesity were recorded. At all ages, short sleepers gained more weight and were 58% more likely to become overweight or obese.

Miller MA, Kruisbrink M, Wallace J, et al. Sleep duration and incidence of obesity in infants, children and adolescents: a systematic review and meta-analysis of prospective studies. Sleep. 2018 Feb 1 [Epub ahead of print].

—Kimberly Williams

A National Institute of Health (NIH) research team that may have found the explanation for why iron supplements can sometimes worsen malaria infection. “Our study helps solve a long-standing mystery,” says Tracey Rouault, MD, a member of the team.

The researchers say the answer may lie with ferroportin, a protein that prevents iron from building to toxic levels in red blood cells and helps prevent malaria infection. Red blood cells use ferroportin to remove excess iron (a food source for malaria parasites). When the researchers fed mice a high-iron diet, they found that a hormone called hepcidin regulates ferroportin in erythroid cells. The hormone, which is more abundant in high-iron environments, not only lowered ferroportin levels in erythroblasts and red blood cells, but physically bound to ferroportin, preventing iron from being removed from cells.  

Findings from 2 malaria studies suggest that Q248H, a ferroportin mutation often found in malaria-endemic regions, protects against malaria. In 1 study, nearly 20% of 66 children hospitalized for malaria in Zambia had the mutation; these children also tended to have fewer malarial parasites in the blood and tolerated their fevers for a longer period before coming to the hospital.

In the other study, of 290 pregnant women in Ghana, nearly 9% had the mutation. Those women were significantly less likely to have pregnancy-associated malaria.

Rouault says the findings may help explain why iron supplements can sometimes worsen malaria infection and why, conversely, iron deficiency can sometimes be protective. The findings also may help researchers develop strategies to prevent and treat malarial infections, which numbered nearly 216 million in 2016.

A National Institute of Health (NIH) research team that may have found the explanation for why iron supplements can sometimes worsen malaria infection. “Our study helps solve a long-standing mystery,” says Tracey Rouault, MD, a member of the team.

The researchers say the answer may lie with ferroportin, a protein that prevents iron from building to toxic levels in red blood cells and helps prevent malaria infection. Red blood cells use ferroportin to remove excess iron (a food source for malaria parasites). When the researchers fed mice a high-iron diet, they found that a hormone called hepcidin regulates ferroportin in erythroid cells. The hormone, which is more abundant in high-iron environments, not only lowered ferroportin levels in erythroblasts and red blood cells, but physically bound to ferroportin, preventing iron from being removed from cells.  

Findings from 2 malaria studies suggest that Q248H, a ferroportin mutation often found in malaria-endemic regions, protects against malaria. In 1 study, nearly 20% of 66 children hospitalized for malaria in Zambia had the mutation; these children also tended to have fewer malarial parasites in the blood and tolerated their fevers for a longer period before coming to the hospital.

In the other study, of 290 pregnant women in Ghana, nearly 9% had the mutation. Those women were significantly less likely to have pregnancy-associated malaria.

Rouault says the findings may help explain why iron supplements can sometimes worsen malaria infection and why, conversely, iron deficiency can sometimes be protective. The findings also may help researchers develop strategies to prevent and treat malarial infections, which numbered nearly 216 million in 2016.

A National Institute of Health (NIH) research team that may have found the explanation for why iron supplements can sometimes worsen malaria infection. “Our study helps solve a long-standing mystery,” says Tracey Rouault, MD, a member of the team.

The researchers say the answer may lie with ferroportin, a protein that prevents iron from building to toxic levels in red blood cells and helps prevent malaria infection. Red blood cells use ferroportin to remove excess iron (a food source for malaria parasites). When the researchers fed mice a high-iron diet, they found that a hormone called hepcidin regulates ferroportin in erythroid cells. The hormone, which is more abundant in high-iron environments, not only lowered ferroportin levels in erythroblasts and red blood cells, but physically bound to ferroportin, preventing iron from being removed from cells.  

Findings from 2 malaria studies suggest that Q248H, a ferroportin mutation often found in malaria-endemic regions, protects against malaria. In 1 study, nearly 20% of 66 children hospitalized for malaria in Zambia had the mutation; these children also tended to have fewer malarial parasites in the blood and tolerated their fevers for a longer period before coming to the hospital.

In the other study, of 290 pregnant women in Ghana, nearly 9% had the mutation. Those women were significantly less likely to have pregnancy-associated malaria.

Rouault says the findings may help explain why iron supplements can sometimes worsen malaria infection and why, conversely, iron deficiency can sometimes be protective. The findings also may help researchers develop strategies to prevent and treat malarial infections, which numbered nearly 216 million in 2016.

Photo credit: University of Leeds

A detailed image at near-atomic levels of the BK polyomavirus (BKV), which affects kidney and bone marrow transplant patients, is now available for the first time.

This molecular-level structural visualization could allow scientists to study potential targets for antiviral therapies or drugs.

Approximately 80% to 90% of the general population are seropositive for the most prevalent BKV genotypes. Yet the virus rarely causes illness in people with healthy immune systems.

But the BKV causes nephropathy and hemorrhagic cystitis in immunosuppressed patients. Currently, no effective antiviral agents are available specifically targeting BKV.

Using high-resolution cryoelectron microscopy (cryo-EM), the research team at the University of Leeds Astbury Centre for Structural Molecular Biology determined the structure of BKV at 3.8 Å resolution.

At this resolution, they could highlight differences between human BKV and BKV pathogens that infect simian and murine hosts.

The investigators created the structures by freezing infectious BKV particles and taking thousands of images using the microscopes. The two-dimensional images were then combined computationally to produce a high-resolution, three-dimensional view of the virus.

They reported their findings in the journal Structure.

Senior investigator Neil A. Ranson, PhD, of the University of Leeds , noted that cryo-EM has been around for 30 years.

Although it’s been useful, the technology lacked the ability to routinely look at molecules at the level of detail needed, he said.

"However, the Titan Krios microscopes we have installed in Leeds are absolutely state-of-the-art and mean that these limitations have been shattered. Researchers and industry users who work with us can now image biological molecules with an incredible resolution. “

The investigators believe the quality and completeness of the cryo-EM structures they captured allows researchers to describe the various conformations of the C termini of the major capsid protein VP1, which play a fundamental role in the assembly and stability of a polyomavirus capsid.

The investigators say the images also present a more complete picture of disulfide bonding in the capsid.

Thus, the images provide insights into the structure of the human pathogen at near native conditions and give scientists a better-quality research tool to use.

“Crucially, we'll also be able to see how these molecules interact with each other," Dr Ransom said.

The BK Polyomavirus structure research was funded by Wellcome, Kidney Research UK, and Kidney Research Yorkshire. 

Photo credit: University of Leeds

A detailed image at near-atomic levels of the BK polyomavirus (BKV), which affects kidney and bone marrow transplant patients, is now available for the first time.

This molecular-level structural visualization could allow scientists to study potential targets for antiviral therapies or drugs.

Approximately 80% to 90% of the general population are seropositive for the most prevalent BKV genotypes. Yet the virus rarely causes illness in people with healthy immune systems.

But the BKV causes nephropathy and hemorrhagic cystitis in immunosuppressed patients. Currently, no effective antiviral agents are available specifically targeting BKV.

Using high-resolution cryoelectron microscopy (cryo-EM), the research team at the University of Leeds Astbury Centre for Structural Molecular Biology determined the structure of BKV at 3.8 Å resolution.

At this resolution, they could highlight differences between human BKV and BKV pathogens that infect simian and murine hosts.

The investigators created the structures by freezing infectious BKV particles and taking thousands of images using the microscopes. The two-dimensional images were then combined computationally to produce a high-resolution, three-dimensional view of the virus.

They reported their findings in the journal Structure.

Senior investigator Neil A. Ranson, PhD, of the University of Leeds , noted that cryo-EM has been around for 30 years.

Although it’s been useful, the technology lacked the ability to routinely look at molecules at the level of detail needed, he said.

"However, the Titan Krios microscopes we have installed in Leeds are absolutely state-of-the-art and mean that these limitations have been shattered. Researchers and industry users who work with us can now image biological molecules with an incredible resolution. “

The investigators believe the quality and completeness of the cryo-EM structures they captured allows researchers to describe the various conformations of the C termini of the major capsid protein VP1, which play a fundamental role in the assembly and stability of a polyomavirus capsid.

The investigators say the images also present a more complete picture of disulfide bonding in the capsid.

Thus, the images provide insights into the structure of the human pathogen at near native conditions and give scientists a better-quality research tool to use.

“Crucially, we'll also be able to see how these molecules interact with each other," Dr Ransom said.

The BK Polyomavirus structure research was funded by Wellcome, Kidney Research UK, and Kidney Research Yorkshire. 

Photo credit: University of Leeds

A detailed image at near-atomic levels of the BK polyomavirus (BKV), which affects kidney and bone marrow transplant patients, is now available for the first time.

This molecular-level structural visualization could allow scientists to study potential targets for antiviral therapies or drugs.

Approximately 80% to 90% of the general population are seropositive for the most prevalent BKV genotypes. Yet the virus rarely causes illness in people with healthy immune systems.

But the BKV causes nephropathy and hemorrhagic cystitis in immunosuppressed patients. Currently, no effective antiviral agents are available specifically targeting BKV.

Using high-resolution cryoelectron microscopy (cryo-EM), the research team at the University of Leeds Astbury Centre for Structural Molecular Biology determined the structure of BKV at 3.8 Å resolution.

At this resolution, they could highlight differences between human BKV and BKV pathogens that infect simian and murine hosts.

The investigators created the structures by freezing infectious BKV particles and taking thousands of images using the microscopes. The two-dimensional images were then combined computationally to produce a high-resolution, three-dimensional view of the virus.

They reported their findings in the journal Structure.

Senior investigator Neil A. Ranson, PhD, of the University of Leeds , noted that cryo-EM has been around for 30 years.

Although it’s been useful, the technology lacked the ability to routinely look at molecules at the level of detail needed, he said.

"However, the Titan Krios microscopes we have installed in Leeds are absolutely state-of-the-art and mean that these limitations have been shattered. Researchers and industry users who work with us can now image biological molecules with an incredible resolution. “

The investigators believe the quality and completeness of the cryo-EM structures they captured allows researchers to describe the various conformations of the C termini of the major capsid protein VP1, which play a fundamental role in the assembly and stability of a polyomavirus capsid.

The investigators say the images also present a more complete picture of disulfide bonding in the capsid.

Thus, the images provide insights into the structure of the human pathogen at near native conditions and give scientists a better-quality research tool to use.

“Crucially, we'll also be able to see how these molecules interact with each other," Dr Ransom said.

The BK Polyomavirus structure research was funded by Wellcome, Kidney Research UK, and Kidney Research Yorkshire. 

Click here to read Neurology Board Review: Multiple Sclerosis

Neurology Board Review: Multiple Sclerosis is a resource developed by leading clinical educators for studying for board certification and maintenance of certification exams.

After reading the article, Click Here to Access the Board Review Questions

About the Authors

Michael J. Bradshaw, MD
Clinical Fellow in Neurology
Partners Multiple Sclerosis Center
Brigham and Women’s Hospital
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts

Maria K. Houtchens, MD, MMSC
Director, Women’s Health Program
Partners Multiple Sclerosis Center
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts

Click here to read Neurology Board Review: Multiple Sclerosis

After reading the article, Click Here to Access the Board Review Questions

Click here to read Neurology Board Review: Multiple Sclerosis

Neurology Board Review: Multiple Sclerosis is a resource developed by leading clinical educators for studying for board certification and maintenance of certification exams.

After reading the article, Click Here to Access the Board Review Questions

About the Authors

Michael J. Bradshaw, MD
Clinical Fellow in Neurology
Partners Multiple Sclerosis Center
Brigham and Women’s Hospital
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts

Maria K. Houtchens, MD, MMSC
Director, Women’s Health Program
Partners Multiple Sclerosis Center
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts

Click here to read Neurology Board Review: Multiple Sclerosis

After reading the article, Click Here to Access the Board Review Questions

Click here to read Neurology Board Review: Multiple Sclerosis

Neurology Board Review: Multiple Sclerosis is a resource developed by leading clinical educators for studying for board certification and maintenance of certification exams.

After reading the article, Click Here to Access the Board Review Questions

About the Authors

Michael J. Bradshaw, MD
Clinical Fellow in Neurology
Partners Multiple Sclerosis Center
Brigham and Women’s Hospital
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts

Maria K. Houtchens, MD, MMSC
Director, Women’s Health Program
Partners Multiple Sclerosis Center
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts

Click here to read Neurology Board Review: Multiple Sclerosis

After reading the article, Click Here to Access the Board Review Questions