Altaf Saadi

Trends in the Utilization of Endoscopic Retrograde Cholangiopancreatography (ERCP) in the United States

OBJECTIVES:To evaluate nationwide trends in the utilization of endoscopic retrograde cholangiopancreatography (ERCP) in relation to the advent of noninvasive methods of visualizing the biliary and pancreatic tree.METHODS:Retrospective cohort study. The Nationwide Inpatient Sample (NIS) database was used to calculate the age-adjusted rate for ERCPs performed from 1988 to 2002. The State Ambulatory Surgery Database (SASD) was used to evaluate trends in outpatient ERCPs from 1997 to 2003. Linear Poisson multivariate regression model was used to control for variations in age, gender, and ethnicity among the overall patient population.RESULTS:The NIS database contained 402,343 patients who had an ERCP performed from 1988 to 2002. The mean age for these patients was 60.21 ± 19.56 yr old. From 1988 to 1996; the age-adjusted rate for ERCPs increased by nearly threefold, from 25.66 per 100,000 in 1988 to 74.95 in 1996. The rate of 74.95 in 1996 declined to a rate of 59.70 by the year 2002. The rates of diagnostic ERCPs in men and women were 26.76 and 31.58 per 100,000 in 1988–1990, respectively. This rate then increased to 35.66 and 43.18 per 100,000 in 1994–1996, which then declined to 29.01 and 29.06 in 2000–2002. The age-adjusted rate for therapeutic ERCPs in men and women was 13.74 and 15.61 per 100,000 in 1988–1990, respectively, which continued to increase throughout the time span to 38.76 and 43.75 in 2000–2002. The SASD revealed a continual decline in outpatient ERCPs from 25.45 per 100,000 in 1997 down to 16.17 per 100,000 in the year 2003.CONCLUSION:The utilization of ERCP dramatically increased from 1988 to 1996; however, since the advent of noninvasive diagnostic techniques such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), there has been a steady decline in the utilization of diagnostic ERCPs from 1996 to 2002.

Dose-dependent effects of post-training estradiol plus progesterone treatment on object memory consolidation and hippocampal extracellular signal-regulated kinase activation in young ovariectomized mice.

Previous work from our laboratory has shown that the ability of estradiol to enhance object memory consolidation in young ovariectomized mice is dependent on dorsal hippocampal activation of the extracellular signal-regulated kinase/mitogen-activated protein kinase (ERK/MAPK) signaling pathway [Fernandez SM, Lewis MC, Pechenino AS, Harburger LL, Orr PT, Gresack JE, Schafe GE, Frick KM (2008) Estradiol-induced enhancement of object memory consolidation involves hippocampal extracellular signal-regulated kinase activation and membrane-bound estrogen receptors. J Neurosci 28:8660-8667]. However, it is unclear if estradiol modulates memory or ERK activation similarly in the presence of progesterone. Therefore, the present study investigated effects of combined estradiol and progesterone treatment on object memory consolidation and dorsal hippocampal ERK activation in young ovariectomized C57BL/6 mice. Object memory was tested in a novel object recognition task. Immediately after training, mice received intraperiotoneal (i.p.) injections of vehicle, 17beta-estradiol (E(2); 0.2 mg/kg), or E(2) plus 5, 10, or 20 mg/kg progesterone (P). Forty-eight hours later, mice receiving E(2) alone or E(2) plus 10 or 20 mg/kg P exhibited significantly enhanced memory for the novel object relative to chance, whereas those receiving vehicle or E(2) plus 5 mg/kg P spent no more time than chance with the novel object. Two weeks later, ERK phosphorylation was measured in the dorsal hippocampus 1 h after i.p. injection of vehicle, E(2), or E(2) plus P. Consistent with our previous work [Fernandez SM, Lewis MC, Pechenino AS, Harburger LL, Orr PT, Gresack JE, Schafe GE, Frick KM (2008) Estradiol-induced enhancement of object memory consolidation involves hippocampal extracellular signal-regulated kinase activation and membrane-bound estrogen receptors. J Neurosci 28:8660-8667], E(2) alone significantly increased phospho-p42 ERK protein levels in the dorsal hippocampus relative to vehicle controls. In contrast, no combination of E(2) and P affected dorsal hippocampal phospho-ERK levels. These data indicate that, unlike E(2) alone, the beneficial effects of combined E(2) plus P treatment on memory are not associated with ERK activation in the dorsal hippocampus 1 h after treatment, and suggest that E(2) alone and combined E(2) plus P may influence ERK activation in different time frames or enhance memory through different mechanisms.

Post-training progesterone dose-dependently enhances object, but not spatial, memory consolidation

The aim of this study was to determine if progesterone modulates object and spatial memory consolidation in young ovariectomized C57BL/6 mice. Object memory was tested in an object recognition task using 24- and 48-h delays. Spatial memory was tested in a 2-day version of the Morris water maze in which retention was tested 24 or 48 h after training. Immediately after training in each task, mice received a single intraperitoneal injection of vehicle or 5, 10, or 20mg/kg water-soluble progesterone. Mice were then tested 24 or 48 h later in the absence of circulating progesterone. Post-training injections of 10 and 20mg/kg progesterone enhanced object recognition, but not memory in the spatial water maze. These findings suggest that object memory consolidation in young female mice is more sensitive to the modulatory effects of progesterone than spatial memory consolidation, at least using the tasks, doses, and delays tested. As such, these findings may have important implications for the design of progesterone therapies intended to reduce age-related memory decline.

Racial disparities in neurologic health care access and utilization in the United States

Objective: To evaluate racial and ethnic differences in the utilization of neurologic care across a wide range of neurologic conditions in the United States. Methods: We analyzed nationally representative data from the 2006–2013 Medical Expenditure Panel Survey (MEPS), including information on demographics, patient-reported health conditions, neurology visit rates, and costs. Using diagnostic codes, we identified persons with any self-identified neurologic disorder except back pain, as well as 5 subgroups (Parkinson disease, multiple sclerosis, headache, cerebrovascular disease, and epilepsy). To assess disparities in neurologic care utilization, we performed logistic regression analyses of outpatient department neurologic care visit rates and expenditures for each racial ethnic group controlling for age, sex, health status, socioeconomic characteristics, and geographic region of care. Results: Of the 279,103 MEPS respondents, 16,936 (6%) self-reported a neurologic condition; 5,890 (2%) received a total of 13,685 outpatient neurology visits. Black participants were nearly 30% less likely to see an outpatient neurologist (odds ratio [OR] 0.72, confidence interval [CI] 0.64–0.81) relative to their white counterparts, even after adjustment for demographic, insurance, and health status differences. Hispanic participants were 40% less likely to see an outpatient neurologist (OR 0.61, CI 0.54–0.69). Among participants with known neurologic conditions, blacks were more likely to be cared for in the emergency department, to have more hospital stays, and to have higher per capita inpatient expenditures than their white counterparts. Conclusions: Our findings highlight racial and ethnic inequalities in the utilization of neurologic care in the United States.

Quality of life in epilepsy-31 inventory (QOLIE-31) scores: A global comparison.

Quality of life is a pragmatic endpoint for understanding the experience of people with epilepsy (PWE) in low- and middle-income countries (LMICs), where>80% of PWE reside. However, the literature is bereft of QOL in epilepsy (QOLIE) studies among LMICs and knowledge of the variation in QOLIE globally. We therefore performed a Medline search of original research studies using the quality of life in epilepsy-31 inventory (QOLIE-31) in a recent fifteen-year period (2000-2015). Each of the 194 countries listed by the World Health Organization (WHO) was individually included as search terms. Differences in QOLIE were tested across WHO world regions and World Bank country income group classifications. Sixteen percent of all countries (n=31) reported on 7255 individuals, including only 8 LMICs. The global mean QOLIE-31 score was 59.8 (standard deviation (SD): 8.0), with a range from 42.1 (SD: 4.1) in the Russian Federation to 82 (SD: 32.8) in Canada. There was a statistically significant difference seen in the QOLIE-31 score by world region and income category, with lower country income level associated with worse QOL (test for trend, p<0.0001). There exists substantial global variation in QOLIE, and country income level may play a role. Understanding what contributes to international differences in QOLIE can help reduce disparities in QOL among PWE worldwide.

Quality of life in epilepsy in Bhutan

PURPOSE To assess the quality of life in epilepsy (QOLIE) among adults in the lower middle-income country of Bhutan and assess the potential demographic and clinical associations with better QOLIE. METHODS People with clinically diagnosed epilepsy were prospectively enrolled at the Jigme Dorji Wangchuck National Referral Hospital in Thimphu (2014-2015). Regression models were constructed to assess the potential impact of age, sex, residence in the capital city, wealth quintile, educational attainment, seizure in the prior year, seizures with loss of consciousness, self-reported stigma score, and need for multiple antiepileptic drugs. RESULTS The mean Bhutanese 48.4/100 ± 17.3 [corrected] score among 172 adults (mean age 31.1 years, 93 female) was 48.9/100±17.7. Younger age, lower educational attainment level, and increased self-perceived stigma were each observed to have an independent, negative association with QOLIE (p<0.05), while a patients wealth quintile, sex, seizure frequency, seizure type and number of antiepileptic drugs were not. Education appeared to be most strongly associated with QOL at the high school and college levels. CONCLUSIONS There are potentially modifiable associations with low QOLIE. Addressing the educational level and self-perceived stigma of PWE may have an especial impact. The low QOLIE in Bhutan may reflect cultural approaches to epilepsy, health services, or other factors including those outside of the health sector.

Making a Case for Sanctuary Hospitals

In July 2017, Jose de Jesus Martinez, an undocumented immigrant, wept at the bedside of his 16-yearold son Brandon, who was comatose in the intensive care unit of a San Antonio, Texas, hospital after being found in a parked unventilated trailer. Several agents from US Immigration and Customs Enforcement (ICE) entered Brandon’s hospital room and aggressively began questioning Jose.1 The incident was just one in a recent trend of disturbing actions by ICE agents at or near hospitals and other health care facilities. In February 2017, Sara BeltranHernandez, a 26-year-old undocumented immigrant, was bound by her hands and feet and removed by wheelchair from a Fort Worth, Texas, hospital by ICE agents while she was awaiting emergency brain surgery.2 In June 2017, ICE agents arrested Oscar Millan, a 37-year-old undocumented immigrant, on his way to pick up his newborn son who was recovering from surgery for pyloric stenosis at a Boston, Massachusetts, hospital.3 In recent months, other undocumented workers injured on the job have been arrested at appointments in physicians’ offices and detained by ICE after filing workers’ compensation claims.4 Stories like these have created justifiable concern by many undocumented immigrants who believe they will not be safe when visiting hospitals to receive care for themselves or their families. The way that ICE has

Pearls & Oy-sters: Tacrolimus neurotoxicity presenting as an isolated brainstem lesion

A 52-year-old man with hepatitis C–induced cirrhosis underwent cadaveric liver transplant in July 2014. Postoperative immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. He presented 3 months later with 2 weeks of intermittent headaches, diplopia mostly with down gaze, and gait unsteadiness. He reported no constitutional symptoms. He was normotensive at 136/73 mm Hg. Pertinent findings on neurologic examination were sustained gaze-evoked direction-beating nystagmus in the horizontal plane, upper and lower extremity dysmetria bilaterally, gait ataxia, and normal deep tendon reflexes. Pinprick and vibratory loss in the right leg were attributed to prior trauma.

International Issues: Teleneurology in humanitarian crises Lessons from the Médecins Sans Frontières experience

Humanitarian emergencies defined by armed conflict, political strife, famine, or natural disaster can devastate populations rapidly. Neurologic disorders accompany these complex humanitarian emergencies but often go unheeded, exacerbated by a scarcity of neurologists. Teleneurology offers the promise of neurologic care remotely in the face of this inadequate local clinician supply. We describe our experiences as voluntary neurology teleconsultants with Médecins Sans Frontières in order to highlight both the promises and challenges of teleneurology in humanitarian contexts. We identified the major advantages of this service as (1) minimal resources and incurred costs while (2) changing a patients clinical course favorably, and (3) creating a community for the field referrer and neurology specialist. Current challenges include (1) limited diagnostic resources and difficult diagnostic and therapeutic decision-making, (2) need for greater continuity and familiarity between the field site and neurologist, (3) gaps in the US neurology curriculum to provide expertise for all sites, (4) lack of follow-up and feedback from the field to advise future cases, and (5) low frequency of consultations. Growth opportunities include eventual expansion to the development of a community of neurologists who can provide context-specific care and maximize use of multimedia at low Internet bandwidth. Lessons from our experience may help optimize teleneurologys effect and reduce disparities in neurologic care, particularly in humanitarian crises.

The internationalization of the American Academy of Neurology

The American Academy of Neurology (AAN), established in March 1948, was born out of a desire to create an inclusive professional society for neurologists, particularly for those nascent in their careers as young neurologists and those in training. This was in deliberate contrast to the more established American Neurological Association (ANA), at that time a 75-year-old association whose restrictive membership comprised only senior, mostly male leaders of American academic neurology predominantly in Northeast American institutions.1 The AANs agenda for inclusivity was reflected not only in its relatively open membership requirements but also in the creation of a womans auxiliary.