2021 February AANnews by American Academy of Neurology

VOLUME 34 · ISSUE 2 · FEBRUARY 2021

Visit AAN.com/Covid19 for the latest pandemic information and resources to support you and your crucial work.

2021 PRESIDENTIAL PLENARY SESSION TO SHOWCASE PREMIER LECTURES Most Significant Findings Highlighted

Stevens

Galetta

Mendell

Tanner

An impressive lineup has been confirmed for the 2021 Virtual Annual Meeting’s premier lectures on some of the most significant new findings in neurology. The hugely popular Presidential Plenary Session will once again be moderated by Science Committee Chair Natalia S. Rost, MD, MPH, FAAN, FAHA, and open to all meeting attendees. Continued on page 11

Get Ready for the 2021 Neurology Compensation and Productivity Survey

April 17– April 22

›

Frontiers in Neuroscience Plenary Speakers Announced Five top researchers have been selected to present their basic and translational research as it relates to clinical issues of

Launching March 8, the AAN’s Neurology Compensation and Productivity Survey is the largest and only survey and report dedicated solely to the field of neurology and neurologic subspecialties. Complete the survey by May 14 and you can equip yourself with free, powerful benchmarking data to help improve your practice and evaluate factors that affect your compensation.

Continued on page 9

New this year, the survey will capture data on how the COVID-19 pandemic disrupted practices in 2020, including effects on telehealth use, salaries, hours worked, visit volume, and more.

Soltesz

Chang

Roll-Mecak

The 2019 survey had more than 3,000 responses, and this year the AAN seeks greater participation to ensure this survey continues to provide meaningful data from neurologists and Continued on page 13

17 Learn the New Tracks in the Quality Payment Program

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18 CNN Medical Reporter Sanjay Gupta

Describes Research into Brain Health

Tuszynski

Shih

21 AAN Study Shows Rising Out-of-

pocket Costs for Tests, Office Visits

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Not representative of a patient.

INDICATION KESIMPTA is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

IMPORTANT SAFETY INFORMATION Contraindication: KESIMPTA is contraindicated in patients with active hepatitis B virus infection.

WARNINGS AND PRECAUTIONS Infections: An increased risk of infections has been observed with other anti-CD20 B-cell depleting therapies. KESIMPTA has the potential for an increased risk of infections including serious bacterial, fungal, and new or reactivated viral infections; some have been fatal in patients treated with other anti-CD20 antibodies. The overall rate of infections and serious infections in KESIMPTA-treated patients was similar to teriflunomide-treated patients (51.6% vs 52.7%, and 2.5% vs 1.8%, respectively). The most common infections reported by KESIMPTA-treated patients in relapsing MS (RMS) trials included upper respiratory tract infection (39%) and urinary tract infection (10%). Delay KESIMPTA administration in patients with an active infection until resolved. Consider the potential increased immunosuppressive effects when initiating KESIMPTA after an immunosuppressive therapy or initiating an immunosuppressive therapy after KESIMPTA. Please see additional Important Safety Information and Brief Summary of full Prescribing Information on the following pages.

Make KESIMPTA your 1 st choice for RMS POWER In two Phase 3 pivotal clinical trials vs teriflunomide, KESIMPTA demonstrated: • Significant reduction in ARR of up to nearly 60% vs teriflunomide ((P<0.001)1,2* • Profound reduction in mean number of Gd+ T1 lesions per scan of up to 98% ((P<0.001)1† • Superior reduction in mean number of new or enlarging T2 lesions per year of up to 85% ((P<0.001)1† • Significant risk reduction in 3-month CDP of 34% (P (P=0.002) and 6-month CDP of 32% (P=0.01)1,2†

PRECISION • A targeted and precisely delivered B-cell therapy1,3‡ Safety • Favorable safety profile similar to teriflunomide as demonstrated in 2 pivotal trials1

FLEXIBILITY • The first once-monthly (20 mg), SC, B-cell therapy administered at home or anywhere1§II

Learn more at KesimptaHCP.com Study Design: ASCLEPIOS I and II were 2 identical randomized, active-controlled, double-blind Phase 3 studies in patients with RMS, approximately 40% of whom were DMT treatment naïve. Patients were randomized to double-dummy subcutaneous KESIMPTA (20 mg every 4 weeks) or oral teriflunomide (14 mg daily) for up to 30 months. Primary endpoint was ARR. Key MRI endpoints were number of Gd+ T1 lesions, and annualized rate of new or enlarging T2 lesions. A key clinical endpoint was reduction in risk of 3-month CDP. Treatment duration was variable based on end of study criteria. Maximum duration 120 weeks, median duration 85 weeks.

ARR=annualized relapse rate; CDP=confirmed disability progression; DMT=disease-modifying therapy; Gd+=gadolinium-enhancing; MRI=magnetic resonance imaging; RMS=relapsing multiple sclerosis; SC=subcutaneous. *Primary endpoint: relative reduction in adjusted ARR vs teriflunomide of 51% (0.11 vs 0.22) in ASCLEPIOS I and 59% (0.10 vs 0.25) in ASCLEPIOS II. †Key clinical and MRI endpoints: reduction in mean number of Gd+ T1 lesions per scan vs teriflunomide of 98% (0.01 vs 0.45) in ASCLEPIOS I and 94% (0.03 vs 0.51) in ASCLEPIOS II; reductions in T2 lesions vs teriflunomide of 82% (0.72 vs 4.00) in ASCLEPIOS I and 85% (0.64 vs 4.15) in ASCLEPIOS II; reduced risk in 3-month CDP vs teriflunomide of 34% (15.0 vs 10.9) and 6-month CDP of 32% (8.1 vs 12.0) in pooled populations from both trials. ‡ The precise mechanism by which KESIMPTA exerts its therapeutic effects is unknown. § The initial dose period consists of 20 mg SC doses at Weeks 0, 1, and 2. II KESIMPTA Sensoready® Pens must be refrigerated at 2°C to 8°C (36°F to 46°F). Keep product in the original carton to protect from light until the time of use. Do not freeze. To avoid foaming, do not shake. References: 1. Kesimpta [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2020. 2. Hauser SL, Bar-Or A, Cohen JA, et al; for the ASCLEPIOS I and ASCLEPIOS II trial groups. Ofatumumab versus teriflunomide in multiple sclerosis. N Engl J Med. 2020;383(6):546-557. 3. Huck C, Leppert D, Wegert V, et al. Low-dose subcutaneous anti-CD20 treatment depletes disease relevant B cell subsets and attenuates neuroinflammation. J Neuroimmune Pharmacol. 2019;14(4):709-719.

IMPORTANT SAFETY INFORMATION (cont) WARNINGS AND PRECAUTIONS (cont) Hepatitis B Virus: Reactivation: No reports of hepatitis B virus (HBV) reactivation in patients with MS treated with KESIMPTA. However, HBV reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, has occurred in patients treated with ofatumumab at higher intravenous doses for chronic lymphocytic leukemia (CLL) than the recommended dose in MS and in patients treated with other anti-CD20 antibodies. Infection: KESIMPTA is contraindicated in patients with active hepatitis B disease. Fatal infections caused by HBV in patients who have not been previously infected have occurred in patients treated with ofatumumab at higher intravenous doses for CLL than the recommended dose in MS. Perform HBV screening in all patients before initiation of KESIMPTA. Patients who are negative for HBsAg and positive for HB core antibody [HBcAb+] or are carriers of HBV [HBsAg+], should consult liver disease experts before starting and during KESIMPTA treatment. Progressive Multifocal Leukoencephalopathy: No cases of progressive multifocal leukoencephalopathy (PML) have been reported for KESIMPTA in RMS clinical studies; however, PML resulting in death has occurred in patients being treated with ofatumumab at higher intravenous doses for CLL than the recommended dose in MS. In addition, JC virus infection resulting in PML has also been observed in patients treated with other anti-CD20 antibodies and other MS therapies. If PML is suspected, withhold KESIMPTA and perform an appropriate diagnostic evaluation. If PML is confirmed, KESIMPTA should be discontinued. Vaccinations: Administer all immunizations according to immunization guidelines: for live or live-attenuated vaccines at least 4 weeks and, whenever possible at least 2 weeks prior to starting KESIMPTA for inactivated vaccines. The safety of immunization with live or live-attenuated vaccines following KESIMPTA therapy has not been studied. Vaccination with live or live-attenuated vaccines is not recommended during treatment and after discontinuation until B-cell repletion.

Vaccination of Infants Born to Mothers Treated with KESIMPTA During Pregnancy. For infants whose mother was treated with KESIMPTA during pregnancy, assess B-cell counts prior to administration of live or live-attenuated vaccines. If the B-cell count has not recovered in the infant, do not administer the vaccine as having depleted B-cells may pose an increased risk in these infants. Injection-Related Reactions: Injection-related reactions with systemic symptoms occurred most commonly within 24 hours of the first injection, but were also observed with later injections. There were no life-threatening injection reactions in RMS clinical studies. The first injection of KESIMPTA should be performed under the guidance of an appropriately trained health care professional. If injection-related reactions occur, symptomatic treatment is recommended. Reduction in Immunoglobulins: As expected with any B-cell depleting therapy, decreased immunoglobulin levels were observed. Monitor the levels of quantitative serum immunoglobulins during treatment, especially in patients with opportunistic or recurrent infections and after discontinuation of therapy until B-cell repletion. Consider discontinuing KESIMPTA therapy if a patient with low immunoglobulins develops a serious opportunistic infection or recurrent infections, or if prolonged hypogammaglobulinemia requires treatment with intravenous immunoglobulins. Fetal Risk: Based on animal data, KESIMPTA can cause fetal harm due to B-cell lymphopenia and reduce antibody response in offspring exposed to KESIMPTA in utero. Transient peripheral B-cell depletion and lymphocytopenia have been reported in infants born to mothers exposed to other anti-CD20 B-cell depleting antibodies during pregnancy. Advise females of reproductive potential to use effective contraception while receiving KESIMPTA and for at least 6 months after the last dose. Most common adverse reactions (>10%) are upper respiratory tract infection, headache, injection-related reactions, and local injectionsite reactions. Please see additional Important Safety Information on the previous page and Brief Summary of full Prescribing Information on the following pages.

KESIMPTA, the KESIMPTA logo, and SENSOREADY are registered trademarks of Novartis AG.

Novartis Pharmaceuticals Corporation One Health Plaza East Hanover, New Jersey 07936-1080

ÂŠâ&#x20AC;&#x2030;2020 Novartis

10/ 20

KSM-1395660

KESIMPTA® (ofatumumab) injection, for subcutaneous use Initial U.S. Approval: 2009 BRIEF SUMMARY: Please see package insert for full prescribing information. 1 INDICATIONS AND USAGE KESIMPTA is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. 4 CONTRAINDICATIONS KESIMPTA is contraindicated in patients with: • Active HBV infection [see Warnings and Precautions (5.1)]. 5 WARNINGS AND PRECAUTIONS 5.1 Infections An increased risk of infections has been observed with other anti-CD20 B-cell depleting therapies. KESIMPTA has the potential for an increased risk of infections, including serious bacterial, fungal, and new or reactivated viral infections; some of these infections have been fatal in patients treated with other anti-CD20 antibodies. In Study 1 and Study 2 [see Clinical Studies (14) in the full prescribing information], the overall rate of infections and serious infections in patients treated with KESIMPTA was similar to patients who were treated with teriflunomide (51.6% vs 52.7%, and 2.5% vs 1.8%, respectively). The most common infections reported by KESIMPTA-treated patients in the randomized clinical relapsing MS (RMS) trials included upper respiratory tract infection (39%) and urinary tract infection (10%). Delay KESIMPTA administration in patients with an active infection until the infection is resolved. Possible Increased Risk of Immunosuppressant Effects with Other Immunosuppressants When initiating KESIMPTA after an immunosuppressive therapy or initiating an immunosuppressive therapy after KESIMPTA, consider the potential for increased immunosuppressive effects [see Drug Interactions (7.1) and Clinical Pharmacology (12.2) in the full prescribing information]. KESIMPTA has not been studied in combination with other MS therapies. Hepatitis B Virus Reactivation There were no reports of HBV reactivation in patients with MS treated with KESIMPTA. However, HBV reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, has occurred in patients being treated with ofatumumab for chronic lymphocytic leukemia (CLL) (at higher intravenous doses than the recommended dose in MS but for a shorter duration of treatment) and in patients treated with other anti-CD20 antibodies. Infection KESIMPTA is contraindicated in patients with active hepatitis B disease. Fatal infections caused by HBV in patients who have not been previously infected have occurred in patients being treated with ofatumumab for CLL (at higher intravenous doses than the recommended dose in MS but for a shorter duration of treatment). HBV screening should be performed in all patients before initiation of treatment with KESIMPTA. At a minimum, screening should include Hepatitis B surface antigen (HBsAg) and Hepatitis B Core Antibody (HBcAb) testing. These can be complemented with other appropriate markers as per local guidelines. For patients who are negative for HBsAg and positive for HB core antibody [HBcAb+] or are carriers of HBV [HBsAg+], consult liver disease experts before starting and during treatment with KESIMPTA. These patients should be monitored and managed following local medical standards to prevent HBV infection or reactivation. Progressive Multifocal Leukoencephalopathy Progressive multifocal leukoencephalopathy (PML) is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically occurs in patients who are immunocompromised, and that usually leads to death or severe disability. Although no cases of PML have been reported for KESIMPTA in the RMS clinical studies, PML resulting in death has occurred in patients being treated with ofatumumab for CLL (at substantially higher intravenous doses than the recommended dose in MS but for a shorter duration of treatment). In addition, JCV infection resulting in PML has also been observed in patients treated with other anti-CD20 antibodies and other MS therapies. At the first sign or symptom suggestive of PML, withhold KESIMPTA and perform an appropriate diagnostic evaluation. Magnetic resonance imaging (MRI) findings may be apparent before clinical signs or symptoms. 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. If PML is confirmed, treatment with KESIMPTA should be discontinued. Vaccinations Administer all immunizations according to immunization guidelines at least 4 weeks prior to initiation of KESIMPTA for live or live-attenuated vaccines,

and whenever possible, at least 2 weeks prior to initiation of KESIMPTA for inactivated vaccines. KESIMPTA may interfere with the effectiveness of inactivated vaccines. The safety of immunization with live or live-attenuated vaccines following KESIMPTA therapy has not been studied. Vaccination with live or liveattenuated vaccines is not recommended during treatment and after discontinuation until B-cell repletion [see Clinical Pharmacology (12.2) in the full prescribing information]. Vaccination of Infants Born to Mothers Treated with KESIMPTA During Pregnancy In infants of mothers treated with KESIMPTA during pregnancy, do not administer live or live-attenuated vaccines before confirming the recovery of B-cell counts. Depletion of B-cells in these infants may increase the risks from live or live-attenuated vaccines. Inactivated vaccines may be administered, as indicated, prior to recovery from B-cell depletion, but an assessment of vaccine immune responses, including consultation with a qualified specialist, should be considered to determine whether a protective immune response was mounted. 5.2 Injection-Related Reactions In Study 1 and Study 2, systemic and local injection reactions were reported in 21% and 11% of patients treated with KESIMPTA compared to 15% and 6% of patients treated with teriflunomide who received matching placebo injections, respectively [see Adverse Reactions (6.1) and Clinical Studies (14) in the full prescribing information]. Injection-related reactions with systemic symptoms observed in clinical studies occurred most commonly within 24 hours of the first injection, but were also observed with later injections. Symptoms observed included fever, headache, myalgia, chills, and fatigue, and were predominantly (99.8%) mild to moderate in severity. There were no life-threatening injection reactions in RMS clinical studies. Local injection-site reaction symptoms observed in clinical studies included erythema, swelling, itching, and pain. Only limited benefit of premedication with corticosteroids, antihistamines, or acetaminophen was observed in RMS clinical studies. The first injection of KESIMPTA should be performed under the guidance of an appropriately trained healthcare professional. If injection-related reactions occur, symptomatic treatment is recommended. 5.3 Reduction in Immunoglobulins As expected with any B-cell depleting therapy, decreased immunoglobulin levels were observed. Decrease in immunoglobulin M (IgM) was reported in 7.7% of patients treated with KESIMPTA compared to 3.1% of patients treated with teriflunomide in RMS clinical trials [see Adverse Reactions (6.1)]. Treatment was discontinued because of decreased immunoglobulins in 3.4% of patients treated with KESIMPTA and in 0.8% of patients treated with teriflunomide. No decline in immunoglobulin G (IgG) was observed at the end of the study. Monitor the levels of quantitative serum immunoglobulins during treatment, especially in patients with opportunistic or recurrent infections, and after discontinuation of therapy until B-cell repletion. Consider discontinuing KESIMPTA therapy if a patient with low immunoglobulins develops a serious opportunistic infection or recurrent infections, or if prolonged hypogammaglobulinemia requires treatment with intravenous immunoglobulins. 5.4 Fetal Risk Based on animal data, KESIMPTA can cause fetal harm due to B-cell lymphopenia and reduce antibody response in offspring exposed to KESIMPTA in utero. Transient peripheral B-cell depletion and lymphocytopenia have been reported in infants born to mothers exposed to other anti-CD20 B-cell depleting antibodies during pregnancy. Advise females of reproductive potential to use effective contraception while receiving KESIMPTA and for at least 6 months after the last dose [see Use in Specific Populations (8.1)]. 6 ADVERSE REACTIONS The following clinically significant adverse reactions are discussed in greater detail elsewhere in the labeling: • Infections [see Warnings and Precautions (5.1)] • Injection-Related Reactions [see Warnings and Precautions (5.2)] • Reduction in Immunoglobulins [see Warnings and Precautions (5.3)] 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reactions 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. Approximately 1500 patients with RMS received KESIMPTA in clinical studies. In Study 1 and Study 2, 1882 patients with RMS were randomized, 946 of whom were treated with KESIMPTA for a median duration of 85 weeks; 33% of patients receiving KESIMPTA were treated for up to 120 weeks [see Clinical Studies (14.1) in the full prescribing information]. The most common adverse reactions occurring in greater than 10% of patients treated

with KESIMPTA and more frequently than in patients treated with teriflunomide were upper respiratory tract infections, injection-related reactions (systemic), headache, and injection-site reactions (local). The most common cause of discontinuation in patients treated with KESIMPTA was low immunoglobulin M (3.3%), defined in trial protocols as IgM at 10% below the lower limit of normal (LLN). Table 1 summarizes the adverse drug reactions that occurred in Study 1 and Study 2. Table 1: Adverse Reactions in Patients with RMS with an Incidence of at Least 5% with KESIMPTA and a Greater Incidence Than Teriflunomide (Pooled Study 1 and Study 2) KESIMPTA 20 mg N = 946 % 39

Teriflunomide 14 mg N = 936 % 38

Injection-related reactions (systemic)

Headache

Injection-site reactions (local)

Urinary tract infection

Back pain

Blood immunoglobulin M decreased

Adverse Reactions Upper respiratory tract infectionsa

aIncludes

the following: nasopharyngitis, upper respiratory tract infection, influenza, sinusitis, pharyngitis, rhinitis, viral upper respiratory infection, tonsillitis, acute sinusitis, pharyngotonsillitis, laryngitis, pharyngitis streptococcal, viral rhinitis, sinusitis bacterial, tonsillitis bacterial, viral pharyngitis, viral tonsillitis, chronic sinusitis, nasal herpes, tracheitis. Injection-Related Reactions and Injection-Site Reactions The incidence of injection-related reactions (systemic) was highest with the first injection (14.4%), decreasing with subsequent injections (4.4% with second, less than 3% with third injection). Injection-related reactions were mostly (99.8%) mild to moderate in severity. Two (0.2%) patients treated with KESIMPTA reported serious injection-related reactions. There were no life-threatening injection-related reactions. Most frequently reported symptoms (2% or greater) included fever, headache, myalgia, chills, and fatigue. In addition to systemic injection-related reactions, local reactions at the administration site were very common. Local injection-site reactions were all mild to moderate in severity. The most frequently reported symptoms (2% or greater) included erythema, pain, itching, and swelling [see Warnings and Precautions (5.2)]. Laboratory Abnormalities Immunoglobulins In Study 1 and Study 2, a decrease in the mean level of IgM was observed in KESIMPTA-treated patients but was not associated with an increased risk of infections [see Warnings and Precautions (5.3)]. In 14.3% of patients in Study 1 and Study 2, treatment with KESIMPTA resulted in a decrease in a serum IgM that reached a value below 0.34 g/dL. KESIMPTA was associated with a decrease of 4.3% in mean IgG levels after 48 weeks of treatment and an increase of 2.2% after 96 weeks. 6.2 Immunogenicity As with all therapeutic proteins, there is potential for immunogenicity. The detection of antibody formation 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 medication, and the underlying disease. For these reasons, comparison of the incidence of antibodies in the studies described below with the incidence of antibodies in other studies or to other ofatumumab products may be misleading. Treatment induced anti-drug antibodies (ADAs) were detected in 2 of 914 (0.2%) KESIMPTA-treated patients; no patients with treatment enhancing or neutralizing ADAs were identified. There was no impact of positive ADA titers on PK, safety profile or B-cell kinetics in any patient; however, these data are not adequate to assess the impact of ADAs on the safety and efficacy of KESIMPTA. 7 DRUG INTERACTIONS 7.1 Immunosuppressive or Immune-Modulating Therapies Concomitant usage of KESIMPTA with immunosuppressant drugs, including systemic corticosteroids, may increase the risk of infection. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with KESIMPTA.

When switching from therapies with immune effects, the duration and mechanism of action of these therapies should be taken into account because of potential additive immunosuppressive effects when initiating KESIMPTA. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk Summary There are no adequate data on the developmental risk associated with the use of KESIMPTA in pregnant women. Ofatumumab may cross the placenta and cause fetal B-cell depletion based on findings from animal studies (see Data). Transient peripheral B-cell depletion and lymphocytopenia have been reported in infants born to mothers exposed to other anti-CD20 antibodies during pregnancy. B-cell levels in infants following maternal exposure to KESIMPTA have not been studied in clinical trials. The potential duration of B-cell depletion in infants exposed to ofatumumab in utero, and the impact of B-cell depletion on the safety and effectiveness of vaccines, are unknown. Avoid administering live vaccines to neonates and infants exposed to KESIMPTA in utero until B-cell recovery occurs [see Warnings and Precautions (5.2) and Clinical Pharmacology (12.2) in the full prescribing information]. Following administration of ofatumumab to pregnant monkeys, increased mortality, depletion of B-cell populations, and impaired immune function were observed in the offspring, in the absence of maternal toxicity, at plasma levels substantially higher than that in humans (see Data). In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. The background risk of major birth defects and miscarriage for the indicated population is unknown. Data Animal Data Intravenous administration of ofatumumab (weekly doses of 0, 20, or 100 mg/kg) to pregnant monkeys during the period of organogenesis (gestations days 20 to 50) resulted in no adverse effects on embryofetal development; however, B-cell depletion was observed in fetuses at both doses when assessed on gestation day 100. Plasma exposure (Cave) at the no-effect dose (100 mg/kg) for adverse effects on embryofetal development was greater than 5000 times that in humans at the recommended human maintenance dose of 20 mg. A no-effect dose for effects on B-cells was not identified; plasma exposure (Cave) at the low-effect dose (20 mg/kg) was approximately 780 times that in humans at the recommended human maintenance dose (RHMD) of 20 mg/month. Intravenous administration of ofatumumab (5 weekly doses of 0, 10, and 100 mg/kg, followed by biweekly doses of 0, 3, and 20 mg/kg) to pregnant monkeys throughout pregnancy resulted in no adverse effects on the development of the offspring. However, postnatal death, B-cell depletion, and impaired immune function were observed in the offspring at the high dose. The deaths at the high dose were considered secondary to B-cell depletion. Plasma exposure (Cave) in dams at the no-effect dose (100/20 mg/kg) for adverse developmental effects was approximately 500 times that in humans at RHMD. A no-effect level for mortality and immune effects in offspring was not established because of the limited number of evaluable offspring at the low dose. 8.2 Lactation Risk Summary There are no data on the presence of ofatumumab in human milk, the effects on the breastfed infant, or the effects of the drug on milk production. Human IgG is excreted in human milk, and the potential for absorption of ofatumumab to lead to B-cell depletion in the infant is unknown. The developmental and health benefits of breastfeeding should be considered along with the motherâ&#x20AC;&#x2122;s clinical need for KESIMPTA and any potential adverse effects on the breastfed infant from KESIMPTA or from the underlying maternal condition. 8.3 Females and Males of Reproductive Potential Contraception Females of childbearing potential should use effective contraception while receiving KESIMPTA and for 6 months after the last treatment of KESIMPTA [see Warnings and Precautions (5.4) and Clinical Pharmacology (12.3) in the full prescribing information]. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use Clinical studies of KESIMPTA did not include sufficient numbers of geriatric patients to determine whether they respond differently from younger subjects. Manufactured by: Novartis Pharmaceuticals Corporation East Hanover, NJ 07936 U.S. License No.: 1244 KESIMPTA and SENSOREADY is a [registered] trademark of Novartis AG. T2020-112

AANnews · February 2021

February Highlights The Mission of the AAN is to promote the highest quality patient-centered neurologic care and enhance member career satisfaction.

The Vision of the AAN is to be indispensable to our members.

No one exemplifies the success of this program more than recent graduates Alyx B. Porter, MD, FAAN; Daniel J. Correa, MD, MS; and Reena Thomas, MD, PhD.

Contact Information American Academy of Neurology 201 Chicago Avenue Minneapolis, MN 55415 Phone: (800) 879-1960 (toll free) (612) 928-6000 (international) Email:

memberservices@aan.com

Continuum LIFELONG LEARNING IN NEUROLOGY®

FEBRUARY 2021

Website: AAN.com

VOL. 27

NO. 1

Spinal Cord Disorders EDITOR-IN-CHIEF: STEVEN L. LEWIS, MD, FA AN GUEST EDITOR: EOIN P. FLANAGAN, MBBCH

For advertising rates, contact: Eileen R. Henry Wolters Kluwer Health | Medical Research Lippincott, Williams & Wilkins Phone: (732) 778-2261

021 Diversity Leadership Program 2 Launches, Recent Graduates Achieve Success

Spinal Cord Disorders Is Continuum’s First 2021 Topic

Neurologists seeking to improve their clinical skills and earn valuable CME will benefit from the new issue of Continuum: Lifelong Learning in Neurology ® addressing spinal cord disorders.

CONTINUUMJOURNAL.COM

Email: Eileen.Henry@wolterskluwer.com

T:10.875"

B:11.125"

S:9.75"

24 AAN Chief Executive Officer: Mary E. Post, MBA, CAE

cholarship Recipient Seeks S to Improve Understanding of Tourette Syndrome

Alonso Zea Vera, MD, is using the scholarship he received through the American Brain Foundation’s Next Generation Research Grant Program to help find new treatments.

Editor-in-Chief: Melissa W. Ko, MD, FAAN, CPE

Editor: Tim Streeter

News Briefs

Writers: Ryan Knoke and Sarah Parsons

Attend Virtual 2021 AAN Business Meeting

Designer: Siu Lee

The Academy’s yearly Business Meeting will be held virtually this year during the Annual Meeting. Watch for more information on the Business Meeting agenda including nominees to the Board of Directors in the March issue of AANnews.

Managing Editor: Angela M. Babb, MS, CAE, APR

Email: aannews@aan.com AANnews® is published monthly by the American Academy of Neurology for its 36,000 members worldwide. Access this magazine and other AAN publications online at AAN.com. 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. The inclusion of advertisements and/or promotions of Sponsors and other Internet sites or resources that offer content, goods, or services on the Website does not imply endorsement of the advertised/promoted products or services by AAN.

Neurology Today Highlights the News That Mattered in 2020 The January 21, 2021, issue of Neurology Today ® features the Editorial Board Top Picks of articles from 2020 that highlight advances that moved neurology and the field forward in the clinic, at the bench, in the therapeutic pipeline, and in areas of policy and practice. To read what you might have missed, visit http://bit.ly/NT-BestAdvances. Vote in AAN Section Elections Elections are underway in 19 sections, with over 90 candidates on the ballot for 38 positions. Voting is open until February 12. 

AANnews • February 2021 7

President’s Column

New Strategic Plan Sets Course for Unpredictable 2021 I’m sure no one’s 2020 turned out as they planned. Nor did the AAN’s year. Nonetheless, our Academy leaders, members, and staff pulled together like never before and demonstrated our resiliency, agility, and resourcefulness in proving the AAN’s value to the neurology profession. From launching outstanding and record-breaking virtual conferences to fighting for proper E/M coding and reimbursement to maintaining a healthy membership of 36,000 and growth in many key segments, we had a very strong year. In spite of significant challenges, the Academy in 2020 achieved progress in accomplishing the goals and objectives we set before the pandemic, using scenario and operational planning and a concerted effort at meaningful prioritization of new, critical initiatives―all while transitioning to a new chief executive officer and chief financial officer. I’m tremendously proud of what our leadership and staff accomplished—and very excited about the year to come. And even though 2021 holds many unknowns when it comes to COVID-19 and our ability to safely come together physically, we are ready for various contingencies. The 2021 Strategic Plan approved by the Board of Directors sets our course for the year and considers how our goals and objectives may be affected by the ongoing pandemic, which we have gauged to be a lingering disruption over the coming months as progress is made in delivering vaccines to prevent the virus and improvements are made to treating it. Our 2021 goals describe how we as leaders, members, and staff will accomplish our mission and achieve our vision. Substantial changes were incorporated into the goals from 2020 to reflect new opportunities and challenges, including the need for novel approaches to educate and assist members, commitment to be a fully inclusive and anti-racist organization, more patient and public outreach and engagement, member resiliency, and more focus on the viability and innovation in our neurology practices. These goals envision a preferred future to which we aspire for the American Academy of Neurology—a future in which we achieve our vision to be indispensable to all our members: 1. Demonstrate and assert the value of neurology to policymakers, patients, and the public and other major stakeholders 2. Grow the neurology workforce and innovate care delivery to meet the future needs for patient care 3. Demonstrate and communicate our commitment to be a fully inclusive, diverse, and anti-racist organization that promotes neurologic health equity and actively works to recruit and support a diverse membership 4. Ensure the health of the neurology community and enhance member and staff satisfaction, well-being and resiliency, and engagement 5. Advocate and support the financial well-being, continuing viability, and innovation of the practice of neurology 6. Expand and support neuroscience research

AANnews • February 2021

Stevens

7. Create novel ways to educate and assist members in providing high-value, team-based, patient-centered, clinical care The Academy’s budget development process incorporated our planning and aligned with the ongoing strategic work, with a commitment to balancing the bottom line for 2021. As we continue to look forward with foresight, our strategic themes will guide our planning process and budget priorities for 2021. These include our goals and ongoing commitment to our core functions and mission: A commitment to innovation—creating novel approaches to building our neurology community, and developing education and other programs, products, and services that meet the needs of our diverse members A commitment to improve access to neurologic care—working to expand the neurology pipeline and address health care disparities, and supporting conversations, experience, and resources to bring young minds to neurology A commitment to quality improvement—driving systemic change in health care to support neurologists in all practice settings to provide the best possible patient care and access for all our patients

Conferences & Community

A commitment to value—demonstrating and asserting the value of neurology to policymakers, patients, and the public and other major stakeholders While 2021 continues in lingering disruption, it also ushers in a spirit of optimism and commitment, with hope for a better future as we move to the other side of the COVID-19 pandemic. The Academy in 2021 will continue to tell the story of resilient adaptation in support of the entire community of neurology. What role do you play in this plan? You can take advantage of everything your AAN membership has to offer you! Attend our exciting first-ever virtual Annual Meeting from April 17 to 22 and enjoy unparalleled educational and scientific content without leaving home. Another virtual opportunity on May 19 is our acclaimed advocacy event Neurology on the Hill; apply by February 26. Participate in our enhanced Neurology Compensation and Productivity Survey coming in March. Use our abundant online education, practice management, and job search resources that are available to you 24/7. As stated in the strategic plan, “No one knows how the future will unfold, but the tools of scenario and strategic planning can help the Academy prepare for the different, possible futures that may unfold.” The AAN is here for you every day and every step of the way as our futures unfold together. 

February 8 Deadline Approaching to Submit Emerging Science Abstracts Be sure to visit AAN.com/ EmergingScience no later than 11:59 p.m. CT on February 8 to submit your abstracts for the 2021 Annual Meeting’s Emerging Science program. Abstracts must be previously unpublished research in which key aspects were completed after the October 19 abstract submission deadline. The work should showcase timely, significant, and innovative content warranting expedited presentation. Contact Laura Southwick at science@aan.com for questions. 

April 17– April 22

FEBRUARY

SUBMIT

Sincerely,

James C. Stevens, MD, FAAN President, AAN jstevens@aan.com @JimStevensMD on Twitter

Frontiers in Neuroscience Plenary Speakers Announced continued from cover importance during the 2021 Frontiers in Neuroscience Plenary Session. The speakers will provide summaries of their recent research findings and describe the clinical implications of the results. Presenters and topics include:

Organization and Control of Hippocampal Circuits Ivan Soltesz, PhD, Stanford, CA

Decoding Speech Cortex

Edward Chang, MD, San Francisco, CA

Microtubules in Health and Disease Antonina Roll-Mecak, PhD, Bethesda, MD

Stem Cell Therapy for Spinal Cord Injury: Transition to the Clinic

Mark H. Tuszynski, MD, PhD, FAAN, La Jolla, CA

Dissecting the Control of Blood Flow Through Brain Capillaries Andy Shih, PhD, Seattle, WA

Visit AAN.com/21AM to learn more about the 2021 Annual Meeting—coming to you in a new, fully virtual format—and register by March 25 for the best rates. 

AANnews • February 2021 9

Conferences & Community

2021 Diversity Leadership Program Launches, Recent Graduates Achieve Success The 2021 Diversity Leadership Program recently launched in a new format that marks the first in the program’s seven-year history—a virtual kickoff meeting. During the meeting, the 10 neurologists that make up this year’s cohort learned about the AAN’s mission, organizational structure, and commitment to Inclusion, Diversity, Equity, Anti-racism, and Social Justice (IDEAS), as well as foundational leadership skills such as resiliency and leading one’s self. Over the course of the nine-month program, participants will be paired with a mentor and will learn about topics like conflict management, emotional intelligence, and leading a team. They will also be assigned a group project to challenge, engage, and support each other’s learning and development, and will present to the AAN Board of Directors at the conclusion of the program. Skills learned during the program will be essential as the cohorts continue their careers and leadership journeys—and no one exemplifies the success of this journey more than recent graduates Alyx B. Porter, MD, FAAN; Daniel J. Correa, MD, MS; and Reena Thomas, MD, PhD.

Porter

Correa

Thomas

Porter, a 2018 graduate, was highlighted in the September 2020 issue of AANnews for her efforts in founding the nonprofit organization ElevateMeD, which focuses on achieving a physician workforce that is racially and ethnically representative of the communities it serves. In December 2020, ElevateMeD was awarded a True Inspiration Award by ChickFil-A. The award comes with a $100,000 grant that will support the organization as it continues its mission. “The Diversity Leadership Program allowed me to recognize and leverage my own strengths while also learning to build a high-functioning team,” said Porter. Data collected by the AAN also supports the positive impact of the Diversity Leadership Program. According to a postprogram assessment, 100 percent of Diversity Leadership Program graduates agree that they learned tools for better addressing systemic change and acquired new approaches for building and maintaining strategic alliances. 2019 graduate Correa, who is assistant professor in the Saul R. Korey Department of Neurology at Albert Einstein College of Medicine, credits the program with preparing him to respond to the spring COVID-19 surge in New York City. Over the course of three weeks, Correa and his colleagues delivered care to “over 600 hospitalized patients with neuro-COVID and over 1,742 total neuroscience hospital bed days.” For these efforts, Correa was recently featured on the cover and profiled in Brain & Life En Español magazine. “The skills I learned in the Diversity Leadership Program were essential as I worked alongside our neurology and hospital leadership in responding to the pandemic,” he said. Thomas, a clinical associate professor in the Division of Neuro-oncology at Stanford University School of Medicine and 2019 graduate from the Diversity Leadership Program, is also quick to recognize the key skills gained from the program and share how that has shaped her career. “First, [it] allowed me to hone concrete leadership skills,” she said.

AANnews • February 2021

“Specifically, the one-on-one coaching and mentoring sessions allowed me the space and perspective to explore the impact I wanted to have in my career and clinical practice.” Since graduating from the program, Thomas also started in new roles as associate dean for diversity in medical education at the Stanford School of Medicine and director of diversity in the Department of Neurology. She credits the skills she learned from the Diversity Leadership Program with helping her excel in her new positions. “Both roles required the ability to apply the competencies we covered in [the] program including the importance of having resilience and challenging myself to advocate for what I needed to be successful.” Thomas also values the bond that is built on a personal level, pointing out that her fellow cohort members have published manuscripts and served on national committees together, as well as supported each other through the difficult challenges of 2020. “We began the journey as learning partners and completed the program as a group of lifelong friends who remain in frequent contact with each other,” she added. The AAN thanks the following organizations that supported this program in part: ACADIA Pharmaceuticals, Inc.; Allergan, Inc.; argenx; Biogen; Eisai, Inc.; Genentech, a member of the Roche group; and Sanofi Genzyme. Visit AAN.com/view/DLP to learn more about the Diversity Leadership Program. 

2021 Presidential Plenary Session to Showcase Premier Lecture continued from cover Lectures include:

Presidential Lecture In non-AAN election years, this premier lecture is awarded to a neurologist chosen by the AAN president. In election years, the lecture is presented by the outgoing president. James C. Stevens, MD, FAAN Fort Wayne, IN President, American Academy of Neurology

H. Houston Merritt Lecture This lecture honors excellence in education involving clinically relevant

Robert Wartenberg Lecture

research and is awarded every other year during the Presidential Plenary Session.

This annual lecture is awarded to a neurologist for excellence in clinically relevant research.

Steven Galetta, MD, FAAN New York, NY

Caroline Tanner, MD, PhD, FAAN San Francisco, CA

Sidney Carter Award in Child Neurology Endowed by an anonymous donor and presented every year during the Presidential Plenary Session, this lecture recognizes outstanding work by an individual in the field of child neurology/ developmental neurobiology. Jerry R. Mendell, MD, FAAN Columbus, OH

April 17– April 22 Visit AAN.com/21AM to learn more about the 2021 Annual Meeting—coming to you in a

PubPolicy: 21new, NOH fully Ad—Half Page Horizontal> AN virtual format—and register by March 25 for the best rates.  Placed in AANnews 8.25 x 5.25 +0.125 bleed, 4C

Neurology on the Hill

Visit Your Lawmakers in Washington, DC—from Your Office or Home! 2021 Neurology on the Hill will be a virtual event on May 19. Share your passion for making a positive change and educate members of Congress on issues impacting neurology.

Apply by February 26 at AAN.com/NOH

AANnews • February 2021 11

Conferences & Community

In Memoriam: Nelson G. Richards, MD, FAAN Nelson G. Richards, MD, FAAN, the first private practice clinician to be elected to the office of president of the American Academy of Neurology from 1983 to 1985, passed away at age 96 at his home on December 13, 2020. “Nelson Richards was special to all of us,” said Laura Powers, MD, FAAN, former chair of the Practice Committee. “He was prescient in stressing how the economics of practicing medicine would affect our abilities to provide appropriate care. The AAN was ahead of other similar specialties early on in representing our patients’ needs to regulatory agencies.”

Richards was in the forefront of addressing problems resulting from growth of Academy membership. The Annual Meeting days had doubled from the initial three days, making it difficult for many practitioners to attend both scientific and educational programs. Richards proposed sandwiching scientific sessions between two educational programs. Initially, Richards opposition on the Executive Board was strong, but he persisted. During his presidency, however, the wisdom of the change was accepted, and the meeting format altered accordingly.

“Nelson was a father figure to many over the years,” said Marc R. Nuwer, MD, FAAN. “He encouraged many individuals to participate in AAN activities. He was a delegate to AMA House of Delegates, where he founded the Brain Trust caucus for neurology, neurosurgery, psychiatry, physical medicine/rehabilitation, and related subspecialties to meet. We are all aware of one of the many accomplishments of the Brain Trust—the Americans with Disabilities Act. Nelson has been the only neurologist to serve on the CPT Editorial Panel. While there, he lobbied unsuccessfully for codes for Principal Care, and to create separate codes for services provided by neurologists. He fought for years to realize that dream of recognition for Principal Care, and that campaign finally was realized last year in new CPT codes. Nelson’s legacy lives on with substantial impact all across neurology, organized medicine, and health care in America. We all will miss him.” Richards became active in the Academy early in his career. He was elected assistant secretary-treasurer in 1968 and secretary-treasurer the following year. Recognizing the growing importance of patient care, he became a driving force on the Practice Committee. His devotion to the practitioner was continually apparent for the 10 years he served on the Academy's Executive Board. He was a member of the Education Committee from 1982 to 1985 and chaired the Nominations Committee from 1987 to 1989.

Richards, right, with former President Maynard Cohen, MD, FAAN, at AAN 50th anniversary event in 1998.

AANnews • February 2021

Born in Orange, NJ, in 1924, Richards attended the University of Virginia for both undergraduate and graduate schools. Richards served his country in the United States Navy from 1944 to 1946 and was assigned to the Hospital Corpsman School during World War II before his college education was complete. He earned a bachelor’s degree in zoology in 1948 followed by a doctorate in medicine in 1952. After his internship in internal medicine, Richards served an additional year as assistant resident in medicine, then two years in neurology under Harold G. Wolff, all at New York Hospital. He moved to Bethesda for a final year of fellowship at the National Institute of Neurological Disorders and Blindness (NINDB) under G. Milton Shy, combining the fellowship with an instructorship in neurology at Georgetown University Medical School. Following his tenure at the NINDB, he joined the Cleveland Clinic as associate professor of neurology, where he remained from 1958 to 1969. He returned to set up practice in Virginia. He retired from practice with Associated Neurologists in 1996 but continued as an attending neurologist, half-time, at the McGuire Veterans Administration Hospital in Richmond from 1972 until his retirement in 2001. He was also founding president of the Northeastern Ohio Neurologic Society and the Virginia Neurologic Society and president of both the Virginia Society of Internal Medicine (1995–1996) and the Society of Clinical Neurology. 

Richards in 1970.

Richards led a long-range planning retreat in 1991.

Tools & Resources

New APP Onboarding Resources Now Available The advanced practice provider (APP) community at the AAN continues to grow. While APPs have considerable educational and practical training before entering neurology, many new and more experienced APPs and the physicians who work with them have requested onboarding resources for APPs working in neurology practices. Under the guidance of the Medical Economics and Practice Committee, a work group of APP members from the Consortium of Neurology Advanced Practice Providers developed several onboarding resources including: A Clinical Evaluation Template for APPs and preceptors to use during the onboarding process to assess clinical competencies. A Clinical Competency Guide which includes clinical components that APPs should demonstrate proficiencies in by the end of the onboarding period. Competency areas include general neurology, patient diagnoses and care, communication and documentation, test review, interpretation, and ordering. An Administrative Guide that provides a checklist of items that APPs should understand and demonstrate competencies within each related to practice/department overview, practice/department safety procedures, job responsibilities and practice policies and procedures. A Top 5: Billing and Coding for Neurology APPs that offers high-level education on billing and coding methodology for neurology providers.

These resources were developed to deliver high-level information for neurology practices onboarding APPs, and they are encouraged to adapt these resources to suit their unique practice setup and needs. Review the resources at AAN.com/appresources and email practice@aan.com to share feedback, future suggestions, or questions.  NEUROLOGY ADVANCED PRACTICE PROVIDER ADMINISTRATIVE ITEMS The American Academy of Neurology (AAN) supports team-based care models, of which neurology advanced practices providers (APP) are a vital component. The following guide is meant to serve as a general list of administrative items that neurology APPs should understand and complete by the end of their onboarding period into a neurology practice. Practices and academic departments should add to and adapt this checklist, depending on their practice setting and type and in compliance with their state’s scope of practice regulations. Employee Name:

NEUROLOGY ADVANCED PRACTICE PROVIDER Preceptor Name: CLINICAL EVALUATION Start Date:

End Date:

This guide should be used to evaluate an Advanced Practice Provider’s (APP) clinicalItem competencies during the onboarding period. Administrative Evaluations should reflect the APP’s ability to provide appropriate care for a variety of neurologic conditions or within their Practice/Department Overview neurologic subspecialty. In addition to clinical evaluation, review of fundamental documentation and communication elements Practice Mission, Goals, and Objectives such as office notes, message follow-up, etc. should be discussed and considered when evaluating clinical competencies. • • • • • • •

Brain and Spine Trauma Cognitive and Behavioral Disorders Demyelinating and Immunologic Disorders Developmental and Congenital Disorders Epilepsy and Episodic Disorders Headache and Pain Disorders Movement Disorders

Chief Complaint/Condition: Reviewer Name/Signature:

History Level 1

Level 2

Obtains a neurologic history, but is incomplete and disorganized

Obtains a complete neurologic history

Comments:

Neurologic Examination (Specify initial or follow-up) Level 1

Level 2

Performs an incomplete and inaccurate neurologic examination

Performs a neurologic exam but missing relevant portions

Comments:

Practice Organizational Structure • Neuromuscular Disorders

Scope of Practice Services • Neuro-oncologic and Paraneoplastic Disorders

Level 2

Unable to localize history and neurologic exam findings

Inconsistently able to localize history and neurologic exam findings to general regions of the nervous system

Complete — N/A

• SleepTour Disorders Practice

• •Toxic, Metabolic, and activities Nutritional Disease Quality improvement

The American Academy of Neurology (AAN) supports team-based care models, of which neurology advanced practices providers

• Stroke and Other Activities Vascular Conditions Ongoing Professional • • • •

Complete — N/A

Practice/department committees (APP) are a vital component. The following is a guide of clinical competencies that neurology APPs should complete by the end of Ongoing Professional Practice Evaluation (OPPE) their onboarding period into a neurology practice. Practices and academic departments should add to and adapt this checklist, Focused Professional Practice Evaluation (FPPE) depending on their practice setting and type and in compliance with their state’s scope of practice regulations. APP Name: Professional association memberships (e.g., AAN, others) Employee Name: Complete — N/A Practice/Department Safety ProceduresDate: Preceptor Name: Fire safety Start Date: End Date: Complete — N/A Adverse event occurrence reporting

Level 3

Level 4

Complete — N/A Infection control and prevention practices Efficiently obtains a complete Consistently obtains a complete, Clinical Competency Complete — N/A andUtilities organized history relevant, and organized management neurologic history sufficient General to Neurology Complete — N/A National patient safety goals guide subsequent examination, investigation, and treatment Perform and record history and physical and initial consultation Complete — N/A Hazardous materials and waste Perform the following neurologic exams: Complete — N/A Emergency preparedness • Detailed, comprehensive neurologic examination and focused neurologic Complete — N/A Infant/child abduction and other codes exam including ophthalmological exam Cexam — omplete • Demonstrate ability to distinguish normal from abnormalN/A findings Job Responsibilities • Describe/document normal and abnormal examination findings Job 3description and responsibilities Level Level 4 Perform the following cognitive screening assessments: Complete — N/A Performs a complete and Consistently performs an Core competencies accurate neurologic examination efficient, complete, and relevant • Mini-Mental Status Examination© (MMSE) Complete — N/A Performance expectations neurologic examination • Montreal Cognitive Assessment© (MoCA) Complete — N/A HIPAA, Patient confidentiality/privacy • Other tests as applicable (SLUMS, RBANS, etc.)

Prescriptive Privileges

Level 3

Patient Diagnoses and Care

Differential Diagnoses Level 1

Level 2

Unable to summarize history and Able to summarize history examination. Unable to formulate and examination. Unable to any differential diagnoses. synthesize information to formulate relevant differential diagnoses. Comments:

Date

Complete (or N/A)

Complete — N/A

Complete — Review indications for procedures to be performed by the APPN/A

Level 4

Complete — N/A Provide care for neurology patients with the following diagnoses:

• Brain and Spine Trauma Drug Enforcement Administration (DEA) number Able to localize history and Accurately localizes history and neurologic exam findings neurologic exam findings to • Cognitive and Behavioral Disorders Billing education • Demyelinating and Immunologic Disorders to general regions of the specific regions/structures of the Telehealth education nervous system nervous system • Developmental and Congenital Disorders • Epilepsy and Episodic Disorders • Headache and Pain Disorders • Movement Disorders • Neuromuscular Disorders • Neuro-oncologic and Paraneoplastic Disorders Level 3 Level 4 • Neuro-ophthalmologic and Neuro-otologic Disorders Able to summarize history and Consistently able to summarize • Sleep Disorders examination, partial synthesis of and synthesize history and • Stroke and Other Vascular Conditions information, and formulate some examination to formulate differential diagnoses. relevant differential diagnoses.• Toxic, Metabolic, and Nutritional Disease

Get Ready for the 2021 Neurology Compensation and Productivity Survey continued from cover Comments:

Complete — N/A

NEUROLOGY ADVANCED PRACTICE Complete PROVIDER — N/A Complete — N/A CLINICAL COMPETENCIES

Test ordering

Level 1

Complete (or N/A)

Care Team Model Overview and Neuro-otologic Disorders • Neuro-ophthalmologic

Documentation expectations

Localization

Date

Complete — N/A Complete — N/A Complete — N/A Complete — N/A Page 1 of 2

Review and initiate power plans for stroke with and without thrombolytics, and for endovascular therapy Order and adjust medications appropriately

advanced practice providers, representing up to 18 subspecialties and various practice settings including solo and private, government-based, and academic.

Page Communication 1 of 2 and Documentation

Document all patient encounters appropriately and within time expectations Communicate with physicians and other providers of record to enhance patient care Provide education and updates to patients and families Write appropriate consultation for physical therapy, speech therapy, occupational therapy, and other services

Page 1 of 3

To reduce the time needed to complete the survey, collect these documents in advance: Provider salary spreadsheets, W2s, K1s Provider RVU reports Financial and accounting reports Payer mix analysis Provider benefits reports EHR and billing system reports (charges and collections) Department, school (for academic centers), and practice reports Visit AAN.com/Benchmark to learn more. 

AANnews • February 2021 13

NIGHTTIME DOSING

DAYTIME COVER

For Parkinson's disease patients with motor complications,1,2

GOCOVRI® COULD MEAN THE DIFFERENCE

BETWEEN GETTING UP

AND GETTING OUT GOCOVRI® is ready when your Parkinson’s disease (PD) patients with dyskinesia need it 2 With a single bedtime dose, high levels of GOCOVRI® are reached by morning before the ﬁrst levodopa dose, providing all-day coverage with levels slowly decreasing in the hours before bedtime.2 In clinical trials, GOCOVRI® reduced PD dyskinesia (primary endpoint) and OFF time and increased GOOD ON time (secondary endpoints).1 *

INDICATION GOCOVRI® (amantadine) extended release capsules is indicated for the treatment of dyskinesia in patients with Parkinson’s disease receiving levodopa-based therapy, with or without concomitant dopaminergic medications. It is not known if GOCOVRI is safe and effective in children. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS GOCOVRI is contraindicated in patients with creatinine clearance below 15 mL/min/1.73 m2. WARNINGS AND PRECAUTIONS Falling Asleep During Activities of Daily Living and Somnolence: Patients treated with Parkinson’s disease medications have reported falling asleep during activities of daily living. If a patient develops daytime sleepiness during activities that require full attention

(e.g., driving a motor vehicle, conversations, eating), GOCOVRI should ordinarily be discontinued or the patient should be advised to avoid potentially dangerous activities. Suicidality and Depression: Monitor patients for depression, including suicidal ideation or behavior. Prescribers should consider whether the beneﬁts outweigh the risks of treatment with GOCOVRI in patients with a history of suicidality or depression. Hallucinations/Psychotic Behavior: Patients with a major psychotic disorder should ordinarily not be treated with GOCOVRI because of the risk of exacerbating psychosis. Observe patients for the occurrence of hallucinations throughout treatment, especially at initiation and after dose increases. Dizziness and Orthostatic Hypotension: Monitor patients for dizziness and orthostatic hypotension, especially after starting GOCOVRI or increasing the dose.

RAGE NIGHTTIME DOSING

DAYTIME COVERAGE

Not an actual patient.

27% DECREASE IN DYSKINESIA 36% DECREASE IN OFF TIME 29% INCREASE IN GOOD ON TIME

10.1-point reduction in UDysRS score (-17.7 GOCOVRI® vs -7.6 placebo) 3†

1-hour decrease (-0.6 GOCOVRI® vs 0.4 placebo) 3,4†

GOOD ON time, ON time without troublesome dyskinesia; UDysRS, Uniﬁed Dyskinesia Rating Scale.

2.4-hour increase (3.8 GOCOVRI® vs 1.4 placebo) 3,4†

Withdrawal-Emergent Hyperpyrexia and Confusion: Rapid dose reduction or abrupt discontinuation of GOCOVRI, may cause an increase in the symptoms of Parkinson’s disease or cause delirium, agitation, delusions, hallucinations, paranoid reaction, stupor, anxiety, depression, or slurred speech. Avoid sudden discontinuation of GOCOVRI. Impulse Control/Compulsive Behaviors: Patients may experience urges (e.g. gambling, sexual, money spending, binge eating) and the inability to control them. It is important for prescribers to ask patients or their caregivers about the development of new or increased urges. Consider dose reduction or stopping medications. ADVERSE REACTIONS The most common adverse reactions (>10%) were hallucination, dizziness, dry mouth, peripheral edema, constipation, fall, and orthostatic hypotension.

Visit GocovriHCP.com to learn more.

*As seen in pooled results of 2 independently positive, pivotal, Phase 3, randomized, placebo-controlled trials (Study 1 and Study 2) in PD patients on levodopa. Study 1, a 24-week study, was conducted in 121 PD patients with dyskinesia (GOCOVRI® [n = 63], placebo [n = 58]). Study 2, a 12-week study, was conducted in 75 PD patients with dyskinesia (GOCOVRI® [n = 37], placebo [n = 38]).1,3 † In Study 1, GOCOVRI® reduced the UDysRS total score by 15.9 points (vs 8.0 with placebo) (P = 0.0009), decreased OFF time by 0.6 hours (vs an increase of 0.3 hours with placebo) (P = 0.0171), and increased GOOD ON time by 3.6 hours (vs 0.8 hours with placebo) (P < 0.0001) from baseline. In Study 2, GOCOVRI® reduced the UDysRS total score by 20.7 points (vs 6.3 with placebo) (P < 0.0001), decreased OFF time by 0.5 hours (vs an increase of 0.6 hours with placebo) (P = 0.0199), and increased GOOD ON time by 4.0 hours (vs 2.1 hours with placebo) (P = 0.0168) from baseline.1

Please see Brief Summary of full Prescribing Information on the adjacent page.

GOCOVRI® (amantadine) extended release capsules Brief Summary of full Prescribing Information. See full Prescribing Information. Rx Only. INDICATIONS AND USAGE: GOCOVRI is indicated for the treatment of dyskinesia in patients with Parkinson’s disease receiving levodopa-based therapy, with or without concomitant dopaminergic medications. CONTRAINDICATIONS: Contraindicated in patients with creatinine clearance below 15 mL/min/1.73 m2 WARNINGS AND PRECAUTIONS: Falling Asleep During Activities of Daily Living and Somnolence: Patients treated with Parkinson’s disease medications have reported falling asleep while engaged in activities of daily living, including the operation of motor vehicles, which sometimes has resulted in accidents. Patients may not perceive warning signs, such as excessive drowsiness, or they may report feeling alert immediately prior to the event. In controlled clinical trials, somnolence and fatigue were reported in 4% vs 1% of patients treated with GOCOVRI or placebo, respectively. Before initiating treatment with GOCOVRI, advise patients of the potential to develop drowsiness and specifically ask about factors that may increase the risk for somnolence with GOCOVRI, such as concomitant sedating medications or the presence of a sleep disorder. If a patient develops daytime sleepiness or episodes of falling asleep during activities that require full attention (eg, driving a motor vehicle, conversations, eating), GOCOVRI should ordinarily be discontinued. If a decision is made to continue GOCOVRI, patients should be advised not to drive and to avoid other potentially dangerous activities. There is insufficient information to establish whether dose reduction will eliminate episodes of falling asleep while engaged in activities of daily living or daytime somnolence. Suicidality and Depression: In controlled clinical trials, suicidal ideation or suicide attempt was reported in 2% vs 0%; depression or depressed mood 6% vs 1%; confusional state 3% vs 2%; apathy 2% vs 0%, of patients treated with GOCOVRI or placebo, respectively. Monitor patients for depression, including suicidal ideation or behavior. Prescribers should consider whether the benefits outweigh the risks of treatment with GOCOVRI in patients with a history of suicidality or depression. Hallucinations/Psychotic Behavior: Patients with a major psychotic disorder should ordinarily not be treated with GOCOVRI because of the risk of exacerbating psychosis. In controlled trials, the incidence of patients who experienced visual hallucination, auditory hallucination, delusions, illusions, or paranoia was 25% vs 3%; hallucinations caused discontinuation of treatment in 8% vs 0%; of patients treated with GOCOVRI or placebo, respectively. Observe patients for the occurrence of hallucinations throughout treatment, especially at initiation and after dose increases. Dizziness and Orthostatic Hypotension: In controlled clinical trials, 29% vs 2% experienced dizziness, syncope, orthostatic hypotension, presyncope, postural dizziness or hypotension; and 3% vs 0% discontinued study treatment because of dizziness, postural dizziness, or syncope; of patients receiving GOCOVRI or placebo, respectively. Monitor patients for dizziness and orthostatic hypotension, especially after starting GOCOVRI or increasing the dose. Concomitant use of alcohol with GOCOVRI is not recommended. Withdrawal-Emergent Hyperpyrexia and Confusion: A symptom complex resembling neuroleptic malignant syndrome (characterized by elevated temperature, muscular rigidity, altered consciousness, and autonomic instability), with no other obvious etiology, has been reported in association with rapid dose reduction, withdrawal of, or changes in drugs that increase central dopaminergic tone. Abrupt discontinuation of GOCOVRI may cause an increase in the symptoms of Parkinson’s disease or cause delirium, agitation, delusions, hallucinations, paranoid reaction, stupor, anxiety, depression, or slurred speech. If possible, avoid sudden discontinuation of GOCOVRI. Impulse Control/Compulsive Behaviors: Patients can experience intense urges to gamble, increased sexual urges, intense urges to spend money, binge eating, and/or other intense urges, and the inability to control these urges while taking one or more of the medications, including GOCOVRI, that increase central dopaminergic tone. In some cases, these urges were reported to have stopped when the dose was reduced or the medication was discontinued. Because patients may not recognize these behaviors as abnormal, it is important for prescribers to specifically ask patients or their caregivers about the development of such urges, and to consider dose reduction or stopping GOCOVRI treatment. ADVERSE REACTIONS: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice. GOCOVRI was evaluated in 2 double-blind, placebo-controlled efficacy trials of similar design and population: Study 1 (123 patients) and Study 2 (75 patients). The study population was approximately 56% male and 94% white, with a mean age of 65 years (age range from 34 years to 82 years). The mean duration of levodopa-induced dyskinesia was 4 years (range 0.1 to 14 years). Active treatment started at 137 mg once daily for 1 week, followed by a dose increase to 274 mg once daily. The treatment duration was 25 weeks for Study 1 and 13 weeks for Study 2. Study 1 was stopped prematurely unrelated to safety, with 39/100 patients (safety population) treated with GOCOVRI for 24 weeks. The most common adverse reactions reported in >10% of GOCOVRI-treated patients and more frequently than on placebo were: hallucination, dizziness, dry mouth, peripheral edema, constipation, falls, and orthostatic hypotension. The overall rate of discontinuation because of adverse reactions was 20% vs 8% for patients treated with GOCOVRI or placebo, respectively. Adverse reactions that led to treatment discontinuation in at least 2% of patients were hallucination (8% GOCOVRI vs 0% placebo), dry mouth (3% GOCOVRI vs 0% placebo), peripheral edema (3% GOCOVRI vs 0% placebo), blurred vision (3% GOCOVRI vs 0% placebo), postural dizziness and syncope (2% GOCOVRI vs 0% placebo), abnormal dreams (2% GOCOVRI vs 1% placebo), dysphagia (2% GOCOVRI vs 0% placebo), and gait disturbance (2% GOCOVRI vs 0% placebo). Pooled Analysis of Adverse Reactions Reported for ≥3% of Patients Treated With GOCOVRI 274 mg (n=100) or placebo (n=98), respectively: Psychiatric disorders: visual and/or auditory hallucination (21%, 3%); anxiety and/or generalized anxiety (7%, 3%); insomnia (7%, 2%); depression/depressed mood (6%, 1%); abnormal dreams (4%, 2%); confusional state (3%, 2%) Nervous system disorders: dizziness (16%, 1%); headache (6%, 4%); dystonia (3%, 1%) Gastrointestinal disorders: dry mouth (16%, 1%); constipation (13%, 3%); nausea (8%, 3%); vomiting (3%, 0%) General disorders and administration-site conditions: peripheral edema (16%, 1%); gait disturbance (3%, 0%) Injury, poisoning, and procedural complications: fall (13%, 7%); contusion (6%, 1%) Infections and infestations: urinary tract infection (10%, 5%) Skin and subcutaneous tissue disorders: livedo reticularis (6%, 0%); pigmentation disorder (3%, 0%) Metabolism and nutrition disorders: decreased appetite (6%, 1%) Vascular disorders: orthostatic hypotension, including postural dizziness, syncope, presyncope, and hypotension (13%, 1%) Eye disorders: blurred vision (4%, 1%); cataract (3%, 1%); dry eye (3%, 0%) Musculoskeletal and connective tissue disorders: joint swelling (3%, 0%), muscle spasm (3%, 0%) Reproductive system and breast disorders: benign prostatic

hyperplasia—all male (6%, 2%) Respiratory, thoracic, and mediastinal disorders: cough (3%, 0%). Other clinically relevant adverse reactions observed at <3% included somnolence, fatigue, suicide ideation or attempt, apathy, delusions, illusions, and paranoia. Difference in the Frequency of Adverse Reactions by Gender in Patients Treated With GOCOVRI Adverse reactions reported more frequently in women (n=46) vs men (n=54) were: dry mouth (22% vs 11%), nausea (13% vs 4%), livedo reticularis (13% vs 0%), abnormal dreams (9% vs 0%), and cataracts (7% vs 0%), respectively. Men vs women reported the following adverse reactions more frequently: dizziness (20% vs 11%), peripheral edema (19% vs 11%), anxiety (11% vs 2%), orthostatic hypotension (7% vs 2%), and gait disturbance (6% vs 0%), respectively. Difference in the Frequency of Adverse Reactions by Age in Patients Treated With GOCOVRI Hallucinations (visual or auditory) were reported in 31% of patients age 65 years and over (n=52) vs 10% in patients below the age of 65 years (n=48). Falls were reported in 17% of patients age 65 and over vs 8% of patients below age 65. Orthostatic hypotension was reported in 8% of patients age 65 and over compared with 2% of patients below age 65. DRUG INTERACTIONS: Other Anticholinergic Drugs: Products with anticholinergic properties may potentiate the anticholinergic-like side effects of amantadine. The dose of anticholinergic drugs or of GOCOVRI should be reduced if atropine-like effects appear when these drugs are used concurrently. Drugs Affecting Urinary pH: The pH of the urine has been reported to influence the excretion rate of amantadine. Urine pH is altered by diet, drugs (eg, carbonic anhydrase inhibitors, sodium bicarbonate), and clinical state of the patient (eg, renal tubular acidosis or severe infections of the urinary tract). Since the excretion rate of amantadine increases rapidly when the urine is acidic, the administration of urine acidifying drugs may increase the elimination of the drug from the body. Alterations of urine pH towards the alkaline condition may lead to an accumulation of the drug with a possible increase in adverse reactions. Monitor for efficacy or adverse reactions under conditions that alter the urine pH to more acidic or alkaline, respectively. Live Attenuated Influenza Vaccines: Due to its antiviral properties, amantadine may interfere with the efficacy of live attenuated influenza vaccines. Therefore, live vaccines are not recommended during treatment with GOCOVRI. Inactivated influenza vaccines may be used, as appropriate. Alcohol: Concomitant use with alcohol is not recommended, as it may increase the potential for CNS effects such as dizziness, confusion, lightheadedness, and orthostatic hypotension, and may result in dose-dumping. USE IN SPECIFIC POPULATIONS: Pregnancy: There are no adequate data on the developmental risk associated with use of amantadine in pregnant women. Based on animal data, it may cause fetal harm. Lactation: Amantadine is excreted into human milk, but amounts have not been quantified. There is no information on the risk to a breastfed infant. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for GOCOVRI and any potential adverse effects on the breastfed infant from GOCOVRI or from the underlying maternal condition. Pediatric Use: Safety and effectiveness of GOCOVRI in pediatric patients have not been established. Geriatric Use: In Phase 3 clinical trials, the mean age of patients at study entry was 65 years. Of the total number of patients in clinical studies of GOCOVRI, 46% were less than 65 years of age, 39% were 65-74 years of age, and 15% were 75 years of age or older. Hallucinations and falls occurred more frequently in patients 65 years of age or older, compared with those less than 65 years of age. No dose adjustment is recommended on the basis of age. GOCOVRI is known to be substantially excreted by the kidney, and the risk of adverse reactions may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. Renal Impairment: GOCOVRI is contraindicated for use in patients with end-stage renal disease (creatinine clearance values lower than 15 mL/min/1.73 m2). A 50% dose reduction of GOCOVRI to a starting daily dose of 68.5 mg daily for a week, followed by a daily maintenance dose of 137 mg is recommended in patients with moderate renal impairment (creatinine clearance between 30 and 59 mL/min/1.73 m2). For patients with severe renal impairment (creatinine clearance between 15 and 29 mL/min/1.73 m2), a daily dose of 68.5 mg is recommended. Overdosage: Deaths have been reported from overdose with amantadine immediaterelease. The lowest reported acute lethal dose was 1 g of amantadine hydrochloride (equivalent to 0.8 g amantadine). Acute toxicity may be attributable to the anticholinergic effects of amantadine. Drug overdose has resulted in cardiac, respiratory, renal, or central nervous system toxicity. Pulmonary edema and respiratory distress (including adult respiratory distress syndrome, ARDS) have been reported with amantadine; renal dysfunction, including increased BUN and decreased creatinine clearance, can occur. Central nervous system effects that have been reported with overdose include agitation, aggressive behavior, hypertonia, hyperkinesia, ataxia, tremor, disorientation, depersonalization, fear, delirium, psychotic reactions, lethargy, and coma. Seizures may be exacerbated in patients with prior history of seizure disorders. Hyperthermia has occurred with amantadine overdose. For acute overdosing, general supportive measures should be employed along with immediate gastric decontamination if appropriate. Give intravenous fluids if necessary. The excretion rate of amantadine increases with acidification of urine, which may increase the elimination of the drug. Monitor patients for arrhythmias and hypotension. Electrocardiographic monitoring may be needed after ingestion because arrhythmias have been reported after overdose, including arrhythmias with fatal outcomes. Adrenergic agents, such as isoproterenol, in patients with an amantadine overdose has been reported to induce arrhythmias. Monitor blood electrolytes, urine pH, and urinary output. Although amantadine is not efficiently removed by hemodialysis, this procedure may be useful in the treatment of amantadine toxicity in patients with renal failure. References: 1. GOCOVRI® (amantadine) [Prescribing Information]. Emeryville, CA: Adamas Pharma LLC; 2020. 2. Hauser RA, Pahwa R, Wargin WA, et al. Pharmacokinetics of ADS-5102 (amantadine) extended release capsules administered once daily at bedtime for the treatment of dyskinesia. Clin Pharmacokinet. 2018;58(1):77-88. 3. Elmer LW, Juncos JL, Singer C, et al. Pooled analyses of phase III studies of ADS- 5102 (amantadine) extended-release capsules for dyskinesia in Parkinson disease. CNS Drugs. 2018;32(4): 387-398. 4. Data on file. Adamas Pharma LLC, Emeryville, CA.

Tools & Resources

Learn the New Tracks in the Quality Payment Program On December 1, 2020, the Centers for Medicare & Medicaid Services (CMS) released its final rule on the Physician Fee Schedule and the Quality Payment Program (QPP). Within the rule, CMS finalized several policies and guidance related to its Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) tracks, as well as two additional tracks that will be incorporated into the QPP moving forward. First, the implementation of the MIPS Value Pathways (MVP) track, which was introduced and finalized last year, has been delayed until 2022 or later due to COVID-19. MVPs are intended to offer MIPS participants smaller, more cohesive sets of measures and activities related to a specialty or condition for reporting and scoring. The AAN is carefully considering opportunities for neurologists to participate in the MVP track in the future. However, the APM Performance Pathway (APP) was introduced and finalized in 2020 and began on January 1, 2021. This track aims to provide a standard set of measures and activities for MIPS APM participants and aligns with the MVP framework

<60 POINTS

that will eventually be implemented. The APP is required for ACOs in the Medicare Shared Savings Program (MSSP) and is optional for other MIPS APMs such as the Bundled Payments for Care Improvement–Advanced (BPCI-A) model which some neurologists may participate in. The APP framework is organized around the MIPS components and has standardized sets of Quality and Promoting Interoperability measures. Given some of the requirements of MIPS APM entities related to Cost and Improvement Activities are already being performed, these components will require no or little reporting. Members should check if and how they participate in the QPP by visiting the participation lookup tool at qpp.cms.gov/participation-lookup. The AAN is dedicated to providing members with tools and resources to understand these new tracks, meet participation requirements, avoid penalties, and achieve success in the QPP. For more information and up-to-date QPP resources, visit AAN.com/QPP or email practice@aan.com. 

POINTS

HIGH PERFORMANCE BONUS UP TO -9% PAYMENT ADJUST MENT

60 POINTS TO AVOID PENALTY

UP TO +9% PAYMENT ADJUSTMENT

WHY THIS MATTERS: There is potentially more to gain (but also more to lose) The AAN will help you “get to 60 points” and beyond.

COVID-19 Impact Reflected in Axon Registry Annual Survey Results In the fall of 2020, the Axon Registry ® conducted its annual user survey to solicit feedback from registry participants. For 2020, 65 percent of the survey participants were clinicians and 35 percent were administrators. While participation increased in the 2018 and 2019 surveys, the number of survey respondents decreased by 24 participants in 2020. The current health care environment could be a reason for the decrease in participation. The Axon Registry was rated as “highly valuable” or “valuable” resource for their practice by 65 percent of the survey participants. MIPS reporting was the main reason for 94 percent of respondents joining the registry. Quality

registry may have been impacted by the COVID-19 pandemic.

improvement and continuing certification were the next two most frequently reported reasons, with 53 percent and 41 percent of registry participants responding, respectively.

Approximately 50 percent of the respondents indicated that COVID-19 impacted quality improvement in their practice. Lower patient volume, an emphasis in telehealth, and shifting priorities were effects of the pandemic that respondents reported.

The amount of time current participants use the Axon Registry varies greatly. Approximately 38 percent of respondents reported using the registry for one hour monthly and over 39 percent of staff members reported using the registry for two or more hours monthly. The amount of time participants spent on the

If you are interested in joining the Axon Registry or would like more information, please contact registry@aan.com. 

AANnews • February 2021 17

Tools & Resources

CNN Medical Reporter and Neurosurgeon Sanjay Gupta Describes Research into Brain Health Brain & Life® continues to provide your patients with information they can use from respected experts they can trust, and the February/March issue is sure to be popular. In his new book, Keep Sharp: Build a Better Brain at any Age, neurosurgeon and CNN medical correspondent Sanjay Gupta, MD, explains how to optimize

F E B R UA RY/M A R C H 2 0 2 1

Insomnia How to Sleep Better During the Pandemic Ask Your Neurologist Can COVID-19 Trigger Seizures? Nutrition How a Plant-Based Diet May Lower Risk of Parkinson’s

We’re making great progress in understanding why people develop diseases like dementia.”

brain health no matter how old you are. He also talks about the pandemic and how the country will move on from it. Rising rates of insomnia have led to a new word: COVID-somnia or coronasomnia. A feature story explores how the pandemic has exacerbated this common sleep disorder and offers ways to treat and manage it. Another feature tells the story of Mark Macy, an endurance athlete diagnosed with early-onset Alzheimer’s disease. He and his son, Travis, talk about their experience in the grueling EcoChallenge Fiji, billed as the world’s toughest race, and how they worked to compensate for Mark’s cognitive deficits. The story includes information on the relationship between exercise and brain health.

In other departments, stories look at caregivers who are bringing relatives home from senior living facilities because of restrictive visiting policies, mobility devices for children, facts about migraine, and a surfer who was diagnosed with ataxia and took up birdwatching instead. Brain & Life magazine is free for AAN members in the United States to distribute to patients, who also can subscribe for free. If you would like to adjust the number of copies you receive for your patients or update your clinic address, email BeGreen@WasteFreeMail.com. All members have online access to the magazine articles and additional resources at BrainandLife.org. Please share the website with your patients. 

— C N N C O R R E S P O N D E N T D R . S A N JAY G U P TA

Neurology: Clinical Practice Examines Migraine, Guillain-Barré Syndrome, Stroke Ethical Issues The February issue of Neurology ® Clinical Practice features thought-provoking editorials: “Are Two Head(ache)s Better Than One: Consequences of Diagnosing Migraine and Occipital Neuralgia,” by Heidi Beck Schwarz, MD, FAAN, and Matthew Stuart Robbins, MD; and “Ethical Issues in Stroke Management,” by James L. Bernat, MD, FAAN, and Timothy G. Lukovits, MD. Research papers include “Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death,” by Joseph M. Darby, MD, et al.; “Prolonged Ventilatory Support for Patients Recovering from Guillain-Barré Syndrome,” by Michael C.F. Cheng, MD, et al.; and “Equipoise in Management of Patients with Acute Symptomatic Carotid Stenosis (Hot Carotid),” by Aravind Ganesh, MD, DPhil, FRCPC, et al. Published six times a year, Neurology: Clinical Practice is available free to all AAN members online and in print for US members only. Visit Neurology.org/cp for more information. 

Volume 11, Number 1, February 2021

Neurology.org/CP

A peer-reviewed clinical neurology journal for the practicing neurologist

RESEARCH

Prevalence of Occipital Neuralgia at a Community Hospital-based Headache Clinic RESEARCH

Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death REVIEW

Systematic Review and Meta-analysis of Diagnostic Agreement in Suspected TIA REVIEW

Predicting Language Outcome After Left Hemispherotomy

AANnews • February 2021

Education & Research

Spinal Cord Disorders Is Continuum’s First 2021 Topic Neurologists seeking to improve their clinical skills and earn valuable CME will benefit from the new issue of Continuum: Lifelong Learning in Neurology® addressing spinal cord disorders. “Spinal cord disorders can present quickly, and irreversible disability can develop rapidly. In this issue, there is a major focus on getting the diagnosis right and avoiding misdiagnosis,” said Guest Editor Eoin P. Flanagan, MBBCh. “This will ensure rapid disease-specific treatment can be initiated to improve outcomes of patients with myelopathy. Neurologists will learn that reviewing imaging, particularly the gadolinium enhancement pattern, and combining that with their clinical assessment can be a very powerful tool in getting quickly to the correct diagnosis. I suggest the reader focus on the high-quality imaging pearls throughout the issue and take them back to their practice.” The robust issue’s topics include: Spinal Cord Anatomy and Localization / Todd A. Hardy, PhD, MBBS, FRACP Vascular Myelopathies / Nicholas L. Zalewski, MD Myelitis and Other Autoimmune Myelopathies / Sebastian Lopez Chiriboga, MD; Eoin P. Flanagan, MBBCh Infectious Myelopathies / Michel Toledano, MD

Spondylotic and Other Structural Myelopathies / Shamik Bhattacharyya, MD, MS

June: Headache August: Neuroinfectious Disease October: Behavioral Neurology and Psychiatry December: Neurocritical Care

Hereditary Myelopathies / John K. Fink, MD Disorders of the Cauda Equina / Samantha LoRusso, MD

AAN members pay only $399 per year for a subscription to Continuum® and Continuum® Audio. Subscribe now by contacting Wolters Kluwer at (800) 3610633 or (301) 223-2300 (international) or visit shop.LWW.com/continuum. AAN Junior members who are transitioning to neurologist memberships are eligible to receive a 60-percent discount on the already low member rate for the Continuum and Continuum Audio subscription. 

Neuroimaging of Spinal Cord and Cauda Equina Disorders / Felix E. Diehn, MD; Karl N. Krecke, MD, FACR

Neoplastic Myelopathies / Amy A. Pruitt, MD, FAAN

The issue includes a postreading selfassessment and test with the opportunity to earn up to 20 AMA PRA Category 1 Credits™ toward Self-assessment CME.

Metabolic and Toxic Myelopathies / Natalie Elizabeth Parks, MD

Upcoming topics for 2021 include: April: Neuro-otology

Flanagan

Work of New Cover Artist Debuts The artwork of Canadian illustrator Raymond Biesinger will grace the covers of Continuum for the next three years starting with the February issue. Biesinger succeeds Peter Grundy, who was the first cover illustrator of the newly redesigned Continuum, which premiered in February 2018. “It was exciting to work with British illustrator Peter Grundy on the first round of Continuum cover artwork that coincided with the redesign in 2018,” said Editor-in-Chief Steven L. Lewis, MD, FAAN. “Likewise, the process of working with Canadian illustrator Raymond Biesinger on the next three years of cover artwork has been equally rewarding. Raymond brings his own sensibility and understanding of the overall concepts being depicted in each issue, and it has been a pleasure to work so closely with him as we hone the ideas within his unique style.” “The most challenging part of my 18-issue Continuum ‘residency’ was

finding the intersection where my kind of abstraction and the required precision of neuroscience can meet comfortably,” said Biesinger. “Put simply: the organized, symbolic, hard-edged and simplified style I work in often struggles to illustrate a plate of nachos (I'm not joking—drawing that kind of chaos stresses me out), let alone the manifold gyri and sulci, or the random tangle of amyloid plaque. To get these things right was difficult, but thankfully I had the time to show things correctly and beautifully, I think.”

Billboard, BMW, Canada Council for the Arts, the Economist, Le Monde, Scientific American, and the Washington Post. 

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EDITO R-INCHIEF: STEV EN GUES T EDITO EDITO L. LEWIS R-IN- CHIEF R: EOIN , MD, FA P. FLAN : STEV AN GUES T EDITO EN L. AGAN LEWIS, ,MBBC H R: EOIN MD, FA P. FLAN AGAN , MBBC AN H

Biesinger has been involved in more than 1,000 assignments since 2005. His past clients include Adidas,

FEBR UARY 2021 VOL. 27 FEBR UARY 2021 VOL. 27

NO. 1 NO. 1

CONT INUUM JOUR NAL.C OM CONT INUUM JOUR NAL.C OM

AANnews • February 2021 19

Education & Research

Resident Sought to Join Continuum Editorial Board AAN member residents are encouraged to apply to serve on the Continuum® Editorial Board. The Editorial Board provides oversight of Continuum: Lifelong Learning in Neurology ®, the official CME journal of the AAN, and Continuum® Audio. It is responsible for providing input on the direction of Continuum, for topic and guest editor suggestions, and review and evaluation of issues in accordance with the ACCME. One or two residents will be selected to serve a one-year term on the Editorial Board starting on June 1, 2021, representing the perspective of Junior members of the Academy for Continuum, which is provided complimentary to all Junior members. The resident member is expected to attend the fall Editorial Board meeting in 2021 (likely virtual) and the spring Editorial Board meeting in 2022. Eligible applicants should be in their PGY3, PGY4 (or PGY5 if in child neurology) year of training.

To apply, candidates should submit a one-page letter of interest, CV, and a letter of recommendation from their program Lewis director or department chair. For more information or to apply, contact Amanda Doering, Continuum Managing Editor, at adoering@aan.com by March 15, 2021. Applicants will be notified of selection by May 15, 2021. 

“Having a neurology resident on our Editorial Board provides an important voice to our trainees in the direction of Continuum, while at the same time providing a unique opportunity for a resident to learn the ‘ins and outs’ of production of a major clinical journal,” said Continuum Editor-in-Chief Steven L. Lewis, MD, FAAN.

AAN Study: People in Rural Areas Less Likely to Receive Specialty Care for Neurologic Conditions A new study funded and published by the AAN has found that while the prevalence of neurologic conditions like dementia, stroke, Parkinson’s disease, and multiple sclerosis is consistent across the US, the distribution of neurologists is not, and people in more rural areas may be less likely to receive specialty care for certain neurologic conditions. The study was published in the December 23, 2020, online issue of Neurology ®. “Our research found that some areas of the country have up to four times as many neurologists as the lowest served areas, and these differences mean that some people do not have access to neurologists,” said Brian C. Callaghan, MD, MS, FAAN, of the AAN Health Services Research Subcommittee. However, Callaghan noted that the proportion of people receiving specialty care from a neurologist in more rural areas varied by condition. People with specific, less common conditions such as Parkinson’s disease and multiple sclerosis were just as likely to see a neurologist in more rural areas as in more urban areas, while people with less specific neurologic symptoms that are more common, such as dementia, pain, dizziness or vertigo or sleep

AANnews • February 2021

disorders, were more likely to see a neurologist in more urban areas than in more rural areas. “It is important that all people have access to the best neurologic care,” said James C. Stevens, MD, FAAN, AAN president. “Not surprisingly, more neurologists tend to work and live in metropolitan areas, but this study underlines the need to ensure that more rural areas also have a supply of neurologists to meet demand. One way to give people more access to neurologic care is with telemedicine, which has been used successfully during the COVID-19 pandemic. Remote office visits by computer or telephone are one way to extend neurological service to people in underserved areas.”

To read the study, visit AAN.com/DensityStudy. 

Education & Research

AAN Study Shows Rising Out-of-pocket Costs for Tests, Office Visits The AAN has published a study showing that out-of-pocket costs for diagnostic tests and office visits for neurologic conditions have risen over 15 years, just like drug costs. The study, funded by the AAN, was published in the December 23, 2020, online issue of Neurology®. People enrolled in high-deductible health plans were more likely to have high out-of-pocket costs than people in other types of plans, according to the study. “This trend of increased out-of-pocket costs could be harmful, as people may forgo diagnostic evaluation due to costs, or those who complete diagnostic testing may be put in a position of financial hardship before they can even start to

treat their condition,” said Chloe E. Hill, MD, MS, of the AAN Health Services Research Subcommittee. “What’s more, right now neurologists and patients may not have individualized information available regarding what the out-of-pocket costs might be to make informed decisions about use of care.” AAN President James C. Stevens, MD, FAAN, said, “This study adds further weight to earlier studies from the American Academy of Neurology showing that out-of-pocket costs for neurologic medications are rising sharply, making people less likely to take their medications as often as their doctors prescribed. Costs have risen to the point where systematic changes are needed. These changes could include legislative action to place a cap on outof-pocket costs. The AAN is advocating for such caps on out-ofpocket drug costs in Washington, DC.” To read the study, visit AAN.com/OOPStudy. 

Five Training Programs Receive UCNS Accreditation Five fellowship training programs were recently accredited by the United Council for Neurologic Subspecialties (UCNS) in recognition of their offering the core curriculum established by their individual subspecialty and meeting required quality standards established by UCNS. Congratulations to the following:

Autonomic Disorders

Vanderbilt University Medical Center

Behavioral Neurology and Neuropsychiatry Houston Methodist Hospital

Headache Medicine

University of California, Los Angeles Oregon Health and Science University

New Behavioral Neurology and Neuropsychiatry Diplomates Announced Fifty-five physicians recently demonstrated their expert knowledge in Behavioral Neurology and Neuropsychiatry by passing the 2020 United Council for Neurologic Subspecialties (UCNS) Behavioral Neurology and Neuropsychiatry certification examination. There are currently 475 physician diplomates certified in Behavioral Neurology and Neuropsychiatry. Physicians in the United States and Canada who meet the eligibility requirements may apply for certification, and the next UCNS Behavioral Neurology and Neuropsychiatry certification examination will take place in 2022. Visit UCNS.org/News for more information and a listing of the new diplomates. 

Neuro-oncology

Washington University/Barnes Jewish Hospital/St. Louis Children’s Hospital Consortium UCNS accreditation is a voluntary process of evaluation and peer review based on UCNS accreditation standards. Fellows who complete a UCNS-accredited program meet the training eligibility requirements to apply for certification in the subspecialty. There are currently 210 UCNS-accredited training programs in UCNS-recognized neurologic subspecialties. Visit UCNS.org/Accreditation for more information. 

AANnews • February 2021 21

HOW DO YOU KNOW IF MCI IS LIKELY TO PROGRESS TO AD DEMENTIA?

TESTING FOR AMYLOID BETA CAN HELP CONFIRM A CLINICAL DIAGNOSIS.

ntil recently, the diagnosis of Alzheimer’s disease (AD) was almost solely based on clinical evaluation. And the average time to diagnosis has been 2 to 3 years after symptom onset.1 But diagnosis of AD may be ready to evolve.

Recently, the large-scale IDEAS Study (N=11,409) showed the utility of Aβ conﬁrmation to inform appropriate care, which led to changes in the management of over 60% of MCI patients and ~64% of patients with dementia.9

AD is thought to be caused by a cascade of neurological damage triggered by the accumulation of amyloid beta (Aβ).2 These Aβ aggregates can serve as a biological marker of AD pathology, and may help inform the diagnosis and management of the ﬁrst symptomatic stage of AD: mild cognitive impairment (MCI) due to AD.3,4

With the potential for Aβ testing to impact the management of AD, and other biomarker tests on the horizon, advances in AD diagnostics offer hope that diagnosing AD at the MCI stage may become the standard of care and improve the management of Alzheimer’s disease.10

Currently used in cutting-edge investigational research, biomarker conﬁrmation of Aβ via positron emission tomography (PET) scan or cerebrospinal ﬂuid (CSF) test is beginning to move into clinical practice.3,5-8 The diagnostic value of ascertaining AD as the cause of MCI is that the clinician can intervene before greater neuronal damage occurs and more cognition and function are lost.4

Aβ testing can help support a diagnosis of Alzheimer’s disease7,8,11

COGNITIVELY NORMAL

ALZHEIMER’S DISEASE

Images from Huang CC, et al, used under CC BY 4.0, https://creativecommons.org/licenses/by/4.0/.

See how Aβ testing can help confirm AD pathology at identifyalz.com. MMSE=Mini-Mental State Examination; MoCA=Montreal Cognitive Assessment; IDEAS=Imaging Dementia—Evidence for Amyloid Scanning. References: 1. Sabbagh MN, Lue L-F, Fayard D, Shi J. Increasing precision of clinical diagnosis of Alzheimer’s disease using a combined algorithm incorporating clinical and novel biomarker data. Neurol Ther. 2017;6(suppl 1):S83-S95. 2. Hardy J, Selkoe DJ. The amyloid hypothesis of Alzheimer’s disease: progress and problems on the road to therapeutics. Science. 2002;297(5580):353-356. 3. Oboudiyat C, Glazer H, Seifan A, Greer C, Isaacson RS. Alzheimer’s disease. Semin Neurol. 2013;33(4):313-329. 4. Jack CR Jr, Knopman DS, Jagust WJ, et al. Hypothetical model of dynamic biomarkers of the Alzheimer’s pathological cascade. Lancet Neurol. 2010;9(1):119-128. 5. Cummings J, Lee G, Ritter A, Sabbagh M, Zhong K. Alzheimer’s disease drug development pipeline: 2019. Alzheimers Dement. 2019;5:272-293. 6. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging–Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7(3):263-269. 7. Shaw LM, Arias J, Blennow K, et al. Appropriate use criteria for lumbar puncture and cerebrospinal fluid testing in the diagnosis of Alzheimer’s disease. Alzheimers Dement. 2018;14(11):1505-1521. 8. Johnson KA, Minoshima S, Bohnen NI, et al. Appropriate use criteria for amyloid PET: a report of the Amyloid Imaging Task Force, the Society of Nuclear Medicine and Molecular Imaging, and the Alzheimer’s Association. Alzheimers Dement. 2013;9(1):e1-e16. 9. Rabinovici GD, Gatsonis C, Apgar C, et al. Association of amyloid positron emission tomography with subsequent change in clinical management among Medicare beneficiaries with mild cognitive impairment or dementia. JAMA. 2019;321(13):1286-1294. 10. Jack CR Jr, Bennett DA, Blennow K, et al. NIA-AA research framework: toward a biological definition of Alzheimer’s disease. Alzheimers Dement. 2018;14(4):535-562. 11. Huang CC, Hsiao IT, Huang CY, et al. Tau PET with 18F-THK-5351 Taiwan patients with familial Alzheimer’s disease with the APP p.D678H mutation. Front Neurol. 2019;10:503. doi:10.3389/fneur.2019.00503.

American Brain Foundation

Scholarship Recipient Seeks to Improve Understanding of Tourette Syndrome Chronic movement disorders such as Tourette syndrome affect approximately one percent of youth. Often, patients seem to outgrow—or gain better control of—their symptoms as they get older. Alonso Zea Vera, MD, a neurologist at Cincinnati Children’s Hospital Medical Center, is using the Clinical Research Training Scholarship he received through the American Brain Foundation’s Next Generation Research Grant Program to improve understanding of Tourette syndrome in the hopes of finding new treatments. “The prefrontal cortex gets stronger as we age, and that might be why patients have better control as they get older,” said Zea Vera. “If we are able to figure out how these patients get over their symptoms or what happens in their brain to get over their symptoms, the next step would be, ‘How do we make this happen for patients who are having more difficulties?’” The study is using EEG to evaluate electrical activity in the brain to help determine how the brain reacts to different situations. “If we get enough information and we find a specific characteristic of this ability to stop [one’s] actions, our hope would be that this could be used as a marker,” he said. Researchers could then use this marker to diagnose and treat patients, as well as better select patients for clinical trials to test treatments. Zea Vera sees a link between Tourette syndrome, obsessivecompulsive disorder (OCD), and attention deficit hyperactivity disorder (ADHD). “Think about these diseases as having trouble controlling certain things,” he explained. “For Tourette syndrome, it’s difficulty controlling movements; for OCD,

it’s difficulty controlling certain thoughts and actions; and for ADHD, it’s difficulty controlling external stimuli.”

Zea Vera believes it’s possible that all of these diseases could share a similar pathway in the brain. “If we find what we hope to find, it will be interesting to see if there’s something similar happening in patients with these other conditions—and if there is, then treatments that work for one disorder could be adapted to help patients with another disorder.” Funding for Zea Vera’s research comes from the Tourette Association of America and the American Brain Foundation, in collaboration with the American Academy of Neurology. The American Brain Foundation’s Next Generation Research Grant program recruits the best and brightest researchers to work on early diagnoses, treatments, and cures for brain disease; encourages passion for research; and lays the groundwork for future success and advancements in the field. Visit AmericanBrainFoundation.org to learn more or to make a donation in support of innovative brain disease research. 

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AANnews • February 2021

Zea Vera

DISCOVERING CONNECTIONS

Recipients of an American Brain Foundation Next Generation Research Grant work hard to find connections between brain diseases to better diagnose and treat patients. Researchers like Alonso Zea Vera, MD, whose research on Tourette syndrome uses electrical activity to show how the brain reacts in different situations. “If we find what we hope to find, it will be interesting to see if there’s something similar happening in patients with other conditions,” said Dr. Zea Vera.

The American Brain Foundation is dedicated to supporting researchers searching for connections between brain diseases. When we cure one brain disease, we will cure many.

Donate today to support the researchers seeking to discover these critical connections at americanbrainfoundation.org/give

Policy & Guidelines

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. January 12, 2021 The AAN unreservedly stands in strong support for a peaceful transfer of power and implementation of measures to ensure the health and safety of all individuals working at the US Capitol. Violence cannot be tolerated. We will continue to closely monitor the situation in Washington, DC.

New Congress Update The 117th Congress gaveled into session on January 3. Democrats will maintain a very slim majority in the House of Representatives. With the win of two additional Democratic seats in the Georgia Senate runoff races, the Senate will now be a 50-50 split between the Democrats and Republicans. As president of the Senate, Democratic Vice President Kamala Harris will become the deciding 51st vote to break any tie. While we do not yet know the full impact these events will have, it is clear the policy agenda in Washington will not advance along the same pathway expected just a week ago. The AAN will be closely monitoring this situation and reassessing how to ensure AAN priorities are heard at the appropriate time. We know that you, our readers, are processing these events too, if you’d like to share your reaction, please reach out to us at advocacy@aan.com.

Applications for Neurology on the Hill 2021 are Now Open! The 2021 Neurology on the Hill will be a virtual event on May 19, 2021. Share your passion for making a positive change and educate members of Congress on issues impacting neurology. Learn more about Neurology on the Hill at AAN.com/NOH. Applications will be open until February 26.

Update of Most Favored Nation Model On December 17, the AAN submitted comments in opposition to an interim final rule from the Centers for Medicare & Medicaid Services (CMS) that would implement a new payment model for Medicare Part B drugs, known as the “Most Favored

AANnews • February 2021

Nation” (MFN) model. This new payment model was scheduled to be implemented on January 1, 2021, and will reimburse 50 Medicare Part B drugs that encompass a high percentage of Medicare Part B drug spending at levels that are aligned with the lowest price paid by peer countries and will make modifications to the existing add-on payment methodology. If implemented, the new model will be mandatory and apply to providers nationwide, unless they fall under a narrow set of exceptions or are granted a financial hardship exemption. On December 23, a temporary restraining order was issued, delaying implementation of the MFN model. On December 28, in a parallel case, the MFN rule was vacated in its entirety pending completion of the notice and comment process. Due to ongoing litigation, it is possible that the model is never implemented as currently constructed. The AAN will continue to closely monitor the litigation as it proceeds.

AAN Supports Proposed Changes Aimed at Reducing Prior Authorization Burden On December 29, the AAN submitted comments in response to a proposed rule from CMS that will implement new requirements on Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plans (QHP) issuers on the Federallyfacilitated Exchanges (FFEs) with the goal of improving the electronic exchange of health care data and streamlining processes related to prior authorization (PA). The AAN’s comments are highly supportive of these changes as several of the new proposed requirements are consistent with the AAN’s advocacy on this issue. The AAN’s comments also urged the agency to extend the changes to Medicare Advantage and to Part D drugs.

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Applications Open: UCNS Neurocritical Care Certification UCNS.org/NCCcertification

FEBRUARY 8

Submission Deadline: Emerging Science Abstracts AAN.com/EmergingScience

MARCH 1

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APRIL 17–22

Applications Open: UCNS Autonomic Disorders Certification UCNS.org/ADcertification Early Registration Deadline: 2021 AAN Annual Meeting AAN.com/21AM

Application Deadline: UCNS Clinical Neuromuscular Pathology Certification UCNS.org/CNMPcertification 2021 AAN Annual Meeting AAN.com/21AM

FEBRUARY 9–26

RITE® Administration Dates AAN.com/RITE2021

FEBRUARY 16

AAN Trainee Trivia: Online Neurology Contest bit.ly/34EOTEb

FEBRUARY 26

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

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Comprehensive General Neurology Qualied applicants should send a letter of interest and CV to: J. Kirk Roberts, MD Associate Professor of Neurology at CUMC Chief, Division of Multispecialty Neurology Columbia University Medical Center 710 168th Street New York, NY 10032 Email: jkr2@cumc.columbia.edu

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