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Natalizumab and Risk of PML
original article

In patients treated with natalizumab, PML incidence was about 11 cases per 1000 patients with 25 to 48 months of treatment, prior immunosuppressant use, and anti–JC virus antibody–positive status. The incidence was estimated to be 0.09 cases or fewer per 1000 antibody-negative patients.

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A Woman with Diplopia, Headaches, and Papilledema
case records of the massachusetts
general hospital

A 48-year-old woman was admitted to the hospital because of diplopia, headaches, and papilledema. Imaging revealed cysts in the fourth ventricle and spinal canal. A diagnostic procedure was performed.

Secondary Prevention after Ischemic Stroke or TIA
clinical practice

Patients with stroke are at high risk for subsequent vascular events, including recurrent stroke (highest risk), myocardial infarction, and death from vascular causes. This article reviews recommended strategies to reduce the risk of a subsequent stroke in patients with a history of transient ischemic attack (TIA) or stroke.

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Stem Cells and Spinal Cord Repair
clinical implications of basic research

The effective treatment of spinal cord injury and the establishment of a robust source of cells that do not trigger a host immune response have been two major goals of stem-cell research. A recent study reaches toward these goals, but substantial challenges remain.

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A Startling Decline
Interactive Medical Case

An 89-year-old man was brought to the emergency department for evaluation of changes in his cognition and personality. He exhibited poor memory for recent events and difficulty expressing himself.

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original article

Slowly increasing oral doses of L-dopa induced at least partial improvement of some manifestations in a series of 28 patients with Parkinsonism.

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Journal Watch Covers Other Key Research

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A post hoc analysis of the focal epilepsy arm in the SANAD trial reveals outcome predictors for patients receiving specific AED treatments.

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Oral lasmiditan, a novel 5-HT1F receptor agonist, appears to be a safe and effective acute migraine therapy without the vasoactive adverse effects of triptans.

Medical Journals, Medical News and Research: Journal Watch

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  • Case Records of the Massachusetts General Hospital

    Presentation of Case. Dr. Rocío Hurtado (Infectious Diseases): A 48-year-old woman was admitted to the hospital because of diplopia, headaches, and papilledema. The patient had been well until 2 weeks before admission, when diplopia developed, which improved when she covered either eye. One week…

    • May 17, 2012
    • Venna N., Coyle C.M., González R.G., Hedley-Whyte E.T.
    • N Engl J Med 2012; 366:1924-1934

      A 48-year-old woman was admitted to the hospital because of diplopia, headaches, and papilledema. Imaging revealed cysts in the fourth ventricle and spinal canal. A diagnostic procedure was performed.

    • Clinical Implications of Basic Research

      For the past couple of decades, clinicians have watched the stem-cell field with a mixture of anticipation and skepticism. No group of patients has been more expectant than those with spinal cord injuries. Therapies for spinal cord injury have been promised almost since the dawning of the stem-cell…

      • May 17, 2012
      • Snyder E.Y. and Teng Y.D.
      • N Engl J Med 2012; 366:1940-1942

        For the past couple of decades, clinicians have watched the stem-cell field with a mixture of anticipation and skepticism. No group of patients has been more expectant than those with spinal cord injuries. Therapies for spinal cord injury have been ...

      • Clinical Practice

        Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations. Stage. A 62-year-old…

        • May 17, 2012
        • Davis S.M. and Donnan G.A.
        • N Engl J Med 2012; 366:1914-1922
        • CME
        • Full Text Audio

        This article reviews recommended strategies to reduce the risk of a subsequent stroke in patients with a history of transient ischemic attack (TIA) or stroke.

      • Editorial

        After a century of futility in the treatment of multiple sclerosis, there is now a deluge of drugs that alter the course of the disease. The half-dozen new oral drugs have excited the most interest, but the monoclonal antibodies, and specifically natalizumab, have a more focused biologic activity…

        • May 17, 2012
        • Ropper A.H.
        • N Engl J Med 2012; 366:1938-1939

          After a century of futility in the treatment of multiple sclerosis, there is now a deluge of drugs that alter the course of the disease. The half-dozen new oral drugs have excited the most interest, but the monoclonal antibodies, and specifically ...

        • Original Article

          Natalizumab (Tysabri, Biogen Idec and Elan Pharmaceuticals) is approved for the treatment of relapsing–remitting multiple sclerosis in more than 50 countries and also for the treatment of moderate-to-severe Crohn's disease in the United States. As of February 2012, approximately 100,000 patients…

          • May 17, 2012
          • Bloomgren G., Richman S., Hotermans C., et al.
          • N Engl J Med 2012; 366:1870-1880
          • CME

          In patients treated with natalizumab, PML incidence was about 11 cases per 1000 patients with 25 to 48 months of treatment, prior immunosuppressant use, and anti–JC virus antibody–positive status. The incidence was estimated to be 0.09 cases or fewer per 1000 antibody-negative patients.

        • Correspondence

          To the Editor: Magnesium wasting with hypomagnesemia is well known, but cyclic disorders of magnesium without losses are not usually reported. Similarly, diastolic heart failure and obstructive sleep apnea are rarely described in connection with magnesium depletion. A 56-year-old woman was admitted…

          • May 10, 2012
          • N Engl J Med 2012; 366:1845-1846
          • Free Full Text

          A patient with chronic weakness, muscle cramps, paresthesia, gait disturbance, somnolence, and cognitive impairment was found to be magnesium deficient. However, no source of magnesium loss could be identified. Her symptoms resolved with magnesium repletion.

        • Correspondence

          To the Editor: Within a 3-week period, two women, 46 and 48 years of age, presented with peripheral neuropathy and associated pancytopenia with macrocytic anemia. Clinical suspicion for pernicious anemia was high, but vitamin B12 levels were 1644 pg per milliliter (1228 pmol per liter) and 1321 pg…

          • May 3, 2012
          • N Engl J Med 2012; 366:1742-1743
          • Free Full Text

          To the Editor: Within a 3-week period, two women, 46 and 48 years of age, presented with peripheral neuropathy and associated pancytopenia with macrocytic anemia. Clinical suspicion for pernicious anemia was high, but vitamin B12 levels were 1644 pg per ...

        • Case Records of the Massachusetts General Hospital

          Presentation of Case. Dr. Norifumi Kamo (Medicine): A 62-year-old man was admitted to this hospital because of paresthesias, weight loss, jaundice, and anemia. The patient had been well until approximately 2 months before admission, when numbness, tingling ("pins and needles"), and burning in his…

          • April 26, 2012
          • Puig A., Mino-Kenudson M., Dighe A.S.
          • N Engl J Med 2012; 366:1626-1633
          • CME

          A 62-year-old man was admitted to this hospital because of paresthesias, weight loss, jaundice, and anemia. Diagnostic test results were received.

        • Case Records of the Massachusetts General Hospital

          Presentation of Case. Dr. Helen H. Yeung (Pediatrics): A 10-month-old girl was seen in the emergency department at this hospital because of vomiting and episodes of unresponsiveness. The patient had been well until 2 a.m. on the day of admission, when she awoke with vomiting that was associated…

          • April 19, 2012
          • Sassower K.C., Allister L.M., Westra S.J.
          • N Engl J Med 2012; 366:1527-1536
          • CME

          A 10-month-old girl was seen in the emergency department because of vomiting and episodes of unresponsiveness, which had begun suddenly 7 hours earlier. She gradually became somnolent. Vital signs, a physical examination, and brain imaging were normal.

        • Original Article

          Platelets play a central role in atherothrombosis and are an important target for pharmacotherapy. In patients with acute coronary syndromes, the use of potent platelet inhibitors has been shown to reduce the rate of thrombotic events at the cost of increased bleeding.– In contrast, among…

          • April 12, 2012
          • Morrow D.A., Braunwald E., Bonaca M.P., et al.
          • N Engl J Med 2012; 366:1404-1413

            Patients with atherosclerotic vascular disease were randomly assigned to receive the thrombin antagonist vorapaxar or placebo. Vorapaxar reduced the rate of subsequent cardiovascular death, myocardial infarction, or stroke but increased the rate of moderate or severe bleeding.

          • Original Article

            Thrombolytic treatment with alteplase, a recombinant tissue plasminogen activator, for acute ischemic stroke is of proven benefit. However, alteplase is far from ideal, with incomplete and often delayed reperfusion in many patients. Tenecteplase, a genetically engineered mutant tissue plasminogen…

            • March 22, 2012
            • Parsons M., Spratt N., Bivard A., et al.
            • N Engl J Med 2012; 366:1099-1107
            • CME

            In this phase 2B trial involving 75 patients with acute ischemic stroke, tenecteplase was more effective than alteplase in achieving reperfusion and clinical improvement at 24 hours. Bleeding complications were similar in the two groups.

          • Images in Clinical Medicine

            Figure 1.

            • March 22, 2012
            • Schrag A. and Schott J.M.
            • N Engl J Med 2012; 366:e18
            • Free Full Text

            An 18-year-old woman presented with color and temperature changes in her hands, as well as intermittent tremor of the hands for 3 years. She also reported involuntary right arm movements and difficulties with concentration.

          • Review Article

            To function normally, human cells require energy in the form of ATP. In many cell types, ATP is primarily generated by mitochondria, which are also key players in other important cellular processes, such as adaptive thermogenesis, ion homeostasis, innate immune responses, production of reactive…

            • March 22, 2012
            • Koopman W.J.H., Willems P.H.G.M., Smeitink J.A.M.
            • N Engl J Med 2012; 366:1132-1141

              Rare monogenic disorders of mitochondria have shed light on mitochondrial function, and the development of therapeutic agents for these disorders may be applicable to more common sporadic diseases characterized by mitochondrial dysfunction.

            • Editorial

              Patent foramen ovale is a well established cause of stroke. A thrombus from venous structures can embolize through a patent foramen ovale and ultimately reach the brain. However, a patent foramen ovale can also be present in 25% of healthy people. Although detected in nearly twice as many patients…

              • March 15, 2012
              • Johnston S.C.
              • N Engl J Med 2012; 366:1048-1050

                Patent foramen ovale is a well established cause of stroke. A thrombus from venous structures can embolize through a patent foramen ovale1 and ultimately reach the brain.2 However, a patent foramen ovale can also be present in 25% of healthy people. ...

              • Original Article

                As many as 40% of acute ischemic strokes have no identifiable cause and are classified as cryptogenic.– Some cryptogenic strokes or transient ischemic attacks (TIAs) may be the result of an embolus from the venous system traversing from the right to left atrium and into the systemic circulation…

                • March 15, 2012
                • Furlan A.J., Reisman M., Massaro J., et al.
                • N Engl J Med 2012; 366:991-999

                  Patients with a cryptogenic stroke or transient ischemic attack (TIA) who had a patent foramen ovale were randomly assigned to closure with a percutaneous device or to medical therapy. There was no significant between-group difference in the subsequent rate of stroke or TIA.

                • Original Article

                  Laquinimod is an oral quinoline-3-carboxamide small molecule selected for its efficacy and safety from a pool of 60 quinoline-3-carboxamide derivatives of the parent compound, roquinimex, a drug previously evaluated in phase 2 trials of treatment for multiple sclerosis but withdrawn because of…

                  • March 15, 2012
                  • Comi G., Jeffery D., Kappos L., et al.
                  • N Engl J Med 2012; 366:1000-1009

                    In this placebo-controlled, phase 3 trial involving patients with relapsing–remitting multiple sclerosis, oral laquinimod administered once daily reduced the number of clinical relapses and slowed disability progression.

                  • Original Article

                    Most studies evaluating cholinesterase inhibitors for the treatment of Alzheimer's disease have focused on patients with mild-to-moderate disease. Despite questions about the methods used in the trials and about the clinical significance of reported benefits,, guidelines advocate treatment with a…

                    • March 8, 2012
                    • Howard R., McShane R., Lindesay J., et al.
                    • N Engl J Med 2012; 366:893-903
                    • CME

                    In patients with moderate or severe Alzheimer's disease receiving donepezil, those assigned to continue donepezil had less cognitive decline than did those assigned to discontinue donepezil. The combination of donepezil and memantine did not confer benefits over donepezil alone.

                  • Editorial

                    Donepezil, the most frequently prescribed cholinesterase inhibitor for the treatment of Alzheimer's disease, was marketed in 1997 on the basis of the results of 3-month and 6-month clinical trials showing that patients had improvements in cognitive test scores and in the ability to perform daily…

                    • March 8, 2012
                    • Schneider L.S.
                    • N Engl J Med 2012; 366:957-959

                      Donepezil, the most frequently prescribed cholinesterase inhibitor for the treatment of Alzheimer's disease, was marketed in 1997 on the basis of the results of 3-month and 6-month clinical trials showing that patients had improvements in cognitive test ...

                    • Review Article

                      The diaphragm is the dome-shaped structure that separates the thoracic and abdominal cavities. It is the principal muscle of respiration, is innervated by the phrenic nerves that arise from the nerve roots at C3 through C5, and is primarily composed of fatigue-resistant slow-twitch type I and fast…

                      • March 8, 2012
                      • McCool F.D. and Tzelepis G.E.
                      • N Engl J Med 2012; 366:932-942
                      • CME
                      • Video

                      Dysfunction of one or both hemidiaphragms is an underdiagnosed cause of dyspnea. Weakness or paralysis may be seen during mechanical ventilation, after surgery or trauma, with metabolic or inflammatory disorders, and with myopathy, neuropathy, or diseases causing lung hyperinflation.

                    • Case Records of the Massachusetts General Hospital

                      Presentation of Case. Dr. Aida E. Kuri (Medicine): A 79-year-old man was admitted to this hospital because of pain and weakness in the legs. The patient had multiple medical problems but had been in his usual state of health until 6 days before admission, when progressive, generalized pain and…

                      • March 8, 2012
                      • David W.S., Chad D.A., Kambadakone A., Hedley-Whyte E.T.
                      • N Engl J Med 2012; 366:944-954
                      • CME
                      • Video

                      A 79-year-old man was admitted to the hospital because of pain and weakness in the legs. He had multiple chronic medical problems and took numerous medications, with no recent changes. Examination revealed leg weakness and decreased reflexes.

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                    Medical Meetings Neurology/Neurosurgery Conferences and Meetings

                    University of California, San Francisco

                    The following conferences will be held in San Francisco: "Occupational and Environmental Factors in Neurological Disease" (Nov. 1) and "Occupational and Environmental Medicine Update" (Nov. 2 and 3).

                    Contact the University of California, San Francisco, Division of Occupational & Environmental Medicine, 350 Parnassus Ave., Suite 609, San Francisco, CA 94143; or see https://www.cme.ucsf.edu/cme/CourseDetail.aspx?coursenumber=MDM13N01 .

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