2018 October AANnews by American Academy of Neurology

VOLUME 32 · ISSUE 10 · OCTOBER 2018

ANNUAL MEETING EDUCATION HIGHLIGHTS Features Robust Friday Finale The record-setting 2018 Annual Meeting was the most innovative to date, providing a unique and creative experience for the more than 14,000 neurology professionals who attended, and 2019 in Philly will further advance the focus on innovation and inspiration. Whether you’re a clinician, researcher, resident, student, or other neurology professional—and no matter what your subspecialty area of interest—the 71st AAN Annual Meeting is gearing up to offer even more neurology inspiration to fuel your mind, body, and spirit in a fully flexible and customizable format so you can get the most out of your week.

Friday Grand Finale Program While you’ll find fresh and creative education content all week long through more than 200 expert-led courses and experiential learning areas covering the full spectrum of neurology, you’ll want to make sure and stay until the end of the week to take in this year’s enhanced Friday experience, including a new innovation lunch with can’t-miss scientific presentations and new Education Blitz programs bringing you up-to-date in an energetic one-hour format. Continued on page 19

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Registration Still Available for This Month’s Fall Conference

President’s Column

Online and on-site registration are still available for this month’s Fall Conference, taking place October 26 through 28 at the Cosmopolitan of Las Vegas. Secure your OCTOBER 26–28 The Cosmopolitan of Las Vegas spot now for the most compelling Fall Conference yet, featuring the latest updates in neurology, most useful practice management tips, and valuable CME credits you’ve come to expect, with an expanded curriculum that includes Continued on page 17

12 Webinar Highlights Role of Health Services Research Subcommittee

AAN Continues to Fight Back on Proposed Medicare Fee Changes AAN President Ralph L. Sacco, MD, MS, FAHA, FAAN, explains how the AAN is fighting against proposed changes to the Medicare fee schedule and how you can prepare in case they are part of the final rule issued in November. 

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18 Annual Meeting Abstract Submission Deadline Is October 22

Continued on page 4

31 AAN Joins Forces with Target ALS on New Research Opportunity

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In Multiple Sclerosis–

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AANnews · October 2018

CONTENTS

NEWS BRIEFS

Cover Annual Meeting Education Highlights Registration Still Available for This Month’s Fall Conference

Graduate Learns to Lead ‘From the Inside Out’ · · · · · · · · 22 October 15 Is Deadline for 2019 Diversity Leadership Program · · · · · · · · · · · · · · ·

President’s Column AAN Continues to Fight Back on Proposed Medicare Fee Changes

Journal Studies, Sports Concussion Conference Draw Media Coverage · · · · · · · 23

Through Their Eyes Recollections of Past AAN Presidents · · · · · · · · · 8

Policy & Guidelines Educating Congress—at Home and in DC—on the Neurology Perspective in Health Care · · · · 24

Tools & Resources Up to Five Percent of Your Medicare Payments Are at Risk—Are You Ready? · · · · · · · 10

Capitol Hill Report · · · · · · · · ·

She’s a Neuroscientist—and She Plays One on TV! · · · · · · ·

Education & Research AAN Joins Forces with Target ALS on New Research Opportunity · · · · · · · · · · · · · · 31

AAN Gets UnitedHealthcare to Revise IONM Policy · · · · · · · ·

Webinar Highlights Role of Health Services Research Subcommittee · · · · · · · · · ·

Practice Leadership Program Graduates Develop New Practice Support Network · · · ·

Conferences & Community Annual Meeting Abstract Submission Deadline Is October 22 · · · · · · · · · · · · · · 18 Applications Opening Soon for Exhibit Opportunities During 2019 Annual Meeting · · · · · · ·

Elevate Your Status, Enhance Your Professional Credentials with FAAN Designation · · · · · ·

October 24 Is Application Deadline for 2019 AAN Awards ·

UCNS Accreditation Application Deadline Is December 1 · · · · · · 32 Neuro-oncology Certification Applications Now Available · · · · 32 Neuroinfectious Disease Is Focus of This Month’s Continuum · · · · · · · · · · · · · · · 33

Dates & Deadlines · · · · · · · · 35 American Brain Foundation Speak Volumes with Easy Dues Check-off Donation · · · · · · · · · 36 Careers · · · · · · · · · · · · · · · 37

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

A work group that was formed following the first Neurology Department Chair Summit in March, hosted by the AAN in collaboration with the American Neurological Association and the Association of University Professors of Neurology, has been meeting monthly to work to maximize the effectiveness of the AAN’s support for academic neurology. Chaired by AAN President Ralph L. Sacco, MD, MS, FAHA, FAAN, the work group is currently focused on how to better meet the needs of business administrators in academic centers. As a part of the AAN’s Neuroscience Is…TM initiative, the Neuroscience Is… Rewarding Internship was piloted to AAN members and 21 high-quality applications were received. Ten internship scholarships were awarded to AAN member applicants to provide college students an experience working in neuroscience and exposure to patient care in neurology. These internships allow for a variety of hands-on experiences in both a research and clinical setting, direct mentoring from the AAN member, and the creation of an educational product that promotes interest in neuroscience and neurology in the community. For more information, visit AAN.com/education-and-research/ neuroscience-is. The redesign of AAN.com won a 2018 National Communicators Award for Website Excellence in the category of General-Science. 

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 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

AAN Continues to Fight Back on Proposed Medicare Fee Changes Advocacy continues to be an incredibly key mission for the AAN as we do everything we can to enhance career satisfaction, improve the quality of care, and reduce regulatory burden while fighting to increase reimbursement for our services. Since mid-July, we have alerted members to the alarming fact that the Centers for Medicare & Medicaid Services (CMS) has included possible cuts to evaluation and management codes (E/M) in the proposed Medicare Physician Fee Schedule for 2019. The AAN is vigorously fighting the proposed cuts and encouraging members to put pressure on CMS and Congress to abandon this short-sighted proposal. Sacco

Every member should know what the AAN is doing to fight back this proposal. I want to use this President’s Column to review the situation and the actions we’ve taken and are continuing to pursue.

What changes is CMS proposing? In its proposed rule for 2019, CMS suggests reducing documentation requirements for E/M services and paying physicians $134 for each new E/M patient visit, regardless of complexity or length of visit, and $92 for each established patient visit.

How might these changes impact neurologists? By collapsing E/M levels 2–5 into one payment, CMS offers to reduce some administrative burden, which typically we would welcome. But this “flattening” is not, in our estimation, worth the hurtful impact of reduced reimbursement.

How might these changes impact patients? The proposed changes would offer a flat fee for each office visit with a patient, regardless if it’s a simple patient visit or a more complex, lengthy visit. This negatively impacts the patient who presents with multiple issues. These coding changes may mean that complex patients will need to make multiple office visits to handle all of their problems, putting even more strain on access to neurologic care and increasing the cost burden on the patient. Moreover, some physicians also may stop taking Medicare patients altogether. Devaluing the time that neurologists spend with patients is not an acceptable path.

Met with key staff and individual members of the House Energy & Commerce and Ways & Means Committees and the Senate Finance Committee, which have jurisdiction over CMS decisions that affect neurologists Urged multiple members of the House and Senate to contact CMS in opposition to the proposed E/M cuts Sent an Action Alert email to Academy members asking you to reach out to your congressional members seeking their support to oppose these CMS changes

How has the AAN communicated this to members? The AAN wants to make sure that all our members understand what is happening and what the AAN is doing to protect you and your patients. We have made communication about these proposed rules a top priority and have leveraged all member communications channels to ensure you that we are doing everything we can to fight back. Since the proposed rule was issued in July, members have seen the latest updates in: Capitol Hill Report featuring AAN member leaders and their meetings with key lawmakers and regulators

What is the AAN doing to fight these changes?

AAN.com—home page story

The AAN has sent formal comments to CMS through multiple channels. In Washington, DC, our regulatory and legislative physician leaders and staff launched a face-to-face campaign, pleading our case to lawmakers and regulators. To date, the AAN has:

Letter from myself mailed to all US members

Expressed our deep concerns to top officials at the Department of Health & Human Services and CMS about the impact of the proposed cuts on neurologists and their patients Allied with the American College of Rheumatology and the Community Oncology Alliance to raise awareness on Capitol Hill of the proposed cuts to E/M reimbursement

Signed onto multiple letters opposing these cuts, including letters from the American Medical Association and the Coalition for Patient Centered Evaluation and Management Services

AANnews • October 2018

AANe-news™ (biweekly) headline AANnews® stories Leadership Updates Social media—posts of Capitol Hill Report, miscellaneous retweets Media coverage—Policy and Medicine, Inside Health, Politico Neurology Today® story

How is the AAN informing the public? The AAN has connected with several national patient groups and will continue to expand outreach as the strategy is refined. We need to educate our patients about the potential negative impact these CMS changes could have to their care and energize them to join us as part of the opposition. Once CMS releases the final rule, the AAN will re-engage the patient advocacy groups based on the outcome of the final rule.

What can members do? As the AAN continues to push back on this high level, there are steps you should take now to be prepared for the CMS announcement in November. Continue to make your voice heard about your opposition to these CMS rule changes. Tweet your concerns using #ProtectTimeWithPatients and #AANadvocacy. Review your practice’s historical billing on outpatient E/M services to gain an understanding of the financial impact the proposed collapsed payment structure could have on your practice, should it be finalized by CMS. Visit the Medicare Payments page at bit.ly/2Kp4Ced to use an E/M calculator. Review your practice’s time data associated with each

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that may be necessary in the event that the new payment structure is passed in the final rule. Explore alternate staffing models (e.g., advance practice providers) that could help minimize the financial impact to your bottom line in the event that outpatient E/M service times and payment changes for 2019. Consider your Medicare participation options. Physicians may be participating, non-participating, or private contracting. CMS is expected to announce its final rule in early November. We hope all of our members know how serious we consider this issue and every step we are taking to oppose these changes. We will continue to press on this issue daily, right to the end. Thanks for helping us fight to maintain the highest quality neurologic care. To get the most up-to-date news on this topic, visit AAN.com/view/SpeakOutNow. 

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

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Through Their Eyes

Recollections of Past AAN Presidents Stephen M. Sergay, MB BCh, FAAN AAN President 2007−2009 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 Stephen M. Sergay, MB Bch, FAAN (SS), conducted by AANnews editor Tim Streeter (TS). TS: During your term, the Future of the Profession and the AAN Taskforce [FPAAN] was formed. What was its purpose, and what did it accomplish? SS: In my two years as president elect, I read a lot and I dreamed what was, maybe, missing from the Academy that could be done better, and what were the threats that the Academy and the profession of neurology faced. I came to realize that the threats to the Academy are of one kind, and the threats to the profession are of a different kind. Both need to be paid attention to. So, I drew up a method of handling that and I wanted that to be a main thing for myself, as president, that would be the platform I’d like to move forward. I called it the “FPAAN.” That was the Future of the Profession and the Academy, and that both needed full attention. TS: Can you tell me what those threats were that you saw? SS: The threats were, from the point of view of the profession, it was all the changes that the country and the world is going through because of the scientific revolution, and the cultural things that we’ve been living with, the growing US population, the polyglot nature of the US population, the cost of care—all of those things that could directly impact the profession. And, if they had a negative impact on the profession, it could affect the Academy, but the way it was going to impact the profession needed to be carefully scrutinized and managed. The Academy—and my major issue with the Academy was not the staff because I was always comfortable with the staff—but my major issue was that the debates in the board weren’t always based on context, because there are many contexts out there and everybody had different views of what context was. Secondly, there was not really a deeply thought-through question before the debates came about, and so, the board meetings were nice happy places of people giving their opinion, but I felt like the Academy was a mature enough organization that it needed to move forward from an opinion board to a data-informed board. The saying “informed” rather than “driven” because there are emotions and feelings and philosophies that are far beyond data. So, it had to be data-informed, and then I thought the debate would really be meaningful. It would be more exciting to be on the board; the board would keep up with all of the breaking issues in neurology, and I thought it would be a better board and would be better for the organization. I had hopes to plan for both and, like any change, there’s all

AANnews • October 2018

kinds of difficulties when one attempts to accomplish that. That was what my focus was. I actually went into the presidency with two focuses, and the FPAAN was one of them, and the other one was to try to define what the issues were that doctors were facing. In my second year as Academy president, I actually developed that philosophy and tried to get myself invited to many medical schools to talk about it, so I could be criticized, and then I could really see my way clear more easily. That led to my presidential address, ultimately, at the end of my presidency. I had a spectacular two years—a wonderful two years as president—a life-changing two years. Two years I’ll never forget. TS: In the middle of your term, the great recession hit. That affected everybody; that certainly affected the Academy’s outlook as to revenue, and such. What steps did the Academy take to protect itself? SS: We had lots of debates, but the debating that we did as the docs in the Academy, I suspect, was one-tenth of what was going on in the executive office. That was an expense that could be directly controlled. I think the staff was spectacular in the accomplishments during that time of

Sergay (second from left) with Drs. Kenneth M. Viste, Jr.; Michael L. Goldstein; and Jack P. Whisnant in Washington, DC, 1992.

preventing any significant damage to the programs that we were trying to deliver to the members, and in maintaining the fluidity of the economy of the Academy. I think Cathy [Executive Director/CEO Catherine M. Rydell, CAE] could probably take the credit and probably discuss that on a staff level far more meaningfully than I could. From my perspective, when I saw that coming and I understood what was happening also in practice, with the expense ratios and so on, and I knew the Academy’s state of financial health, I always felt it very important to try not to ever increase the cost of the meeting or the cost of the dues to people who wanted to come to the meeting. The lifeblood of the Academy was keeping people comfortable in their practice and coming to the Annual Meeting. If we could earn other than by dues, it would be a really good thing. TS: There was a shift in the board, and you alluded to this earlier, to becoming more of a strategic focus body rather than micromanaging the day-to-day tactics. Why did that come about? SS: Well, during my time of trying to put forward the FPAAN issues, that was the focus, that that should be the outcome of that program—that discussion—that, ultimately, we should have a far more strategic board. I could never have done that on my own; I might have brought up the idea. [Future AAN President] Terry Cascino, who was a young neurologist in those days and was very helpful for me in bringing that through. Changing legislation takes more than a horse; it takes several horses to be in the race, and he really had done strategic planning, himself, at Mayo, and understood the issues far better than I did. I understood the concept; he understood some of the issues. Collectively, that helped move the board forward. I think that if the board had not wanted that, it would not have gone forward. So, it really required the acceptance by the board and by the Academy staff, that that was a valuable way to move forward.

the way and move different things forward. That wasn’t the case with us. I had been vice president and then I actually stepped down from the opportunity to repeat that during [President] Stan Fahn’s time. I did that to develop the UCNS, and I was very happy for that experience of developing the UCNS. So, I did not go into the Academy presidency expecting more than two years. I didn’t feel like I was unfinished, so to speak. My two major things that I wanted to accomplish, I think I set them both in process. I think that had I had another year, I might have done more, not on the strategy side because that was happening, but in trying to define how we in medicine should interact with the people who are trying to define medicine for us. I don’t think people understand what the issues are in caregiving, and that—in people who try to plan for medical care delivery without understanding those issues—it’s just a matter of time until that falls short. I would have loved to have done more about that at that particular time, but, time was up. As I was told when I was president, the most important thing about being president is to learn how to be past president, which means biting your tongue, so that’s what it is. Visit AAN.com/view/AANhistory to read the complete transcript of Sergay’s interview and learn about how his views were shaped by growing up in Johannesburg, South Africa, and how he was instrumental in establishing the United Council of Neurologic Subspecialties. 

Stephen M. Sergay, MB BCh, FAAN, during the “Hall of Presidents” session at the 2017 Annual Meeting in Boston.

TS: The Academy adopted a new vision and mission statement at that time. Do you recall the reason for refreshing that? SS: Well, there’s always a reason to refresh that because things change, and if you can really have a vision and a mission that is unchanging, then you haven’t kept up with the times. That was the time to look at it again, particularly, in light of the process of strategic planning that we had been through. Again, Terry was helpful, and Cathy was helpful with the formulation of that. TS: Two years is a very brief time to be president. Were there things that you were—what were some of the things that you were the proudest of accomplishing, and what were some of the things—or one thing—that you wish you had had more time to work on? SS: The way the Academy is now set up will make that never be a problem for people because one goes through the vice presidency, president-elect, presidency, the whole evolution of that person allows that person to define things along

AANnews • October 2018 9

Tools & Resources

Up to Five Percent of Your Medicare Payments Are at Risk— Are You Ready? Satisfy Your MIPS Requirements with the Axon Registry or MIPSwizard The AAN’s Axon Registry ® and MIPSwizard can assist eligible clinicians and group practices in avoiding the maximum penalty and achieving the maximum incentive for the 2018 Merit-based Incentive Payment System (MIPS) performance year.

What’s at risk?

About the Axon Registry

This year, the Quality Payment Program (QPP) added in some exemptions for smaller practices and those hit hardest by extreme circumstances, such as natural disasters, to help reduce some of the burdens of the ongoing process. However, if your practice does not fall into these categories, be aware that the cost for not participating in MIPS is steep. You stand to lose five percent of each 2020 Medicare reimbursement.

The Axon Registry is a Qualified Clinical Data Registry (QCDR), meaning it’s able to collect performance rates on neurology measures that can’t be collected by any other method in the MIPS program. Axon is a free AAN US member benefit with 40 neurology-specific quality measures that are automatically calculated by extracting data directly from your EMR system. In addition, the MIPS dashboard can be used to submit Promoting Interoperability criteria and Improvement Activities.

How do I get started?

About MIPSwizard

Consider using the Axon Registry or MIPSwizard to report for MIPS. The Axon Registry was created by the AAN and is offered for free to AAN US members. More than 230 practices are currently participating.

MIPSwizard is an easy-to-use online manual submission tool to help eligible clinicians quickly and easily participate in MIPS. Similar to online tax preparation software, the MIPSwizard helps guide clinicians through a few easy steps to rapidly collect, validate, and submit their results to CMS. MIPSwizard is powered by the Premier Inc. registry, a CMS qualified registry for MIPS reporting.

Tens of thousands of providers rely on MIPSwizard to annually submit their MIPS reporting. This year, the AAN continues to offer members an exclusive discounted rate of $100 off MIPSwizard. Visit aanmipswizard.com to register today.

Before you make your reporting selection, you can access all of the available MIPS reporting products including the Specialty Measures Sets and Individual Measures options for eligible clinicians. Regardless of the type of reporting selected, both options guide users through the steps for reporting to ensure that requirements are satisfied. 

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy Falls: Querying About Falls for Patients Headache: Medication Prescribed for Acute Migraine Attack Total

Parkinson's: Psychiatric Symptoms Assessment ALS: End of Life Planning Assistance

AANnews • October 2018

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She’s a Neuroscientist—and She Plays One on TV! The cover story for the October/November 2018 issue of Brain & Life® (formerly Neurology Now ®) features actress Mayim Bialik, who has a PhD in neuroscience and plays a neuroscientist on television’s "The Big Bang Theory." She’s also written several parenting books and books for teens, including one for girls about growing up to be smart, spectacular, and successful. Bialik did her dissertation on OCD in adolescents with Prader-Willi syndrome. She shares how she uses her visibility to encourage science in young people. Other features in this issue look at how research into young-onset Alzheimer’s disease is helping scientists understand more about the disease in general, as well as the promise of cannabidiol therapies following the FDA’s recent approval of an oral solution of cannabidiol to treat children with Lennox-Gastaut syndrome, a severe form of childhood epilepsy. Brain & Life and its companion patient website BrainandLife.org debuted in April. The magazine and website provide the same trusted, neurologistapproved information for patients, families, and caregivers as Neurology Now did with a fresh new look.

Additional copies are mailed to our subscribers. Quantities of Spanish copies can be requested or changed at BeGreen@WasteFreeMail.com. Brain & Life is a free resource to AAN members in the United States to distribute to patients, who also can subscribe for free. If you need to adjust the number of copies you receive for your patients or update your clinic address, visit BrainandLife.org or email BeGreen@WasteFreeMail.com. 

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Also publishing in October is the fall quarterly issue of Brain & Life® en Español, with a profile of Alfredo Quiñones Hinojosa, MD, a Mayo Clinic neurosurgeon. This free Spanish-language version of the magazine is sent to AAN member offices in areas with large Hispanic and Latino populations to distribute to their patients.

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AAN Gets UnitedHealthcare to Revise IONM Policy Based on AAN feedback, UnitedHealthcare (UHC) revised changes to its IONM coverage policy that was due to go into effect September 1. Originally, UHC cited the AAN IOM Model Coverage Policy to justify its decision to restrict reimbursement for codes 95940 and 95941 to sites of service 19, 21, and 22, excluding site

that it cover IONM performed at site of service 24 as well as 19, 21, and 22. In its September bulletin, UHC announced that it have revised its new IONM policy to include consideration of site 24. 

of service 24. Members of the original model coverage policy author panel confirmed that listing hospital sites was meant as guidance and agreed POS 19 and 24 should be included. The AAN Board of Directors approved an amendment to the model coverage policy, and the Payment Policy Subcommittee sent the amended policy and a comment letter to UHC requesting

AANnews • October 2018 11

Tools & Resources

Webinar Highlights Role of Health Services Research Subcommittee The October 23 practice management webinar “How Does Health Services Research Help Me?” is the first hosted by members of the AAN’s Health Services Research Subcommittee. The webinar will explain the different tracks within this broad field of study, outline how the AAN is using this information to support its members, and demonstrate how you can use health services research to influence your practice. Identifying value is one of the pivotal components of the AAN’s mission of being indispensable to its members. By providing evidence that demonstrates the value of neurologists, health services research can arm neurology advocates. In order to effectively understand and improve the regulatory environment, the subcommittee provides quantitative and qualitative evidence such as the paper “The Association of Neurologists with Headache Health Care Utilization Costs,” published in the February 6, 2018, issue of Neurology ® (available at n.neurology.org/content/90/6/e525). The subcommittee is currently exploring topics such as out-ofpocket drug costs and medication adherence. The current charge of the Health Services Research Subcommittee is to identify effective and efficient health care delivery models involving neurologists by: Evaluating the impact of neurologists on the care of patients (i.e., value of neurologists) Evaluating the impact of health care reform on neurologists (i.e., policy evaluations) Creating a national focus and community for health services research in neurology A private Health Services Research community has been created as part of the SynapseSM online communities to unify researchers in this growing field. For more information about joining this community, contact Brandon Magliocco at bmagliocco@aan.com. 

How Does Health Services Research Help Me? October 23, 2018 12:00 p.m.–1:00 p.m. ET Deadline to Register: October 22 Faculty: Gregory J. Esper, MD, MBA, FAAN You can purchase this single webinar for $99 or subscribe to the complete series of 2018 webinars for only $189—that’s less than $19 per webinar! All webinars are now available in the new AAN Online Learning Center and feature:

Esper

Convenient one-hour live webinar sessions from 12:00 p.m.–1:00 p.m. ET On-demand access to webinar recording and presentation slides if you miss the live event 1 AMA PRA Category 1 Credit™ per webinar for physicians, or certificate of completion for nonphysicians Visit AAN.com/view/pmw18 to learn more and register or contact Jessica Nickrand at jnickrand@aan.com. 

How Does Health Services Research Help Me?

Practice Leadership Program Graduates Develop New Practice Support Network The group of AAN members who graduated from the Practice Leadership Program in 2018 decided they wanted to give back to the AAN. Out of this desire, they worked with Academy to create the new Practice Support Network to better facilitate answering member questions directed to the practice@aan.com inbox. The practice@aan.com inbox was a concept generated by the Small and Solo Task Force in 2016. Members direct their questions regarding practice issues—such as payers, MIPS/ MACRA, coding, and practice management—to this email address, and staff members respond within one business day. Now, staff has the additional assistance from a group of practicing neurologists comprising the Practice Support Network. “The 10 Practice Leadership Program graduates met at the Annual Meeting in Los Angeles and brainstormed how we could ‘give back’ to the AAN,” said participant Michael E. Markowski, DO, FAAN. “We proposed a system to assist our fellow neurologists in practice, in particular those who may be geographically isolated or unable to take advantage of some of the AAN resources through Annual Meetings or leadership programs. We felt this would be the best way for CESC: 18 Scientific Awards Ad—Half Horizontal> AN our colleagues neurologists toFiller support eachPage other, in particular Placed in AANnews 8.25 x TBD +0.125 bleed, 4C

struggling with practice-related issues. Over the course of the meeting, we met with multiple AAN staff members and learned that neurologists contact the AAN regularly with a variety of practice-related questions, many of which may be best answered by a practicing neurologist. I Markowski have seen firsthand over many years that the AAN has incredible staff throughout the organization, however, many member questions could be best addressed by a neurologist who has encountered that same issue and is better able to provide advice based on shared experiences. These discussions ultimately led to the creation of the AAN’s new Practice Support Network.” Questions submitted by members to the practice@aan.com inbox are stripped of identifying information for anonymity and forwarded to members of the Practice Support Network. Their insights are then returned, anonymously, by staff to the questioner. In this way, members are free to ask potentially sensitive questions regarding fees, compensation, or legal issues (which is not possible with our other popular collaborative resource, the SynapseSM online communities). 

IMPORTANT DATES AND DEADLINES Don’t miss these important dates for the 2019 AAN Annual Meeting, set for May 4-10, 2019 in Philadelphia.

Learn more at AAN.com/view/AM19 Abstract Submission Deadline: October 22, 2018 Awards Application Deadline: October 24, 2018

ADVANCING NEUROLOGY. ADVANCING YOU.

AANnews • October 2018 13

Give Patients with ALS a Chance.

Help Slow the Decline in Functional Loss. Shown to slow the decline of physical function in patients with ALS1 In the treatment of amyotrophic lateral sclerosis (ALS), every move matters. As you decide the next move for your patients, consider Radicava® (edaravone), the only FDA-approved treatment option for patients with ALS in the last 20 years.1,2 33% less change in total ALS Functional Rating Scale–Revised (ALSFRS-R) scores vs placebo1,* Safety profile established with 300+ patients in 3 clinical trials1 Product access programs from Searchlight Support™ *In a 6-month study of 137 participants.1 Individual results may vary.

2000+ PATIENTS

Treated With Radicava® In the US as of March 1, 2018

Indication Radicava® (edaravone) is indicated for the treatment of amyotrophic lateral sclerosis (ALS).

Important Safety Information Hypersensitivity Reactions Radicava® is contraindicated in patients with a history of hypersensitivity to edaravone or any of the inactive ingredients in Radicava®. Hypersensitivity reactions (redness, wheals, and erythema multiforme) and cases of anaphylaxis (urticaria, decreased blood pressure, and dyspnea) have been reported. Patients should be monitored carefully for hypersensitivity reactions, and if they occur, discontinue Radicava®, treat per standard of care, and monitor until the condition resolves.

Overall shift in point loss between Change in ALSFRS-R scores over 24 weeks treatment groups at 6 months1,3 Patients who : 1,3

Lost

39.1%

Lost

≥11 points

53.6

% 63.2 %

63.2% (n=43)

(n=43)

13.2%

23.5%

(n=9)

13.2%

7.2%

(n=16)

(n=5)

Lost

Actor portrayals. Lost

≤2

points

Lost

3-10

≥11

10 lost ≤2 points vs those given placebo 10

= one patient

5 23.5% 3X as many patients given placebo (n=16) % lost ≥11 points vs those given Radicava® 7.2 5

(n=5)

0 –1 –2

Radicava (n=69)

–3 –4 –5 –6 –7 –8 –9 –10

0 –1 –2

–3 –4 –5 –6

–11 –12 –13 –14 –15 –16 –17 –18 –19 –20

Placebo (n=68)

Point Change in ALSFRS-R Score

Placebo (n=68)

This shift in distribution demonstrates that a majority of patients responded to treatment—not a specific subtype of patient.3 Discover more at Radicava.com/move Sulfite Allergic Reactions Radicava® contains sodium bisulfite, and may cause allergic type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown, but occurs more frequently in asthmatic people.

points 3X aspoints many patients given Radicava®points

0 Radicava (n=69)

Number of

≥11 points

≤2

(n=37)

39.1 % 53.6(n=27)

Lost

Number of Radicava patients (n=69) who1,2:

(n=37)

(n=27)

(n=9)

3-10 points

Number of Patients

Percent of Patients

≤2 points Percent of Patients

Lost 100

Lost

Number of Patients

≤2

Change in ALSFRS-RLost scores over 24 weeks points 1,3 100 Patients who :

Geriatric Use No overall differences in safety or effectiveness were observed between patients 65 years of age and older and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Most Common Adverse Reactions Most common adverse reactions (at least 10% and greater than placebo) are contusion, gait disturbance, and headache.

To report suspected adverse reactions or product complaints, contact Mitsubishi Tanabe Pharma America, Inc., at 1-888-292-0058. You may also report suspected adverse reactions to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Pregnancy Based on animal data, Radicava® may cause fetal harm.

Please see brief summary of the full Prescribing Information on the next page.

References: 1. Radicava Prescribing Information. Jersey City, NJ: Mitsubishi Tanabe Pharma America; 2017. 2. Rilutek Prescribing Information. Cary, NC: Covis Pharmaceuticals Inc.; 2016. 3. Takei K, Takahashi F, Liu S, Tsuda K, Palumbo J. Post-hoc analysis of randomised, placebo-controlled, double-blind study (MCI186-19) of edaravone (MCI-186) in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener. 2017;18(sup 1):49-54.

Radicava, the Radicava logo, and the corporate symbol of Mitsubishi Tanabe Pharma America are registered trademarks of Mitsubishi Tanabe Pharma Corporation. Searchlight Support is a trademark of Mitsubishi Tanabe Pharma America, Inc. For US audiences only. © 2018 Mitsubishi Tanabe Pharma America, Inc. All rights reserved. CP-RC-US-0503 06/18

Brief Summary of Full Prescribing Information INDICATIONS AND USAGE RADICAVA (edaravone injection) is indicated for the treatment of amyotrophic lateral sclerosis (ALS). CONTRAINDICATIONS RADICAVA is contraindicated in patients with a history of hypersensitivity to edaravone or any of the inactive ingredients of this product. Hypersensitivity reactions and anaphylactic reactions have occurred [see Warnings and Precautions]. WARNINGS AND PRECAUTIONS Hypersensitivity Reactions

Hypersensitivity reactions (redness, wheals, and erythema multiforme) and cases of anaphylaxis (urticaria, decreased blood pressure, and dyspnea) have been reported in spontaneous postmarketing reports with RADICAVA. Patients should be monitored carefully for hypersensitivity reactions. If hypersensitivity reactions occur, discontinue RADICAVA, treat per standard of care, and monitor until the condition resolves [see Contraindications]. Sulfite Allergic Reactions

RADICAVA contains sodium bisulfite, a sulfite that may cause allergic type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown. Sulfite sensitivity occurs more frequently in asthmatic people. ADVERSE REACTIONS The following serious adverse reactions are described elsewhere in the labeling: • Hypersensitivity Reactions [see Warnings and Precautions] • Sulfite Allergic Reactions [see Warnings and Precautions] Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the 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 practice. In randomized, placebo-controlled trials, 184 ALS patients were administered RADICAVA 60 mg in treatment cycles for 6 months. The population consisted of Japanese patients who had a median age of 60 years (range 29-75) and were 59% male. Most (93%) of these patients were living independently at the time of screening. Most Common Adverse Reactions Observed During Clinical Studies

Adverse reactions that occurred in ≥ 2% of patients in the RADICAVA-treated group and that occurred at least 2% more frequently than in the placebo-treated group in randomized placebo-controlled ALS trials were as follows for RADICAVA (N=184) versus Placebo (N=184), respectively: Contusion (15% versus 9%), Gait disturbance (13% versus 9%), Headache (10% versus 6%), Dermatitis (8% versus 5%), Eczema (7% versus 4%), Respiratory failure, respiratory disorder, hypoxia (6% versus 4%), Glycosuria (4% versus 2%), Tinea infection (4% versus 2%). Results are from pooled placebo-controlled studies including two additional studies with 231 additional patients, all using the same treatment regimen. The most common adverse reactions that occurred in ≥10% of RADICAVA-treated patients were contusion, gait disturbance, and headache. Postmarketing Experience The following adverse reactions have been identified during postapproval use of RADICAVA outside of the United States. 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. Skin and subcutaneous tissue disorders: Hypersensitivity reactions and anaphylaxis. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary

There are no adequate data on the developmental risk associated with the use of RADICAVA in pregnant women. In animal studies, administration of edaravone to pregnant rats and rabbits resulted in adverse developmental effects (increased mortality, decreased growth, delayed sexual development, and altered behavior) at clinically relevant doses. Most of these effects occurred at doses that were also associated with maternal toxicity [see Animal Data].

In the US 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 for major birth defects and miscarriage in patients with ALS is unknown. Data Animal Data

In rats, intravenous administration of edaravone (0, 3, 30, or 300 mg/kg/day) throughout the period of organogenesis resulted in reduced fetal weight at all doses. In dams allowed to deliver naturally, offspring weight was reduced at the highest dose tested. Maternal toxicity was also observed at the highest dose tested. There were no adverse effects on reproductive function in the offspring. A noeffect dose for embryofetal developmental toxicity was not identified; the low dose is less than the recommended human dose of 60 mg, on a body surface area (mg/ m2) basis.

In rabbits, intravenous administration of edaravone (0, 3, 20, or 100 mg/kg/day) throughout the period of organogenesis resulted in embryofetal death at the highest dose tested, which was associated with maternal toxicity. The higher no-effect dose for embryofetal developmental toxicity is approximately 6 times the recommended human dose (RHD) on a body surface area (mg/m2) basis.

The effects on offspring of edaravone (0, 3, 20, or 200 mg/kg/day), administered by intravenous injection to rats from GD 17 throughout lactation, were assessed in two studies. In the first study, offspring mortality was observed at the high dose and increased activity was observed at the mid and high doses. In the second study, there was an increase in stillbirths, offspring mortality, and delayed physical development (vaginal opening) at the highest dose tested. Reproduction function in offspring was not affected in either study. Maternal toxicity was evident in both studies at all but the lowest dose tested. The no-effect dose for developmental toxicity (3 mg/kg/day) is less than the RHD on an mg/m2 basis. Lactation Risk Summary

There are no data on the presence of edaravone in human milk, the effects on the breastfed infant, or the effects of the drug on milk production. Edaravone and its metabolites are excreted in the milk of lactating rats. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for RADICAVA and any potential adverse effects on the breastfed infant from RADICAVA or from the underlying maternal condition. Pediatric Use Safety and effectiveness of RADICAVA in pediatric patients have not been established. Geriatric Use Of the 184 patients with ALS who received RADICAVA in 3 placebo-controlled clinical trials, a total of 53 patients were 65 years of age and older, including 2 patients 75 years of age and older. No overall differences in safety or effectiveness were observed between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis

The carcinogenic potential of edaravone has not been adequately assessed. Mutagenesis

Edaravone was negative in in vitro (bacterial reverse mutation and Chinese hamster lung chromosomal aberration) and in vivo (mouse micronucleus) assays. Impairment of Fertility

Intravenous administration of edaravone (0, 3, 20, or 200 mg/kg) prior to and throughout mating in males and females and continuing in females to gestation day 7 had no effect on fertility; however, disruption of the estrus cycle and mating behavior was observed at the highest dose tested. No effects on reproductive function were observed at the lower doses, which are up to 3 times the RHD of 60 mg, on a body surface area (mg/m2) basis. Marketed and distributed by: Mitsubishi Tanabe Pharma America, Inc., a US subsidiary of Mitsubishi Tanabe Pharma Corporation 525 Washington Blvd., Suite 400, Jersey City, NJ 07310 RADICAVA is a registered trademark of Mitsubishi Tanabe Pharma Corporation. CNP-RC-US-0080 04/18

Registration Still Available for This Month’s Fall Conference

continued from cover

complimentary, innovative education courses and breakthrough scientific research from the record-setting Annual Meeting. Visit AAN.com/view/Fall for full program descriptions and to register.

Meeting-At-A-Glance Friday, October 26 8:00 a.m.–9:30 a.m.

Neurology Update I: Dementia and Movement Disorders Practice Management I: Coding for Chronic Patients Critical Care EEG Monitoring 10:00 a.m.–11:30 a.m. Neurology Update II: Neuro-infectious Disease and Neuro-otology Practice Management II: Best Practice Management Techniques for Stroke Care Multiple Sclerosis Therapy: Disease-modifying Treatment

Practice Management IV: Small and Solo Practice Essentials Controversies Plenary Session 4:00 p.m.–6:00 p.m. Exhibit Hall Opening Reception

Saturday, October 27 8:00 a.m.–9:30 a.m.

Neurology Update V: Sports Neurology and Palliative Care Practice Management V: Improving Patient Engagement Case Studies: Unusual Movement Disorders 10:00 a.m.–11:30 a.m. Neurology Update VI: Stroke and Neurocritical Care

11:30 a.m.–1:00 p.m. Lunch in Exhibit Hall

Practice Management VI: Being a Provider in the Era of APMs

1:00 p.m.–2:30 p.m. Neurology Update III: Headache and Sleep

Clinical Pearls: Learning from Complex Cases—Simple Lessons that Apply to Everyday Problems

Practice Management III: Using Integrated Care Models in Your Practice Neuroscience in the Clinic: Stress and Neurologic Diseases: What Is It, and What Is the Provider to Do? 1:00 p.m.–4:30 p.m. Management of Acute Seizure and Acute Stroke Workshop (Additional Fee Required) 3:00 p.m.–4:30 p.m. Neurology Update IV: Autoimmune Neurology and Multiple Sclerosis

11:30 a.m.–1:00 p.m. Lunch in Exhibit Hall 1:00 p.m.–2:30 p.m. Continuum® Test Your Knowledge: A Multiple-choice Question Review I

3:00 p.m.–4:30 p.m. Continuum Test Your Knowledge: A Multiple-choice Question Review II Neurology Year in Review Plenary Session 5:00 p.m.–6:00 p.m. Maintenance of Certification Information Session

Sunday, October 28 7:30 a.m.–9:00 a.m.

Neurology Update VII: Neuromuscular Diseases Practice Management VII: Improve Your Quality, Improve Your Value What Do I Do Now: Emergency Inpatient Management of Migraine and Other Headache Disorders 7:30 a.m.–9:30 a.m. Clinical Usefulness of Botulinum Toxin for Spasticity Skills Workshop (Additional Fee Required) 9:15 a.m.–10:45 a.m. Neurology Update VIII: Epilepsy and Pregnancy Neuroscience in the Clinic: Amyotrophic Lateral Sclerosis 

Neuroscience in the Clinic: Intertwined Epidemics: Opioids and Chronic Pain 1:00 p.m.–5:00 p.m. Leadership Challenges in Practice Clinical Uses of Botulinum Toxin for Dystonia Skills Workshop (Additional Fee Required)

OCTOBER 26–28

The Cosmopolitan of Las Vegas

AANnews • October 2018 17

Conferences & Community

Annual Meeting Abstract Submission Deadline Is October 22 You could gain significant exposure for your work if it’s selected for presentation to as many as 14,000 neurologists, neuroscientists, and researchers from around the world at the 2019 AAN Annual Meeting, to be held in Philadelphia, PA, May 4 through 10. In addition, AAN abstracts are often picked up by major media outlets from around the globe, including the New York Times, USA Today, CNN, Associated Press, and more. “Original science is the lifeblood of our scientific program at the Annual Meeting, and the volume of abstracts we receive each year is the proof of how important this platform is for our community of neurologists and neuroscientists,” said Natalia S. Rost, MD, MPH, FAAN, FAHA, chair of the

AAN Science Committee. Abstracts will be accepted in all facets of neurology and neuroscience and could be chosen for Neuroscience in the Clinic sessions, “Best Of” Rost sessions, scientific platform or poster sessions, interactive e-poster displays, or could be awarded one of 25 “Abstracts of Distinction,” which recognizes top scientific achievement in each abstract topic area. Original research is emphasized; however, previously presented work is encouraged if it is of interest to meeting attendees.

chair, to know that we get to showcase the most exciting, cutting-edge discoveries every year.” Show the world your enthusiasm for your work by visiting AAN.com/ view/19Abstracts and submitting your abstract by no later than 11:59 p.m. CT on Monday, October 22. For more information, contact nkosher@aan.com or (612) 928-6088. 

Added Rost, “The breadth and the depth of neurological research at the Annual Meeting reflected in the submitted abstracts is staggering, and it is extremely gratifying for me, as Science

CESC: 19AM Science+ Awards Ad Ad—Half Page Horizontal> AN Placed in AANnews 8.25 x 5.25 +0.125 bleed, 4C

AAN AWARDS A BETTER FUTURE STARTS WITH YOU

Whether it’s scientific research or patient advocacy, your work has the potential to impact us all. Apply or nominate by October 24, 2018:

AAN.com/view/AANAwards

Advancing Neurology. Advancing You. May 4–1O • Philadelhia

Annual Meeting Education Highlights Here’s a quick look at the Friday highlights: 7:00 a.m.–9:00 a.m. • Course programming Get the latest on a variety of topics from experts in the field. 9:15 a.m.–11:30 a.m. • Neurology Year in Review Plenary Session Speakers will focus on the latest research that has happened in the last year within a specific subspecialty topic. 11:30 a.m.–1:00 p.m. • Science Innovation Lunch Head to the poster hall to view some of the best scientific posters and presentations from the week. 1:00–3:30 p.m. • Neurology Update Programs and Scientific Sessions Four major scientific sessions will focus on MS, neuromuscular disease, stroke, and headache and four Neurology Update programs will highlight movement disorders, aging/dementia, epilepsy, and neuro-ophthalmology/neuro-otology. 3:30 p.m.–4:30 p.m. • Education Blitz Programs Look for the debut of one-hour education blitz programs that cover key topics in a shorter, more focused format. 5:00 p.m. • Closing Party Celebrate the end of a great meeting! In addition, look for these other exciting education opportunities throughout your week in Philly: Expanded Continuing the Conversation Talks This popular education program enhancement will return with one course per day concluding with the director and faculty relocating to a reception setting to engage in small group conversations with interested audience members. “What Do I Do Now?” Audience Participation Opportunities During select courses, faculty will share a challenging real-life

continued from cover case before asking “What do I do now?” Audience members will be given the opportunity to weigh in on what they would do in a similar scenario before panel members explain how they actually handled the situation. Spanish-language Curriculum Look for education courses and experiential learning area talks going on all week long and taught entirely in Spanish. Topics include: MS/Autoimmune Neurology Neurocritical Care Headache, Neuromuscular Disease, and TBI Movement Disorders Annual Meeting Science Updates Neuroexam Career-focused Tracks These audience-based programming tracks offers focused programming geared specifically toward a variety of neurology professionals. Neurohospitalist Track For neurohospitalists, those whose primary focus is inpatient care, or for anyone who would like to learn more about the care of hospitalized patients. Business of Neurology Track For those starting a new practice, as well as anyone who wants to learn the fundamentals of neurology business. Foundations of Clinical Neurology Track For advanced practice providers who are new to neurology, this track will help lay the foundation for success as new care-team member. Visit AAN.com/view/AM19 to learn more. 

Applications Opening Soon for Exhibit Opportunities During 2019 Annual Meeting The Exhibit Hall during the 2019 AAN Annual Meeting in Philadelphia is a not-to-bemissed opportunity for your organizations or one you might work with to showcase products, information, and services of particular interest to the neurology community. The exhibit hall offers a unique space for our attendees to meet face to face with varying groups such as hospital networks, industry partners, tech start-ups, and non-profits to connect and share ideas and information. Please help us get the word out to smaller organizations that may be less familiar with our meeting but would benefit from exhibiting during the week of May 4 through 10. Applications will open in November. 

PHARMA AD

G. Joseph Herr, MD Neurologist

Hendricks Regional Health is a nationally recognized, nonprofit, healthcare system with a deeply rooted legacy of community service. Hendricks thrives in a close-knit, growing community just west of Indianapolis. Our neurology candidates can expect: • Custom, innovative practice design • Optimal work/life balance • Personalized onboarding • Strong marketing support to grow your practice • Support from an award-winning clinical team • Generous benefits program outpacing industry Take the next step at CHOOSEHENDRICKS.ORG or contact our provider liaison, Kirsten Tracy, at (317) 519-9396 or Kirsten.Tracy@Hendricks.org.

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:

Congratulate These New FAANs!

The AAN congratulates the following members who were named Fellows between May and August 2018. Namir Mohammed Taher Abdullah, MD, PhD, FAAN Catherine M. Amlie-Lefond, MD, FAAN Sylvia Anagnos, MD, FAAN Christopher D. Anderson, MD, PhD Jinsy Andrews, MD, FAAN Hrayr P. Attarian, MD, FAAN Selma Aybek, MD, FAAN Kevin M. Barrett, MD, FAAN Martin Berghoff, MD, FAAN Brian D. Berman, MD, MS, FAAN Andrew M. Blumenfeld, MD, FAAN Cynthia B. Brown, MD, FAAN Tamika M. Burrus, MD, FAAN Flavio Devetag Chalaupka, MD, FAAN Chadwick W. Christine, MD, FAAN Christopher Commichau, MD, FAAN Anne H. Cross, MD, FAAN Esther Cubo Delgado, MD, FAAN Jorg Dietrich, MD, PhD, FAAN Alan Ettinger, MD, FAAN J. Americo M. Fernandes, Jr., MD, FAAN William H. Fleming, III, MD, FAAN Nancy R. Foldvary-Schaefer, DO, FAAN Thomas Freedom, MD, FAAN

Edwin B. George, MD, PhD, FAAN Christopher Giza, MD, FAAN Christopher Glisson, DO, FAAN Andres A. Gonzalez, MD, FAAN Mark J. Gorman, MD, FAAN M. Sean Green, MD, FAAN Roop Gursahani, MD, FAAN David H. Gutmann, MD, PhD, FAAN Andrew D. Hershey, MD, PhD, FAHS, FAAN William T. Hu, MD, PhD, FAAN Riaz A. Janjua, MD, FAAN Shafali Jeste, MD, FAAN Gordon R. Kelley, MD, FAAN Babar Khokhar, MD, FAAN Igor J. Koralnik, MD, FAAN Christian Krarup, MD, DMSc, FRcP, FAAN Deepak K. Lachhwani, MD, FAAN Douglas Roy Langford, MD Victoria Lawson, MD, FAAN Jerome Lisk, MD, FAAN Warren D. Lo, MD Sharon G. Lynch, MD, FAAN Ramesh Madhavan, MD, FAAN Jennifer J. Majersik, MD, FAAN Irene Malaty, MD, FAAN Gary N. McAbee, DO, FAAN

Nicte I. Mejia, MD, FAAN John J. Millichap, MD, FAAN Xavier Montalban, MD, FAAN J. Layne Moore, MD, FAAN Brian James Murray, MD, FAAN Maria Muste, MD, FAAN Robert T. Naismith, MD, FAAN Stephen L. Nelson, Jr., MD, FAAN John Ney, MD, MPH, FAAN Lilia Nunez-Orozco, MD, FAAN Ronald E. Oppenheim, MD, FAAN Genko Oyama, MD, FAAN Gaurang M. Palikh, MD Gabriel Pardo, MD, FAAN Katherine B. Peters, MD, PhD, FAAN Scott L. Pomeroy, MD, PhD, FAAN Anca S. Popescu, MD, FAAN Peter Portegies, MD, PhD, FAAN Alyx B. Porter, MD, FAAN Neal Prakash, MD, PhD, FAAN Carlos Quintana, MD, FAAN Patrick S. Reynolds, MD, FAAN Julie Roth, MD, FAAN Michael Rubenstein, MD, FAAN Ned C. Sacktor, MD, FAAN Kinshuk Sahaya, MD, FAAN Richard A. Sater, MD, PhD, FAAN

Belinda A. Savage-Edwards, MD, FAAN Raphael Schiffmann, MD, FAAN Roland J. Schwab, MD, FAAN Beverly Rice Scott, MD, FAAN Alan Z. Segal, MD, FAAN Johann Sellner, MD, FAAN Amit M. Shelat, DO, MPA, MS, FACP, FAAN Anant Shenoy, MD, FAAN Fouzia Siddiqui, MD, FAAN David S. Silvers, MD, FAAN Matthew E. Simmons, MD, FAAN David H. Sirken, DO, MD, FAAN Kyle Smoot, MD, FAAN Yuen T. So, MD, PhD, FAAN Mohamed N. Tarkhan, MD, FAAN David E. Thaler, MD, PhD, FAAN Peter K. Todd, MD, PhD, FAAN Michel T. Torbey, MD, MPH, FAAN Paul T. Twydell, DO, MD, FAAN A.B.M. Salah Uddin, MD, FAAN John J. Vaccaro, MD, FAAN Anna Wojcicka-Mitchell, MD, FAAN Melissa Yu, MD, FAAN Hui-Juan Zhang, MD, PhD, FAAN Stephan Zuchner, MD, FAAN 

AANnews • October 2018 21

Conferences & Community

Graduate Learns to Lead ‘From the Inside Out’ Roy H. Hamilton, MD, MS, FAAN, learned more about himself than he ever thought possible throughout the personalized coaching and individual mentoring he received as part of his participation in the AAN’s Diversity Leadership Program. And it’s this new self-awareness that has led to new successes in his professional and personal life. “One of the core lessons of the Diversity Leadership curriculum was that leadership starts by cultivating clear insight into one’s own mental and emotional traits, states, strengths, and weaknesses,” said the 2017 graduate. “It is from the vantage point of increased self-awareness that one begins to more fully understand the viewpoints, needs, and goals of one’s team, and makes genuine strides toward shaping a vision and approach that can truly motivate both oneself and others to action.” To this end, upon graduating in 2017, Hamilton was inspired to create and assume the role of vice chair of Inclusion and Diversity for the Department of Neurology at the University of Pennsylvania, in which he serves as associate professor. In this new vice chair position, Hamilton is charged with promoting a culture of inclusion within his department, ensuring that it attracts and retains diverse talent among its residents, fellows, and faculty, and enhancing its efforts to address disparities in neurologic care. “My decision to take on this role was greatly facilitated by my participation in the Diversity Leadership Program, where I had direct access to an incredible mentor with a long track record of advancing diversity and inclusion in his own institution,” he said. “Also, my colleagues in my leadership cohort (who are now also my friends) understood the value of what I had decided to do and were extremely supportive.” Throughout all of his many roles, Hamilton strives to apply the introspection he gained from the Diversity Leadership Program, “asking myself what hidden motivations and

unnecessary baggage I bring to my roles, whether there are personal styles and strategies that I tend toward that are detrimental to the goals my team is trying to achieve, and what the unique strengths are that I bring to the table. I have found that this process of leading ‘from the inside out’ has made me more transparent, approachable, and ultimately more effective in a variety of leadership venues.” Hamilton sees a big need for the kind of leadership training and skills he feels so fortunate to have received and honed through the AAN. “Unfortunately, despite the ubiquitous need for this skill, formal leadership training is generally lacking in medical and neurologic education,” he said. However, Hamilton believes the AAN’s lineup of leadership programs can fill that gap by benefiting any neurologist, whether they are managing a clinical team, directing research efforts, or fulfilling a critical administrative role in an academic center. “[The programs] will help you hone your skills as a leader by increasing awareness of your own strengths, enhancing your interpersonal interactions within a team, and increasing your ability to work effectively to create change within organizations,” he said. “Effective leaders combine the ability to develop a sound, innovative, and tractable vision with the ability to convince others to share and eventually realize that vision, and the AAN’s range of leadership programs work to fill this critical gap and help to prepare neurologists to meet the challenges of our field with vision, passion, and a commitment to innovative and productive teamwork.” “Finally,” added Hamilton, “I would like to give special thanks to the AAN specifically for creating and continuing the Diversity Leadership Program and applaud it for recognizing the need to enhance diversity among its future leaders. I am honored to have been part of this outstanding and much-needed program.” 

Roy H. Hamilton, MD, MS, FAAN, right.

AANnews • October 2018

Conferences & Community

October 15 Is Deadline for 2019 Diversity Leadership Program Diversity is essential to the AAN’s success. As such, the AAN is committed to building leadership reflective of its varied member and patient demographics. The Diversity Leadership Program is a prestigious and interactive program designed to develop and engage a more diverse membership and demonstrate to participants the long-term benefits of AAN involvement. If you are, or know of someone who is, a talented and highly motivated individual from a qualifying underrepresented ethnic background—at any stage in post-residency and committed to the profession of neurology and to providing high-quality patient-centered care—then consider applying or nominating for this life-enriching opportunity.

Previous participants have praised the program, citing its positive impact on self-confidence, relationship building and comradery, burnout reduction, presentation and management skills, AAN engagement, and more through: In-depth leadership training One-on-one professional coaching Group dynamic skills through work on a specific AAN project Access to AAN leadership Presentation of group project to the AAN Board of Directors One-on-one mentoring with AAN leader Site visit to AAN mentor’s institution or practice Attendance at AAN Annual Meeting Lifelong connections and friendships To be considered, applicants must be US AAN members from one of the following underrepresented groups in neurology: African American/Black, Hispanic/Latino, American Indian, Native Hawaiian, or Alaska Native ethnicity. Visit AAN.com/view/DiversityLeadership to learn more and to apply by the October 15 deadline. 

Journal Studies, Sports Concussion Conference Draw Media Coverage The AAN’s weekly press releases on Neurology ® studies have received robust news coverage in recent months. A press release on how higher blood pressure may be linked to brain disease was covered by outlets including the New York Times, TIME, CNN, CBS News, ABC News, and the Denver Post. Another press release on how pregnancy history may be tied to Alzheimer’s disease was covered by TIME, CNN, United Press International, Newsweek, and the San Diego Union Tribune, among others.

In addition, the AAN issued a press release on a study published in Neurology ® Clinical Practice on exercise and how much is needed to help improve thinking skills. That press release was covered by organizations including ABC News, CBS News, TIME, U.S. News & World Report, and the Boston Globe.

local FOX television station WXIN. The AAN also issued two press releases on abstracts presented at the conference. One press release about concussion risks for athletes with ADHD was covered by Medscape, HealthDay and WebMD, among others. The other press release about soccer headers and how they may be linked to balance problems was covered by publications such as the Daily Mail, U.S. News & World Report, and MedPage Today. 

The AAN Sports Concussion Conference, held in Indianapolis in July, also drew sizeable news coverage. David W. Dodick, MD, FAAN, co-director of the conference, was interviewed by

AANnews • October 2018 23

Policy & Guidelines

Educating Congress—at Home and in DC—on the Neurology Perspective in Health Care Legendary Speaker of the House Tip O’Neill famously said, “All politics is local.” Even though changes to federal health care policies are made in Washington, DC, it’s the neurologists and patients (aka “voters”) back home who are affected. The AAN’s Neurology off the Hill program helps arrange member involvement in meetings at district congressional offices, local fundraisers, site visits at hospitals and clinics, and other local events with members of Congress and their staff so they can see and hear firsthand the impact of legislative issues like drug pricing and research funding. Even though the Senate did not recess for August as the House of Representatives did, there were several successful events that gave policymakers much to think about as they returned to Washington during this election season. The AAN thanks these members for their advocacy for neurology! 

7 6

1. Maya Lichtenstein, MD (second from left); Glen Finney, MD (second from right); and clinic staff with Rep. Lou Barletta’s (R-PA) staff 2. Mohammad Sajed, MD, and Rep. Peter Roskam (R-IL) 3. Sen. Amy Klobuchar (D-MN) and Kinshuk Sahaya, MD, FAAN 4. Maureen Callaghan, MD, FAAN, and Rep. Denny Heck (D-WA) 5. Calvin Hansen, MD, FAAN; Lynn Rankin, MD; Rep. David Young (R-IA); and Todd Janus, PhD, MD, FAAN 6. Sarah Hon, DO, FAAN, and Sen. Claire McCaskill (D-MO) 7. Jeanne Feuerstein, MD; Rep. Diana DeGette (D-CO); and Lisa Deuel, MD 8. Rep. Lloyd Smucker (R-PA) with Will Jens, DO 9. Mark Mintz, MD, FAAN; Pnina Mintz, PhD; and Rep. Leonard Lance (R-NJ) 10. Steve Holtz, MD, FAAN, and Rep. Mike Thompson (D-CA) 11. Rep. Mark Sanford (R-SC) and Amy Chen, MD, PhD 12. Lourdes Benes-Cases, MD (left); Michael Hoffmann, MD, FCP, FAAN, FAHA (second from left); with Rep. Val Demings (D-FL) (center) and her staff

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. As reported in this month’s President’s Column on page 4, the Centers for Medicare & Medicaid Services (CMS), has been considering proposed new rules that consolidate E/M payment codes. CMS will release the final rule on or around November 1 and the AAN is preparing contingency plans for possible outcomes. In the meantime, the AAN has been hard at work opposing this proposal. Check out our advocacy by the numbers as of mid-September:

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Apply Now for 2019 Neurology on the Hill in Washington, DC AAN members are encouraged to take their advocacy efforts to the next level by applying to participate in the 2019 Neurology on the Hill, to be held in Washington, DC, February 25 and 26. This event provides the opportunity to share your experiences and insights face-to-face with lawmakers and educate them about the critical role of neurologists in health care and the need for legislation to improve neurologic patient care. You don't need a public policy background to join us! After you arrive at the Ritz-Carlton in Arlington, VA, member volunteers and Academy staff will prep you on the critical issues and AAN advocacy priorities. Learn more and apply by November 2 at AAN.com/view/NOH. 

133 90 54 39 5 1

AAN members responded to our Action Alert email and urged Congress to oppose the E/M changes. Patient and provider groups joined the AAN-led letter sent to CMS. Members of US House of Representatives signed letter of opposition sent to CMS. Capitol Hill meetings, including the top staff for the relevant congressional committees, over the last month to discuss the E/M issue. Pages in the comment letter sent to the Department of Health and Human Services outlining the AAN's concerns with the E/M proposal and other feedback on the Fee Schedule. This letter was covered in Politico last month. Meetings with staff members at HHS. Goal in mind: to protect AAN members and their patients from these misguided proposals. 

AANnews • October 2018 25

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

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)]. 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

Education & Research

AAN Joins Forces with Target ALS on New Research Opportunity The AAN and Target ALS have partnered on a unique opportunity that now allows grant recipients who have ALSor FTD-related research proposals to use Target ALS’s resources for free, or at a significantly reduced cost, during the course of their 2019 AAN Research Program grant.

ALS Foundation. “Target ALS’s mission is to provide access to researchers at all career stages with critical resources—such as postmortem tissue, human stem cell lines, biofluids, in vivo testing of novel targets, etc.—to help them accelerate their pursuit of finding effective treatments for ALS.”

“This is a great opportunity for a researcher with limited funds or lack of access to critical research tools, and an ideal partnership in terms of shared goals for both organizations,” said Manish Raisinghani, MBBS, PhD, president of the Target

Target ALS is a privately funded consortium of researchers from academic and biotechnology/pharmaceutical company laboratories focused entirely on finding a treatment for patients living with ALS. Visit TargetALS.org to learn more. 

October 24 Is Application Deadline for 2019 AAN Awards Prestigious AAN awards honor the best research and achievements by neurologists and neuroscientists around the globe and at all career stages, and Wednesday, October 24, is the last chance to apply or nominate a deserving colleague for one of the many that will be presented at the 2019 AAN Annual Meeting in Philadelphia. In addition to recognition, recipients will also receive prizes and other compensation, such as complimentary travel expenses and registration for the meeting. Learn more and apply or nominate at AAN.com/view/19Awards. 

AANnews • October 2018 31

Education & Research

UCNS Accreditation Application Deadline Is December 1 The United Council for Neurologic Subspecialties (UCNS) is accepting accreditation applications for fellowship training programs through December 1, 2018. Applications received by the deadline will be reviewed at the UCNS Accreditation Council meeting in the spring of 2019. Approved programs will be accredited effective June 1, 2019.

Neurocritical Care, Neuroimaging, Neuro-oncology, Clinical Neuromuscular Pathology, Geriatric Neurology, Behavioral Neurology & Neuropsychiatry, and Neural Repair and Rehabilitation. There are currently 197 UCNS-accredited fellowship programs. The next application period deadline will be June 1, 2019.

Programs that attain accreditation status offer the core content established by the subspecialty and meet the required quality standards established by UCNS. Residents seeking fellowships in UCNS subspecialty areas know that the UCNS training programs offer the training defined by experts in that subspecialty and the programs have the oversight of the UCNS Accreditation Council. Fellows graduating from UCNSaccredited training programs meet the training eligibility requirements for certification in their respective UCNSrecognized subspecialty, creating a strong career path for fellow graduates.

For more information, visit UCNS.org or contact Amanda Carpenter, UCNS Senior Manager Accreditation, at acarpenter@ucns.org or (612) 987-6065. 

UCNS accredits programs in nine neurologic subspecialty areas including Autonomic Disorders, Headache Medicine,

Neuro-oncology Certification Applications Now Available Neuro-oncology certification applications are now available online through the United Council for Neurologic Subspecialties (UCNS). Those who apply by the early deadline of January 3, 2019, will save $500 on the application fee. The late application deadline is January 17. Graduates and faculty of UCNSaccredited Neuro-oncology fellowships

and reexamination applicants are eligible to apply and must be a diplomate in good standing of the one of the American Board of Medical Specialties in Neurology, Child Neurology, Neurological Surgery, Internal Medicine and Medical Oncology, Pediatrics and Pediatric Hematology-Oncology, Radiation Oncology, or the equivalent

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.

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AANnews • October 2018

certification by the Royal College of Physicians and Surgeons of Canada (RCPSC). For complete eligibility criteria, examination content outline, and to apply, visit UCNS.org/go/subspecialty/ neuro-oncology/certification. 

Neuroinfectious Disease Is Focus of This Month’s Continuum The October issue of Continuum: Lifelong Learning in Neurology ® takes a deep dive into causes, symptoms, and treatments for a number of neuroinfectious diseases. “With the increase in international travel, emergence of new pathogens, re-emergence of older pathogens, and more widespread use of immunosuppressive therapies, the practicing neurologist should be alert to the potential manifestations and treatment of the typical and atypical CNS infections reviewed in this edition of Continuum,” said guest editor Joseph R. Zunt, MD, MPH, who is a professor in the Departments of Neurology and Global Health, and adjunct professor in the Departments of Medicine (Infectious Diseases) and Epidemiology at Harborview Medical Center at the University of Washington in Seattle. All of the articles have corresponding interviews on Continuum® Audio, which is now included in a subscription to Continuum.

Topics in this issue include: Acute Bacterial Meningitis Larry E. Davis, MD, FAAN Viral Meningitis and Encephalitis Jennifer L. Lyons, MD

AAN members pay only $349 per year for a subscription to Continuum and Continuum Audio. Subscribe now by using Zunt the convenient check-off box on your AAN membership dues statement; by contacting Wolters Kluwer at (800) 361-0633, (301) 223-2300 (international); or Shop.LWW.com/continuum. Junior members who are transitioning to neurologist memberships can receive a 50-percent discount on the already low member rate for the Continuum and Continuum Audio subscription. 

Chronic Meningitis Kiran T. Thakur, MD, and Michael R. Wilson, MD, MAS Brain and Spinal Epidural Abscess Felicia Chow, MD, MAS Herpesvirus Infections of the Nervous System Kelly J. Baldwin, MD, and Christopher L. Cummings, MD Central Nervous System Infections Complicating Immunosuppression and Transplantation Amy A. Pruitt, MD Neurologic Complications of Human Immunodeficiency Virus Infection Deanna Saylor, MD, MHS Tuberculosis of the Central Nervous System Joseph R. Zunt, MD, MPH Neuroborreliosis and Neurosyphilis John J. Halperin, MD, FAAN, FIDSA Tetanus, Botulism, and Diphtheria Aaron L. Berkowitz, MD, PhD

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Helminthic Infections of the Central Nervous System Tracey A. Cho, MD, FAAN Zika Virus and Other Emerging Arboviral Central Nervous System Infections James J. Sejvar, MD Legal and Ethical Considerations of Disclosing Human Immunodeficiency Virus Seropositivity to a Surrogate Decision Maker Rachel V. Rose, JD, MBA, and Joseph S. Kass, MD, JD, FAAN CO NT INU

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AANnews • October 2018 33

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11:59 p.m. CT, Monday, October 22, 2018 Submit Today at AAN.com/view/19SubmitÂ

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Deadline: 2019 Research Program AAN.com/view/ResearchProgram

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Webinar: How Does Health Services Research Help Me? (Register by October 22) AAN.com/view/pmw18

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Application Deadline: Neurology on the Hill AAN.com/view/NOH

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Registration Deadline: RITE® (Residency In-service Training Examination) AAN.com/tools-and-resources/residentsfellows/residency-in-service-trainingexamination-rite

The American Academy of Neurology is proud to offer

THE #1 CAREER CENTER FOR NEUROLOGISTS

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American AmericanBrain BrainFoundation Foundation

Speak Volumes with Easy Dues Check-off Donation Since 1992, the American Brain Foundation has been investing in the Academy’s research program, supporting AAN members with a goal to end the battle against brain disease. In 2017, the Foundation raised $3.9 million for future research funds. This year, we added new research opportunities in cognitiveaging and age-related memory loss, headache, interventional neurology, muscle study, and Lewy body disease, and are currently working to add significant dollars to identify a biomarker for Lewy body dementia. In an effort to assure our dollars have the strongest impact, the research we fund is vetted by bright members of the world’s premier neurology organization—our Research Advisory Board includes members of the Academy. As the Foundation continues to grow and become increasingly recognizable among patients, caregivers, and investigators as the organization for unifying, connecting, and funding research across all brain diseases, charitable donations from Academy members become even more critical to show members of the general public that the Foundation has the steadfast support and backing of neurologists. When you receive your 2018 AAN membership dues renewal invoice in the mail, or online, later this month, please take special notice of the option to make an additional gift of supportAd—Half to the American BrainAN Foundation. MEM: 17 FAAN Recruitment Campaign Page Horizontal> Your investment in the Foundation speaks volumes.  Placed in AANnews 8.25 x 5.25 +0.125 bleed, 4C

Set Yourself Apart Get the recognition you deserve. Add the Fellow of the AAN (FAAN) designation to your already impressive credentials. Learn how at AAN.com/view/FAAN.

Lead with Generosity: Join the Rowland Circle! Donors who give $2,500 or more cumulatively in a year will be recognized and honored in the Rowland Circle, named after former AAN President Lewis P. “Bud” Rowland, MD, FAAN, in memory of his generous, longRowland time support of the Foundation. 2018 Rowland Circle donors will be named as Charter Members and will be included in a special reception on May 8 during the 2019 Annual Meeting in Philadelphia. For more information or to become a member, contact Shelly Rucks at srucks@americanbrainfoundation.org or (612) 928-6318. 

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.

Neurohospitalist opening affiliated with teaching hospital with new Neurology Residency Program Medical school affiliated Academic Medical Center. Opportunity to join growing Neurology department of 8 Neurologists. Faculty members including General, Pediatric, Neuromuscular, Movement, Epilepsy and Vascular. 7 days on 7 days off schedule with opportunity for outpatient clinic. Accredited Neurophysiology Center on site. Multidisciplinary team includes Radiologists, Pharmacists, Nursing, Dietitians, Physical, Occupational and Speech Therapists. Comprehensive benefits package including malpractice. Excellent starting salary and sign-on bonus. Academic Appointment. Educational stipend available. Named one of 150 Great Places to Work in Healthcare—Becker´s Hospital Review. Excellent Public and Private Schools. NCAA Division I Intercollegiate Sports Teams. Driving distance for skiing, water sports, hiking, etc. Short Distance to 4 Major Metro Areas. Expanding Downtown Area, Concert Halls and a Theater Community. Mention code 180418 NHO. Email: rrectorweb@phg.com Pediatric Neurology opening affiliated with teaching hospital with new Neurology Residency Program Opportunity to join two practicing Pediatric Neurologists. Join medical school Department of Neuroscience including Neurology, Neurosurgery & Neurophysiology. Faculty members including Child & Adult Neurologists, as well as Functional, Pediatric & Spine Neurosurgeons. Established, Accredited Long-Term Epilepsy Monitoring Unit. 36 Bed NICU; 12 Bed Pediatric ICU Level III Center. New, $30 Million Pediatric Hospital Expansion. Clinical Research Interest Encourage. Excellent starting salary, full benefits and sign-on bonus. Educational stipend available. An outdoor enthusiast´s haven. Enjoy the scenic shores of a historic River. Take in the four-season views while mountain hiking. Enjoy a sunset cruise under the stars. The region’s best skiing at your doorstep. Year-round family fun. A down-to-earth place to live combined with amazing cultural sensations. NCAA Division One Intercollegiate Sports Teams. Mention code 180420 CHN. Email: jpolver1@phg.com Outpatient Neurologists, Subspecialists, Neurohospitalists to join our 40+ physicians in South Florida—locations in Palm Beach, Fort Lauderdale, Miami—Tenet South Florida's Advanced Neuroscience Network includes employed physicians (neurologists, interventional neurologists, neurosurgeons, and neuropsychologists), 10 award winning hospitals, 4 comprehensive stroke centers, and multiple full-service outpatient centers across Miami-Dade, Fort Lauderdale and Palm Beach counties. We are looking for additional general neurologists, neuro subspecialists and neurohospitalists to join our busy practices in South Florida. Please review our websites at: (http://www. tenetfloridaphysicianservices.com/neurology). Our team provides comprehensive neurological & ancillary services and features some of the leading neurologists in South Florida. Many professionals and programs come together under the Advanced Neuroscience Network with the goal of providing the highest quality care possible. We are adding further staff due to increased patient volumes. Some of the benefits of becoming employed by Tenet include: Guaranteed salary with production bonus. Physician paid time off (vacation + CME with stipend). Malpractice insurance. Health, dental, life insurance, retirement benefits. Residents and Fellows are welcome to apply. I am currently conducting a nationwide,

confidential search for qualified candidates. If you would like to obtain additional information about this opportunity, please contact me or send a copy of your Curriculum Vitae for consideration: lane.mitnick@tenethealth.com

Just a mile-long drive over the Benjamin Franklin Bridge or a ferry boat ride will put you at the doorstep of Philadelphia’s cultural, culinary and historic venues. Applicants are required to be currently certified or eligible by the American Board of Psychiatry and Neurology and eligible for New Jersey licensure. Fellowship trained or new graduate applicants with or without subspecialty interest are encouraged. Interested candidates should email a CV to Dr. Melissa Carran, MD, Associate Professor and Interim Chair: carran-melissa@cooperhealth.edu

Join one of the best health care providers and teaching hospital in the state Pediatric Neurology. Employed Position. Competitive salary with full benefit package. $50K sign-on bonus. More than 30 specialties are represented. Procedures performed: Advanced MS infusion therapies, Electromyography (EMG), Electroencephalogram (EEG), Evoked potentials studies, Lumbar puncture, Nerve conduction studies, Therapeutic injections for migraine and Epilepsy Monitoring Unit for long-term monitoring. Neurology department specializes in the following conditions Autism, Cerebral palsy, Dementia, Epilepsy, Multiple sclerosis (MS), Neuropathy, Stroke, Seizures, Migraine, Nerve and muscle disorders and Tremors, "Hip, Historic and Almost Heaven"—Tourism Board. The cultural, recreational, and business capital of the Appalachian Mountains. Excellent Public and Private Schools. NCAA Division I Intercollegiate Sports Teams. Driving distance for skiing, water sports, hiking, etc. Bike friendly community with a network of trails. Art walks, downtown street festivals and brown bag concert series. Come play—multiple family friendly venues and activities. Timothy Stanley; Direct: (404) 591-4224, (800) 492-7771; tstanleyweb@phg.com. Fax: (404) 591-4237; Cell/Text: (770) 265-2001. Mention Code 180802—CHN.

Join Dignity Health in California We have an array of exciting Neurology opportunities available in the following communities: Bay Area California, San Francisco. Central California, Merced & Stockton. Northern California, Grass Valley & Redding & Sacramento (3 positions available Neurocritical Care, Neurohospiltalist and Sleep Neurologist). All positions are General Neurology opportunities unless noted otherwise. Practice highlights: Established multi-specialty Group(s), Tele-Neurology service in place (with affiliate Group), Affiliated with Joint Commission Gold Certified Primary Stroke Centers, Alignment with the fifth largest health system in the nation and largest hospital provider in California. Compensation & Benefits: Competitive salary guarantee period & bonus incentives, Attractive benefits package (free medical insurance, 401K, paid malpractice, CME allowance, etc.), Generous time off. Community highlights: Proximity to San Francisco, Sacramento, Napa, Lake Tahoe and Yosemite, Warm weather, Top-ranked schools (charter, public, private, faith-based), Ideal for outdoor lovers (hiking, biking, skiing, fishing, boating). The Dignity Health network includes 10,000 physicians and 55,000 employees providing care at more than 150 ancillary care sites and 36 acute care hospitals throughout Arizona, California and Nevada. We provide an environment where employees feel welcome and inspired to learn from one another. The way in which we approach our patients and each other is engrained in our culture, and can be summed up in two powerful words: Hello humankindness™ (hellohumankindness.org). Find out more at dignityphysiciancareers.org.

Neurologist—Houston, TX Kingwood Neurology and Sleep is a well-established, highly respected private neurology group in Kingwood, Texas 22 miles north of downtown Houston. We are looking for a fourth BC/BE general or subspecialty-trained neurologist to join our growing practice. Current subspecialties include Epilepsy, Stroke, Sleep Medicine, Clinical Neurophysiology, and Neuro Rehabilitation. We offer EEG, EMG, and EP, in-patient EEG monitoring and sleep studies. We are seeking candidates to complement our current scope of practice and expand our range of services. Call will be 1:4. We are on staff at two nearby hospitals and enjoy friendly inpatient and outpatient practice environments. The area around Kingwood is growing rapidly and both hospitals are expanding. Over the next few years we will be instrumental in developing undergraduate and postgraduate education for the University of Houston Medical School. Kingwood Neurology and Sleep offers the following: Base Salary, Production Bonus Eligibility, Paid Time Off. Excellent Health Benefits. Paid Malpractice Insurance. CME Allowance, 401(k). Two Year Partnership Track. For more information about our practice, visit our website at KingwoodNeurology.com. If you are interested, please send your CV to cv@KingwoodNeurology.com

To apply, please send CV to: Physician Recruitment, Providers@DignityHealth.org, Tel: (888) 599-7787 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 December 2018 print edition of A AANnews must be submitted by November 1, 2018. The same deadline applies to changes/cancellations.

Attending Neurologist Cooper Hospital and Medical School of Rowan University Neurology Department seeks to hire neurohospitalists, stroke, general, movement disorder, and neuromuscular specialists. We are an employed group of 13 neurologists covering ambulatory neurology and one hospital. We have a very successful nine neurology resident program, which is expanding soon. We are growing health science campus that also includes MD Anderson Cancer Center at Cooper, the internationally acclaimed Coriell Institute for Research, The John Sheridan medical offices and the Ronald McDonald House and state-of-the-art patient care facilities. Cooper is conveniently close to Philadelphia.

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.

AANnews • October 2018 37

enough already. it’s time to help prevent migraine.

Aimovig™ is the first and only FDA-approved therapy specifically designed to help prevent migraine by targeting and blocking the calcitonin gene-related peptide receptor (CGRP-R).1 • Aimovig™ reduced monthly migraine days.1 • The most common adverse reactions in clinical studies (≥ 3% of Aimovig™-treated patients and more often than placebo) were injection site reactions and constipation.1 • In 3- and 6-month clinical studies, up to 95% of patients stayed on Aimovig™.1 – Less than 2% of patients receiving Aimovig™ discontinued due to adverse events.

• Patients will have access to Aimovig Ally™— a range of personalized product support services designed to help them start and stay on therapy as prescribed.

Give patients less days marked by migraine with Aimovig™.

Learn more about Aimovig™ and how to get your Hypothetical patient.

next patient started at AimovigHCP.com/GetStarted

Indication Aimovig™ is indicated for the preventive treatment of migraine in adults.

Important Safety Information • The most common adverse reactions in clinical studies (≥ 3% of Aimovig™-treated patients and more often than placebo) were injection site reactions and constipation. Please see a brief summary of the Prescribing Information on the adjacent page. Reference: 1. Aimovig™ (erenumab-aooe) prescribing information, Amgen.

BRIEF SUMMARY OF PRESCRIBING INFORMATION

Please see package insert for full Prescribing Information INDICATIONS AND USAGE AIMOVIG is indicated for the preventive treatment of migraine in adults. CONTRAINDICATIONS None. ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the 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 safety of AIMOVIG has been evaluated in 2,537 patients with migraine who received at least one dose of AIMOVIG, representing 2,310 patient-years of exposure. Of these, 2,057 patients were exposed to 70 mg or 140 mg once monthly for at least 6 months, 1,198 patients were exposed for at least 12 months, and 287 patients were exposed for at least 18 months. In placebo-controlled clinical studies (Studies 1, 2, and 3) of 2,184 patients, 787 patients received at least one dose of AIMOVIG 70 mg once monthly, 507 patients received at least one dose of AIMOVIG 140 mg once monthly, and 890 patients received placebo during 3 months or 6 months of double-blind treatment. Approximately 84% were female, 91% were white, and the mean age was 42 years at study entry. The most common adverse reactions (incidence ≥ 3% and more often than placebo) in the migraine studies were injection site reactions and constipation. Table 1 summarizes the adverse reactions that occurred during the first 3 months in the migraine studies (Studies 1, 2, and 3). Adverse Reactions Occurring with an Incidence of at Least 2% for Either Dose of AIMOVIG and at Least 2% Greater than Placebo During the First 3 Months in Studies 1, 2, and 3 AIMOVIG 70 mg Once Monthly N = 787 %

AIMOVIG 140 mg Once Monthly N = 507 %

N = 890 %

Injection site reactionsa

Constipation

Adverse Reaction

Cramps, muscle spasms

Placebo

a Injection site reactions include multiple adverse reactions related terms, such as injection site pain and injection site erythema.

In Studies 1, 2, and 3, 1.3% of patients treated with AIMOVIG discontinued double blind treatment because of adverse events. The most frequent injection site reactions were injection site pain, injection site erythema, and injection site pruritus. Immunogenicity As with all therapeutic proteins, there is potential for immunogenicity. The detection of antibody formation, including neutralizing antibodies, is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to erenumab-aooe in the studies described below with the incidence of antibodies in other studies or to other products may be misleading. The immunogenicity of AIMOVIG has been evaluated using an immunoassay for the detection of binding anti-erenumab-aooe antibodies. For patients whose sera tested positive in the screening immunoassay, an in vitro biological assay was performed to detect neutralizing antibodies.

In controlled studies with AIMOVIG, the incidence of anti-erenumab-aooe antibody development was 6.2% (48/778) in patients receiving AIMOVIG 70 mg once monthly (2 of whom had in vitro neutralizing activity) and 2.6% (13/504) in patients receiving AIMOVIG 140 mg once monthly (none of whom had in vitro neutralizing activity). The neutralizing anti-erenumab-aooe antibody positive rate may be underestimated because of limitations of the assay. Although these data do not demonstrate an impact of anti-erenumabaooe antibody development on the efficacy or safety of AIMOVIG in these patients, the available data are too limited to make definitive conclusions. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary There are no adequate data on the developmental risk associated with the use of AIMOVIG in pregnant women. No adverse effects on offspring were observed when pregnant monkeys were administered erenumab-aooe throughout gestation (see Data). Serum erenumab-aooe exposures in pregnant monkeys were greater than those in humans at clinical doses. 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 estimated rate of major birth defects (2.2% - 2.9%) and miscarriage (17%) among deliveries to women with migraine are similar to rates reported in women without migraine. Clinical Considerations Disease-Associated Maternal and/or Embryo/Fetal Risk Published data have suggested that women with migraine may be at increased risk of preeclampsia during pregnancy. Data Animal Data In a study in which female monkeys were administered erenumab-aooe (0 or 50 mg/kg) twice weekly by subcutaneous injection throughout pregnancy (gestation day 20 - 22 to parturition), no adverse effects on offspring were observed. Serum erenumab-aooe exposures (AUC) in pregnant monkeys were approximately 20 times that in humans at a dose of 140 mg once monthly. Lactation Risk Summary There are no data on the presence of erenumab-aooe in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for AIMOVIG and any potential adverse effects on the breastfed infant from AIMOVIG or from the underlying maternal condition. Pediatric Use Safety and effectiveness in pediatric patients have not been established. Geriatric Use Clinical studies of AIMOVIG did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

AIMOVIG™ (erenumab-aooe) Manufactured by: Amgen Inc. One Amgen Center Drive Thousand Oaks, CA 91320-1799 USA U.S. License No. 1080 Marketed by: Amgen Inc. (Thousand Oaks, CA 91320), and Novartis Pharmaceuticals Corporation (East Hanover, NJ 07936) Patent: http://pat.amgen.com/aimovig/ © 2018 Amgen Inc. All rights reserved. v1 05/2018