Bobby Lazzara, MD

looked at the most common neurological diagnoses leading to hospitalization for the homeless, and whether the characteristic of being homeless is an independent risk factor for 30-day readmission based on a patient’s diagnosis.

The study encompassed almost 2 million individuals with a primary neurologic diagnosis. Of the group, the homelessness rate was 0.37%. Seizures and traumatic brain injury were the most common diagnosis in the homeless.

After controlling for multiple variables, homelessness was associated with increased 30-day readmission rates.

No surprises here in this study...but, we are getting closer to identifying interventions that can help the homeless population with neurologic disease.

1. Rosendale N, Guterman EL, Betjemann JP, et al. 

Hospital admission and readmission among homeless patients with neurologic disease.

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A large study may bring us closer to identifying interventions that can help the homeless population with neurologic disease.

Readmissions in the Homeless Population

 compared 26 former NFL players with cognitive and neuropsychiatric symptoms with 31 controls looking at tau deposition with positron emission tomography.

Why? Because the neuropatholical diagnosis of chronic traumatic encephalopathy (CTE) from repetitive head impacts is based on a specific pattern of tau deposition with minimal amyloid deposition, which distinguishes it from other disorders like Alzheimer disease.

Tau deposition was higher in former players compared with controls in three regions:

Participants did not have elevated amyloid beta levels and there was no association between tau and scores on cognitive or neuropsychiatric tests.

The study is a small cohort and more research is needed, but how are you counseling patients and families about the risks and benefits of playing sports with repetitive head blows and the risk of CTE?

Tau Positron-Emission Tomography in Former National Football League Players

How are you counseling patients and families about the risks and benefits of playing sports with repetitive head blows and the risk of CTE?

Tau Deposition Patterns in Retired NFL Football Players

of 32 participants looked at the relationship of retinal blood ï¬ow and vessel density to early onset Alzheimer disease (AD) and mild cognitive impairment.

Patients with early onset AD and mild cognitive impairment were matched 1:1 with a control group. Evaluation of retinal blood ï¬ow and vessel density was done with optical coherence tomography angiography.

Patients with early cognitive impairment associated with AD showed a signiï¬cant decline in parafoveal blood ï¬ow and vascular density. The authors suggest these parameters when evaluated with optical coherence tomography angiography could have potential utility as an early  biomarker in AD.

Parafoveal vessel loss and correlation between peripapillary vessel density and cognitive performance in amnestic mild cognitive impairment and early Alzheimer's Disease on optical coherence tomography angiography

A prospective case controlled study looked at the relationship of retinal blood ﬂow and vessel density to early onset Alzheimer disease and mild cognitive impairment.

Alzheimer Disease and Retinal Blood Flow

In a recent multicenter double-blind placebo controlled delay start trial, 

 looked at at levodopa/carbidopa administration soon after the diagnosis of Parkinson disease (PD). The study compared treatment at 80 weeks with 40 weeks of placebo followed by 40 weeks of treatment.

The primary outcome was an analysis of the Unified Parkinson’s Disease Rating Score between the two groups to determine if therapy should be initiated after diagnosis or if a delay had any effects on altering the course of the disease.

The findings...the difference in the progression of the disease between the two groups was not significant.

Levodopa for Early Parkinson Disease: Some Answers, More Questions

1. Verschuur CVM, Suwijn SR, Boel JA, et al. 

Randomized Delayed-Start Trial of Levodopa in Parkinson's Disease

A study looked at at levodopa/carbidopa administration soon after the diagnosis of Parkinson disease.

Parkinson Disease: When to Treat?

A randomized clinical trial published in the journal 

 studied 132 cognitively normal adults between the ages of 20 to 67. The study looked at the effect of aerobic exercise over a 6-month period, 4 times weekly, on cognitive function and physical conditioning.

The researchers found that as a result of aerobic conditioning:

• aerobic capacity increased and BMI decreased

• executive function increased significantly and was more pronounced as age increased.

• cortical thickness increased significantly in the left frontal region and was not related to age

When patients ask about a good drug to prevent cognitive impairment, you might want to say, “Yeah, it’s called exercise!”

1. Stern Y1, MacKay-Brandt A2, Lee S, et al. 

Effect of aerobic exercise on cognition in younger adults: A randomized clinical trial

A recent study evaluated the effect of aerobic exercise on cognitive function and physical conditioning in young adults. The result? These boots are made for more than walking.

 The Mind Wins by a Nose, But the Heart Leads the Way

 a randomized 2-year clinical trial of 221 black participants with mild cognitive impairment assessed whether supportive therapy or behavioral activation increased cognitive, physical, and social activity.

The findings…behavioral activation significantly reduced cognitive decline compared with supportive therapy. Memory decline was 1.2% compared with 9.3% for supportive therapy.

Given the basic fact that the black population has twice the rate of dementia as their white counterparts, behavioral activation techniques may offer an approach to change another racial disparity in health care.

Despite this dramatic difference in rates of Alzheimer disease (AD) between the black and white population, clinical studies of African-American patients 

 those of non-Hispanic white patients. Future research should address these disparities.

Here: Results from a clinical study of African-American patients with mild cognitive impairment.

Prevention Strategies for Cognitive Decline in Black Patients With MCI

, a meta-analysis of 5 clinical studies looked at a comparison of non–vitamin K antagonist oral anticoagulants (NOACs) with low-dose aspirin with regard to risk of intracranial hemorrhage in patients without atrial fibrillation.

In this analysis, a rivaroxaban dose of 15 mg to 20 mg daily greatly increased the risk of 

 compared with aspirin, while lower doses of either rivaroxaban or apixaban did not show an increased risk.

, it appears the risk of intracranial hemorrhage may be dose-dependent in NOACs. The patient group that requires further study using these drugs is patients without atrial fibrillation, but with sources of cardiac emboli that have a potential for causing embolic 

. Perhaps at lower doses the risk of intracranial hemorrhage can be reduced compared with aspirin.

In a nutshell: results from a meta-analysis of 5 clinical studies that assessed non–vitamin K antagonist oral anticoagulants vs aspirin.

Intracranial Hemorrhage: Comparing NOACs With Low-Dose Aspirin

A retrospective analysis published in the 

 conducted a comparison between mechanical thrombectomy alone versus intravenous thrombolysis and mechanical thrombectomy in acute ischemic stroke.

A total of 325 patients were analyzed. No difference was found in safety and efficacy outcomes. After multivariate analysis, the combined treatment was not associated with lower mortality.

So, according to this study, mechanical thrombectomy alone is safe and effective in patients with contraindications to intravenous thrombolysis. These findings support an earlier study published in 

The study was a pooled analysis of SWIFT and STAR studies, concluding that the addition of intravenous thrombolysis did not appear to add clinical benefit in acute ischemic stroke. Further studies are needed.

1. Sallustio F, Koch G, Alemseged F, et al. Effect of mechanical thrombectomy alone or in combination with intravenous thrombolysis for acute ischemic stroke. 

2. Coutinho JM, Liebeskind DS, Slater LA, et al. Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke: A Pooled Analysis of the SWIFT and STAR Studies. 

Findings from a pooled analysis of SWIFT and STAR studies analyzed whether IV thrombolysis added clinical benefit in acute ischemic stroke.

Thrombolysis Versus Thrombolysis Plus Thrombectomy in Stroke

used a random sample of Medicare beneficiaries hospitalized for ischemic stroke between 1999 and 2013. Over 128,000 patients having an ischemic stroke were included in the analysis.

The results: The risk of stroke recurrence was higher for blacks compared with whites; however 30-day mortality was lower for blacks.

How about that racial disparity in clinical outcomes for a disease process that results in significant morbidity and mortality in the United States? We can only speculate. And why do we continue to spend millions of dollars on bipartisan political campaigns that end in empty promises and ignore answering the important questions in health care? As my Dad would say in the face of a recurrent unsolved problem, “Who is in charge here?”

1. Albright KC, Huang L, Blackburn J, et al. Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality. 

Over 128,000 patients having an ischemic stroke were included in a recent analysis. Here's what researchers found.

Racial Differences in Stroke Recurrence and Fatality

An analysis of 126 amyloid-negative adults aged 30 to 89 years with PET and a cognitive battery at baseline and at 4-year follow-up showed a relationship between specific regional accumulation of amyloid in posterior cortical regions and declining episodic memory.

The authors pointed out that assessing regional changes in amyloid accumulation may indeed be a marker for detecting subclinical amyloid related decline. As always, more research is needed.

1. Farrell ME, Chen X, Rundle MM, et al. 

Regional amyloid accumulation and cognitive decline in initially amyloid-negative adults

Can amyloid accumulation predict a decline in episodic memory over time?