2018 May AANnews by American Academy of Neurology

VOLUME 32 · ISSUE 5 · MAY 2018

NEUROLOGY NOW IS BRAIN & LIFE In English and en Español! After 13 years of service to the public—and answering the needs of members who asked the AAN for more patient education resources—the AAN’s award-winning monthly patient education magazine Neurology Now ® has been rebranded Brain & Life™. We also have launched our first quarterly issue of Brain & Life en Español, published for our Spanish-speaking communities.

N E U R O LO G Í A PA R A L A V I DA D I A R I A P R I M AV E R A 2 0 1 8

A P R I L/M AY 2 0 1 8

Exercise Find the Right Type and Amount formas de for Your aligerar el Condition cuidado a distancia Nerve Pain Smart Ways to Manage Neuropathy

After My Stroke In 2001, I Feel So Blessed and I’ve Learned So Much.”

Learn more in the President’s Column on page 3.

Consuelo en la tristeza Cómo un diagnóstico brinda más espacio para la alegría

Rebound Headaches How to Break the Cycle

Escuchando con Cuidado

La periodista Soledad O’Brien ayuda a que su hijo con discapacidad auditiva interceda por sí mismo

— AC TR E S S S H A R O N S TO N E

Early Registration Deadline Approaching for Sports Concussion Conference

Webinar Helps You Manage Headache Care, Improve Your Practice

June 14 is the last chance to save with early registration discounts to the 2018 Sports Concussion Conference scheduled for July 20 through 22 at the JW Marriott in Indianapolis, IN. Visit AAN.com/view/SCC to book your hotel and secure your spot.

Headache is one of the most common neurological conditions. This practice management webinar will demonstrate how quality tools, payment models, and technology will help you provide highquality, high-value care to your patients. Using headache as a case study will help you to identify the practice management tools available to you to effectively and efficiently manage other neurological conditions as well.

Indianapolis is home to the National Collegiate Athletic Association (NCAA) and NCAA Sports Science Institute, Continued on page 24

SPORTS CONCUSSION JULY 20–22, 2018 INDIANAPOLIS, IN

›

CONFERENCE

New Registry Module Helps with Outcomes, MIPS Reporting

Using Neuro-specific Measures Can Gain Higher QPP Score

Spears

Continued on page 8

Member Gains 25 Board Valuable Satisfaction Through Leadership Program

›

In Multiple Sclerosis–

THE ART OF BRAIN PRESERVATION Adding Grey to the Palette Completes the Picture

GREY MATTERS, TOO

PHARMA AD

AANnews · MAY 2018

CONTENTS Cover Neurology Now Is Brain & Life Early Registration Deadline Approaching for Sports Concussion Conference

Capitol Hill Report · · · · · · · · · 19 Buchwald Shows Value of Patient Group Collaboration with National MS Society · · · · 22 Conferences & Community Call for Course Proposals for 2019 Annual Meeting · · · · · 24

Webinar Helps You Manage Headache Care, Improve Your Practice President’s Colum Neurology Now Rebranded as Brain & Life—in English and en Español! · · · · · · · · · · 4 Through Their Eyes Recollections of Past AAN Presidents · · · · · · · · · · 6

B:11.125” T:10.875” S:10.375”

Tools & Resources New Registry Module Helps with Outcomes, MIPS Reporting · · · · · · · · · · 8 Using Neuro-specific Measures Can Gain Higher QPP Score · · · · · · · · ·9 Improve Patients’ Experience with Interactive Electronic Exam Room Posters · · · · · · 15 Podcast Central · · · · · · · · · 15 Practice Ambassador Program Considers 2017 Input, Begins 2018 Visits · · · · 16 AAN Publishes Guideline on Disease-modifying Therapies for MS · · · · · · · · 18 Academy Publishes Position Statements on Medical Marijuana and Opioids · · · · · 19

May 7 Is Last Chance to Submit Online Evaluations for Annual Meeting CME · · · · · 24 Board Member Gains Valuable Insight, Satisfaction Through Leadership Program · · · · · · 25 Neuro Film Festival Winners Announced · · · · · · · 26 Elevate Your Status, Enhance Your Professional Credentials with FAAN Designation · · · · · · · · · · · · 28 Education & Research Resident Sought to Join Continuum Editorial Board · · · 28 Subspecialty Fellowship Training Program Accreditation Applications Due June 1 · · · · · · · · · · · · 28 American Brain Foundation A Year of Innovation, Growth · · · · · · · · · · · · · · · 29 Careers · · · · · · · · · · · · · · · 30 Dates & Deadlines · · · · · · · · 31

The Vision of the AAN is to be indispensable to our members. The Mission of the AAN is to promote the highest quality patient-centered neurologic care and enhance member career satisfaction. Contact Information

For advertising rates, contact:

American Academy of Neurology 201 Chicago Avenue Minneapolis, MN 55415

Eileen R. Henry Wolters Kluwer Health | Medical Research Lippincott, Williams & Wilkins

Phone: (800) 879-1960 (toll free) (612) 928-6000 (international) Email:

memberservices@aan.com

Website: AAN.com

Phone: (732) 778-2261 Email: Eileen.Henry@wolterskluwer.com

NEWS BRIEFS The AAN and the American Board of Psychiatry and Neurology (ABPN) held their annual leadership meeting on March 29. Among other topics, the ABPN updated AAN leaders on its MOC Part III Pilot Project, which is a professional journal articlebased assessment activity designed as an optional alternative to the current secure, proctored 10-year MOC examination. A select number of eligible ABPN diplomates were emailed invitations to participate in the pilot program in December 2017. The pilot project will run for three years, from 2019 to 2021, and, if approved by the ABMS, the ABPN plans to transition diplomates into this program in 2022 as a permanent alternative to the secure MOC exam. The AAN successfully nominated three members to participate on Acumen’s MACRA Episodebased Cost Measure Clinical Subcommittees. Medical Economics and Management Committee members Marc Raphaelson, MD, and John Ney, MD, MPH, will continue to participate on the Neuropsychiatry Subcommittee. AAN Coding Subcommittee member J. Mark Bailey, DO, PhD, will contribute to a new subcommittee: Musculoskeletal Disease Management—Spine. These subcommittees create episodebased cost measures to assess resource use in the Merit-based Incentive Payment System. 

AAN Executive Director: Catherine M. Rydell, CAE Editor-in-Chief: John D. Hixson, MD Managing Editor: Angela Babb, CAE Editor: Tim Streeter Writers: Ryan Knoke and Sarah Parsons Designers: Siu Lee and Jim Hopwood Email: aannews@aan.com

AANnews is published monthly by the American Academy of Neurology for its 34,000 members worldwide. Access this magazine and other AAN publications online at AAN.com/go/elibrary. The American Academy of Neurology ’ s registered trademarks and service marks are registered in the United States and various other countries around the world. “American Brain Foundation” is a registered service mark of the American Brain Foundation and is registered in the United States.

President’s Column

Neurology Now Rebranded as Brain & Life—in English and en Español! Promoting high-quality patient-oriented care is central to our mission and we have provided many resources to our members to educate and inform the public about the latest advances in neurology. I am happy to announce that we have just made a quantum leap. After 13 years of service to the public, the AAN’s award-winning monthly patient education magazine Neurology Now ® has been enhanced and rebranded Brain & Life™. We also have launched our first quarterly issue of Brain & Life en Español, published for our rapidly growing Spanish-speaking communities. This free patient and caregiver resource has a fresh, clean look while still providing the same expert content your patients rely on. And all of our patient resources for the public are now available on our new website, BrainandLife.org. The magazines are a FREE resource to AAN members in the United States to distribute to your patients, who also can subscribe for free. The print magazine currently reaches nearly 2 million readers, and the new website allows us to reach millions more. Your help in getting Brain & Life into the hands or onto device displays of your patients and their family members could be a life-changing experience for them. The name change to Brain & Life allows us to focus on the broader important topic of brain health that will resonate with our public. As our population ages and people are seeing their parents and friends living with neurological conditions like Alzheimer’s and stroke, the public is eagerly looking for ways to

YOUR TRUSTED RESOURCE FOR BRAIN HEALTH

Journalist Soledad O’Brien Helps Her Hearing-impaired Son Advocate for Himself Why Drugs Are So Expensive and What You Can Do About It

AANnews • May 2018

So Much.” — AC T R E S S S H A R O N S TO N E

Sirven

take control of their health, improve quality of life, and protect their brains through healthy lifestyles. Prevention of brain disease is now a new and exciting area for neurology, and this repositioning of our publication will appeal to a much wider audience. We need to be the go-to place to let the public know all the latest and greatest advances in our field. Editor-In-Chief Orly Avitzur, MD, MBA, FAAN, is an ex-officio member of the AAN Board of Directors, chair of the Medical Economics and Management Committee, and member of the Publications Committee. She’s in her third year as editor-inchief of this magazine and with her at the helm we are making amazing progress. She shared these thoughts about these exciting changes. “After more than 10 years, we knew it was time for a makeover and an upgrade. We wanted a publication that was fun to read, easy to understand, and chock full of inspirational stories. We wanted to build on the unparalleled expertise from

N E U R O LO G Í A PA R A L A V I DA D I A R I A P R I M AV E R A 2 0 1 8

Consuelo en la tristeza Cómo un diagnóstico brinda más espacio APR I L/M AY 018 para la2alegría

Exercise formas de Find theel aligerar Right Type cuidado andaAmount distancia for Your Condition Nerve Pain Smart Ways to Manage Neuropathy

DR. Q: From Migrant Worker After My to Brain Surgeon Stroke In 2001, I Feel So 10 Ways to Take Charge Blessed and of Your Disease I’ve Learned

Avitzur

FEBRUARY / MARCH 2O18

LISTENING IN

BRAIN HEALTH FAIR Meet Neurologists and Win a Bike Helmet

Sacco

Rebound Headaches How to Break the Cycle

Escuchando con Cuidado

La periodista Soledad O’Brien ayuda a que su hijo con discapacidad auditiva interceda por sí mismo

neurologists our readers have grown to trust and respect. Enter Brain & Life, a modern approach to brain health and living with neurologic conditions. We also wanted a website that would serve as a dynamic companion to the print magazine. We created BrainandLife.org, which debuts in conjunction with our first issue. Along with the latest stories from Brain & Life, it includes web-only content, past issues, videos, podcasts, and neurologist and patient blogs. BrainandLife.org also showcases additional resources and information from the AAN.” In the research that we considered in the process of making these changes, we learned that the word “brain” resonated with a farther-reaching audience as a way to draw them in to the magazine’s educational content about neurology. We also found that many readers assumed Neurology Now was for a professional audience and not for them. Finally, some patients don’t want people to know about their neurologic disease and preferred to read information in a much more discreet and friendly way. There were concerns that being seen reading Neurology Now outside of the clinic might prompt questions or even discrimination. “We knew our readers had come to appreciate Neurology Now, but the word ‘neurology’ can be intimidating,” said Dr. Avitzur. “With Brain & Life, we hope we will connect with new readers and build even greater public awareness of the field of neurology, brain health, and living with neurologic conditions.” If you are an AAN member in the US, you should be receiving, or have received, our first issue of Brain & Life, in which actress Sharon Stone discusses the impact that her 2001 stroke had on her life and career. Other articles emphasize self-care for people living with neurologic disease, including proper exercise, pain management, and meditation. If you need to adjust the number of copies you receive for your patients or update your clinic address, go to BrainandLife.org or email BeGreen@WasteFreeMail.com. Also rolling off the presses is the first quarterly issue of Brain & Life en Español, featuring journalist Soledad O’Brien. This Spanish-language version of the magazine was well received when it was piloted last year. AAN member offices in areas with large Hispanic and Latino populations will receive free copies to distribute to their patients, and additional copies will be mailed to our growing subscriber base.

Joseph I. Sirven, MD, FAAN, editor of Brain & Life en Español and chair of its Editorial Board, addressed the need for this type of publication. “It is estimated that more than 52 million Americans speak Spanish as either their primary or secondary language. Put another way, there are now more people who speak Spanish living in the United States than there are in all of Spain. So, it is with great excitement that we introduce Brain & Life en Español. With its own bilingual Editorial Board, Brain & Life en Español will be able to reach millions of Spanish-speaking neurology patients throughout the US and all of Latin America with the award-winning content we all love about Brain & Life.” I invite you to visit BrainandLife.org so you can see what a marvelous transformation we have made to our online platform. The AAN’s new patient website centralizes the content from the magazine and our valued educational resources into one convenient place. This is a great treasure trove of life-enhancing information to access and share with your patients, and also includes content in Spanish. I hope you will join me in thanking Drs. Avitzur and Sirven for their outstanding leadership on these two remarkable publications, and the many volunteer members and staff who worked to answer the needs of you and your patients. Again, I urge you to make Brain & Life available in your waiting rooms, and share the news about our website and magazine through your social media. Just as we lead the way in providing the best care possible for our patients, we must also be leaders in the prevention of diseases of the brain and inspire the public to promote brain health. 

Ralph L. Sacco, MD, MS, FAHA, FAAN President, AAN rsacco@aan.com @DrSaccoNeuro on Twitter

Neurology ® Podcasts:

20 Minutes Pack a Punch! Download the latest podcast at neurology.org/podcast

AANnews • May 2018 5

Through Their Eyes

Recollections of Past AAN Presidents Steven P. Ringel, MD, FAAN / 1997–1999 AANnews celebrates the history of the Academy during its 70th anniversary with a series of interviews of past presidents. The following excerpt is from a 2017 interview with Steven P. Ringel, MD, FAAN (SR), conducted by AANnews® editor Tim Streeter (TS). Ringel leveraged his experience as a Robert Wood Johnson Health Policy Fellow for Sen. Jay Rockefeller (D-WV) from 1991 to 1992 to enhance the effectiveness of the AAN’s advocacy activities and stimulate more member involvement. TS: Before you became president, I have a list of committees here a mile long that you participated in. Why did you get interested in these leadership positions? SR: I’ve always thought of myself as sort of an instrument of change. I think you can’t be static and you have to grow, and the way you do that is you learn, and you see what is known in your field and what you can do to improve. I always felt that the Academy afforded me that opportunity to learn and to grow. Throughout my career, the Academy met a lot of my needs. In subsequent years, I’ve gotten very interested in health policy throughout and not just in neurology, but it was really always how it applied to neurology. It really became my way of understanding where medicine was going. Keep in mind, when I started—I went to medical school in 1964—it was a year later that Medicare and Medicaid came into being, so in my career—basically we’re talking 50 years—the change, the whole financial structure, the AMA opposed Medicare at that time. They thought of it as socialized medicine, and then the doctors quickly figured out they could make a lot of money doing that. I sort of lived through that whole period, and the Academy allowed me to understand it….

The biggest change in my career, which led to me being more and more involved in the Academy, was attributable to my wife. My wife is a public policy person who worked for the governor of Colorado, and was involved in all kinds of activities related to legislative affairs. When she was a lobbyist she represented insurance companies, so I got very interested. I said, “My goodness gracious, people like my wife are controlling what’s going to happen in the medical system.” We laughed about that a lot, but she really sensitized me to the importance of the political process in all of these decisions. I was fortunate enough to be able to do a sabbatical to work in the United States Senate. I was a Robert Wood Johnson Health Policy Fellow, and that made me very knowledgeable about all of the interest groups involved and the importance of the dollar. When I came to the Academy, and before I became president of the Academy, I was in charge of their legislative process. I wanted other members to understand these issues, so that’s why we started the Town Hall Forum, because it was to talk about the political process and how that influences what we do. It was a wonderful experience. Michael Kinsley, who’s a very wellknown journalist, moderated it for years. It was really a very fun experience and learning experience…. TS: You alluded to your fellowship in Washington, DC. In your advocacy and meetings with the lawmakers and their staff, how difficult was it to get across the message of the value of the neurologist in patient access? Steven P. Ringel, MD, FAAN, speaking in Washington, DC, 1992.

AANnews • May 2018

SR: You could get the message across, but keep in mind that a lot of other people were sending messages to them, too. It’s a fascinating world, the political world. It really is all about money and access. People are bombarded, so every 10 minutes they’re getting something else from somebody. Much of the work you do is with their staff, because you make their staff aware of these issues. All politics is local. I’m trying to remember the congressman from Massachusetts— TS: Tip O’Neill. SR: Yes, Tip O’Neill. He said, “All politics is local.” It’s true, and I think the Academy has understood that. No matter what’s going on in Washington, we need our members to work on their congressmen in their district because that person is going to vote, and you have to do that. The legislative effort isn’t just when you’re in Washington. It really is back home, as well. TS: The Academy started to talk about creating a political action committee during this period of time. What were the pros and cons of that debate? SR: The pro was that we definitely felt that we could have more influence if we could also provide funds to the person’s campaign, because that has an influence. It does. I can remember distinctly sitting—while I was having a conversation with Senator Rockefeller, he was going through a stack of checks he received and he would say, “Oh, gee. That guy gave that much?” It would register in his mind. They will never say that they’re influenced by the money, but they’re influenced by the money. That’s the reality. The disadvantage of it is that neurologists give a relatively small amount of money, so how much impact can you have? That was what we were weighing all along. We just didn’t have the dollars, and even now it’s hard to raise the dollars to have a great impact, but it’s better than nothing. It works. TS: For some time, the Academy had worked with the Child Neurology Society and American Neurological Association in— SR: I started that [the Neurology Public Policy Fellowship, which supported a neurologist to be on a congressional or executive branch staff for a year]. TS: You started that?

SR: Yeah. Because of my time in Washington, I decided that we needed more people, and it wasn’t just me. Ira Shoulson, who had done a Kennedy Fellowship, was involved in making this decision. We knew that we needed a critical mass of people who were more sophisticated in understanding the legislature and how you work with Congress in doing these things, so we started that program where we would train people and get them in Washington, not just with Kennedy or with Robert Wood Johnson, but with our own program. TS: And then the Palatucci Advocacy Leadership Forum was, I suspect, inspired by that? SR: Yes. It’s just an evolution of involvement of what are the ways we can get to—and the Academy got increasingly involved in state societies, because you had a group of neurologists who originally got together for educational programs in every state practically, like in my own state, the Colorado Neurologic Society, so we started to try to get the Academy to feed into that more the importance of legislative approach. TS: The other big change during that period of time, [AAN Executive Director] Jan Kolehmainen left. Had you had the chance to work with him? SR: Yes, I had. Cathy Rydell came in [1999 as new executive director], during my presidency, but I was already on the board in the ‘80s, so I worked with Jan for quite a few years. He was terrific, but as the organization grew it was timely to bring in a new person with new ideas who was younger. That’s the nature of organizations; you have to. But Jan was wonderful. He really fine-tuned the whole educational part of the Academy, which was really the big focus. The legislative effort came much [later]. Cathy had been in the state legislature in her state in North Dakota, so she understood that process. I think that, in many respects, she expanded the whole advocacy role of the Academy. We already knew how to deliver the educational products, but that was one of the big changes that she brought. Visit AAN.com/view/AANhistory to read the complete transcript of Ringel’s interview and learn about the AAN’s first foray into creating a registry in the 1990s and Ringel’s views on practice guidelines, evidence-based medicine, and launching Neurology Today® with Lewis P. “Bud” Rowland, MD, FAAN. 

Standing, from left, in 1994: Ringel; former AAN President Jack Whisnant, MD, FAAN; Zach W. Hall, PhD, director of the National Institute of Neurological Disorders and Stroke. Seated: former AAN President Kenneth M. Viste, Jr., MD, FAAN.

Ringel and Neurology Today Senior Executive Editor Fay Ellis serenaded outgoing Editor-in-Chief Lewis P. “Bud” Rowland at a 2008 appreciation event.

AANnews • May 2018 7

Tools & Resources

New Registry Module Helps with Outcomes, MIPS Reporting The AAN has launched a Patient Reported Outcomes (PRO) module of the Axon Registry® that will allow you to collect data and track assessments directly from your patients. Currently, the Axon Registry is using the QoLIE-10 (Quality of Life in Epilepsy), PHQ-9 (patient health questionnaire for depression), and the PROMIS-29 (global health questionnaire). These assessments are tied to measures on the Axon Registry dashboard, where you will be able to track performance such as improvement of the QoLIE-10 or PHQ-9. Not only does administering a PRO improve outcomes for your patients but it may also give you credit toward MIPS reporting. In addition to integrating these three Patient Reported Outcome measures into the module, there are also three measures that are reportable for MIPS credit—two of which will satisfy the outcome measure requirement. They are quality of life

assessment for patients with epilepsy (outcome measure), depression remission at 12 months (outcome measure), and quality of life assessment using the PROMIS-29 (process measure). For those practices currently participating in the Axon Registry that are interested in also participating in the PRO module, contact Gina Gjorvad at ggjorvad@aan.com for more information. Learn more about the only registry dedicated to quality improvement in neurology and sign up to participate at AAN.com/view/Axon. 

Webinar Helps You Manage Headache Care, Improve Your Practice Continued from cover Managing Headache Without Giving Yourself One: Using Tools and Technologies for Better Practice Management May 22, 2018 12:00 p.m.–1:00 p.m. ET Deadline to Register: May 21 Faculty: Roderick Spears, MD Remember, many of the 2018 practice management webinars will include a panel to provide more perspectives on the information presented. Also, members who subscribe to the complete series of webinars can access a Synapse online community page to ask further questions, whether they participate live or watch the recorded webinar.

Subscribe to All Webinars for Best Member Value The AAN’s practice management webinars provide the valuable insights and tools you need to navigate through the ever-changing health care landscape—and receive year-end CME credits! Single webinars are

AANnews • May 2018

$99 but AAN members get the greatest value with the $189 subscription to all 10 live one-hour webinars. All webinars include access to presentation slides and recordings. Physicians receive 1 AMA PRA Category 1 Credit™ per webinar; non-physicians receive a certificate of completion. Visit AAN.com/view/pmw18 to learn more and register, or contact Jessica Nickrand at jnickrand@aan.com. 

Using Neuro-specific Measures Can Gain Higher QPP Score The AAN has developed neuro-specific measures that you can use in your practice to get a higher score for the MIPS payment program because neurology measures are not “topped out” and they may be more relevant to your practice. And to help make reporting your scores more easily, you can use either the AAN’s Axon Registry® or MIPSwizard™ to report these. Jose Rocha is the director of Central Business Office, Performance Medical Management, and is practice manager for AAN Board Member James N. Goldenberg, MD, FAAN, at FirstChoice Neurology. In this practice, there are 68 neurologists among the 88 providers in the group. The group―which is spread across Miami, Ft. Lauderdale, Palm Beach, Tampa, and the Florida Keys―has physical medicine and rehabilitation, pain management, sleep specialists, and ancillary providers.

Rocha

Develop a MIPS Strategy

Lessons Learned

For Rocha, the work on preparing for the new payment program has evolved over the last three years. He said they have been trying to figure out “What do we need to do to meet CMS’s requirements? And what do we need to do in the system to make it less intrusive to the physician’s day-to-day?”

Rocha shared some tips he gleaned from his experiences:

The first step was to figure out the best way to report. The group considered reporting via EHR or third-party registry. Using an EHR was the easiest way to do it since data was already in their system. And there was no guarantee that it would take less work if they did it any other way. They decided not to use the Axon Registry because they have been using different measures and they would have to “push” data up to the registry rather than having it “pulled” by the service. But he is anxiously waiting for the interface between the EHR and Axon. The group is fully committed to supporting the AAN and the Axon Registry. Then, Rocha and his team identified measures and mapped these to their EHR system. They chose mostly primary care measures in the first year (e.g., BMI, documenting current meds, and tobacco screening) because it was easy to do. They also selected measures around depression screening and controlling high blood pressure. Because of the preponderance of stroke management work at the clinics, these were relevant to practice. All of this, Rocha noted, would have been impossible to do without an EHR. The team also selected several Improvement Activities. They encouraged providers to use a patient portal and rolled out more providers using telemedicine for “snow birds” (patients who are only in Florida during winter months) more for 24/7 access. “Part of our roll out was education on the patient side. Many were excited about telecommunication aspects,” said Rocha.

Get physicians involved: It’s important to get all the physicians involved early, according to Rocha. “This is not a top-down approach. Physicians were involved at every level. First, I asked what measures would be easy. I asked them which measures were relevant to them. Then, it was interest level. You must communicate to physicians the importance of this: this is how they’ll rate you. This is how plans will determine how valuable the physicians are to them. So, it’s important to get the physicians engaged to come out with a better product.” Make sure physicians are aware of their performance: “Every month, give physicians a ‘report card’ letting them know how they’re doing on their quality measures. This keeps them engaged throughout the year. At quarterly meetings, share how the group is doing.” Make it easy for clinicians: “Find alignment between quality measures and improvement activities,” said Rocha. The AAN provides a table of suggested high-impact Improvement Activities at AAN.com/view/TipSheet. The document can help providers understand how to implement measures and complete Improvement Activities. The AAN is committed to your success. For more information or assistance, visit AAN.com/view/QPP or email macra@aan.com. CMS has free technical assistance available for eligible clinicians, and you could get answers to your MIPS questions in just one business day. Visit QPP.cms.gov/about/smallunderserved-rural-practices to learn how. 

Rocha expects to achieve more than 90 points in MIPS for 2017 reporting.

AANnews • May 2018 9

BECAUSE RELAPSING MS AFFECTS MORE THAN HER. . .

NEWLY DIAGNOSED PATIENTS DESERVE THE #1 PRESCRIBED ORAL RMS THERAPY 1,2*†

Indication

Tecfidera® (dimethyl fumarate) is indicated for adults with relapsing forms of multiple sclerosis.

Important Safety Information

TECFIDERA is contraindicated in patients with known hypersensitivity to dimethyl fumarate or any of the excipients of TECFIDERA. TECFIDERA can cause anaphylaxis and angioedema after the first dose or at any time during treatment. Patients experiencing signs and symptoms of anaphylaxis and angioedema (which have included difficulty breathing, urticaria, and swelling of the throat and tongue) should discontinue TECFIDERA and seek immediate medical care. Progressive multifocal leukoencephalopathy (PML) has occurred in patients with MS treated with TECFIDERA. PML is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. A fatal case of PML occurred in a patient who received TECFIDERA in a clinical trial. PML has also occurred in the postmarketing setting in the presence of lymphopenia (<0.8x109/L) persisting for more than 6 months. While the role of lymphopenia in these cases is uncertain, the majority of cases occurred in patients with lymphocyte counts <0.5x109/L. The symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes. At the first sign or symptom suggestive of PML, withhold

TECFIDERA and perform an appropriate diagnostic evaluation. MRI findings may be apparent before clinical signs or symptoms. TECFIDERA may decrease lymphocyte counts; in clinical trials there was a mean decrease of ~30% in lymphocyte counts during the first year which then remained stable. Four weeks after stopping TECFIDERA, mean lymphocyte counts increased but not to baseline. Six percent of TECFIDERA patients and <1% of placebo patients had lymphocyte counts <0.5x109/L. TECFIDERA has not been studied in patients with pre-existing low lymphocyte counts. There was no increased incidence of serious infections observed in patients with lymphocyte counts <0.8x109/L or ≤0.5x109/L in controlled trials, although one patient in an extension study developed PML in the setting of prolonged lymphopenia (lymphocyte counts predominantly <0.5x109/L for 3.5 years). In controlled and uncontrolled clinical trials, 2% of patients experienced lymphocyte counts <0.5x109/L for at least six months. In these patients, the majority of lymphocyte counts remained <0.5x109/L with continued therapy. A complete blood count including lymphocyte count should be obtained before initiating treatment, 6 months after starting, every 6 to 12 months thereafter and as clinically indicated. Consider treatment interruption if lymphocyte counts <0.5x109/L persist for more than six months and follow lymphocyte counts until lymphopenia is resolved. Consider withholding treatment in patients with serious infections until resolved. Decisions about whether or not to restart TECFIDERA should be based on clinical circumstances. Clinically significant cases of liver injury have been reported in

IN THE DEFINE‡ CLINICAL TRIAL, PATIENTS WERE:

LESS LIKELY TO EXPERIENCE

A RELAPSE3§ TECFIDERA: 27% (n=410) Placebo: 46% (n=408) [P<0.0001] Based on proportion of patients relapsed (PPR)||

LESS LIKELY TO EXPERIENCE

DISABILITY PROGRESSION3¶

TECFIDERA: 16% (n=410) Placebo: 27% (n=408) [P=0.0050]

84% OF PATIENTS IN THE DEFINE TRIAL WERE FREE OF DISABILITY PROGRESSION VS 73% OF PLACEBO PATIENTS3

IN A SEPARATE ANALYSIS, THE NEWLY DIAGNOSED PATIENTS FROM THE PIVOTAL TRIALS WERE:

LESS LIKELY TO EXPERIENCE

DISABILITY PROGRESSION1

TECFIDERA: 0.073 (n=221) Placebo: 0.233 (n=223) [P<0.0001]

STUDY DESIGN: This post hoc analysis of integrated data from DEFINE and CONFIRM# was conducted to examine the efficacy and safety of TECFIDERA in 678 newly diagnosed patients (59% of patients in DEFINE and 71% in CONFIRM were treatment-naive4,5). The newly diagnosed population included patients who had been diagnosed with RRMS within 1 year prior to study entry and were naive to MS disease-modifying therapy. The analysis included clinical and neuroradiological efficacy endpoints as well as basic safety data, or adverse events. This study was not designed in advance to analyze the endpoints presented in the subgroup of newly diagnosed patients.1 Most common adverse events reported in patients receiving TECFIDERA compared with placebo included flushing, nasopharyngitis, headache, diarrhea, nausea, upper abdominal pain, and abdominal pain.3

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Important Safety Information (cont’d)

patients treated with TECFIDERA in the postmarketing setting. The onset has ranged from a few days to several months after initiation of treatment. Signs and symptoms of liver injury, including elevation of serum aminotransferases to greater than 5-fold the upper limit of normal and elevation of total bilirubin to greater than 2-fold the upper limit of normal have been observed. These abnormalities resolved upon treatment discontinuation. Some cases required hospitalization. None of the reported cases resulted in liver failure, liver transplant, or death. However, the combination of new serum aminotransferase elevations with increased levels of bilirubin caused by drug-induced hepatocellular injury is an important predictor of serious liver injury that may lead to acute liver failure, liver transplant, or death in some patients. Elevations of hepatic transaminases (most no greater than 3 times the upper limit of normal) were observed during controlled trials. Obtain serum aminotransferase, alkaline phosphatase, and total bilirubin levels before initiating TECFIDERA and during treatment, as clinically indicated. Discontinue TECFIDERA if clinically significant liver injury induced by TECFIDERA is suspected. TECFIDERA may cause flushing (e.g. warmth, redness, itching, and/or burning sensation). 40% of patients taking TECFIDERA reported flushing, which was mostly mild to moderate in severity. Three percent of patients discontinued TECFIDERA for flushing and <1% had serious flushing events that led to hospitalization. Taking TECFIDERA with food may reduce flushing. Alternatively, administration of non-enteric coated aspirin prior to dosing may reduce the incidence or severity of flushing. TECFIDERA may cause gastrointestinal (GI) events (e.g., nausea, vomiting, diarrhea, abdominal pain, and dyspepsia). Four percent of TECFIDERA patients and <1% of placebo patients discontinued due to GI events. The incidence of serious GI events was 1%. The most common adverse reactions associated with TECFIDERA

versus placebo are flushing (40% vs 6%) and GI events: abdominal pain (18% vs 10%), diarrhea (14% vs 11%), nausea (12% vs 9%). A transient increase in mean eosinophil counts was seen during the first two months. TECFIDERA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Encourage patients who become pregnant while taking TECFIDERA to enroll in the TECFIDERA pregnancy registry by calling 1-866-810-1462 or visiting www.TECFIDERApregnancyregistry.com. For additional Important Safety Information, please see adjacent Brief Summary of full Prescribing Information. *TECFIDERA is approved for adult patients only. † Based on prescriptions. ‡ Determination of Efficacy and Safety of Oral Fumarate in RelapsingRemitting MS.4 § Relapses were defined as new or recurrent neurologic symptoms not associated with fever or infection that lasted for at least 24 hours and were accompanied by new objective neurologic findings.4 || PPR is the percentage of patients who had one or more relapses over the course of the trial.4 ¶ Disability progression is defined as at least a 1-point increase from baseline EDSS of ≥1.0, OR at least a 1.5-point increase for patients with baseline EDSS of 0 sustained for 12 weeks.3 # Comparator and an Oral Fumarate in Relapsing-Remitting Multiple Sclerosis.5 References: 1. Gold R, Giovannoni G, Phillips JT, et al. Mult Scler. 2015;21(1):57-66. 2. IMS data September 27, 2013-December 8, 2017. 3. TECFIDERA Prescribing Information, Biogen, Cambridge, MA. 4. Gold R, Kappos L, Arnold DL, et al. N Engl J Med. 2012;367:10981107. Erratum in: N Engl J Med. 2012;367:2362. 5. Fox RJ, Miller DH, Phillips JT, et al. N Engl J Med. 2012;367:1087-1097. Erratum in: N Engl J Med. 2012;367:1673. © 2018 Biogen. All rights reserved. 02/18 TEC-US-2505

Tecfidera® (dimethyl fumarate) delayed-release capsules, for oral use Brief Summary of Full Prescribing Information 1 INDICATIONS AND USAGE TECFIDERA is indicated for the treatment of patients with relapsing forms of multiple sclerosis. 2 DOSAGE AND ADMINISTRATION 2.1 Dosing Information The starting dose for TECFIDERA is 120 mg twice a day orally. After 7 days, the dose should be increased to the maintenance dose of 240 mg twice a day orally. Temporary dose reductions to 120 mg twice a day may be considered for individuals who do not tolerate the maintenance dose. Within 4 weeks, the recommended dose of 240 mg twice a day should be resumed. Discontinuation of TECFIDERA should be considered for patients unable to tolerate return to the maintenance dose. The incidence of flushing may be reduced by administration of TECFIDERA with food. Alternatively, administration of non-enteric coated aspirin (up to a dose of 325 mg) 30 minutes prior to TECFIDERA dosing may reduce the incidence or severity of flushing [see Clinical Pharmacology (12.3)]. TECFIDERA should be swallowed whole and intact. TECFIDERA should not be crushed or chewed and the capsule contents should not be sprinkled on food. TECFIDERA can be taken with or without food. 2.2 Blood Tests Prior to Initiation of Therapy Obtain a complete blood cell count (CBC) including lymphocyte count before initiation of therapy [see Warnings and Precautions (5.3)]. Obtain serum aminotransferase, alkaline phosphatase, and total bilirubin levels prior to treatment with TECFIDERA [see Warnings and Precautions (5.4)]. 3 DOSAGE FORMS AND STRENGTHS TECFIDERA is available as hard gelatin delayed-release capsules containing 120 mg or 240 mg of dimethyl fumarate. The 120 mg capsules have a green cap and white body, printed with “BG-12 120 mg” in black ink on the body. The 240 mg capsules have a green cap and a green body, printed with “BG-12 240 mg” in black ink on the body. 4 CONTRAINDICATIONS TECFIDERA is contraindicated in patients with known hypersensitivity to dimethyl fumarate or to any of the excipients of TECFIDERA. Reactions have included anaphylaxis and angioedema [see Warnings and Precautions (5.1)]. 5 WARNINGS AND PRECAUTIONS 5.1 Anaphylaxis and Angioedema TECFIDERA can cause anaphylaxis and angioedema after the first dose or at any time during treatment. Signs and symptoms have included difficulty breathing, urticaria, and swelling of the throat and tongue. Patients should be instructed to discontinue TECFIDERA and seek immediate medical care should they experience signs and symptoms of anaphylaxis or angioedema. 5.2 Progressive Multifocal Leukoencephalopathy Progressive multifocal leukoencephalopathy (PML) has occurred in patients with MS treated with TECFIDERA. PML is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. A fatal case of PML occurred in a patient who received TECFIDERA for 4 years while enrolled in a clinical trial. During the clinical trial, the patient experienced prolonged lymphopenia (lymphocyte counts predominantly <0.5x109/L for 3.5 years) while taking TECFIDERA [see Warnings and Precautions (5.3)]. The patient had no other identified systemic medical conditions resulting in compromised immune system function and had not previously been treated with natalizumab, which has a known association with PML. The patient was also not taking any immunosuppressive or immunomodulatory medications concomitantly. PML has also occurred in the postmarketing setting in the presence of lymphopenia (<0.8x109/L) persisting for more than 6 months. While the role of lymphopenia in these cases is uncertain, the majority of cases occurred in patients with lymphocyte counts <0.5x109/L. At the first sign or symptom suggestive of PML, withhold TECFIDERA and perform an appropriate diagnostic evaluation. Typical symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes. MRI findings may be apparent before clinical signs or symptoms. Cases of PML, diagnosed based on MRI findings and the detection of JCV DNA in the cerebrospinal fluid in the absence of clinical signs or symptoms specific to PML, have been reported in patients treated with

other MS medications associated with PML. Many of these patients subsequently became symptomatic with PML. Therefore, monitoring with MRI for signs that may be consistent with PML may be useful, and any suspicious findings should lead to further investigation to allow for an early diagnosis of PML, if present. Lower PML-related mortality and morbidity have been reported following discontinuation of another MS medication associated with PML in patients with PML who were initially asymptomatic compared to patients with PML who had characteristic clinical signs and symptoms at diagnosis. It is not known whether these differences are due to early detection and discontinuation of MS treatment or due to differences in disease in these patients. 5.3 Lymphopenia TECFIDERA may decrease lymphocyte counts. In the MS placebo controlled trials, mean lymphocyte counts decreased by approximately 30% during the first year of treatment with TECFIDERA and then remained stable. Four weeks after stopping TECFIDERA, mean lymphocyte counts increased but did not return to baseline. Six percent (6%) of TECFIDERA patients and <1% of placebo patients experienced lymphocyte counts <0.5x109/L (lower limit of normal 0.91x109/L). The incidence of infections (60% vs 58%) and serious infections (2% vs 2%) was similar in patients treated with TECFIDERA or placebo, respectively. There was no increased incidence of serious infections observed in patients with lymphocyte counts <0.8x109/L or ≤0.5x109/L in controlled trials, although one patient in an extension study developed PML in the setting of prolonged lymphopenia (lymphocyte counts predominantly <0.5x109/L for 3.5 years) [see Warnings and Precautions (5.2)]. In controlled and uncontrolled clinical trials, 2% of patients experienced lymphocyte counts <0.5x109/L for at least six months, and in this group the majority of lymphocyte counts remained <0.5x109/L with continued therapy. TECFIDERA has not been studied in patients with pre-existing low lymphocyte counts. Obtain a CBC, including lymphocyte count, before initiating treatment with TECFIDERA, 6 months after starting treatment, and then every 6 to 12 months thereafter, and as clinically indicated. Consider interruption of TECFIDERA in patients with lymphocyte counts less than 0.5x109/L persisting for more than six months. Given the potential for delayed recovery of lymphocyte counts, continue to obtain lymphocyte counts until their recovery if TECFIDERA is discontinued or interrupted due to lymphopenia. Consider withholding treatment from patients with serious infections until resolution. Decisions about whether or not to restart TECFIDERA should be individualized based on clinical circumstances. 5.4 Liver Injury Clinically significant cases of liver injury have been reported in patients treated with TECFIDERA in the postmarketing setting. The onset has ranged from a few days to several months after initiation of treatment with TECFIDERA. Signs and symptoms of liver injury, including elevation of serum aminotransferases to greater than 5-fold the upper limit of normal and elevation of total bilirubin to greater than 2-fold the upper limit of normal have been observed. These abnormalities resolved upon treatment discontinuation. Some cases required hospitalization. None of the reported cases resulted in liver failure, liver transplant, or death. However, the combination of new serum aminotransferase elevations with increased levels of bilirubin caused by drug-induced hepatocellular injury is an important predictor of serious liver injury that may lead to acute liver failure, liver transplant, or death in some patients. Elevations of hepatic transaminases (most no greater than 3 times the upper limit of normal) were observed during controlled trials [see Adverse Reactions (6.1)]. Obtain serum aminotransferase, alkaline phosphatase (ALP), and total bilirubin levels prior to treatment with TECFIDERA and during treatment, as clinically indicated. Discontinue TECFIDERA if clinically significant liver injury induced by TECFIDERA is suspected. 5.5 Flushing TECFIDERA may cause flushing (e.g., warmth, redness, itching, and/or burning sensation). In clinical trials, 40% of TECFIDERA treated patients experienced flushing. Flushing symptoms generally began soon after initiating TECFIDERA and usually improved or resolved over time. In the majority of patients who experienced flushing, it was mild or moderate in severity. Three percent (3%) of patients discontinued TECFIDERA for flushing and <1% had serious flushing symptoms that were not lifethreatening but led to hospitalization. Administration of TECFIDERA with food may reduce the incidence of flushing. Alternatively, administration of non-enteric coated aspirin (up to a dose of 325 mg) 30 minutes prior to TECFIDERA dosing may reduce the incidence or severity of flushing [see Dosing and Administration (2.1) and Clinical Pharmacology (12.3)]. 6 ADVERSE REACTIONS The following important adverse reactions are described elsewhere in labeling: Anaphylaxis and Angioedema (5.1), Progressive multifocal leukoencephalopathy (5.2), Lymphopenia (5.3), Liver Injury (5.4), Flushing (5.5) [see Warnings and Precautions].

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. The most common adverse reactions (incidence ≥10% and ≥2% more than placebo) for TECFIDERA were flushing, abdominal pain, diarrhea, and nausea. Adverse Reactions in Placebo-Controlled Trials In the two well-controlled studies demonstrating effectiveness, 1529 patients received TECFIDERA with an overall exposure of 2244 person-years [see Clinical Studies (14)]. The adverse reactions presented in the table below are based on safety information from 769 patients treated with TECFIDERA 240 mg twice a day and 771 placebo-treated patients. Table 1: Adverse Reactions in Study 1 and 2 reported for TECFIDERA 240 mg BID at ≥2% higher incidence than placebo

Flushing Abdominal pain Diarrhea Nausea Vomiting Pruritus Rash Albumin urine present Erythema Dyspepsia Aspartate aminotransferase increased Lymphopenia

TECFIDERA N=769 %

Placebo N=771 %

40 18 14 12 9 8 8 6 5 5 4 2

6 10 11 9 5 4 3 4 1 3 2 <1

Gastrointestinal TECFIDERA caused GI events (e.g., nausea, vomiting, diarrhea, abdominal pain, and dyspepsia). The incidence of GI events was higher early in the course of treatment (primarily in month 1) and usually decreased over time in patients treated with TECFIDERA compared with placebo. Four percent (4%) of patients treated with TECFIDERA and less than 1% of placebo patients discontinued due to gastrointestinal events. The incidence of serious GI events was 1% in patients treated with TECFIDERA. Hepatic Transaminases An increased incidence of elevations of hepatic transaminases in patients treated with TECFIDERA was seen primarily during the first six months of treatment, and most patients with elevations had levels <3 times the upper limit of normal (ULN) during controlled trials. Elevations of alanine aminotransferase and aspartate aminotransferase to ≥3 times the ULN occurred in a small number of patients treated with both TECFIDERA and placebo and were balanced between groups. There were no elevations in transaminases ≥3 times the ULN with concomitant elevations in total bilirubin >2 times the ULN. Discontinuations due to elevated hepatic transaminases were <1% and were similar in patients treated with TECFIDERA or placebo. Eosinophilia A transient increase in mean eosinophil counts was seen during the first 2 months of therapy. Adverse Reactions in Placebo-Controlled and Uncontrolled Studies In placebo-controlled and uncontrolled clinical studies, a total of 2513 patients have received TECFIDERA and been followed for periods up to 4 years with an overall exposure of 4603 person-years. Approximately 1162 patients have received more than 2 years of treatment with TECFIDERA. The adverse reaction profile of TECFIDERA in the uncontrolled clinical studies was consistent with the experience in the placebo-controlled clinical trials. 6.2 Post Marketing Experience The following adverse reaction has been identified during post approval use of TECFIDERA. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Liver function abnormalities (elevations in transaminases ≥3 times ULN with concomitant elevations in total bilirubin >2 times ULN) have been reported following TECFIDERA administration in post marketing experience [See Warnings and Precautions (5.4)].

8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Exposure Registry There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to TECFIDERA during pregnancy. Encourage patients to enroll by calling 1-866-810-1462 or visiting www.tecfiderapregnancyregistry.com. Risk Summary There are no adequate data on the developmental risk associated with the use of TECFIDERA in pregnant women. In animals, adverse effects on offspring survival, growth, sexual maturation, and neurobehavioral function were observed when dimethyl fumarate (DMF) was administered during pregnancy and lactation at clinically relevant doses. [see data]. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. The background risk of major birth defects and miscarriage for the indicated population is unknown. Data Animal Data In rats administered DMF orally (25, 100, 250 mg/kg/day) throughout organogenesis, embryofetal toxicity (reduced fetal body weight and delayed ossification) were observed at the highest dose tested. This dose also produced evidence of maternal toxicity (reduced body weight). Plasma exposure (AUC) for monomethyl fumarate (MMF), the major circulating metabolite, at the no-effect dose is approximately three times that in humans at the recommended human dose (RHD) of 480 mg/day. In rabbits administered DMF orally (25, 75, and 150 mg/kg/day) throughout organogenesis, embryolethality and decreased maternal body weight were observed at the highest dose tested. The plasma AUC for MMF at the no-effect dose is approximately 5 times that in humans at the RHD. Oral administration of DMF (25, 100, and 250 mg/kg/day) to rats throughout organogenesis and lactation resulted in increased lethality, persistent reductions in body weight, delayed sexual maturation (male and female pups), and reduced testicular weight at the highest dose tested. Neurobehavioral impairment was observed at all doses. A no-effect dose for developmental toxicity was not identified. The lowest dose tested was associated with plasma AUC for MMF lower than that in humans at the RHD. 8.2 Lactation Risk Summary There are no data on the presence of DMF or MMF in human milk. The effects on the breastfed infant and on milk production are unknown. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for TECFIDERA and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal condition. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use Clinical studies of TECFIDERA did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. 10 OVERDOSE Cases of overdose with TECFIDERA have been reported. The symptoms described in these cases were consistent with the known adverse event profile of TECFIDERA. There are no known therapeutic interventions to enhance elimination of TECFIDERA nor is there a known antidote. In the event of overdose, initiate symptomatic supportive treatment as clinically indicated. 17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information) Dosage Inform patients that they will be provided two strengths of TECFIDERA when starting treatment: 120 mg capsules for the 7 day starter dose and 240 mg capsules for the maintenance dose, both to be taken twice daily. Inform patients to swallow TECFIDERA capsules whole and intact. Inform patients to not crush, chew, or sprinkle capsule contents on food. Inform patients that TECFIDERA can be taken with or without food [see Dosage and Administration (2.1)].

Anaphylaxis and Angioedema Advise patients to discontinue TECFIDERA and seek medical care if they develop signs and symptoms of anaphylaxis or angioedema [see Warnings and Precautions (5.1)]. Progressive Multifocal Leukoencephalopathy Inform patients that progressive multifocal leukoencephalopathy (PML) has occurred in patients who received TECFIDERA. Inform the patient that PML is characterized by a progression of deficits and usually leads to death or severe disability over weeks or months. Instruct the patient of the importance of contacting their doctor if they develop any symptoms suggestive of PML. Inform the patient that typical symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes [see Warnings and Precautions (5.2)]. Lymphocyte Counts Inform patients that TECFIDERA may decrease lymphocyte counts. A blood test should be obtained before they start therapy. Blood tests are also recommended after 6 months of treatment, every 6 to 12 months thereafter, and as clinically indicated [see Warnings and Precautions (5.3), Adverse Reactions (6.1)]. Liver Injury Inform patients that TECFIDERA may cause liver injury. Instruct patients treated with TECFIDERA to report promptly any symptoms that may indicate liver injury, including fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice. A blood test should be obtained before patients start therapy and during treatment, as clinically indicated [see Warnings and Precautions (5.4)]. Flushing and Gastrointestinal (GI) Reactions Flushing and GI reactions (abdominal pain, diarrhea, and nausea) are the most common reactions, especially at the initiation of therapy, and may decrease over time. Advise patients to contact their healthcare provider if they experience persistent and/or severe flushing or GI reactions. Advise patients experiencing flushing that taking TECFIDERA with food or taking a non-enteric coated aspirin prior to taking TECFIDERA may help [see Adverse Reactions (6.1)].

PHARMA AD

Pregnancy and Pregnancy Registry Instruct patients that if they are pregnant or plan to become pregnant while taking TECFIDERA they should inform their physician. Encourage patients to enroll in the TECFIDERA Pregnancy Registry if they become pregnant while taking TECFIDERA. [see Use in Specific Populations (8.1)]. 41347-09 Manufactured by: Biogen Cambridge, MA 02142 TECFIDERA is a trademark of Biogen. ÂŠ 2013-2017 Biogen 2/18

Tools & Resources

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The AAN has partnered with Health Monitor Network, a patient education company, to offer free electronic touchscreen posters for US members’ exam rooms.

Improve Patients’ Experience with Interactive Electronic Exam Room Posters

The AAN will review content for the digital posters for medical accuracy.

“The feedback from physicians who have the digital posters in their exam rooms has been very positive,” said Bert B. Vargas, MD, FAAN, chair of the Digital Strategy Subcommittee. “They especially like the graphics and high-yield informational content which can be used for patient education. These posters may also be an effective way to increase patient satisfaction and decrease their perceived wait time.” Each digital poster features educational charts, diagrams, and tips on managing neurologic conditions. They remain free to all members as they are industry advertiser supported. The 21.5” screen silently rotates panels every 25 seconds, with no interaction needed from health care professionals, office staff, or patients. Clear, engaging videos play only when activated, with a suite of controls, including an easy-to-find pause button. Installation of the posters is free, and they do not require WiFi. They plug into the wall, and any maintenance is conducted by Health Monitor Network. Content is updated quarterly. The posters are available for all member practices in the US, excluding Alaska, Hawaii, and Puerto Rico. Health Monitor Network has partnerships with other medical organizations, such as the American Gastroenterological Association, as well as patient advocacy groups. To learn more about the electronic posters, visit Healthmonitor.com/products/aan-dep to sign up to receive your free electronic poster(s). 

PODCAST CENTRAL Your Guide to New and Recent AAN Podcasts

Neurology Podcasts Visit Neurology.org/podcast to listen to Neurology ® podcasts and earn 0.5 AMA PRA Category 1 CME Credits™ by answering the multiple-choice questions in the online podcast quiz. Interviews based on articles from Neurology ® Clinical Practice, Neurology ® Genetics, and Neurology ® Neuroimmunology & Neuroinflammation are excluded from the CME program.

Available by May 1

Neurology: Baseline Symptoms and Basal Forebrain Volume Predict Future Psychosis in Early Parkinson Disease Erika Jean Takle Axeen, MD, and Tobias Loddenkemper, MD Neurology: Factors Associated with Treatment Delays in Pediatric Refractory Convulsive Status Epilepticus Stacey Lynn Clardy, MD, PhD, and Riley Bove, MD Neurology: ABBY: A Phase 2 Randomized Trial of Crenezumab in Mild-to-moderate Alzheimer's Disease David A. Lapides, MD, and Maarten J. Titulaer, MD, PhD Neurology: Neuroimmunology & Neuroinflammation: Rituximab Before and During Pregnancy: A Systematic Review and Case Series in MS and NMOSD Jeffrey B. Ratliff, MD, and Jeffrey L. Cummings, MD, ScD Neurology: Clinical Practice: Persistent Focal Enhancement of the Cisternal Segment of Oculomotor Nerve in Ophthalmoplegic Migraine Heather D. Harle, MD, and Ihtesham A. Qureshi, MD 

AANnews • May 2018 15

Tools & Resources

Practice Ambassador Program Considers 2017 Input, Begins 2018 Visits In 2017, the AAN received an incredible response from small and solo practices seeking to participate in a visit from the new Practice Ambassador Program. Although the Academy was not able to visit all 273 members who responded with interest, we tried to visit a diverse mix of practices that would represent the membership base and their challenges. Through these visits, we met with many neurologists and practice managers who have implemented strategies to be successful in ways that work best for them and their practice. The findings and recommendations from these visits were shared with AAN leadership and executive staff. As a result, the AAN is using this feedback from members in small and solo practices to adapt our products to ensure they are meaningful and useful to these neurologists. Furthermore, the Academy is evaluating how these suggestions fit in with the AAN’s strategic plan and priorities before making final decisions. “Over the past decade, small and solo neurology practices have come under increased economic pressure due to a variety of regulatory and reimbursement decisions made by governmental agencies, legislative bodies and third-party payers,” said AAN President Elect James C. Stevens, MD, FAAN, who has led this initiative. “The AAN is committed to supporting these members who wish to maintain their current practice model by providing a variety of resources. One of these initiatives is the Practice Ambassador Program. We will closely monitor feedback from our member participants in order to ensure we are offering the highest possible value from the program.” The AAN established the Practice Ambassador Program last year to observe neurologists in small and solo practices to gain firsthand knowledge of challenges, successes, and concerns of these members, who were encouraged to candidly share their perspectives and offer recommendations. Seven visits took place between August and November 2017. Below are responses from the participants at solo and small group practices.

Recommendations from Solo Practices Ensure other specialties are not caring for neurologyspecific issues through advocacy efforts. Approach payers to reward providers with specific qualifications/credentialing. Integrate AAN guidelines and quality measures in to EHR systems. Advocate for nerve conduction studies to be reimbursed according to difficulty. Advocate for additional reimbursement for performing a detailed neuro exam. Offer physician training on getting the most out of the EHR and time/cost saving tips for your EHR. Offer a small/solo practice workshop at the Annual Meeting. Provide opportunity to network, discuss challenges and bounce ideas off colleagues.

AANnews • May 2018

Consider profiling various independent practice models at future AAN education events. Develop a referring guide for PCPs or work more closely with this group so they understand when to refer to neurologists. Develop templates and resources to help neurologists with chronic care management, specifically using telemedicine. Develop resources to help clinic staff manage upset/ aggressive patients effectively. Develop resources to help practice managers keep abreast of what others are doing to run a successful practice. Offer consulting services or partner with a consulting service to help small/solo practices with practice management issues (insurance, HR, supplies, bookkeeping, billing, staff training). Provide dedicated AAN staff to be administrator of third-party service to protect interest of practices.

KEY TAKEAWAYS FROM SOLO PRACTICES Benefits

Challenges

Autonomy and discretion to use medical judgement to care for patients.

EMG cuts financially hurt practices.

Building relationships is the cornerstone of being in practice.

Practices have difficulty managing the business end of the practice.

Able to provide exceptional care. The neurologist can take as much time as needed to talk with patients.

Difficulty with referrals from PCPs. PCPs are inappropriately treating patients and not referring patients to neurologist for follow up.

Patients appreciate being able to spend 45-60 minutes with their physician.

Reimbursements at current rates are not enough to keep the lights on.

Able to try non-traditional practice models.

Practices spend too much time filling out forms for insurance companies, FMLA, disability. This could be a big factor leading to physician burnout. Specialty pharmacies threaten revenue streams. One of the biggest challenges is figuring out what needs to be done to report for MIPS.

Recommendations from Small Group Practices Reach out to neurologists and/or office managers about Business Administration membership, as they may not be aware of practice management resources the AAN has to offer. Determine how the AAN can better integrate the Axon Registry® with cloud-based EHR systems. Continue to offer a virtual way to attend the Annual Meeting and other conferences. Develop resources or a line of support for managing clinic (i.e., ordering office and clinic supplies). Offer educational programming in the evening or on weekends. Provide the opportunity to direct questions to speakers after an education program is over. Develop a seamless way to integrate guidelines and quality measures into practice and clinic workflows. Develop resources/education: For PCPs to better understand when to refer patients to neurologists For managing support staff, and include a customer service module Criteria for selecting a consultant How to negotiate contracts Stevens How to hire someone to negotiate contracts How to evaluate a consultant and measures of success Help members negotiate with payers for both reimbursements and employee health insurance Provide ideas and resources for different revenue streams. Profile other small/solo practices who have multiple revenue streams and are succeeding in practice.

KEY TAKEAWAYS FROM SMALL GROUP PRACTICES Benefits

Challenges

Some neurologists value autonomy over being part of a health care delivery system. Priority is given to practicing medicine how they see fit.

Concerned that relationships are being stripped away from medicine.

Able to implement strategies to avoid burnout.

Neurologists are not getting reimbursed for having meaningful conversations with patients.

Enjoy building relationships with patients and providing own direction in patient care.

EHR/data entry has little benefit. It takes time away from actual patient care. Prior authorizations are a huge burden for the clinic staff and take a lot time. This contributes to staff turnover. Some neurologists have limited understanding of MACRA and QPP. Some practices are willing to take financial penalty because there’s not enough staff to help. Some practices need help training office staff. Maintaining a steady cashflow is a challenge. Some practices are looking to diversify revenue streams, but unsure how to go about this.

In 2018, the AAN will conduct six to 12 visits throughout the year, with an emphasis on covering regions of the US not yet visited. For questions related to practice management, email practice@aan.com. 

AANnews • May 2018 17

Policy & Guidelines

AAN Publishes Guideline on Disease-modifying Therapies for MS The AAN published a new guideline, Practice Guideline: Disease-modifying Therapies for Adults with Multiple Sclerosis, in the April 24, 2018, issue of Neurology ®. A press conference on the guideline was held on April 23 at the AAN Annual Meeting for national and international media. According to the guideline, several DMTs are effective in reducing MS relapses and new MRI lesion formation. The question of whether to start a DMT, switch from one DMT to another, or stop a DMT depends on the benefits and risks of the medications and a personalized approach to each patient. “The treatment landscape for people with MS has changed dramatically since publication of the AAN’s original guideline on DMT use for MS,” said Lead Author Alexander D. Rae-Grant, MD. “Clinicians and patients now have a number of DMTs to choose from, with differing mechanisms of action, risk profiles, and monitoring requirements, and it is hoped that this guideline will provide direction to clinicians and patients as they make choices about starting DMT use, switching from one DMT to another, or stopping DMT use.”

The guideline highlights key findings and provides guidance that clinicians will find helpful: Careful risk management and personalization of treatment strategy are important. There is evidence supporting or not supporting use of several of the DMTs compared with placebo and of several DMTs vs comparator DMTs.

Rae-Grant

For several DMTs, the evidence is insufficient to determine efficacy but provides information regarding risk of adverse effects. Read the guideline and access PDF summaries for clinicians and patients and a slide presentation set at AAN.com. For more information, contact Julie Cox at jcox@aan.com or (612) 928-6069. 

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Academy Publishes Position Statements on Medical Marijuana and Opioids The AAN recently published position statements on two topics often in the news and discussed with patients: medical marijuana and opioids. Both of these position statements can be read at AAN.com/policy-and-guidelines/ policy/position-statements.

Medical Marijuana Position Statement—Updated The AAN’s original Medical Marijuana Position Statement was approved in 2015. Since that time, 30 states and the District of Columbia have passed legislation to support comprehensive medical marijuana programs. While states have made significant progress, federal law still prohibits the research and prescribing of marijuana. This updated position statement provides clarity on the AAN’s position in a complicated landscape. The Academy supports scientific research of medical marijuana, which includes rescheduling from a Schedule I to a Schedule II substance. The Academy does not support the legalization or prescribing of medical marijuana.

Opioid Position Statement—New The new Opioid Position Statement provides information for legislators and policymakers about the important role neurologists play in protecting the brain from the damaging impacts of opioid misuse and abuse. Neurologists are not leading prescribers of opioids, but they treat many patients with pain, which is poorly understood and currently has few viable non-opioid treatments available. This statement establishes the AAN’s position on opioids and the treatment of pain. The Academy supports funding for research of nonopioid pain therapies, the impact of opioids on the developing and recovering brain, and gaps in addiction and recovery services. The Academy also supports interoperability USE OF MEDIC AL MARIJ FOR NEUROL NA with electronic health OGIC DISORUA DERS Background Info rmation records and prescription monitoring programs as S OPIOID well as scienceation nd Inform Description of Backgrou the Issue based resources ue at all points of tion of Iss Descrip care to promote safe prescribing Position practices.  The AAN The POSITION STAT EMENT:

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Capitol Hill Report Capitol Hill Report presents regular updates on legislative and regulatory actions and how the Academy ensures that the voice of neurology is heard on Capitol Hill. It is emailed to US members twice monthly and is posted at AAN.com/ view/HillReport. Below are some recent highlights. While Congress has taken little action to address the high cost of prescription medications, states are actively implementing legislative and regulatory solutions to lower drug prices. Transparency Legislation: California Senate Bill 17 requires manufacturers to provide 60-day notification and justification before raising the price of a drug by more than 16 percent in a two-year period. Nevada Senate Bill 539 requires insulin manufacturers and pharmacy benefit managers to disclose the cost of producing and marketing drugs along with the total percent of rebates that are passed on to consumers. Other states have introduced similar legislation in 2018. ‘Gag Rule’ Legislation: Connecticut Senate Bill 445, which became effective on January 1, bans pharmacy benefit managers from using contract provisions to prohibit pharmacists from informing consumers about less expensive alternatives for prescriptions. Maine, Louisiana, North Dakota, and Georgia each passed similar legislation in 2017 while more states consider the issue in 2018. Regulatory Approaches: New York enacted a law that requires the Department of Health to establish a Medicaid Drug Spending Growth Target each year and demand additional rebates from drug manufacturers to meet that target. In a first for states, New Jersey used the administrative rulemaking process to cap contracts and payments between physicians and pharmaceutical companies at $10,000 per year for non-research and education-related payments. The rule was modeled after several institution-level policies that prohibit or limit industry payments. Prescription drug pricing is a top advocacy priority for the AAN in states and in Congress. To share your story about high drug costs, please contact advocacy@aan.com. 

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AANnews • May 2018 19

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Policy & Guidelines

Buchwald Shows Value of Patient Group Collaboration with National MS Society Linda Y. Buchwald, MD, FAAN, whose subspecialty is multiple sclerosis, has been a longtime neurology advocate. Recently, she represented the AAN at the National Multiple Sclerosis (MS) Society Public Policy Conference, where neurologists and MS advocates gathered in Washington, DC, to visit lawmakers, much in the same way AAN members lobby during Neurology on the Hill. The AAN has had a successful collaboration with the National MS Society for several years. The collaboration between the AAN and National MS Society began “Way, way back,” according to Buchwald, during the 12 years she served on the Academy’s Legislative Affairs Committee (including six years as chair). “They started having their health care policy conference about 25 years ago.” Today, Buchwald is the longest-tenured member (since 1975) of the department of neurology at Cambridge’s Mount Auburn Hospital. She is medical director of the Multiple Sclerosis Care Center and has been on the Medical Advisory Board of the National Multiple Sclerosis Society, as well as the Clinical Advisory Board of Trustees of the Greater New England Multiple Sclerosis Society chapter. She also has been president of the Massachusetts Neurological Association. But she clearly remembers the pivotal moment nearly 50 years ago that sparked her longterm association with the National MS Society.

MS Society, and told us, ‘You support them.’ When I was having difficulty getting what I need for a patient, I’d call them, and they’d be very helpful, getting equipment, or getting money from the society to put an elevator into a home. They help us do things. If you need to get automatic Buchwald pneumatic doors put into an apartment building for a patient, they make some calls and get it done. On our own, we are good at getting things, but when we’re pulling our hair out, we call National MS. We help each other. We tell them the issues and often we can, with our patients and National MS consumer advocates, present a strong voice on the Hill. Sometimes they can connect us to a solution, and sometimes they can put funding in place.” Drug prices are of particular concern for Buchwald. “I’ve taken care of MS patients for a long time, over 40 years. You see what tremendous needs they have and how hard it is to get things

“I remember when I was in training in my first year, Dr. Labe Sheinberg, who was professor and chair of neurology and former dean of the Albert Einstein College of Medicine, took us on field trip to the National

Buchwald and Mark S. Yerby, MD, MPH, FAAN, presented an award to Sen. Ted Kennedy (D-MA) in 2002 for his work on protecting patients.

Buchwald discussed MS drug costs with Rep. Phil Roe, MD (R-TN) and Rep. Ralph Abraham (R-LA) in 2017.

AANnews • May 2018

for them. You end up doing a lot of fighting for them. We have advocated for research, looking for a cure, which we think will come in the not too remote future. Now we’re working on the pricing for MS drugs, which has gone up astronomically. Now it’s as high as $90,000 a year, and the average annual cost is in the $80,000s. That’s up from $8,000 to $12,000 a year, when these drugs first came on the market. Each time a new drug has been introduced at a higher price, the other companies have raised their prices to meet it. And these patients are people often in the prime of their lives. The onset of MS is most often in one’s 20s or 30s. Care is a lifelong situation. These people have families and have to make choices: food, mortgage, college education, or drugs. This isn’t good.” The AAN released its Prescription Drug Pricing Position Statement in early 2017 in response to these high drug prices for neurology patients. Neurologists have been advocating for lower drug prices for their patients as part of Neurology on the Hill for the past two years, working closely with the National MS Society and dual advocates like Buchwald to support legislation like the Fair Accountability and Innovative Research (FAIR) Drug Pricing Act that has the potential to bring down costs of expensive drugs. This bill would require drug companies to submit justification before they increase the price of drugs that cost at least $100 by more than 10 percent in one year or 25 percent over three years. Buchwald takes issue with insurers, as well. “We aren’t happy with the way insurers are covering these drugs. Some decisions are very hard and they are taking them out of the hands of patients and providers. They make changes from brand name meds to biologic equivalents we don’t even know will work. We are advocating for that to be reformed. We need to stabilize the individual marketplace, which means

reinsurance and educating people as to what’s available. MS patients are very high-cost patients. They require expensive rehabilitation and complex devices such as motorized chairs. They have to work with step therapies. And they take a lot of meds for symptomatic relief. We need to get prices down, and improve access to meds and access to specialty care.” Consequently, effective advocacy is essential in providing care that can improve quality of life for these people. The National MS Society Public Policy Conference is very similar in structure to Neurology on the Hill. “We have a very fine briefing session, making sure we have the data and understanding regarding the issues. We go out with patients and providers and consumer advocates from the National MS Society. They’re very informed and together we have a powerful voice. In the Massachusetts congressional delegation, we don’t have to do a lot of convincing. They’re very receptive. We make the case, and give them the info so they can make the case. Patients tell their stories and how their lives could be better, and what Congress can do to make them better. These patient stories impact the legislators and the young aides. They nearly all know someone with MS, so they know what it’s like. Some of the researchers go with us. I’d like to see more doctors go.” The AAN recognizes the value of combining physician and patient advocacy and included two patients in this year’s Neurology on the Hill to share their experience with high drug prices. With five decades of providing neurologic care to back her up, Buchwald stated, “More than ever, we need to be advocates for our patients. We need to advocate so we have an appropriate environment to take care of patients.” Visit AAN.com/view/advocacy to learn how you can join Buchwald as an advocate for your patients and profession. 

Are You Getting Your AANe-news? Don’t miss the latest news headlines from your Academy! As an exclusive member benefit, you should be receiving AANe-news™ the second and fourth Wednesday of each month if your email address is on file. If not, be sure to set your email filter to accept mailer@aan.com as a friendly address. Or update your email address at AAN.com/MemberProfile.

It’s Not Spam... It’s AANe-news!

AANnews • May 2018 23

Conferences & Community

Call for Course Proposals for 2019 Annual Meeting May 18 Deadline May 18, 2018, is the deadline to submit course proposals for the 2019 Annual Meeting, to be held May 4 through 10 in Philadelphia. The AAN is seeking proposals for general education programs, Neuroscience in the Clinic sessions, and experiential learning area talks and presentations. Successful proposals should: Provide new and upcoming “hot” topics

Fill a gap in the topic Appeal to a wide audience Not overlap with current programs; visit AAN.com/view/ AMSearchProgram to view a list of current programs Proposal acceptance is limited. For additional information on the types of proposals sought, guidelines for each, important dates and deadlines, and to submit your proposal, visit AAN.com/view/SubmitProposal. 

Have an Out-of-the-box Idea? We Want to Hear It! Calling all innovators! Do you have a new, big idea that doesn’t necessarily “fit in the box” for Annual Meeting program types listed above? Visit AAN.com/view/ SubmitProposal to find out how to submit yours. 

May 7 Is Last Chance to Submit Online Evaluations for Annual Meeting CME Don’t forget to submit your evaluation forms by May 7 to receive CME for the 2018 Annual Meeting. Forms may be completed online at AAN.com/view/CME or through the Annual Meeting mobile app at AAN.com/view/app. 

Early Registration Deadline Approaching for Sports Concussion Conference Continued from cover offering a special opportunity for the AAN to collaborate with the NCAA on some unique programming, including a networking reception at the NCAA Hall of Champions and a session on the NCAA-DOD CARE Consortium. The conference will also feature a keynote address by Michael McCrea, PhD, on Concussion Research—Then and Now. What used to be a topic that concerned a few lone scientists and clinicians has now become front and center in science, sport, and society and McCrea’s talk will highlight this dramatic shift in relevancy and sense of urgency over the past several decades. McCrea is tenured professor, eminent scholar, and vice chair of research in the Department of Neurosurgery at the Medical College of Wisconsin in Milwaukee. He is also the director of Brain Injury Research, as well as a research neuropsychologist at the Clement Zablocki VA Medical Center in Milwaukee; ABCN board-certified in clinical neuropsychology; and past president of the American Academy of Clinical Neuropsychology. He has been an active researcher in the neurosciences, having led several large, multi-center studies on the effects of traumatic brain injury and sports-related concussion and authored numerous scientific publications, book chapters, and national

AANnews • May 2018

and international lectures on the topic. He authored the text Mild Traumatic Brain Injury and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment published by Oxford University Press. He currently serves as a neuropsychology consultant for the Green Bay Packers, and on the scientific committee for the 2016 International Consensus Conference on Sports Concussion. 

McCrea

May 7 Is Last Chance to Submit Concussion Abstracts May 7 is the deadline to submit scientific abstracts on topics related to sports concussion for the 2018 Sports Concussion Conference. Accepted abstracts will be presented in the general poster sessions. Submission of previously presented work is encouraged if it is of interest to the field. Submit online at AAN.com/view/SCC. 

Board Member Gains Valuable Insight, Satisfaction Through Leadership Program “It was a fantastic experience!” This response comes easily for Charlene Gamaldo, MD, FAAN, FAASM, when asked to sum up her feelings about the AAN’s Transforming Leaders Program. The 2016-2017 participant credits the 11-month opportunity with helping her recognize and appreciate the importance of identifying strengths—not only in herself, but also in others— and optimizing those strengths to achieve personal and professional development, satisfaction, and common goals. “Specifically, I found these skills helpful as I worked with my team to open a new sleep center,” said Gamaldo of the group project she and co-participants tackled as a requirement of the program. “The project called for adaptability in a changing health care climate, innovative ideas, and measured execution of plans to stay ahead of the game. What I learned from program mentors helped me to better appreciate and communicate with my team.” Gamaldo’s new skills have proven equally useful in her daily life as a faculty member of the Johns Hopkins School of Medicine’s neurology, psychiatry, nursing, anesthesiology, and public health departments, as well as her role as medical director of the Johns Hopkins Center for Sleep and vice chair for faculty development for the neurology department. “My experience with Transforming Leaders has been helpful in mentoring our faculty as we address strategies for identifying their paths to career growth and satisfaction—based on developing their strengths, and not harping on limitations. It has also served as an important method to tackle burnout.” After several years of committee work and other volunteer involvement with the AAN, Gamaldo was elected to the AAN Board of Directors in April 2017, a role in which she’s finding plenty of opportunity to leverage her Transforming Leaders training. “Transforming Leaders gave me a firsthand look at the inner workings of the Academy, the organizational mission, and the diverse effort and infrastructure involved to achieve our goal of ‘being indispensable to members.’ With the insight gained regarding methods to optimize my leadership effectiveness and my heightened pride in the efforts of the Academy, I feel poised to put my best foot forward in contributing to the Board, members of the Academy, and our field.”

path to satisfaction. Quite honestly, I am not sure if I would have taken even a fraction of the time to contemplate those issues if it weren’t for Transforming Leaders.” The Transforming Leaders Program is an elite, 10-month, intensive training program designed to identify and develop Gamaldo talent among experienced AAN member neurologists who are 10 or more years out of residency and interested in future leadership roles in the AAN and the field of neurology. For more information and to apply for the 2018-2019 program by the June 4 application deadline, visit AAN.com/Lead. The Transforming Leaders Program is supported in part by grants from Allergan, Inc., Lundbeck LLC., Sanofi Genzyme, and Supernus Pharmaceuticals, Inc. 

Application Deadlines Approaching for These Leadership Programs The June 4 application deadline is quickly approaching for the following career-changing AAN Leadership Programs. Visit AAN.com/view/lead to learn more and apply today. Emerging Leaders—a six-month program for members who are less than 10 years out of residency Transforming Leaders—a 10-month intensive training program for members who are 10 or more years out of residency Practice Leadership—a seven-month program for neurologists in solo or small practice Women Leading in Neurology—a seven-month program designed specifically for women to strengthen communication and leadership skills and to address topics such as gender bias in medicine 

Gamaldo also sees the power of the program extending beyond leadership skills to mental, physical, and spiritual well-being. “Involvement in one’s professional organizations has been linked to less burnout and greater professional satisfaction,” she said. “The Transforming Leaders Program not only gives you a greater appreciation for what the Academy is about and the ongoing efforts, initiatives, and avenues that may be available to contribute to the field of neurology, but it feeds your personal and professional soul. In this busy world and hectic medical landscape, the Transforming Leaders Program forces you to take the invaluable opportunity to exhale, reflect, and think about your personal goals, strengths, development, and overarching

AANnews • May 2018 25

Conferences & Community

Neuro Film Festival Winners Announced Congratulations to the winners of the 2018 Neuro Film Festival® for sharing their powerful stories about the importance of neuroscience research. The AAN received nearly 90 entries for the festival. Four Grand Prize winners, one from each category, were selected by a jury of physicians. Each winner received $1,000.

GRAND PRIZE WINNER

Neuroscience Is… Cool (category kids ages 13-17)

Neuroscience Is…™ Critical (category for advocates, patient groups, and neurology professionals)

™

Anjali Sadarangani for Neuroscience Is Cool! There is energy all around us, but the brain is what makes it all perceivable. This video explores the brain’s role in processing the sights and sounds that we experience every day.

Carlos Muniz for Tough as Iron.

GRAND PRIZE WINNER

A group of doctors travel to a small town in the Dominican Republic to visit residents affected by pantothenate kinaseassociated neurodegeneration (PKAN), a rare neurologic condition that causes involuntary movements.

Neuroscience Is…™ Rewarding (category for undergraduate and graduate students, medical students, and residents)

GRAND PRIZE WINNER

Alison Caldwell for Why I Love Neuroscience. Alison wanted to be an astronaut ever since she was a little kid. But in college she discovered neuroscience. She was amazed to learn there are more synaptic connections in the brain than there are stars in the Milky Way Galaxy. Today, she is pursuing her PhD in neuroscience.

Neuroscience Is…™ Essential (category for patients, families, and caregivers)

Trish Flanagan for Morgan’s Story. Morgan was born with an HNRNPH2 mutation. The condition inhibits her normal development, but it cannot limit the spirit of love and happiness that surrounds her everywhere she goes.

The Neuro Film Festival aims to help build awareness and demonstrate the importance of neuroscience research by creating a culture that supports neurologic research and encourages more young people to pursue careers in neuroscience. View all 2018 Neuro Film Festival submissions on the Neuro Film Festival YouTube channel at Youtube.com/user/neurofilmfest/playlists. 

AANnews • May 2018

Non-motor symptoms of OFF periods affecting the lives of people with Parkinson’s may include anxiety, mood changes, fatigue, irritability and cognitive dysfunction.1,2 Unexpected symptoms can affect everyday life, for example, reduction in mobility and avoidance of activities. 3 Symptom variability among patients can make recognition of OFF periods challenging for clinicians.4

OFFmatters.com

1. 2. 3. 4.

Stacy M et al. Mov Disord. 2005;20(6):726-733. Witjas T et al. Neurology. 2002;59(3):408-413. Hechtner MC et al. Parkinsonism Relat Disord. 2014;20(9):969-974. Pahwa R et al. Curr Res Med Opin. 2009;25(4):841-849.

Conferences & Community

Elevate Your Status, Enhance Your Professional Credentials with FAAN Designation If you’re interested in elevating your AAN membership and adding the prestigious FAAN designation to your professional credentials, then consider applying for Fellow of the American Academy of Neurology (FAAN) membership status—or encourage a qualifying colleague to apply. FAAN status acknowledges exemplary work and achievements in the neurosciences, the clinical practice of neurology, or academic/administrative neurology and will: Set you apart both within the Academy and throughout your professional career Provide the recognition you deserve for your exemplary contributions to the neurosciences, the clinical

practice of neurology, or academic/ administrative neurology—both in the AAN and in your community Offer eligibility to serve on the AAN Board of Directors, a unique opportunity that could allow you

to have a significant impact on the future direction of the AAN Visit AAN.com/view/FAANReq to learn more about eligibility requirements and to apply online. 

Education & Research

Resident Sought to Join Continuum Editorial Board AAN member residents are encouraged to apply to serve on the Continuum® Editorial Board. The Editorial Board provides oversight of Continuum: Lifelong Learning in Neurology®, the official CME journal of the AAN, and Continuum® Audio. The Editorial Board is responsible providing input in Lewis the direction of Continuum, for topic and guest editor suggestions, and review and evaluation of issues in accordance with the ACCME. One or two residents will be selected to serve a one-year term on the editorial board during the 2019 calendar year representing the perspective of Junior members of the Academy for Continuum, which is provided complimentary to all Junior members. The resident member would be expected to attend the spring and fall meetings in 2019. Eligible applicants should be, or have been, in their PGY3, PGY4 (or PGY5 if in child neurology) year of training during the academic year ending June 30, 2018. “Having a neurology resident on our Editorial Board provides an important voice to our trainees in the direction of Continuum, while at the same time providing a unique opportunity for a resident to learn the ‘ins and outs’ of production of a major clinical journal,” said Continuum Editor-in-Chief Steven L. Lewis, MD, FAAN. To apply, candidates should submit a one-page letter of interest, CV, and a letter of recommendation from their program director or department chair. For more information or to apply, contact Amanda Doering, Continuum Managing Editor, at adoering@aan.com by July 31, 2018. Applicants will be notified of selection by November 1, 2018.

AANnews • May 2018

Subspecialty Fellowship Training Program Accreditation Applications Due June 1 Applications are now being accepted until June 1, 2018, from programs seeking accreditation in any of the nine neurologic subspecialty areas recognized by the United Council for Neurologic Subspecialties (UCNS). Accreditation is a voluntary process of evaluation and peer review. Programs that attain accreditation status offer the core curriculum established by the subspecialty and meet the required quality standards established by UCNS. Fellows graduating from UCNS-accredited training programs meet the training eligibility requirements for certification in their respective UCNS-recognized subspecialty, creating a strong career path for fellow graduates. Accreditation applications are accepted throughout the year with spring and fall review deadlines. New applications received by the June 1 deadline will be reviewed for approval in the fall of 2018. The next deadline for program applications will be December 1, 2018, for a spring 2019 application review. Training program applications must be submitted online at tools.ucns.org/ai/request/accreditationrequest. For more information, visit UCNS.org or contact Amanda Carpenter at (612) 928-6065 or acarpenter@ucns.org. 

American Brain Foundation

A Year of Innovation, Growth In 2017, the American Brain Foundation experienced significant innovation and growth in its mission to bring researchers and donors together to defeat brain disease. With an eye toward expanding its reach and involving more people in its mission, the Foundation implemented the world’s first neuroscience crowdfunding platform and honored the outstanding scientists and members of the public who are leading the fight to defeat brain disease.

Raised Nearly $4 Million for Research

Our Research Partners

Funding the innovative projects of early career investigators is the cornerstone of the Foundation, and in 2017 it joined with 19 distinguished national partners to grant nearly $1 million in 10 Clinical Research Training Scholarships to early career researchers. The Foundation raised $3.9 million for current and future awards.

The ALS Association

Muscle Study Group

Alzheimer’s Association

Muscular Dystrophy Association

American Academy of Neurology

Myasthenia Gravis Foundation of America

Launched Crowdfunding Site In 2017, the Foundation built, tested, and launched the world’s first neuroscience crowdfunding platform. The site and corresponding campaign raises public awareness of the Foundation and offers an opportunity to bring donors and researchers together by giving patients, caregivers, and members of the general public the ability to sort through, select, and support disease-specific research projects that are the most meaningful to them—with 100 percent of donations going directly to support designated projects.

Honored Leaders in the Fight to Defeat Brain Disease During the April 2018 Annual Meeting in Los Angeles, the Foundation honored two individuals outside of the medical profession for their efforts in advancing public understanding and awareness of neurologic disease, being effective advocates for neuroscience research, and making significant contributions to improve patient care. Temple Grandin, PhD, professor of animal science at Colorado State University and well-known autism spokesperson, received the 2018 Public Leadership in Neurology Award; and DeMaurice Smith, executive director of the NFL Players’ Association, received the 2018 Commitment to Cures Award as an advocate for athlete brain health.

American Epilepsy Society American Heart Association

National Ataxia Foundation

Consortium of Multiple Sclerosis Centers

National Multiple Sclerosis Society Parkinson’s Foundation

Epilepsy Foundation

Society of Vascular and Interventional Neurology

International Headache Society The Mary E. Groff Charitable Fund

Tourette Association of America

McKnight Brain Research Foundation $34,591

$34,590

$77,500

$34,591 $34,591

$102,091

$34,591

$167,091

$106,736

$67,500

$97,500

Leaders within the medical profession were also recognized and received support for their important work through more than a dozen prestigious scientific awards given through the AAN.

$67,500

Launched Rowland Circle, Recognized Philanthropists

Epilepsy

Intracerebral Hemorrhage

In 2017, the Foundation launched the Rowland Circle in honor of Lewis “Bud” Rowland’s steadfast leadership and commitment to the Foundation and to finding cures for brain disease. The Rowland Circle has 43 charter members as of the end of March. The Foundation also gave special recognition to six individual donors who gave $25,000 in 2017 in honor of the Foundation’s 25th Anniversary.

Stroke

X-Linked Parkinsonism

Muscular Dystrophy

Myasthenia Gravis

Ataxia

Migraine

Multiple Sclerosis

Neurodevelopmental Impairment/ Congenital Heart Disease

Parkinson’s

Alzheimer's

The Foundation’s full Annual Report, including financial results, is available at AmericanBrainFoundation.org, or by contacting info@AmericanBrainFoundation.org or (866) 770-7570. 

AANnews • May 2018 29

AAN.com/careers

Visit the AAN’s Neurology Career Center to view hundreds of additional jobs and sign up for customized, confidential notifications when positions of interest are added.

Neurology and Neurohospitalist Physicians/Sign-On/ Relocation Bonus/Central Coastal Florida Health First Medical Group is part of Health First, a healthcare Integrated Delivery Network (IDN) located on Central Florida’s east coast and Brevard Country’s only IDN. We are currently seeking Neurology and Neurohospitalist physicians to join our team in the Brevard County area. Health First Medical Group has more than 250 physicians and over 25 office locations. Our IDN is comprised of several services, including four hospitals. Our largest hospital facility, Health First’s Holmes Regional Medical Center, has 514 beds and is a premier tertiary referral hospital, while our community hospitals include 150-bed, 152-bed and 84-bed hospitals. We are also home to the only state-accredited Level II trauma center in Brevard and Indian River counties. We are situated just a few miles from several beautiful Florida beaches and are close to major airports, shopping and many Florida attractions. Alongside all the fun, Brevard County has excellent public and private schools and great housing options. At Health First Medical Group, we provide our patients with outstanding services and state-ofthe-art care provided by internists and supported by a wide array of specialists. When you join our team, you can expect a competitive, guaranteed base salary in addition to a production bonus, full benefits offered to you and your family, paid Continuing Medical Education (CME), retirement benefits, relocation allowance and more. To learn more about this opportunity, please email your CV to HFMG Senior Provider Recruiter, Ernesto D’Escoubet or call Ernesto at (321) 7254500 Ext 5582 to discuss the details. Visit myHFMG.org to learn more about Health First Medical Group. Icahn School of Medicine at Mount Sinai As an institutional priority, the Icahn School of Medicine is embarking on a new strategic initiative to further expand and incorporate innovations in care and research to the Mount Sinai Epilepsy Program. The Program has a presence throughout the Mount Sinai Health System with three NAEC Level 4 centers (two adult, one pediatric), located at Mount Sinai West, Mount Sinai Hospital, and Kravis Children’s Hospital. Routine, ambulatory, inpatient portable, and/or long-term video-EEG services are provided at additional locations including Mount Sinai-Downtown Union Square, Mount Sinai Beth Israel, Mount Sinai-St. Luke’s, Mount Sinai Queens, and South Nassau. Outpatient visits to adult providers exceed 4500 annually system-wide. The adult epilepsy program includes eight epilepsy faculty, several neuropsychologists, nurse practitioners, and a dietician, working collaboratively with two neurosurgeons. The program provides comprehensive epilepsy care as both a referral center for diagnostic challenges/second opinions and evaluation and management of drug resistant epilepsy. In addition to medical management, the program—in partnership with colleagues in the Department of Neurosurgery—is very active in epilepsy surgery, performing stereo EEG, resective surgery, laser ablation, responsive neurostimulation, and vagal nerve stimulation. A range of additional treatment and support services include ketogenic diet and support groups (online and in-person) are being developed or expanded. The position includes outpatient faculty practice time as well as epilepsy monitoring unit service at Mount Sinai Hospital, and includes interpretation of a wide range of EEG studies in adults and adolescents. We are particularly interested in increasing our outreach activities to ensure those with drug resistant epilepsy are referred for a comprehensive evaluation in a timely manner to optimize their care and determine their surgical candidacy, if appropriate. As such, the candidate will work closely with the Directors of the Epilepsy Program—Drs. Lara Marcuse and Madeline Fields--and other members of the epilepsy team to achieve the following goals: 1) Community outreach and education. The candidate will collaborate within the division and with other divisions of neurology under the umbrella of “Neurodocs”, to establish a multifaceted ‘academic detailing’ effort to provide subspecialty consultation and knowledge - sharing about advances and guidelines for epilepsy management, in the region. The candidate will be responsible for organizing and structuring the initiative; all epilepsy faculty plan to participate in the initiative. 2) Identification of potentially eligible referrals within Mount Sinai Health

AANnews • May 2018

System through Data Warehouse and faculty outreach. As part of a larger research and clinical care improvement initiative in the department, we are currently working to deploy health information technology resources to identify patients within our large health system who would potentially benefit from a comprehensive epilepsy center. This initiative is led by Dr. Nathalie Jette, Epileptologist and Chief, Division of Health Outcomes and Knowledge Translation Research, and Vice Chair, Neurology Clinical Research. The new faculty recruit will follow-up with providers for those individuals identified as potential referrals and implement educational strategies based on identified knowledge and practice needs. The Icahn School of Medicine at Mount Sinai is home to the Friedman Brain Institute, a large, multidisciplinary effort involving numerous basic science and clinical departments that incorporates all aspects of brain research, with considerable strengths in epilepsy. The ideal candidate will be a dynamic, board-certified adult epileptologist with excellent oral and written communication skills and exceptional at collaborative work. This individual will dedicate a majority of her/his academic effort providing education to community-based neurologists and primary care providers, as well as supporting other faculty epileptologists in outreach. The position also includes outpatient faculty practice time as well as epilepsy monitoring unit service at Mount Sinai Hospital, and it includes interpretation of a wide range of EEG studies in adults and adolescents. Salary commensurate with AAMC benchmarks by rank, region, and subspecialty. Contact Madeline Fields, MD; madeline.fields@mssm.edu, (212) 241.2627 Assistant/Associate Professor/Professor, MD or MD/PhD Neurologist Faculty Positions—Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases Neurologists with subspecialty training in Behavioral/Geriatric/Dementia/ Vascular/Movement Disorders/Sleep sought for tenure-track positions at the Assistant, Associate or full Professor levels in the Clinical Care and Clinical Research Core at the Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases (Biggs Institute) in the Joe R. and Teresa Lozano Long School of Medicine at UT Health San Antonio (UTHSA). We are seeking board certified neurologists interested in combining creative, comprehensive, compassionate clinical care for a broad range of memory and cognitive disorders, as part of a multi-disciplinary team of neurologists, neuropsychologists, nurses, social workers, geriatricians, geriatric psychiatrists, therapists, counselors and care managers, with rapid career advancement in the clinician-scientist, clinician-educator or leadership tracks. Physicians with experience caring for persons with Alzheimer’s disease or other dementias, experience conducting clinical trials (as PI or site PI) or interested in studying preclinical disease are especially welcome. The Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, at UT Health San Antonio in the Joe R. and Teresa Lozano Long School of Medicine, is being established with a vision to transform dementia care in South Texas and accelerate the international race towards effective prevention and treatment. We seek physicians and scientists who are passionate about their work, creative, articulate and enjoy working as generous contributors within a multidimensional team. Salary, benefits, resources and opportunities for rapid career advancement will be excellent for the right candidates and commensurate with their experience, record and future potential. The Biggs Institute is being established as a flagship, free-standing institute within UTHSA to provide superb clinical care to all persons, and undertake innovative and important research into the prevention and treatment of Alzheimer’s Disease and other neurodegenerative conditions, including vascular contributions to dementia, Parkinson’s and Lewy body dementia, chronic traumatic encephalopathy and frontotemporal dementia. It has strong institutional and community support, substantial philanthropic and NIH funding, and will benefit from existing resources within UTHSA such as the Barshop Institute for Longevity and Aging Studies, the Center for Biomedical Neuroscience, the Research Imaging Institute along with the San Antonio campus of the UT Health Houston School of Public Health. In addition, there will be opportunities for immersive, collaborative research within the Framingham

Heart Study, the Cohorts for Heart and Aging Research in Genomic Epidemiology, the Cross-Cohorts Collaboration Consortium, the International Genomics of Alzheimer’s Project, the Alzheimer’s Disease Sequencing Project, the International Stroke Genetics Consortium and other consortia in which the founding director of the Biggs Institute, Dr. Sudha Seshadri, has a leadership role. The Biggs Institute will be comprised of 5 closely integrated cores: a Clinical Care and Clinical Research Core, a Population Neuroscience Core, a Biological and Innovative Research Core, an Education, Ethics and Training Core and a Public Health, Policy and Community Engagement Core. We are seeking up to 3 neurologists who are empathic and engaged clinicians, enthusiastic educators, generous team members and dynamic leaders who want to make a difference. Selected candidates will be expected to see patients at the Biggs Center outpatient clinics for 20–60% of their time and this may be combined with other outpatient and inpatient clinical responsibilities tailored to the neurologist’s preferences. There are opportunities in general neurology, stroke, movement disorders, sleep, neuromuscular and epilepsy divisions within the Department of Neurology. They will be supported with time and resources to provide superb clinical care to a large, clinically, financially and ethnically diverse patient population at the only academic medical school in the 7th largest (and fastest growing) city in the United States. Selected faculty will be afforded protected time and collaborative opportunities for their research, teaching or administrative interests and personalized mentoring from a team of suitable, experienced career and research mentors for rapid career advancement; this will include strong support to obtain K, R01, foundation and philanthropic funding. Salary and benefits will be competitive and will consider the candidates training, clinical, teaching and administrative experience, publications and research/grant funding. Appointments will be on a rolling basis as suitable candidates are identified. San Antonio is a historic, family-friendly city with a low cost of living, good schools and superb outdoor and cultural opportunities. The appointment will be at the Biggs Institute with an academic appointment within the Department of Neurology. The selected candidate(s) will report directly to Prof. Sudha Seshadri and to the Chair of Neurology, Prof. Robin Brey. Additional crossappointments may be feasible in relevant parent departments such as Neurosurgery, Psychiatry, Medicine, Radiology, an appropriate basic science department or at the Audie Murphy VA. For full consideration, please visit the UT Health Careers Faculty applicant portal at: uthscsa.edu/hr/employment.asp to apply for position number 18000015 and upload 1) a cover letter stating career goals and the relevance of the candidate’s training and experience to the position; 2) a current CV; 3) a personal statement describing the candidate’s clinical, administrative and teaching experience; and 4) names and contact information of three references. UT Health San Antonio is an Equal Employment Opportunity/Affirmative Action Employer including protected veterans and persons with disabilities. All faculty appointments are designated as security sensitive positions. Questions? Contact sylvan@uthscsa.edu or (210) 450.8437

AANnews® Classified Advertising he AAN offers a complete package of print, online, T and in-person recruitment advertising opportunities. Visit careers.AAN.com for all AAN options, rates, and deadlines. d copy for the July 2018 print edition of AANnews A must be submitted by June 1, 2018. The same deadline applies to changes/cancellations. he American Academy of Neurology reserves the T right to decline, withdraw, or edit advertisements at its discretion. Every care is taken to avoid mistakes, but the responsibility for clerical or printer errors does not exceed the cost of the ad.

Dates & Deadlines

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JUNE 2018

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JULY 2018

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MAY 1

JUNE 1

JULY 2

Webinar: Building Better Care Teams: Integrating APPs into Your Practice (Register by April 30) AAN.com/view/pmw18

Deadline: UCNS Fellowship Training Program Application Deadline UCNS.org

Deadline: UCNS Neurocritical Care Recertification Examination Application (Early application deadline July 2; late application deadline July 16) UCNS.org/go/subspecialty/neurocritical/ certification

MAY 1

JUNE 4

Deadline: UCNS Autonomic Disorders Certification Applications UCNS.org/go/subspecialty/autonomic/ certification

Leadership Program Application Deadline: Transforming Leaders, Emerging Leaders, Women Leading in Neurology, and Practice Leadership AAN.com/view/Lead

MAY 1

JUNE 14

Deadline: UCNS Behavioral Neurology & Neuropsychiatry Certification and Recertification Applications UCNS.org/go/subspecialty/behavioral/ certification

MAY 7 Deadline: Sports Concussion Conference Abstract Submissions AAN.com/view/ConcussionConference

MAY 22 Webinar: Managing Headache Without Giving Yourself One: Using Tools and Technologies for Better Practice Management (Register by May 21) AAN.com/view/pmw18

JULY 20–22, 2018 Sports Concussion Conference Indianapolis, IN AAN.com/view/SCC

Early Registration and Hotel Deadline: Sports Concussion Conference Indianapolis, IN AAN.com/view/ConcussionConference

JUNE 19 Webinar: 5 Benchmarks That Can Make or Break Your Practice (Register by June 18) AAN.com/view/pmw18

Neurology Disputes & Debates:

Join the Discussion!

Comment on Neurology® journal articles and read what others are saying at Neurology.org/N

AANnews • May 2018 31

PHARMA AD A deeper look at the science behind migraine

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