Steven Karceski

Preventing Alzheimer disease with exercise?About Alzheimer disease

In their article, “Total daily activity and the risk of AD and cognitive decline in older adults,” Buchman and colleagues1 looked at how exercise affects a persons thinking. More specifically, Dr. Buchman evaluated exercise, and how it might help a person who has Alzheimer disease (AD). He and his colleagues became interested in this because there are many reports that exercise helps a person to have better memory and clarity of thinking. All prior studies relied on self-reported exercise regimen. None has tried to carefully measure the amount of exercise or activity. In addition, most studies were retrospective, meaning that after the person developed AD, the doctor asked what the persons activity was like. To obtain the best results, Dr. Buchman decided to perform a prospective study. He did not know which people were going to have AD. He gathered a large amount of information on a big group of normal volunteers. He followed them over several years. During the study, some of the people developed AD. At the end of the observation period, he went back to see if exercise helped people to have clearer thinking and better memory. In other words, does exercise help to prevent AD? Dr. Buchman works at Rush University. In the study, there were 716 people. All were involved in the Memory and Aging Project. All agreed to have their activity measured using actigraphy. They wore a special watch-like device on their wrist for up to 10 days. During that time, the device recorded movements of the arm and wrist. At the end of the observation period, a total “activity score” was calculated for each person using the information from the wrist device. During …

Epilepsy and mood

In their article, “Use of antiepileptic drugs in epilepsy and the risk of self-harm or suicidal behavior,” Dr. Andersohn and his coauthors1 tried to better understand a very difficult problem. For years, it has been known that there is a higher rate of suicide in people with epilepsy. People with epilepsy are also more likely to have depression, which can lead to suicide. In addition, some of the medications that are used for seizures (also called antiepileptic drugs or AEDs) may cause problems with mood. Because all of these problems overlap, it can be difficult to sort out how they are related. In early 2008, the United States Food and Drug Administration (FDA) issued a safety alert concerning all AEDs. The alert was based on 199 studies. In these studies, an antiepileptic medication was compared to placebo. A placebo is a fake medication to see if the actual medication works. When grouped together, the analysis showed that there was an increased risk of suicidal thoughts and behavior in people who were taking an AED. The FDA analysis grouped all seizure medications together. It was not possible, based on the information that they had, to decide if there were specific medications that were more likely to cause mood problems. Dr. Andersohn and his coauthors decided to answer this question, if possible. What they wanted to know was simple: Are there certain medications that cause this more often than others? Dr. Andersohn and his coauthors wanted to gather as much information as possible on these medications. To do this, they used a database of medical information. The database has been in place in the United Kingdom for several years. It is called the General Practice Research Database. The information is gathered in an anonymous way to protect patients. The information is …

Trigeminal nerve stimulator A new treatment for seizures

In their article “Randomized controlled trial of trigeminal nerve stimulation for drug-resistant epilepsy” (Neurology 2013;80:786–791), Dr. DeGiorgio and colleagues studied the safety and effectiveness of a new kind of treatment for seizures. They used a new device called a trigeminal nerve stimulator (TNS). The device is electronic, and sends small electrical impulses through the skin, using small “stick-on” electrodes. These impulses go to a nerve in the face called the trigeminal nerve. The impulses are then transmitted back to deep parts of the brain where they help to decrease seizures.

Multiple sclerosis and stress

Multiple sclerosis (MS) is a chronic disease of the CNS. The exact cause of MS is not known. However, this is a very active area of research. In MS, the immune system attacks the brain and spinal cord, causing areas of tissue damage, or lesions. Typically, the lesions are seen on MRI. In some instances, the lesions are “silent,” meaning that the person was not aware that there was a problem. Other times, a lesion may cause a neurologic deficit like weakness or numbness. Just as scientists do not understand the cause of MS, they also do not fully understand what causes the MS lesion. Are there triggers for developing new lesions? Prior studies suggested that MS lesions occur more often after a stressful life event. Other studies showed that people with MS had fewer attacks (also called exacerbations) when they coped well with their stress. In the article “A randomized trial of stress management for the prevention of new brain lesions in MS,”1 the authors looked at how stress may make MS worse. This study was a randomized controlled trial. In other words, the authors separated the people with MS into 2 groups. One group was assigned to no stress management. In the other group, the participants used specific stress management therapies. The authors used repeated MRIs of the brain, looking carefully for any changes due to MS. The goal of this study was to look at the role of emotional stress on the development of lesions in MS. The study took place in several medical …

Multiple sclerosis and disease-modifying therapies

Over the past 18 years, treatments for multiple sclerosis (MS) called disease-modifying therapies (DMTs) have been developed. These therapies are designed to decrease the number of MS attacks, and to slow the progression of the disease. They have become a standard part of the current treatment for MS. There are different classes of the currently available DMTs: interferons, glatiramer acetate, natalizumab, and mitoxantrone. Although they are effective, these medications have significant side effects, and many are very expensive. The study by Noyes et al.1 was designed to create a new model to examine the cost-effectiveness of DMTs for relapsing-remitting MS in the United States. Researchers used data from an ongoing survey that was sent to over 2,000 people in the United States with MS. Twice a year, participants were asked questions about health care utilization. In other words, they were asked about things like how often they saw a doctor, went to the hospital, or visited the emergency department. Once a year, the same group was asked questions about income, insurance, and their work situation. The researchers examined over 800 of the surveys. Based on this, they estimated the cost of the persons health care. This included the number of hospital stays, outpatient treatments, emergency room visits, office visits, mental health visits, home health provider and home health aide visits, and laboratory and MRI studies. Since each hospital might have different charges for each procedure of tests, the authors used average Medicare reimbursements and published rates for home care to make an estimate of the overall cost of health care for MS. Lost productivity costs were also measured. The authors estimated how …

Progressive supranuclear palsy

In the article, “Tau forms in CSF as a reliable biomarker for progressive supranuclear palsy,” Dr. Borroni and her coauthors ( Neurology ®2008;71:1796–1803) looked at specific medical tests that could help physicians accurately diagnose this illness. Progressive supranuclear palsy (PSP) is rare and has similarities to several other progressive neurologic disorders. Because of this, they looked at the results of these tests not only in people with PSP, but also in those who had the “similar” illnesses. In addition, the authors compared the results of the tests to test results of people who did not have progressive neurologic disease. Dr. Borroni and coauthors carefully studied the tests results for 166 people. All had undergone a detailed history, physical examination, and neurologic examination. All were monitored for more than 2 years. The reason for this long period of monitoring is that the illnesses, especially when they begin, can look like something else. As the illness progresses and other symptoms develop, the diagnosis becomes more clear. By following this group for more than 2 years, Dr. Borroni minimized any errors in diagnosis. Of the 166 people, 21 were diagnosed with PSP. One hundred twenty-five people had progressive neurologic conditions such as Parkinson disease and Alzheimer disease. There were also a few other illnesses. Twenty-seven patients acted as the “controls.” They were “normal.” This last group needs more explaining. The “controls” were a group of people who had an MRI and lumbar puncture for other reasons. For instance, they may have had a headache, and in the process of evaluating the headache, these tests were needed. Although not entirely “normal,” as this group had experienced a neurologic symptom (for example, headache), they did not have a progressive neurologic illness. A subset of patients had a specialized MRI of the brain and brainstem. Dr. Borroni …

Using botulinum toxin to treat diabetic foot pain

Botulinum toxin type A (BoNT/A) is made naturally by certain bacteria. BoNT/A works by paralyzing specific kinds of nerve cells. BoNT/A can be used to treat many illnesses that affect either nerves or the muscles with which they communicate. In the article “Botulinum Toxin for Diabetic Neuropathic Pain: A Randomized Double-Blind Crossover Trial,” Dr. Yuan and associates describe how BoNT/A might be used to treat the kind of nerve pain that develops in some people who have diabetes.1 The study compares whether injecting BoNT/A into the skin is better at reducing neuropathic pain than injecting a placebo (saline, salt water) into the skin. Dr. Yuan and colleagues looked carefully at 20 people who had neuropathic pain due to type 2 diabetes. Each person had been diagnosed with diabetes for at least 3 years. Patients with neuropathy experienced either paresthesias (prickling, tingling, or numbness) or a specific kind of pain (burning, itchy, shooting, etc.) in both of their feet up to the ankle or mid-shin. Doctors assessed the pain by 1) physical examination, 2) a specific questionnaire for pain, and 3) a specific test of nerve function. The nerve test is called a nerve conduction velocity test. It is designed to see how well patients’ nerves can transmit electrical signals. If the nerve is damaged, as happens in diabetes, the signals carried by the nerves are either slower or weaker than normal. As in all studies, there are reasons to include specific participants. This makes sure that the group is alike and that the results are solid. For instance, only people with proven polyneuropathy due to diabetes were included. Since a specific treatment was being studied, only people who had not changed …

Multiple sclerosis, inflammation in the brain, and moodAbout multiple sclerosis

In their study, “Neuroinflammation drives anxiety and depression in relapsing-remitting multiple sclerosis,” Dr. Rossi et al.1 investigated the relationship between mood and inflammation. They did this by looking at a group of people who have multiple sclerosis (MS). It has long been observed that inflammation occurs in the brains and spinal cords of people with a specific kind of MS called relapsing-remitting MS.

Soccer and head injuriesAbout concussion: What is the risk?

In their article “Symptoms from repeated intentional and unintentional head impact in soccer players,” Stewart et al.1 explore the link between heading the soccer ball and the development of neurologic symptoms. In contact sports, most notably football,2 there is a link between so-called subconcussive hits and the development of long-term neurologic symptoms. The authors, in previous work,3 saw a similar link between heading the ball in soccer and poorer scores on a memory function test.

Using stem cells to treat ALSAbout ALS

In their article “Transplantation of spinal cord–derived neural stem cells for ALS: Analysis of phase 1 and 2 trials,” Glass et al.1 set out to study a specific question: Is the injection of human spinal cord–derived neural stem cells (HSSC) into a human spinal cord safe? They also wanted to know if this specialized procedure could be safely performed at multiple surgical centers by different surgeons. Small studies like this are important: they often pave the way for larger studies. In addition, before a study can be done to determine whether stem cells can be used to treat amyotrophic lateral sclerosis (ALS), the safety of the treatment must be assessed. Therefore, the results of this study are critical: these results help to decide whether larger studies of stem cells in the treatment of ALS should be done.