Melanie Cole, MS (Host) : Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And in case you missed it, today, we're offering highlights from the 2024 American Academy of Neurology Annual Meeting. Joining me is Dr. Borna Bonakdarpour. He's an Associate Professor of Neurology at Northwestern Medicine.

Dr. Bonakdarpour, thank you so much for joining us today. Can you please summarize for us some of the highlights from the meeting? What sessions really stood out to you? And tell us about those.

Dr. Borna Bonakdarpour: Hello. Thank you so much for having me. When I go to the Academy of Neurology meetings, there are few sessions that I always check, because they highlight the best of the best from United States and around the world. The main first session I attended was the Presidential Plenary. And the session started with Dr. Carlayne Jackson sitting down with Dr. Sanjay Gupta, a very well-known neurosurgeon and medical journalist. They talked about the future of brain health for all.

The major points from the conversation were the conversations around pillars of brain health, which are exercise, purpose learning and discovery, which are intellectual engagement; sleep relaxation, reducing stress, diet, and human connectivity. So, these are very important. I'm a behavioral neurologist, so I see individuals with cognitive, memory, language, visual disturbances. And then, we make sure that all these aspects are covered under brain health and brain care. So, that would give neurologists a structured approach to brain health.

Another talk during the Presidential Plenary was by Dr. Maiken Nedergaard on glymphatic systems, again, related to the brain health. The brain doesn't have lymphatic drainage like the rest of the body, but there is a system of network, perivascular channels that take the remnants of metabolism and, in other words, clear the brain from the remnants and refresh the brain. And one of the major things that was brought up during the lecture was the fact that how sleep is important. And I'd like to quote from Dr. Nedergaard that sleep is not negotiable. You must sleep. She provided beautiful imaging and molecular data from her work in that area.

Another talk that I really liked was the Robert Wartenberg Lecture. Dr. Mark Hallett who talked about functional neurologic disorders, and the organic changes in the brain in these disorders. We, as neurologists, see many different functional neurologic disorders. In French, they call it la lésion dynamique. He talked about the history of functional neurologic disorders going back to Charcot, a very well known French neurologist of the 19th Century, who is one of the fathers of Neurology, and then the works of Freud, which are still relevant. And what we haven't really seen, and it was very refreshing to hear more about it was the fact that these disorders are not just pure psychological conflicts. They are structural evidence in the brain. For example, hypertrophy in amygdala or the uncinate fasciculus, which happens during childhood or adolescence in individuals who have stressful life events or abuse. And then, that increases the cortisol secretion. And then, following that, there are changes in the amygdala and uncinate fasciculus in the brain. There were imaging data. They were also some recommendations in terms of cognitive therapy, cognitive behavior therapy, and how the results of that can be seen in functional imaging of the brain.

The other section that I attended and I really liked was Contemporary Issues in Neuroscience, another plenary session. So, Dr. Raina Robinson talked about molecular basis of racial and ethnic disparities. And that is very important. We have a common problem with diagnosis of cognitive impairment, and it is very important to take ethnic and cultural background into consideration. A lot of our screening tools, mini mental exam or Montreal test, they are not necessarily standardized for different cultures within, for example, United States. So, we have to be very careful when to call somebody having cognitive impairment. So, that's something that we knew. Dr. Robinson talked also about some molecular and biomarker differences in, for example, African-Americans, where as you know, when we diagnose Alzheimer's disease, we use amyloid and phosphorylated tau in the spinal fluid to make the diagnosis. So, her research shows that African-Americans, for example, have a lower level of tau in CSF. So if that's the case, they may not make it to the diagnosis and they may not receive the treatment needed. So, that is a very important factor to have in mind. She also reported some differences in lipidomic profiles in African-Americans.

The other session that I wanted to highlight a few of the talks were the Clinical Trials Plenary. There were three trials that I found interesting. One is the ADHERE trial. Dr. Jeffrey Allen talked about efgartigimod, that is a monoclonal antibody. It's being used by myasthenia gravis as VYVGART. And then, he showed in a safety and tolerability trial that results were positive for chronic inflammatory polyradiculoneuropathies. So, we'll see more results with regards to this medication, but because we are using VYVGART clinically now, I thought that was very interesting. Another trial that was discussed by Dr. Katherine Peters was the vorasidenib for gliomas. That was a phase III trial, which showed some benefit for quality of life and individuals with gliomas and also some cognitive benefits. And the third one was the ACCORD trial presented by Dr. Anton Porsteinsson, who presented the ACCORD trial. The interventional drug was AXS-05. And it is a NMDA receptor inhibitor, a combination of dextromethorphan and bupropion, which they used as a phase III trial for Alzheimer's disease agitation, and it was shown to be efficacious.

Melanie Cole, MS: Doctor, such interesting sessions that you've highlighted. And now, if you would, summarize the key takeaways and notable highlights from your own presentation and then presentations of other Northwestern Medicine physicians.

Dr. Borna Bonakdarpour: For the second year, myself and my collaborator, Clara Takarabe, we presented at the Wellness Hub some of the work we've done in music and medicine. We've been working with individuals with dementia, with individuals with epilepsy. We've done some work in the hospital with patients who were admitted in the hospital. And then, we have developed a program now where we can make music available as an intervention, as an evidence-based scientific intervention for individuals with neurologic disorders. We have also provided music as a factor for brain health and for general health for our physicians, residents, and care providers at Northwestern. So, we talked about some of the efforts that we've done. We have data from about more 400 individuals who have been part of these music interventions, what we called the clinically-designed improvisatory music. And we have some EEG data that shows its efficacy. And right now, we are running a trial for individuals with Alzheimer's disease with anxiety using this kind of improvisatory calming music, which some of the first results we've gotten are promising.

Another related session at AAN was another session on music and Neurology by Dr. Chémali from Case Western University. So, this field is growing, and I'm coming back from Washington, D.C. where we had our first Music and Dementia Meeting hosted by the NIH. And so, we're going to see more and more trials coming out of that field.

The other studies, there were so many Northwestern residents, fellows, professors who had abstracts, presentations. I got a list of at least 20 people, so I had to choose some because I know our time is limited. You can always go to the Academy of Neurology website. They do have the abstracts. You can see the beautiful work they've done.

Dr. Koralnik from our neuroinfectious division has been pioneering the research in long COVID. And he has shown that the long COVID falls within two categories. The individuals who come out of very severe COVID, they were admitted in ICU, have respiratory distress, and the ones who were mostly handled outpatient. In these two different groups, he shows that there are some vulnerabilities that can be risk factors for long COVID, which are not necessarily immune related, and there are vulnerabilities that are immune related. He's shown some changes in the mitochondrial function that can cause chronic symptoms after COVID, for example, brain fog, or fatigue, or headaches. There was recently a YouTube of one of the patients that he has been following and his team that shows exactly how these symptoms are and then how we can manage them.

Another study that was presented was by Dr. Dan Jia, who now works as a transitional hospitalist and neurologist. This is a new program at Northwestern, which has been very successful in terms of transitioning patients who are discharged from the hospital to the outpatient care. Immediately patients do have some contact with maybe physical therapists or occupation therapists. But for them sometimes to get into an outpatient neurologist, it may take time. But through, Dr. Jia's clinic, he has shown that he can get patients in much faster. And that has changed the outcome of patients by 89%. And in about 60% of patients, the diagnoses changed compared to discharge because sometimes when patients are discharged, there is still some doubt about the final diagnosis and then that's what happens. You know, the outpatient physician or neurologist makes the diagnosis. So, this model has a lot of promise, and I'm very excited see the results that came out of it.

Another study that came from Dr. Danny Bega's group from our Movement Neurology Division. It was a study where they looked at the DAT scan or dopamine transporter scan, what we use to diagnose Lewy body disease, and they underlined the importance of knowing what medications the patient is on. Medications like sertraline and bupropion can cause false positive results. And that scan, which is very important because we built the whole diagnosis based on this test and the treatment. So, it's very important to pay attention to the medications.

Another study that, again, came out of a residency program by one of our former residents, Dr. Chou, looked at the education of Neurology for residents and the fact that having inpatient responsibilities together with having to see patients in outpatient clinic can cause some distress and also interference between patient care and education. They looked at a model where residents were on the inpatient service for four weeks and then did one week of clinic instead of having the clinic on a weekly basis. And they reported feasibility and good results from that. So, we'll see how this goes as more residents come in and then go through this structure.

Melanie Cole, MS: Doctor, that was absolutely fascinating, and the music theory information. There's so much more to be learned, and it's such an exciting time in your field. The advancements are happening very quickly. And thank you for summarizing those for us so very well.

Is there anything else that you would like other providers to know that may not have been able to attend, some of the key takeaways or things that were most exciting? If you were to think of how you're going to be leveraging these learnings right into your practice as far as incorporating some of the latest research and treatment approaches into patient care, what would that be? And what would you like the key takeaways to be for other providers?

Dr. Borna Bonakdarpour: In terms of brain health, I think thinking about those pillars of brain health, exercise, intellectual engagement, sleep and relaxation, and taking times to recuperate, that's a general thing for everybody, including neurologists and physicians themselves, and to make sure that we have that in mind when we are taking care of our patients and their care partners. In Neurology, we take care of a lot of chronic conditions and then we do see caregiver burnout. So, that also is important not only for the patients, but for also the care partners.

The diet is very important. There's more and more studies coming out of how diet is important in brain health, how it contributes to Parkinson's and Alzheimer's disease. And also, a big problem all around the world is isolation of individuals with almost any type of disease, including neurologic disease, and then how we need to make sure that we do something about isolation. The study that Dr. Jia did with transition of care is very important in terms of dealing with this issue of isolation, because it's a risk factor for brain problems and it's also a risk for care in all medicine, not only Neurology.

The other thing that I think stood out is the individualized approach to patient care and using biomarkers, genetics, and the history, everything, to know how we individualize the care for each patient. That is a very big goal at Northwestern Neurology, and we are definitely pursuing that. In some of the talks, there was more focus on that and that is again another important point to talk about. The function of neurologic disorders, that's a very sensitive topic in our field, because we don't know the mechanisms very well. It causes a lot of frustration for physicians, neurologists, and patients. It's very important to pay attention to underlying causes, also the anatomical causes, the imaging. A lot of these cases when I see in the clinic, I do see changes in their MRIs, for example. It's very important to put that in context for patients and their caregivers.

In terms of the clinical trial, so we are waiting for these medications that I mentioned. For the ones that were more earlier stages in terms of clinical trial, we look forward to the phase II and III trials. For the ones for glioma, for example, or for Alzheimer's disease that were phase III, we'll look forward to seeing what happens in terms of their usability in the clinical world. Again, this was a very summarized approach. There was so much more, there's so much more to talk about. I hope that listeners find this helpful.

Melanie Cole, MS: It was very comprehensive, Dr. Bonakdarpour. And thank you so much for highlighting sessions from the 2024 American Academy of Neurology Annual Meeting and for reinforcing the importance of individualized care and shared decision-making. Thank you so much for joining us today. And to refer your patient or for more information, visit please visit our website at breakthroughsforphysicians.nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please always remember to subscribe, rate, and review Better Edge on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.