2019 Annual Meeting AANextra Sunday

THE ANNUAL MEETING NEWS DAILY

Sunday, May 5, 2019

Members Vote on Unprecedented Leadership Change at Business Meeting. See Page 4.

THIS MORNING’S PRESIDENTIAL PLENARY SESSION RECOGNIZES FOUR NEUROLOGY GIANTS

Rost

An impressive lineup will address attendees for the premier lectures at this morning’s Presidential Plenary Session from 9:15 a.m. to 12:00 p.m. in the Terrace Ballroom. The hugely popular session will be moderated by Science Committee Chair Natalia S. Rost, MD, MPH, FAAN, FAHA, and open to all meeting attendees.

Neuroscience Research Prize recipients will also be recognized during the session.

“The Presidential Plenary is the ultimate platform for recognizing some of the biggest names and greatest accomplishments in neurology,” said Rost. “These giants of neurology, who have been at the forefront of their fields for years, will be addressing seminal advances in neuro-oncology, movement disorders, and multiple sclerosis.”

Continued on page 15 u

Make Your Way to the Grand Hall for the Grand Experience Make room in your schedule to make your way to the Grand Hall of the Pennsylvania Convention Center each day of the meeting to experience engaging, innovative, creative opportunities in science, networking, and mentoring at the Grand Experience.

The NIH Brain Initiative: A Dialogue with the AAN will take place on Monday, and Tuesday will be National Institutes of Health Day in the area.

Continued on page 34 u

Today’s Opening Luncheon Kicks off Four Days of Exhibit Hall Happenings Check out the Exhibit Hall today beginning at 11:30 a.m. for the always popular Opening Luncheon that will kick off four days of happenings you won’t want to miss.

Running through Wednesday, May 8, from 11:30 a.m. to 4:00 p.m. this year’s hall promises to be anything but traditional.

Not only will the area offer countless opportunities to meet, mingle, and learn from pharmaceutical and medical device Continued on page 30 u

Inside Invited Science 14 Today’s Examines Infectious Diseases and Global Health

in the 44 Neuroscience Clinic Sessions Kick Off Today with Childhood Epilepsy

the Latest Research 45 Find at Today’s Poster Session

In Multiple

Sclerosis—

GREY MATTERS, TOO

FIND OUT WHY

Booth 2300

© 2019 Celgene Corporation All rights reserved.

03/19 US-CLG-19-0291

Sunday, May 5 Cover This Morning’s Presidential

Plenary Session Recognizes Four Neurology Giants

Make Your Way to the Grand Hall for the Grand Experience

Today’s Opening Luncheon Kicks off Four Days of Exhibit Hall Happenings

4

Members Elect Unprecedented Board Slate at Business Meeting

9

MIT’s Herr Sees End to Disability Through Technological Innovation

10 Trainees: Make the Most of Your Annual Meeting

10 Discover How Stronger Business

24 Registry Grew in Participation,

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

26 The Best of Philly from Those

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

Value in 2018

Who Know It Best

30 Join New EHR Synapse Online Community

31 NIH Seeks Your Input on BRAIN Initiative’s Strategic Plan

36 Behavioral Interviewing: Tell a

Compelling Story with Your Answer

40 AAN Industry Roundtable Celebrates 25 Years

42 What Are Your Colleagues Saying?

44 Neuroscience in the Clinic Sessions Kick Off Today with Childhood Epilepsy

Contact Information: 201 Chicago Avenue Minneapolis, MN 55415 USA Phone: (800) 879-1960 (Toll Free) or

(612) 928-6100 (International) Fax: (612) 454-2744 Email: memberservices@aan.com Website: AAN.com AAN Chief Executive Officer:

Catherine M. Rydell, CAE

Managing Editor:

Angela M. Babb, CAE, APR

14 Today’s Experiential Learning

45 Find the Latest Research at

Editor: Tim Streeter Writers: Ryan Knoke, Sarah Parsons Designers: Siu Lee, Andrew Imholte Photography: Will Evans Printing: Phoenix Lithographing Corporation Email: aannews@aan.com

18 2019 Practice Management Webinar

45 Expanded Symposium Offers

AANextra is published by the American Academy of Neurology.

20 Complete Survey, Benefit from

46 Boxed Lunch Menu 46 What Excited You Today at #AANAM?

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.

Administrators Make a Stronger Practice

12 Kick off a Spectacular Week with Tonight’s Philly Spectacular!

Area Highlights

Changes Enable Greater Topic Depth Compensation and Productivity Data

23 Momentum of 2018 Advocacy

44 Today’s Invited Science Examines Infectious Diseases and Global Health Today’s Poster Session

Robust Opportunities for Medical Students

Successes Carries into 2019

Daily Reminders SUNDAY, MAY

Education Program Syllabi and Slides Available Online Only Education Program syllabi and slides are available online only at AAN.com/view/syllabi or through the AAN Conferences Mobile App at AAN.com/view/MobileApp.

May 20 Is Deadline to Submit Online Evaluations for Annual Meeting CME Complete your evaluations to get your CME hours by using the AAN Conferences Mobile App at AAN.com/view/MobileApp or by visiting AAN.com/view/CME. CME requests may be made until Monday, May 20, 2019.

Transcripts will be emailed approximately six weeks after the meeting. AAN members can also access their transcript via NeuroTracker™ at AAN.com/view/NeuroTracker.

THE ANNUAL

MEETING NEWS

DAILY

Members Vote on

Leadership Unprecedented

Change at Business

Meeting. See Page

5, 2019

4.

PRESIDENTIAL THIS MORNING’S ION RECOGNIZES PLENARY SESS Y GIANTS FOUR NEUROLOG Rost

will address attendees An impressive lineup at this morning’s a.m. to for the premier lectures Session from 9:15 Presidential Plenary The hugely Terrace Ballroom.

12:00 p.m. in the

by Science will be moderated popular session MD, MPH, Natalia S. Rost, Committee Chair attendees. open to all meeting will FAAN, FAHA, and Prize recipients Neuroscience Research the session. during also be recognized Plenary is the ultimate “The Presidential some of the biggest platform for recognizing ts in accomplishmen names and greatest of Rost. “These giants neurology,” said forefront of have been at the seminal neurology, who will be addressing their fields for years, movement advances in neuro-oncology, sclerosis.” disorders, and multiple u 15 Continued on page

to the Make Your Way Grand Hall for the ce Grand Experien

schedule to make Make room in your Hall of the your way to the Grand Center each Pennsylvania Convention to experience day of the meeting creative engaging, innovative, science, networking, opportunities in the Grand Experience. and mentoring at A Dialogue with The NIH Brain Initiative: on Monday, and place the AAN will take Institutes of Tuesday will be National area.

Health Day in the Continued on page

u 34

Today’s Opening off Luncheon Kicks Four Days of Exhibit Hall Happenings

14

Hall today beginning Check out the Exhibit the always popular at 11:30 a.m. for that will kick off four Opening Luncheon miss. you won’t want to days of happenings 8, Wednesday, May Running through 4:00 p.m. this year’s from 11:30 a.m. to be anything but traditional. hall promises to offer countless Not only will the area mingle, and learn opportunities to meet, and medical device from pharmaceutical Continued on page

Philadelphia

Inside Today’s Invited Science Examines Infectious Diseases and Global Health

44

the Neuroscience in Off Clinic Sessions Kick Today with Childhood Epilepsy

Research

the Latest Session 45 Find at Today’s Poster

u 30

The American Academy of Neurology sincerely thanks Phoenix Lithographing Corporation for its outstanding service, steadfast professionalism, and high quality standards, as well as its generous donation of the 2019 Brain Health Fair program guide.

ÑOL EN ESPA SO AL DOR

EVENT PROGRAM

Thursday, May 9, 2019 • 10:00 a.m.–4:00 p.m.

Pennsylvania Convention Center

Members Elect Unprecedented Board Slate at Business Meeting History was made by Academy members attending Saturday’s AAN Business Meeting. By voting to elect the nominees for the 2019–2021 AAN and AAN Institute Boards of Directors, they set the stage for Orly Avitzur, MD, MBA, FAAN, to become president in 2021, and women now hold a record four of the six officer positions on the board.

President Ralph L. Sacco, MD, MS, FAHA, FAAN; Treasurer Janis Miyasaki, MD, MEd, FRCPC, FAAN; and CEO Catherine M. Rydell, CAE, reported to members on the financial health of the Academy and key successes during 2018. It was a record-setting year for the AAN in several areas, including membership (36,000 members) US neurologist membership retention (96 percent), retention of early career US neurologists (91 percent), and Annual Meeting attendance (more than 14,000). There also were record numbers of medical student members, advanced practice provider members, and international members.

Sacco reported the Academy was meeting its strategic goals and that the board, committees, and subcommittees are working well together.

He also highlighted the new Joint Coordinating Councils on Equity, Diversity, Inclusion, and Disparities and on Wellness. Among the charges of these councils is to ensure communication and action on these issues across the Academy.

The president also cited significant accomplishments in advocacy efforts, including the AAN’s successful delay on E/M reimbursement changes, resulting in a $43 million annual savings in Medicare payment for E/M services starting in 2021; expansion of patient access to telestroke care through passage of the FAST Act; and a total $5 billion increase in NIH funding across fiscal years 2018 and 2019.

BrainandLife.com and was the first year of the quarterly Brain & Life en Espanol edition. All of the AAN’s publications have now been redesigned, with the debut of the revamped Neurology Today ® this past January.

Sacco congratulated Rydell on her 20th year as the AAN’s chief executive officer. Rydell plans to step down in May 2020, and Sacco noted that a search firm has been engaged and recruitment will begin this summer.

Rydell also spoke of the growth of the Axon Registry ®, now up to more than 1,200 participating members, and creation of the new Learning Management System, which delivers a host of free and discounted online education products.

Treasurer Miyasaki reported that in 2018, the AAN had consolidated revenue of $54 million and expenses of $53 million, resulting in an operating increase of $731,000 over 2017.

A downturn in advertising revenue was offset by increases in registration/course income and royalties and publishing. Net assets at the end of 2018 were $67 million. During 2018, $.87 of every $1 of membership dues was used to support products and services for members.

Regarding maintenance of certification, Rydell spoke about her participation on the American Board of Medical Specialties (ABMS) Continuing Board Certification: Vision for the Future Commission.

The ABMS launched this commission to bring together multiple partners to envision a system of continuing board certification that is meaningful, relevant, and of value, while remaining responsive to the patients, hospitals, and others who expect that physician specialists are maintaining their knowledge and skills to provide quality specialty care. With input from stakeholders across the neurology spectrum, ABMS seeks to establish new, integrated standards for continuing certification by 2020.

After highlighting the AAN’s big advocacy win in delaying changes to E/M reimbursement, Rydell touted record attendance numbers for the 2018 Annual Meeting in Los Angeles and Sports Concussion Conference in Indianapolis.

2018 saw the rebranding of the AAN’s patient and caregiver magazine Neurology Now to Brain & Life® and the website

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Sunday, May 5, 2019 • AANextra

To learn more about the AAN’s professional and financial accomplishments last year, read the 2018 Annual Report available online at AAN.com/view/AnnualReport.

2019 Priorities

2019–2021 AAN Board of Directors

Membership and Leadership

Officers

Maintain record membership numbers and retention

President: James C. Stevens, MD, FAAN

Ensure diversity, equity, and inclusion across all of neurology

President Elect: Orly Avitzur, MD, MBA, FAAN

Focus on improving wellness throughout neurology

Vice President: Ann H. Tilton, MD, FAAN

Deliver personalized member experiences Cultivate neurology leaders of tomorrow

Advocacy and Health Policy Ensure patient access to neurologic care Oppose any payment policy that would further

devalue E/M services

Increase drug pricing transparency and access Reduce disparities in health care delivery Expand patient engagement and advocacy

Education and Practice Assure pipeline of neurologists and multidisciplinary

team (APPs)

Educate on gender, race, and equity disparities

across neurology

Expand education in various formats to support

members across lifetime

Expand Axon Registry

Academic Neurology and Science Increase federal research funding and expand

AAN Research Program

Innovate Annual Meeting scientific offerings Support needs of academic neurology departments

Secretary: Carlayne E. Jackson, MD, FAAN Treasurer: Janis M. Miyasaki, MD, MEd, FRCPC, FAAN Past President: Ralph L. Sacco, MD, MS, FAHA, FAAN

Directors Brenda Banwell, MD, FAAN Sarah M. Benish, MD, FAAN Charlene Gamaldo, MD, FAAN James N. Goldenberg, MD, FAAN Jonathan P. Hosey, MD, FAAN Elaine C. Jones, MD, FAAN Shannon M. Kilgore, MD, FAAN Brett M. Kissela, MD, MS, FAAN Thomas R. Vidic, MD, FAAN

Ex Officio (voting) Nicholas E. Johnson, MD, FAAN, Chair, Advocacy Committee Brad C. Klein, MD, MBA, FAAN, Chair, Medical Economics

and Practice Committee

Gregory D. Cascino, MD, FAAN, Chair, Member

Engagement Committee

Robert A. Gross, MD, PhD, FAAN, Editor-in-Chief of

Neurology®

Ex Officio (non-voting) Catherine M. Rydell, CAE, Chief Executive Officer

Engage department chairs and business administrators

2019–2021 AAN Institute Board of Directors The following are additional members of the AAN Institute Board of Directors who do not serve on the AAN Board of Directors.

Officer Charles C. Flippen II, MD, FAAN,

AAN Institute Secretary-Treasurer

Ex Officio (voting) Natalia S. Rost, MD, MPH, FAAN, FAHA,

Chair, Science Committee

Lyell K. Jones, Jr., MD, FAAN, Chair,

Quality Committee

A. Gordon Smith, MD, FAAN, Chair,

Education Committee 

Sunday, May 5, 2019 • AANextra

5

With hereditary transthyretin-mediated (hATTR) amyloidosis...

Patients and their families face a future of functional decline1-3

Important Safety Information Infusion-Related Reactions (IRRs) In a controlled clinical study, 19% of ONPATTROtreated patients experienced IRRs, compared to 9% of placebo-treated patients. The most common symptoms of IRRs with ONPATTRO were flushing, back pain, nausea, abdominal pain, dyspnea, and headache.

To reduce the risk of IRRs, patients should receive premedication with a corticosteroid, acetaminophen, and antihistamines (H1 and H2 blockers) at least 60 minutes prior to ONPATTRO infusion. Monitor patients during the infusion for signs and symptoms of IRRs. If an IRR occurs, consider slowing or interrupting the infusion. In the case of a serious or life-threatening IRR, the infusion should be discontinued and not resumed.

Reduced Serum Vitamin A Levels and Recommended Supplementation ONPATTRO treatment leads to a decrease in serum vitamin A levels. Supplementation at the recommended daily allowance (RDA) of vitamin A is advised for patients taking ONPATTRO. Patients should be referred to an ophthalmologist if they develop ocular symptoms suggestive of vitamin A deficiency (e.g. night blindness).

Adverse Reactions The most common adverse reactions that occurred in patients treated with ONPATTRO were upper respiratory tract infections (29%) and infusion-related reactions (19%).

Please see brief summary of full Prescribing Information following this ad.

References: 1. Ando Y, Coelho T, Berk JL, et al. Orphanet J Rare Dis. 2013; 8:31. 2. Coutinho P, Martins da Silva A, Lopes Lima JL, et al. Excerpta Medica; 1980:88-98.

3. Vinik EJ, Vinik AI, Paulson JF, et al. J Peripher Nerv Syst. 2014;19:104-119. 4. ONPATTRO [package insert]. Cambridge, MA: Alnylam Pharmaceuticals, Inc; 2018.

5. Adams D, Coelho T, Obici L, et al. Neurology. 2015;85(8):675-682. 6. Adams D, Gonzalez-Duarte A, O’Riordan WD, et al. N Engl J Med. 2018;379(1):11-21. 7. Center for Drug Evaluation and Research. NDA 210922—patisiran—cross-discipline team leader review. U.S. Department of Health and Human Services, Food and Drug Administration; 2018.

ONPATTRO is a registered trademark of Alnylam Pharmaceuticals, Inc. © 2019 Alnylam Pharmaceuticals, Inc. All rights reserved. TTR02-USA-00023-012019

ONPATTRO® (patisiran) can reverse polyneuropathy manifestations of the disease4 A novel RNAi-based approach that may transform the future for your patients1,4-6 ONPATTRO is indicated for the treatment of the polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults.

At 18 months, ONPATTRO demonstrated: Reversal in neuropathy impairment4

Study Design The efficacy of ONPATTRO was demonstrated in a randomized, double-blind, placebo-controlled, multicenter clinical trial in adults with hATTR amyloidosis with polyneuropathy. Patients were randomized to receive ONPATTRO 0.3 mg/kg (N=148) or placebo (N=77) via intravenous infusion once every 3 weeks for 18 months.

Primary endpoint: The modified Neuropathy Impairment Score + 7 (mNIS+7) is an objective 304-point assessment of neuropathy that measures cranial nerve function, muscle strength, reflexes, postural blood pressure, quantitative sensory testing, and peripheral nerve electrophysiology.

Key secondary endpoint: The Norfolk Quality of Life-Diabetic Neuropathy (QoL-DN) scale is a patient-reported assessment that evaluates neuropathy in the following domains: physical functioning/large fiber neuropathy, activities of daily living, symptoms, small fiber neuropathy, and autonomic neuropathy (score range -4 to 136).

Select secondary endpoint: The Composite Autonomic Symptom Score 31 (COMPASS 31) is a patient-reported questionnaire that evaluates 6 autonomic domains: orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder, and pupillomotor (score range 0 to 100).

• Mean change from baseline in mNIS+7 of -6.0 points vs 28.0 with placebo, a treatment difference of -34 points (95% CI: -39.9, -28.1; p<0.001)

Improvement in quality of life4 • Mean change from baseline in Norfolk QoL-DN score of -6.7 points vs 14.4 with placebo, a treatment difference of -21.1 points (95% CI: -27.2, -15.0; p<0.001)

Reduction in autonomic symptoms6,7 • Mean change from baseline in COMPASS 31 of -5.3 points vs 2.2 with placebo, a treatment difference of -7.5 points (95% CI: -11.9, -3.2; p<0.001) CI=confidence interval; RNA=ribonucleic acid; RNAi=RNA interference.

Visit Booth #2401 to find out more.

MIT’s Herr Sees End to Disability Through Technological Innovation When Hugh Herr, PhD, lost both of his lower legs to amputation after a rock climbing accident in 1982, he did not see himself as broken.

He thought that technology was broken and inadequate. Today, Herr heads the Biomechatronics group at the MIT Media Lab, creating bionic limbs that emulate the function of natural limbs.

In Saturday’s powerful talk, Herr reiterated his belief, stating that basic levels of physiologic function should be a part of our human rights. He said that every person should have the right to live life without disability if they so choose.

Herr said these rights can be achieved if we accept that humans are not disabled; our built environment and technologies are broken and disabled. We can transcend disability through technological innovation, he said.

compelling discussion on The Origin of Moral Intuitions beginning at 1:00 p.m. Wednesday.

Throughout her successful career, Churchland has contributed to the fields of neurophilosophy, philosophy of the mind, and neuroethics.

Her research has centered on the interface between neuroscience and philosophy with a current focus on the association of morality and the social brain. She is a professor emeritus of philosophy at the University of California, San Diego and adjunct professor at the Salk Institute. 

Herr’s moving speech inspired attendees.

Herr

NEW IN

2019

“Dr. Hugh Herr is the ABSOLUTE inspiring and innovative leader of the Bionic Age!,” tweeted Mam Ibraheem, MD, MPH, CPH. Holly Hinson, MD, MCR, FAAN, tweeted, “Incredible thoughts about transcending disability with augmented ability via #technology from Hugh Herr.”

The Advancing Medicine: Inspiration and Innovation series continues at 1:00 p.m. on Monday with Mona Hanna-Attisha, MD, MPH, a pediatrician, professor, and public health advocate whose research exposed the Flint water crisis. Her bestselling book, What the Eyes Don’t See: A Story of Crisis, Resistance, and Hope in an American City, is a fascinating account of a shameful disaster that became a tale of activism and hope. A limited number of free books will be available to attendees, as well as additional copies for purchase.

The series concludes with Patricia Churchland, BPhil, leading a

Let’s Talk Cannabinoids

Stop by booth #2011 at the AAN annual meeting in Philadelphia, from May 5–8, and learn about the evidence for and against cannabinoids as medicine.

Talk to your patients about cannabinoids with a deeper understanding of the science behind the medicine.

Visit

©2019 Greenwich Biosciences, Inc. All rights reserved. CCL-05121-0319

Evidence-driven medicine

Trainees: Make the Most of Your Annual Meeting Students, residents, and fellows can expect to find programs and events going on all week long that are tailored specifically to their needs and will allow them to gain firsthand access to the latest neurology education and science, hear from renowned experts in their chosen subspecialty area of interest, and make essential connections that will prove invaluable to career advancement. Highlights include:

Trainee Experience

Saturday, May 4–Friday, May 10 The Grand Experience Connect with your peers and physicians to hear about the day’s highlights.

Experiential Learning Areas Saturday, May 4–Friday, May 10 Dynamic and interactive areas that will offer a variety of real-world experiences to engage you intellectually, emotionally, and socially and offer you fresh ideas to help you personally and professionally.

Futures in Neurological Research Track Saturday, May 4–Friday, May 10

Grow your future career in research with a curated set of courses and learning opportunities that will improve your knowledge and skills. Filter for the track within the AAN Conferences app.

For more information, visit AAN.com/view/AMTrainee.

Chief Resident Leadership Program

Sunday, May 5 / 12:00 p.m.–4:00 p.m.

Both current and future neurology chief residents will explore their own leadership potential, learn skills to enhance their success in their leadership role, and develop critical skills for use in this and future leadership roles. This program is designed for the resident poised to lead neurologists who promote the highest quality patient-centered neurologic care and professional development.

Resident Basic Science II: Neuropharmacology

Sunday, May 5 / 1:00 p.m.–5:30 p.m.

Philly Spectacular— at Reading Terminal Market!

Sunday, May 5 / 7:00 p.m.–10:00 p.m.

Pre-reserved ticket required.

See page 12 for details.

Student Interest Group in Neurology (SIGN) Meeting Monday, May 6 / 7:30 a.m.–9:00 a.m.

Resident Basic Science III: Neuroanatomy: All the Lesions Monday, May 6 / 1:00 p.m.–5:30 p.m.

Reception

Early Career

Monday, May 6 / 6:00 p.m.–9:00 p.m.

Philadelphia Marriott Downtown / Grand Ballroom Network with chairs of neurology departments and their faculty, peers, and AAN leaders; view clerkship/residency/ fellowship opportunities and learn about careers in neurology; and find out how the AAN can help you succeed throughout your neurology career.

Digital Scavenger Hunt Offered daily throughout the week. Visit the Annual Meeting Trainee website page for updates on scheduling.

Poster Hall Tour Held during various poster sessions.

Check the Annual Meeting Trainee website page for updates on scheduling.

Discover How Stronger Business Administrators Make a Stronger Practice

If you aren’t able to get to the Experiential Learning Area this week, visit AAN.com/ view/CareTeam to learn more and sign up your business administrators quickly and conveniently online. 

Gene Therapy Reverses MS Symptoms paGe 4

Sunday, May 5, 2019 • AANextra

paGe 9

The Global Burden of Motor Neuron Disease paGe 16

jaNuaRy 10, 2019 | VOluMe 19 | iSSue 1

The cGRp antagonists are here. Now how Do you use Them?

The Real-World Experience of Migraine Experts christine lehmann

S

ince the US Food and Drug Administration (FDA) approved three calcitonin gene-related peptide (CGRP) antagonists in 2018 — erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) — neurologists have begun integrating them into their practice.

More CGRP drugs that can prevent and

treat acute headaches are in the pipeline, with FDA approval expected within two years.

Designed to prevent chronic and episodic migraines, the CGRPs showed rapid, significant, and long-lasting relief of migraines with minimal adverse effects in clinical trials.

Neurology Today interviewed several neurologists specializing in migraines about their recent clinical experience with the drugs, and any concerns that arose. Their experience to date has been

mostly positive, they said, but they did offer several caveats, as well as noteworthy observations from early experiences prescribing them.

“This is the first time we have a preventive class of drugs that was created and designed just for the treatment of migraines based on what we now know about migraine pathophysiology,” said Rebecca Erwin Wells, MD, MPH, associate professor of neurology and founder and director of the comprehensive headContinued on page 24 ache program

Migraine specialists agreed that more clinical practice data is needed to better understand the long-term effects and implications of prescribing CGRPs.

passive eeG Detects covert awareness in Severely Brain-injured patients dan hurley

A

new screening test using electroencephalography (EEG) accurately detected covert consciousness in severely brain-damaged patients who appear clinically unresponsive at the bedside, according to a December 3, 2018, paper published in Current Biology.

Coming 12 years after the first such patients were identified with the use of a functional MRI (fMRI) technique, the new EEG test may eventually make it practical for general neurologists to identify those in nursing homes who are covertly conscious but are currently considered to be unaware of their surroundings, according to an accompanying commentary. At present, only a handful of centers in North America and Europe

have neurologists trained in conducting the costly fMRI exams.

Those fMRI exams involve asking patients with disorders of consciousness to follow spoken instructions by imagining that they are playing tennis or walking through their homes, and then seeing if the resulting pattern of brain activity is consistent with the requested imaginary tasks.

The new test protocol does not require patients to follow such commands, making

it among the first reports of a purely passive measure of awareness that is correlated with an fMRI-based motor imagery task. Instead, patients simply listen on earphones to spoken language — such as stories and memories about their lives prior to their injury shared by family members — and the pattern of their EEG response is compared to that of normal controls.

In the study of 21 severely brainContinued on page 20 injured patients,

Meet Neurology’s Diversity and inclusion “champions”

PerIODICAlS

paGe 12

NeurologyToday (ISSN 1533-7006), an official publication of the American Academy of Neurology, is published twice a month for the Academy by Wolters Kluwer, at 14700 Citicorp Drive, Bldg. 3, Hagerstown, MD 21742. POSTMASTER: Send address changes to Neurology Today, PO Box 1610, Hagerstown, MD 21740. Periodicals Postage Paid at Hagerstown, MD and at additional mailing offices.

LWW_NTY_January 10_19_Layout.indd 1

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Therapy Stops Seizures in NORSe

The Official Ne wS SOuRce Of The a MeRicaN acaDeMy Of NeuROlOGy | NeuROlOGy TODay.cOM

ISTOCKPHOTO

While there, you can learn how for only $270 business administrators can receive exclusive, career-strengthening AAN member benefits valued at up to $4,000, such as free access to the AAN’s 2019 Practice Management Webinar

series; publications such as Neurology:® Clinical Practice and Neurology Today ®; significant discounts on registration to the Annual Meeting; free AAN online education resources like NeuroSAE® and NeuroLearn™; and much more. Or, for as little as $115, business administrators can receive all of the aforementioned benefits, excluding the Practice Management Webinar series, Neurology Today (print), and free access to NeuroSAE and NeuroLearn.

ISTOCKPHOTO

Each member of the neurology practice is essential to high-quality patient care. Stop by the Experience the AAN: Make the Most of Your Membership Experiential Learning Area on Arch Street, Level 100, throughout the week to find out how you can give your business administrators an edge with access to the world’s best neurology resources and education to help them better reduce costs and increase revenue for your practice.

24/12/18 11:17 AM

What’s the key to breakthrough Neuro research and treatments?

Collaboration. At NewYork-Presbyterian Hospital, we partner with specialists

from Columbia University Vagelos College of Physicians and Surgeons and Weill Cornell Medicine to provide care to thousands of neurology and neurosurgery patients. Faculty from both medical schools are at the forefront of conducting research and clinical studies for a wide range of conditions. Recent advances include: Alzheimer’s • A study that uncovered large-scale changes throughout the epigenome of the human Alzheimer’s disease brain, revealing that tau-induced alterations of chromatin structure are more profound than changes attributable to amyloid pathology.

• The launch of our new Alzheimer’s Prevention Clinic that combines evidence-based, low-risk interventions with lifestyle modifications that may help to delay, or in some cases possibly prevent, the progression towards dementia.

Brain Tumors • The first-ever dose escalation study using convection-enhanced delivery for diffuse intrinsic pontine glioma to bypass the blood-brain barrier and administer a drug directly to the brain stem tumor site.

Stroke • Participated in the DEFUSE trial which has shown the benefit of late thrombectomy from 6 to 24 hours past onset of a large vessel occlusive stroke.

Because of these innovations and more, our Neurology and Neurosurgery program is ranked #1 in New York and #5 in the nation by U.S. News & World Report.

Learn more at nyp.org/neuroinnovations

New York’s #1 hospital for a reason.

Source: New York’s #1 hospital as ranked by U.S. News & World Report 2018-19

Kick off a Spectacular Week with Tonight’s Philly Spectacular!

Join your colleagues tonight from 7:00 p.m. to 10:00 p.m. at Reading Terminal Market, adjacent to the Pennsylvania Convention Center.

Embrace the city’s rich history from within one of the United States’ largest and oldest public markets, operating since 1893 in a beautiful National Historic Landmark building. Catch up with old friends and colleagues and meet and make new ones while enjoying an incredible selection of locally grown and exotic produce, locally sourced meats and poultry, and the finest seafood, cheeses, baked goods, and confections.

Eat, drink, and dance in the street to the sounds of Jellyroll, Philly’s original 12-piece horn party dance band, as they perform a repertoire spanning old-school classics to the newest top 40 hits. The awardwinning ensemble has won over audiences from Madison Square Garden in New York

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Sunday, May 5, 2019 • AANextra

City to the White House in Washington, DC. Attendees can also enjoy appetizers, sample local craft beers, participate in trivia for prizes, and play unlimited arcade games at the neighboring Field House sports bar.

Pre-reserved gratis and guest tickets will be distributed with your conference badge at Registration. Tickets that are not picked up by 5:30 p.m. today will be released. If you didn’t get an advance ticket for the Philly Spectacular, stop

by Registration after 6:00 p.m. to see if there are any unclaimed tickets

available. Additional tickets may be purchased for $115 at Registration. Tickets include all-you-can-eat food, beer/wine/ soda, entertainment, and transportation to and from hotels. All attendees and guests must be wearing the special lanyard to enter. 

INDUSTRY THERAPEUTIC UPDATE FROM AVEXIS A NEW FRONTIER FOR NEUROMUSCULAR DISORDERS: SPOTLIGHT ON GENE THERAPY Wednesday May 8 2019, 7:00 PM for 7:30 PM start* Room: Liberty Ballroom, Philadelphia Marriott Downtown

Faculty:

Perry Shieh, MD, PhD (Chair) Meredith Schultz, MD Christopher Walker, PhD Chris Jenkins, PhD *Dinner to be served at 7:00 PM

The Faculty of experts will explore the latest advances in gene therapy (GT) research and the use of GT in the clinical treatment of neuromuscular diseases, taking the treatment from bench to bedside.

Time

Presentation Title

Faculty Member

7:00 – 7:30 PM

Dinner reception

7:30 – 7:35 PM

Welcome and introduction

Perry Shieh, MD, PhD (Chair)

7:35 – 7:55 PM

Gene therapies: a new frontier for neuromuscular disorders

Meredith Schultz, MD

7:55 – 8:15 PM

A focus on adeno-associated virus (AAV) antibodies

Christopher Walker, PhD

8:15 – 8:35 PM

Biosafety considerations for the clinical use of AAVs

Chris Jenkins, PhD

8:35 – 8:45 PM

Panel discussion

All Speakers Facilitated by Chair

8:45 – 8:55 PM

Questions and answers

All Speakers Facilitated by Chair

8:55 – 9:00 PM

Closing remarks

Perry Shieh, MD, PhD (Chair)

In accordance with Federal Law, all food and beverage are reportable. You will have the opportunity to opt-out of food and beverage upon arrival at the Liberty Ballroom, Philadelphia Marriott Downtown This meeting is not part of the AAN Annual Meeting official programming and no CME is given for attendance.

This Industry Therapeutic Update is sponsored and organized by AveXis. ©2019 AveXis, Inc. All Rights Reserved.

MED-CON-UNB-00019-US 04/2019

Today’s Experiential Learning Area Highlights HeadTalks Neurology Pictionary 12:00 p.m.–1:00 p.m.

Join Bert B. Vargas, MD, FAAN, for this charades-inspired guessing game centered on all things neurology.

Maximize Your Value and Advocacy to Action Tip of the Iceberg: Ultra High-cost Neurology Drugs 1:00 p.m.–1:45 p.m.

AAN Board member Nicholas E. Johnson, MD, FAAN, discusses what the AAN is doing to control drug pricing and what you can do for your patients.

Research Corner

Be sure to attend tomorrow’s session:

Updating the NIH BRAIN Initiative: A Dialogue with the AAN Monday, 8:00 a.m.–9:00 a.m., Grand Experience Stage 2

Standing on the Shoulders of Giants 5:15 p.m.–6:15 p.m.

Cynthia L. Comella, MD, FAAN, kicks of this series of five neurology giants who share their personal journeys in neurology and how they have contributed to the evolution of the field.

Live Well: Taking Care of Your Patients Starts with Taking Care of You Happiness Hour 5:00 p.m.–5:30 p.m.

Join us as we celebrate the unique practices and hobbies our members take part in to nourish and bring them satisfaction in their lives—both in and outside of their neurology practice. Light appetizers and wine will be served.

14

Sunday, May 5, 2019 • AANextra

Launched in 2014, the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative is revolutionizing our understanding of the human brain. Guided by its strategic plan BRAIN 2025: A Scientific Vision, NIH has invested over $950 million to fund over 500 projects at more than 100 research institutions accelerating the development of new technologies to identify all cell types in the brain, map out their circuit connections, observe circuit activity in real time, manipulate circuit function to understand how the brain works, and, ultimately, to treat the many neurological and psychiatric disorders that arise from circuit malfunction.

An external scientific working group, the Advisory Committee to the Director of NIH (ACD) BRAIN Initiative Working Group, is reaching out extensively to the research community to assess progress and identify how the Initiative can best invest to realize its vision through the second half of the Initiative. This work group hopes to gain feedback and insight from AAN Annual Meeting attendees into how the BRAIN Initiative can maximize opportunities to meet its audacious goal: understanding how the brain works, and how brain disorders occur.

Navigating Your Career Navigating a Career in Academics 2:00 p.m.–2:45 p.m.

Jennifer Rose Molano, MD, FAAN, and Joseph E. Safdieh, MD, FAAN, will share their experiences navigating the academic environment to start their careers, focusing on negotiation strategies you can employ with your chair to help ensure you have the resources you need to be poised for success.

Experience the AAN Find out how the AAN supports and works for you, and how to better use AAN.com for your specific professional needs.

Innovation Hub Level Up: How Video Games Change the Brain 2:30 p.m.–3:00 p.m.

A whole generation is growing up with massive online role-playing games, e-sports competitions, and mobile technology, which prompts controversial questions about addictiveness, impaired development, improved hand-eye coordination, and therapeutic applications.

Come join a discussion of the potential neurological impacts of video games.

Mona Bahouth, MD, and Justin T. Jordan, MD, MPH, discussed quality improvement research at the Navigating Your Career Experiential Learning Area.

Medical Improv 3:00 p.m.–3:30 p.m.

The first of four sessions focusing on creative ways to improve communication skills. 

This Morning’s Presidential Plenary Session Recognizes Four Neurology Giants continued from cover Presidential Lecture “Neurology: Challenges, Opportunities, and the Way Forward” AAN President Ralph L. Sacco, MD, MS, FAHA, FAAN Miller School of Medicine, University of Miami, Miami, FL

H. Houston Merritt Lecture “Neuronal Ceroid Lipofuscinosis: Natural History Studies in Rare Neurodegenerative Disease” Jonathan W. Mink, MD, PhD, FAAN University of Rochester, Rochester, NY

Sidney Carter Award in Child Neurology Music therapy is being used in the treatment of TBI, PTSD, and other psychological issues in medical military facilities across the country. Renee M. Pazdan, MD, FAAN, and a music therapist demonstrated evidence-based music therapy interventions such as therapeutic singing, instrumental improvisation, and music-assisted relaxation and supportive research, followed by a case presentation by Pazdan on how this technique impacted neurologic patient care in the TBI clinical setting.

“Myelin Plasticity in Health and Disease” Michelle Monje, MD, PhD Stanford University, Stanford, CA

Robert Wartenberg Lecture “Progress in Understanding Progressive MS: From the Microscope to the Bedside” Claudia F. Lucchinetti, MD, FAAN Mayo Clinic, Rochester, MN

Attendees started their morning off with a good laugh, yogic breathing exercises, and some calming mindfulness meditation at the Laughter Yoga session in the Live Well Experiential Learning Area.

What is your "aha" moment from the Presidential Plenary Session?

Join the conversation at #AANAM. 

Sunday, May 5, 2019 • AANextra

15

Visit us at Booth #2345 at the AAN Annual Meeting

Follow the PATH The next step in CIDP

• Learn about our portfolio of Ig products, including the first and only subcutaneous Ig (SCIg) for CIDP maintenance in adults For adults with CIDP stabilized on IVIg

PROVEN CIDP CONTROL Greater Freedom for Everyday Living

• Watch a video of a CIDP patient demonstrating SCIg self-administration • See results from PATH— the largest study in CIDP

Important Safety Information Hizentra is indicated for: • Treatment of primary immunodeficiency (PI) in adults and pediatric patients 2 years and older.

• Maintenance therapy in adults with chronic inflammatory demyelinating polyneuropathy (CIDP) to prevent relapse of neuromuscular disability and impairment.

– Limitation of Use: Maintenance therapy in CIDP has been systematically studied for 6 months and for a further 12 months in a follow-up study. Continued maintenance beyond these periods should be individualized based on patient response and need for continued therapy.

For subcutaneous infusion only.

WARNING: Thrombosis may occur with immune globulin products, including Hizentra. Risk factors may include: advanced age, prolonged immobilization, hypercoagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling vascular catheters, hyperviscosity, and cardiovascular risk factors.

For patients at risk of thrombosis, administer Hizentra at the minimum dose and infusion rate practicable. Ensure adequate hydration in patients before administration. Monitor for signs and symptoms of thrombosis and assess blood viscosity in patients at risk for hyperviscosity.

Hizentra is contraindicated in patients with a history of anaphylactic or severe systemic reaction to human immune globulin (Ig) or components of Hizentra (eg, polysorbate 80), as well as in patients with immunoglobulin A deficiency with

antibodies against IgA and a history of hypersensitivity. Because Hizentra contains L-proline as stabilizer, use in patients with hyperprolinemia is contraindicated.

IgA-deficient patients with anti-IgA antibodies are at greater risk of severe hypersensitivity and anaphylactic reactions. Thrombosis may occur following treatment with Ig products, including Hizentra.

Monitor patients for aseptic meningitis syndrome (AMS), which may occur following treatment with Ig products, including Hizentra.

In patients at risk of acute renal failure, monitor renal function, including blood urea nitrogen, serum creatinine and urine output.

In addition, monitor patients for clinical signs of hemolysis or pulmonary adverse reactions (eg, transfusion-related acute lung injury [TRALI]).

Hizentra is derived from human blood. The risk of transmission of infectious agents, including viruses and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent and its variant (vCJD), cannot be completely eliminated.

The most common adverse reactions (observed in ≥5% of study subjects) were local infusion-site reactions, as well as headache, diarrhea, fatigue, back pain, nausea, extremity pain, cough, upper respiratory tract infection, rash, pruritus, vomiting, upper abdominal pain, migraine, arthralgia, pain, fall, and nasopharyngitis.

The passive transfer of antibodies can interfere with response to live virus vaccines and lead to misinterpretation of serologic test results.

Please see the following brief summary of prescribing information for Hizentra, including boxed warning.

Scan your badge at Booth #2345.

We’ll contribute to support people with CIDP.

CSL Behring will contribute to the GBS|CIDP Foundation International with every scanned badge.

Help us reach our sponsorship goal of $25,000!

CSL Behring does not make products indicated for GBS in the US.

$25,000

May is CIDP Awareness Month

Hizentra is manufactured by CSL Behring AG and distributed by CSL Behring LLC. Hizentra® is a registered trademark of CSL Behring AG. Biotherapies for Life® is a registered trademark of CSL Behring LLC. ©2019 CSL Behring LLC 1020 First Avenue, PO Box 61501, King of Prussia, PA 19406-0901 USA www.CSLBehring.com www.Hizentra.com HIZ-0838-MAR19

HIZENTRA®, Immune Globulin Subcutaneous (Human), 20% Liquid Initial U.S. Approval: 2010 BRIEF SUMMARY OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use HIZENTRA safely and effectively. See full prescribing information for HIZENTRA. WARNING: THROMBOSIS

See full prescribing information for complete boxed warning.

• Thrombosis may occur with immune globulin products, including HIZENTRA. Risk factors may include: advanced age, prolonged immobilization, hypercoagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling vascular catheters, hyperviscosity, and cardiovascular risk factors.

• For patients at risk of thrombosis, administer HIZENTRA at the minimum dose and infusion rate practicable. Ensure adequate hydration in patients before administration. Monitor for signs and symptoms of thrombosis and assess blood viscosity in patients at risk for hyperviscosity.

-----------------------------------INDICATIONS AND USAGE----------------------------------HIZENTRA is indicated for: *Treatment of primary immunodeficiency (PI) in adults and pediatric patients 2 years and older. * Maintenance therapy in adults with chronic inflammatory demyelinating polyneuropathy (CIDP) to prevent relapse of neuromuscular disability and impairment.

-Limitation of Use: Maintenance therapy in CIDP has been systematically studied for 6 months and for a further 12 months in a follow-up study. Continued maintenance beyond these periods should be individualized based on patient response and need for continued therapy.

For subcutaneous infusion only.

-------------------------------DOSAGE FORMS AND STRENGTHS---------------------------0.2 g per mL (20%) protein solution for subcutaneous injection

-------------------------------------CONTRAINDICATIONS-------------------------------------• Anaphylactic or severe systemic reaction to human immune globulin or components of HIZENTRA, such as polysorbate 80 • Hyperprolinemia (type I or II) (HIZENTRA contains the stabilizer L-proline) • IgA-deficient patients with antibodies against IgA and a history of hypersensitivity -------------------------------WARNINGS AND PRECAUTIONS-------------------------------• IgA-deficient patients with anti-IgA antibodies are at greater risk of severe hypersensitivity and anaphylactic reactions.

• Thrombosis may occur following treatment with immune globulin products, including HIZENTRA. • Aseptic meningitis syndrome has been reported with IGIV or IGSC, including HIZENTRA treatment.

• Monitor renal function, including blood urea nitrogen, serum creatinine, and urine output in patients at risk of acute renal failure.

• Monitor for clinical signs and symptoms of hemolysis.

• Monitor for pulmonary adverse reactions (transfusion-related acute lung injury [TRALI]) • HIZENTRA is made from human plasma and may contain infectious agents, e.g., viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent and, theoretically, the CreutzfeldtJakob disease (CJD) agent.

-------------------------------------ADVERSE REACTIONS--------------------------------------The most common adverse reactions observed in ≥5% of study subjects were local infusion site reactions, headache, diarrhea, fatigue, back pain, nausea, pain in extremity, cough, upper respiratory tract infection, rash, pruritus, vomiting, abdominal pain (upper), migraine, arthralgia, pain, fall and nasopharyngitis.

To report SUSPECTED ADVERSE REACTIONS, contact CSL Behring Pharmacovigilance at 1-866-915-6958 or FDA at 1-800-FDA-1088 or www.fda. gov/medwatch.

----------------------------------------DRUG INTERACTIONS-----------------------------------The passive transfer of antibodies may interfere with the response to live virus vaccines, and lead to misinterpretation of the results of serological testing.

Based on March 2018 revision

2019 Practice Management Webinar Changes Enable Greater Topic Depth The AAN’s popular Practice Management Webinar series has undergone significant changes for 2019. The number of webinars was reduced from past years, but each new webinar is designed to allow for a deeper dive into the subject matter and invite more questions from participants.

Each webinar begins with a live, 30-minute session with all course faculty who will introduce the topic and enable registrants to ask questions. Several shorter recorded lectures are posted on learning.aan.com the week following the overview that explore the topic in greater depth, and participants can access these at their convenience. Finally, each topic concludes with a 30-minute live webchat, so participants can ask further questions. Both live components take place at 12:00 p.m. ET and can be accessed at learning.aan.com.

January 15 (recordings available)

August 13

Boss, MD: Managing a Better Practice

Increasing Revenue in Your Practice: Care Models, Ancillary Services, and Other Strategies

J. Todd Barnes, MBA, CMPE; Seth Lefberg

March 12 (recordings available)

David Evans, MBA

Understanding How You Get Paid

October 1

Bruce H. Cohen, MD, FAAN Raissa Villanueva, MD, MPH, FAAN Jeffrey Waugh, MD, PhD Korwyn Williams, MD, PhD

Using Technology for Better Practice Management of Stroke Mark J. Alberts, MD, FAHA Elaine C. Jones, MD, FAAN Lawrence R. Wechsler, MD, FAAN

May 21

November 19

Everything You Wanted to Know About Your Patients but Were Afraid to Ask: Having Difficult Conversations with Patients from Vulnerable Populations

Seeing the Future Clearly: How to Succeed in 2020

Farrah N. Daly, MD, MPH Christopher T. Doughty, MD Justin P. Martello, MD Allan D. Wu, MD, PhD

Joel M. Kaufman, MD, FAAN AAN members can purchase a single webinar series for $99 or purchase a 2019 Practice Management Webinar subscription for only $189—that’s less than $32 per webinar! Webinars are accessible through the AAN Online Learning Center and feature: Convenient live sessions starting at 12:00 p.m. ET On-demand access to recording and presentation slides

if you miss the live event

Convenient on-demand access to shorter, in-depth chapters 2 AMA PRA Category 1 Credits™ per webinar for physicians,

or certificate of completion for non-physicians

Visit AAN.com/view/pmw19 to learn more and register or contact Jessica Nickrand at jnickrand@aan.com. 

18

Sunday, May 5, 2019 • AANextra

EISAI NEUROLOGY: Committed to Solutions That Transform Societies Eisai is making advances in: Alzheimerâ&#x20AC;&#x2122;s disease

Sleep/wake disorders

LEARN MORE AT

Epilepsy

BOOTH 909 CORP-US2259 April 2019

Complete Survey, Benefit from Compensation and Productivity Data The AAN encourages members to participate in the 2019 Neurology Compensation and Productivity Survey, the largest survey devoted to the neurology specialty. It provides vital information for neurologists, advanced practice providers (APPs), and business administrators to have the tools to negotiate on their own behalf and compare practice benchmarks against peers and other practices.

The collected data is secure and de-identified for anonymity. AAN members who respond by May 25 will receive free access to the data via a customizable dashboard, a $600 value.

The revamped survey includes new questions on in-demand topics, including on-call compensation and productivity, telemedicine benchmarks, and practice information such as ancillary services, patient wait times, and compensation methods.

“The AAN’s Neurology Compensation and Productivity Report is an essential tool for our practice,” said David A. Evans, MBA, chief operating officer of Texas Neurology in Dallas and chair of the AAN’s Practice Management & Technology Subcommittee. “By having comparative data, we have been able to identify variances in several areas to include compensation, call pay, benefits, and RVUs. I also use it to analyze the ratios between metrics, such as compensation-to-RVUs and call pay-to-number of hospital beds. When I filter using varying criteria on the report’s online dashboard, I am always finding actionable data points.”

Neurologists can learn: How other practices perform in cost measures and

benchmarking

How to benchmark compensation and RVUs to others in their

subspecialty

The average payer mixes for neurologic practices The average size of other practices and their employee mix

Advanced practice providers can:

and productivity data for APPs, and deliver the data in a new, interactive and user-friendly online dashboard. Respondents will be able to filter the data to benchmark themselves against others within the same subspecialty, geographic region, practice setting, and practice size.

We heard your feedback and have made several changes to the survey this year, making it easier to complete and provide more meaningful data. Improvements include: Compensation and productivity benchmarking for

advanced practice providers specializing in neurology. As important members of the care team, AAN member nurse practitioners, physician assistants, and other advanced practice providers will be included in the survey collection so you can benchmark your compensation and productivity.

Conditional questioning: If a set of questions doesn’t pertain

to you, you can skip past them, making the survey less time consuming to complete.

New, user-friendly dashboard allowing filtering of the data

by subspecialty, geographic region, gender, and more.

Discover key productivity and compensation metrics for APPs

working in neurology

Compare their productivity with other APPs Benchmark the compensation for their work Explore neurology APP salaries using subspecialty data

Business administrators can: Find out how other practices perform in cost measures and

benchmarking

Learn the average size of other practices and their use of

APPs in their employee mix

Discover the payer mix for neurologic practices Benchmark their salary against other practice managers

working in neurologic practice settings

Use a downloadable and savable spreadsheet to import data

on behalf of the neurologists in their practice

More than 1,300 AAN members took the most recent survey in 2017. Based on feedback from previous respondents and several work groups, the new survey has been overhauled to make it faster and easier to complete, obtain compensation

20

Sunday, May 5, 2019 • AANextra

Did You Know Neurologists’ Compensation Went up by Three Percent from 2015 to 2016?

Help us see if this changed in 2018 by completing the Neurology Compensation and Productivity survey.

The following information will be needed when you start the survey: Physician salary spreadsheets, W2s, and/or K1s Physician RVU reports

Visit with Us to Learn More You can learn more and have your questions answered about the Neurology Compensation and Productivity Survey at the Maximizing Your Value Experiential Learning Area, or attend the following sessions:

Financial and accounting report(s) Payer mix analysis Staff and physician benefits reports EHR and billing system reports (charges and collections) Department, school (for academic centers), and

practice reports

The survey takes about 30–60 minutes to complete once you’ve compiled your documentation. The deadline to complete the survey is May 25, 2019.

What Can the AAN’s Compensation and Productivity Survey Do for You? Tuesday, May 7, 2:30 p.m.–3:00 p.m.

in the Innovation Hub Experiential Learning Area

What Is the Neurology Compensation and Productivity Survey, and How Can it Increase My Value?

Tuesday, May 7, 5:00 p.m.–5:45 p.m. in the Maximizing Your Value Experiential Learning Area For more information, visit AAN.com/view/BenchmarkReport.

If you have questions, email benchmark@aan.com. 

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INDUSTRY THERAPEUTIC UPDATE FROM BIOGEN:

COGNITIVE AND ETHNO-CULTURAL DIVERSITY IN MS

Join us for this interactive dinner meeting on the advancement of MS care. We will discuss diversity in MS populations and how to optimize cognitive monitoring.

19:00

Arrival and dinner

19:30

Introduction Prof. Carlo Tornatore, Washington DC

19:40

MS in minority populations: adapting to diversity Assoc. Prof. Lilyana Amezcua, Los Angeles Asst. Prof. Mitzi Williams, Atlanta

20:20

Q&A

20:25

Recommendations for cognitive screening: reality or utopia?

Prof. Ralph Benedict, Buffalo Prof. Carlo Tornatore, Washington DC

20:55

Q&A and closing remarks Prof. Carlo Tornatore, Washington DC

This is a non-CME event and is not part of the AAN Official Program

Biogen-08838 - March 2019

Monday 6 May 2019, 19:00-21:00 Millennium Hall, Loews Philadelphia Hotel, Philadelphia, USA

Momentum of 2018 Advocacy Successes Carries into 2019 The AAN chalked up an impressive number of victories in 2018, thanks to the untiring advocacy of thousands of members who engaged in activities ranging from emailing their views to lawmakers to visiting them in Washington, DC, or hosting them in their practices.

A recent example of this occurred last February, when 214 members from 48 states and 199 unique House districts joined together in Washington for Neurology on the Hill. These impassioned advocates shared with senators, representatives, and their staffs the AAN’s positions on preserving access to neurologists, addressing the rising costs of medications and step therapy exceptions, along with increased funding for vital neurology research.

This face-to-face activity also takes place through Neurology off the Hill, as members invite their legislators to visit them in their clinics and practices and hear firsthand about the challenges faced by neurologists and their patients. This program continues to grow; 70 AAN advocates participated in such local advocacy events last year.

Legislatively, the AAN has been active by supporting several drug pricing bills including the Empowering Medicare Seniors to Negotiate Drug Prices Act, which would allow Medicare to negotiate drug prices. The Academy also continues to advocate for increased neurology-related research funding for the NIH and the BRAIN Initiative and supports the reauthorization of the Patient-Centered Outcomes Research Institute (PCORI).

On the regulatory front, in March the AAN met with regulators from the Centers for Medicare & Medicaid Services (CMS) to raise concerns and offer feedback related to CMS’s recent proposal to collapse the evaluation and management (E/M) codes. In the meeting, the AAN emphasized the disproportionate impact that changes to the E/M codes have on neurologists and offered specific recommendations related to improving the E/M codes. The AAN urged CMS to update and recalibrate the medical decision-making table that is used to determine E/M service levels and requested that CMS evaluate more reliable methods for distinguishing complex services.

AAN physician experts and staff met in January with leadership at CMS to discuss a new code set for long-term EEG monitoring.

Representatives from the National Association of Epilepsy Centers also participated. The goals of the meeting were to ensure CMS understands the indications for long-term EEG monitoring and appropriate coding of the services and to influence the CMS reimbursement levels for EEG in the upcoming proposed 2020 Medicare Physician Fee Schedule that will be published in July.

Also in January, the AAN worked to safeguard the interests of neurologists regarding two significant administration regulatory proposals. The first comments were in response to a proposed rule from CMS that would significantly reform the Medicare drug benefit through changes to Medicare Advantage and Medicare Part D. The Academy also submitted comments to the Office of

the National Coordinator’s “Draft Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.” These activities build upon a very successful 2018, as the AAN won: Delay and modification of the implementation of E/M coding changes until 2021 that collapse code levels 2-4 and maintain level 5, rather than collapsing levels 2-5. Preliminary analysis of the changes to the final rule indicates that the AAN’s advocacy saved neurologists approximately $43 million annually in Medicare payment for E/M services starting in 2021. $3 billion increase in FY2018 and $2 billion increase in FY2019 for NIH funding—the biggest increase in NIH funding in 15 years!

Significant increases in funding for the BRAIN Initiative, Alzheimer’s research, and non-opioid pain research.

Passage of comprehensive opioids legislation that includes flexibility for the NIH to conduct pain research, standardization of electronic prior authorization in Medicare, and the expansion of Open Payments to advanced practice providers.

Passage and implementation of legislation that expands Medicare patient access to telestroke consultations, regardless of the originating site of care.

Passage of the Building Our Largest Dementia (BOLD) Infrastructure for Alzheimer’s Act (S. 2076/H.R. 4256) which establishes Alzheimer’s Centers of Excellence around the country to expand and promote innovative and effective Alzheimer’s interventions; provides funding to state, local, and tribal public health departments to implement those interventions and promote early detection and diagnosis, reducing risk, and preventing avoidable hospitalizations; and increases the collection, analysis, and timely reporting of data on cognitive decline and caregiving to inform future public health actions.

Passage of the Traumatic Brain Injury Program Reauthorization Act of 2018, which reauthorizes the CDC’s Traumatic Brain Injury initiatives and establishes a national concussion surveillance system.

Changes by CMS to the Local Coverage Determination process to increase transparency and patient engagement to ensure that Medicare beneficiaries have access to the latest therapies and devices.

The Academy thanks its member advocates and collaborators from other organizations who helped fight for so many positive changes for neurology over the past year and continue our advocacy in 2019! Stay current on our advocacy efforts by reading Capitol Hill Report, emailed to US members twice monthly and is posted at AAN.com/view/HillReport. You also can follow the advocacy conversations at #AANadvocacy. 

Sunday, May 5, 2019 • AANextra

23

Registry Grew in Participation, Value in 2018 The Axon Registry ® was created by the AAN in 2014 as a tool for neurologists to track the quality of care in their practice. Since 2017, US neurologists have been able to use this free tool to see real-time data for measures relevant to their practice. The registry experienced many successes in 2018 as it continued to grow.

Lyell K. Jones, Jr., MD, FAAN, chair of the Registry Committee, said, “In 2018, Axon focused on including measures for subspecialists, validating the data within the database, and registry can be used for up to establishing itself as a leader eight credits of Part II SelfJones in promoting Patient Reported assessment. Providers that Outcomes. With the movement have fully integrated with Axon to value-based systems of care, can reap the benefits of participation for Axon is positioned to be an invaluable tool those certification purposes. for neurologists to achieve success.”

With the registry maturing and amassing To make the Axon Registry relevant more than 4.5 million patent visits and for the many subspecialties within over 1.3 million unique patients, the neurology, the number of measures in Registry Committee is preparing to use the registry expanded in 2018. There are the data to identify gaps in care to assist in 11 subspecialties included in the registry improving the quality of care in neurology. and multiple measures that are crossA large data validation plan was executed cutting. The various disease states include in 2017 and follow-up on the results epilepsy, Parkinson’s disease, dementia, was completed in 2018. The registry distal symmetric polyneuropathy, data covers a wide breadth of neurology headaches, multiple sclerosis, sleep, child practices, from solo practitioners to neurology, amyotrophic lateral sclerosis, large academic centers and using more essential tremor, and ophthalmology. than 33 electronic medical record (EMR) There are multiple process measures, systems. Also, in 2018 the AAN outcome measures, high-priority registry vendor, FIGmd, Inc., signed measures, and newly integrated Patient a contract with EPIC to be a thirdReported Outcomes. party vendor. In pilot testing, this The American Board of Psychiatry and will create an easier data transfer Neurology (ABPN) has approved the Axon method for practices using EPIC as Registry as a continuing certification Part their EMR. IV PIP clinical module activity, and the

Visit us at our booth in the Broad Street Atrium.

Dementia: Caregiver Education and Support Falls: Querying About Falls for Patients Headache: Medication Prescribed for Acute Migraine Attack

REPORT 4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

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

24

Sunday, May 5, 2019 • AANextra

Total

+

-

%

Q4

400

300

100

75%

Q3

400

250

150

62%

Q2

400

200

200

50%

Q1

400

100

300

25%

The Axon Registry has applied, and was approved, to be a qualified clinical data registry for the fourth year in a row. The Axon Registry can be used by participants to meet up to three reporting requirements for the MIPS track of the Quality Payment Program. Once providers receive a dashboard and complete the measure mapping, they can use the Axon Registry for MIPS reporting to the Centers for Medicare & Medicaid Services for Quality, Advancing Care Information, and Improvement Activity categories.

Visit AAN.com/view/Axon to learn more about the registry and contact registry@aan.com with any questions. 

WHEN PHYSICIANS AND RESEARCHERS PARTNER

DISCOVERIES ARE NEVER FAR APART

Research Institute

Patient Care

Transforming Neurological Care

The Best of Philly from Those Who Know It Best As America’s birthplace, Philadelphia is the nation’s first World Heritage City, not to mention the home of the first medical school and first neurology program. Where else can you walk from the sites where political luminaries debated standing up to a king to the home of one of the largest collections of Rodin sculptures outside of Paris before making your way to grab an authentic hoagie?

Visit the Philadelphia visitors booths (Broad Street Atrium, spiral staircase on the 200 Level Bridge, or 12th and Arch Street-West Concourse) for more local information, including brochures and help making restaurant reservations.

Need some ideas? Here you go!

What a great place to hold our Annual Meeting! Philadelphia has a great mix of history, arts, culture, and food. Don’t miss the Philadelphia Museum of Art in a classic building with amazing art and of course some famous steps from the movie “Rocky.” My first-grade school trip was to this museum and it left an incredible impression.

The Barnes Foundation Museum is another incredibly impressive gallery that is a must see.

Growing up about an hour from Philadelphia, I fondly recall having a Philly-style soft pretzel often in grade school before they became fashionable in most airports. Make sure you try one!

—Ralph L. Sacco, MD, MS, FAHA, FAAN AAN President

What are your Philly recommendations?

Join the conversation at #AANAM

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Sunday, May 5, 2019 • AANextra

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11 POSITIVE

CLINICAL TRIALS FOR THE TREATMENT OF PARTIAL-ONSET SEIZURES2,3

guaranteed, for a minimum of 12 months* www.OxtellarXRhcp.com

INDICATION Oxtellar XR® is indicated for the treatment of partial-onset seizures in patients 6 years of age and older.

CONTRAINDICATIONS Oxtellar XR is contraindicated in patients with a known hypersensitivity to oxcarbazepine, or to any of the components of Oxtellar XR, or to eslicarbazepine acetate. Reactions have included anaphylaxis and angioedema. *Terms and conditions apply.

Not actual patient. Fictionalized for illustrative purposes.

References: 1. Oxtellar XR [package insert]. Rockville, MD: Supernus Pharmaceuticals, Inc.; December 2018. 2. Glauser TA. Oxcarbazepine in the treatment of epilepsy. Pharmacotherapy. 2001;21(8):904-919. 3. French JA, Baroldi P, Brittain ST, Johnson JK; for PROSPER Investigators Study Group. Efficacy and safety of extended-release oxcarbazepine (Oxtellar XR™) as adjunctive therapy in patients with refractory partial-onset seizures: a randomized controlled trial. Acta Neurol Scand. 2014;129:143-153.

Please refer to the brief summary of full Prescribing Information on adjacent pages, or visit www.OxtellarXR.com.

Oxtellar XR is a registered trademark of Supernus Pharmaceuticals, Inc. ©2019 Supernus Pharmaceuticals, Inc. All rights reserved. SPN.OXT.2019-0023

Powerfully evident choice

OXTELLAR XR® (oxcarbazepine) extended-release tablets, for oral use Brief Summary of Prescribing Information For full prescribing information, see Package Insert.

CONTRAINDICATIONS Oxtellar XR is contraindicated in patients with a known hypersensitivity to oxcarbazepine, to any of the components of Oxtellar XR, or to eslicarbazepine acetate. Reactions have included anaphylaxis and angioedema.

WARNINGS AND PRECAUTIONS Hyponatremia Clinically significant hyponatremia (sodium <125 mmol/L) may develop during Oxtellar XR® use. Serum sodium levels less than 125 mmol/L have occurred in immediate-release oxcarbazepine-treated patients generally in the first three months of treatment. However, clinically significant hyponatremia may develop more than a year after initiating therapy.

Most immediate-release oxcarbazepine-treated patients who developed hyponatremia were asymptomatic in clinical trials. However, some of these patients had their dosage reduced, discontinued, or had their fluid intake restricted for hyponatremia. Serum sodium levels returned toward normal when the dosage was reduced or discontinued, or when the patient was treated conservatively (e.g., fluid restriction).

Cases of symptomatic hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (SIADH) have been reported during post-marketing use of immediate-release oxcarbazepine.

Among treated patients in a controlled trial of adjunctive therapy with Oxtellar XR® in 366 adults with complex partial seizures, 1 patient receiving 2400 mg experienced a severe reduction in serum sodium (117 mEq/L), requiring discontinuation from treatment, while 2 other patients receiving 1200 mg experienced serum sodium concentrations low enough (125 and 126 mEq/L) to require discontinuation from treatment. The overall incidence of clinically significant hyponatremia in patients treated with Oxtellar XR® was 1.2%, although slight shifts in serum sodium concentrations from Normal to Low (<135 mEq/L) were observed for the 2400 mg (6.5%) and 1200 mg (9.8%) groups compared to placebo (1.7%).

Measure serum sodium concentrations if patients develop symptoms of hyponatremia (e.g., nausea, malaise, headache, lethargy, confusion, obtunded consciousness, or increase in seizure frequency or severity). Consider measurement of serum sodium concentrations during treatment with Oxtellar XR®, particularly if the patient receives concomitant medications known to decrease serum sodium levels (for example, drugs associated with inappropriate ADH secretion).

Anaphylactic Reactions and Angioedema Rare cases of anaphylaxis and angioedema involving the larynx, glottis, lips, and eyelids have been reported in patients after taking the first or subsequent doses of immediate-release oxcarbazepine. Angioedema associated with laryngeal edema can be fatal. If a patient develops any of these reactions after treatment with Oxtellar XR®, discontinue the drug and initiate an alternative treatment. Do not rechallenge these patients with Oxtellar XR®.

Cross Hypersensitivity Reaction to Carbamazepine Approximately 25% to 30% of patients who have had hypersensitivity reactions to carbamazepine will experience hypersensitivity reactions with Oxtellar XR®. For this reason, patients should be specifically questioned about any prior experience with carbamazepine, and patients with a history of hypersensitivity reactions to carbamazepine should ordinarily be treated with Oxtellar XR® only if the potential benefit justifies the potential risk. Discontinue Oxtellar XR® immediately if signs or symptoms of hypersensitivity develop.

Serious Dermatological Reactions Serious dermatological reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have occurred in both children and adults treated with immediate-release oxcarbazepine use.

The median time of onset for reported cases was 19 days. Such serious skin reactions may be life threatening, and some patients have required hospitalization with very rare reports of fatal outcome. Recurrence of the serious skin reactions following rechallenge with immediate-release oxcarbazepine has also been reported.

The reporting rate of TEN and SJS associated with immediaterelease oxcarbazepine use, which is generally accepted to be an underestimate due to underreporting, exceeds the background incidence rate estimates by a factor of 3- to 10-fold. Estimates of the background incidence rate for these serious skin reactions in the general population range between 0.5 to 6 cases per million-person years. Therefore, if a patient develops a skin reaction while taking Oxtellar XR®, consider discontinuing Oxtellar XR® use and prescribing another AED. Association with HLA-B*1502 Patients carrying the HLA-B*1502 allele may be at increased risk for SJS/TEN with Oxtellar XR® treatment.

Human Leukocyte Antigen (HLA) allele B*1502 increases the risk for developing SJS/TEN in patients treated with carbamazepine. The chemical structures of immediate-release oxcarbazepine and Oxtellar XR® are similar to that of carbamazepine. Available clinical evidence, and data from nonclinical studies showing a direct interaction between immediate-release oxcarbazepine and HLA-B*1502 protein, suggest that the HLA-B*1502 allele may also increase the risk for SJS/TEN with Oxtellar XR®.

The frequency of HLA-B*1502 allele ranges from 2 to 12% in Han Chinese populations, is about 8% in Thai populations, and above 15% in the Philippines and in some Malaysian populations. Allele frequencies up to about 2% and 6% have been reported in Korea and India, respectively.

The frequency of the HLA-B*1502 allele is negligible in people from European descent, several African populations, indigenous peoples of the Americas, Hispanic populations, and in Japanese (<1%).

Testing for the presence of the HLA-B*1502 allele should be considered in patients with ancestry in genetically at-risk populations, prior to initiating treatment with Oxtellar XR®. The use of Oxtellar XR® should be avoided in patients positive for HLA-B*1502 unless the benefits clearly outweigh the risks. Consideration should also be given to avoid the use of other drugs associated with SJS/TEN in HLA-B*1502 positive patients, when alternative therapies are otherwise equally acceptable. Screening is not generally recommended in patients from populations in which the prevalence of HLA-B*1502 is low, or in current Oxtellar XR® users, as the risk of SJS/TEN is largely confined to the first few months of therapy, regardless of HLA-B*1502 status.

The use of HLA-B*1502 genotyping has important limitations and must never substitute for appropriate clinical vigilance and patient management. The role of other possible factors in the development of, and morbidity from, SJS/TEN, such as antiepileptic drug (AED) dosage, compliance, concomitant medications, comorbidities, and the level of

dermatologic monitoring have not been well characterized.

Suicidal Behavior and Ideation Antiepileptic drugs (AEDs), including Oxtellar XR®, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Monitor patients treated with any AED for any indication for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.

Pooled analyses of 199 placebo-controlled clinical trials (mono- and adjunctive therapy) of 11 different AEDs showed that patients randomized to one of the AEDs had approximately twice the risk (adjusted Relative Risk 1.8, 95% CI:1.2, 2.7) of suicidal thinking or behavior compared to patients randomized to placebo. In these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behavior or ideation among 27,863 AED-treated patients was 0.43%, compared to 0.24% among 16,029 placebo-treated patients, representing an increase of approximately one case of suicidal thinking or behavior for every 530 patients treated. There were four suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide.

The increased risk of suicidal thoughts or behavior with AEDs was observed as early as one week after starting drug treatment with AEDs and persisted for the duration of treatment assessed. Because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behavior beyond 24 weeks could not be assessed.

The risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. The finding of increased risk with AEDs of varying mechanisms of action and across a range of indications suggests that the risk applies to all AEDs used for any indication. The risk did not vary substantially by age (5-100 years) in the clinical trials analyzed.

Risk by Indication for Antiepileptic Drugs in the Pooled Analysis Epilepsy: Placebo Patients with Events per 1000 Patients 1.0. Drug Patients with Events per 1000 patients 3.4. Relative Risk: Incidence of Events in Drug Patients/Incidence in Placebo Patients 3.5. Risk Difference: Additional Drug Patients with Events per 1000 Patients 2.4.

Psychiatric: Placebo Patients with Events per 1000 Patients 5.7. Drug Patients with Events per 1000 patients 8.5. Relative Risk: Incidence of Events in Drug Patients/Incidence in Placebo Patients 1.5. Risk Difference: Additional Drug Patients with Events per 1000 Patients 2.9.

Other: Placebo Patients with Events per 1000 Patients 1.0. Drug Patients with Events per 1000 patients 1.8. Relative Risk: Incidence of Events in Drug Patients/Incidence in Placebo Patients 1.9. Risk Difference: Additional Drug Patients with Events per 1000 Patients 0.9. Total: Placebo Patients with Events per 1000 Patients 2.4. Drug Patients with Events per 1000 patients 4.3. Relative Risk: Incidence of Events in Drug Patients/Incidence in Placebo Patients 1.8. Risk Difference: Additional Drug Patients with Events per 1000 Patients 1.9.

The relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications.

Anyone considering prescribing Oxtellar XR® or any other AED must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge during Oxtellar XR® treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated.

Withdrawal of AEDs As with most AEDs, Oxtellar XR® should be withdrawn gradually because of the risk of increased seizure frequency and status epilepticus. But if withdrawal is needed because of a serious adverse event, rapid discontinuation can be considered.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)/ Multi-Organ Hypersensitivity Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known as multi-organ hypersensitivity, has occurred with immediate-release oxcarbazepine. Some of these events have been fatal or life-threatening. DRESS typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling, in association with other organ system involvement, such as hepatitis, nephritis, hematologic abnormalities, myocaraditis, or myositis sometimes resembling an acute viral infection. Eosinophilia is often present. This disorder is variable in its expression, and other organ systems not noted here may be involved. It is important to note that early manifestations of hypersensitivity (e.g., fever, lymphadenopathy) may be present even though rash is not evident. Oxtellar XR® should be discontinued if an alternative etiology for the signs and symptoms cannot be established.

Hematologic Reactions Rare reports of pancytopenia, agranulocytosis, and leukopenia have been seen in patients treated with immediate-release oxcarbazepine during post-marketing experience. Discontinuation of Oxtellar XR® should be considered if any evidence of these hematologic reactions develops.

Risk of Seizures in the Pregnant Patient Due to physiological changes during pregnancy, plasma concentrations of the active metabolite of oxcarbazepine, the 10-monohydroxy derivative (MHD), may gradually decrease throughout pregnancy. Monitor patients carefully during pregnancy and through the postpartum period because MHD concentrations may increase after delivery.

Risk of Seizure Aggravation Exacerbation of or new onset primary generalized seizures has been reported with immediate-release oxcarbazepine. The risk of aggravation of primary generalized seizures is seen especially in children but may also occur in adults. In case of seizure aggravation, Oxtellar XR® should be discontinued.

ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

The safety data presented below are from 384 patients with partial-onset seizures who received Oxtellar XR® (366 adults and 18 pediatric patients) with concomitant AEDs. In addition, safety data presented below are from a total of 2288 patients with seizure disorders treated with immediate-release oxcarbazepine; 1832 were adults and 456 were pediatric patients.

Most Common Adverse Reactions Reported by Adult Patients Receiving Concomitant AEDs in Oxtellar XR® Clinical Studies Table 3 lists adverse reactions that occurred in at least 2% of adult patients with epilepsy treated with Oxtellar XR® or placebo and concomitant AEDs and that were numerically more common in the patients treated with any dosage of Oxtellar XR® than in patients receiving placebo.

The overall incidence of adverse reactions appeared to be dose related, particularly during the titration period. The most commonly observed (≥5%) adverse reactions seen in association with Oxtellar XR® and more frequent than in placebo-treated patients were: dizziness, somnolence, headache, balance disorder, tremor, vomiting, diplopia, and asthenia.

Table 3: Adverse Reaction Incidence in a Controlled Clinical Study of Oxtellar XR® with Concomitant AEDs in Adults* Oxtellar XR® 2400 mg/day (N=123); Oxtellar XR® 1200 mg/day (N=122).

Placebo (N=121). Any System/Any Term: 69%, 57%, 55%. Nervous System Disorders: Dizziness: 41%, 20%, 15%; Somnolence: 14%, 12% 9%; Headache: 15% 8%, 7%; Balance Disorder: 7%, 5% 5%; Tremor: 1%, 5%, 2%; Nystagmus: 3%, 3%, 1%; Ataxia 1%, 3%, 1%. Gastrointestinal Disorders: Vomiting: 15% 6%, 9%; Abdominal Pain Upper: 0%, 3% 1%; Dyspepsia: 0% 3% 1%; Gastritis: 0%, 3% 2%. Eye Disorders: Diplopia: 13%, 10% 4%; Vision Blurred: 1%, 4%, 3%; Visual Impairment: 1%, 3%, 0%.

General Disorders and Administration Site Conditions: Asthenia: 7% 3%, 1%; Fatigue: 3%, 6%, 1%; Gait Disturbance: 0%, 3%, 1%; Drug Intolerance: 2%, 0%, 0%. Infections and Infestations: Nasopharyngitis: 0% 3%, 0%; Sinusitis: 0%, 3%, 2%. *Reported by ≥2% of patients treated with Oxtellar XR® and numerically more frequent than in the placebo group.

Adverse Reactions Associated with Discontinuation of Oxtellar XR® Treatment: Approximately 23.3% of the 366 adult patients receiving Oxtellar XR® in clinical studies discontinued treatment because of an adverse reaction. The adverse reactions most commonly associated with discontinuation of Oxtellar XR® (reported by ≥2%) were: dizziness (9.8%), vomiting (5.3%), nausea (3.7%), diplopia (3.2%), and somnolence (2.4%).

Adjunctive Therapy with Oxtellar XR® in Pediatric Patients 6 to Less Than 17 Years of Age Previously Treated with Other AEDs In a pharmacokinetic study in 18 pediatric patients (including patients 6 to less than 17 years of age) with partial-onset seizures treated with different dosages of Oxtellar XR®, the observed adverse reactions seen in association with Oxtellar XR® were similar to those seen in adults.

Most Common Adverse Reactions in Immediate-Release Oxcarbazepine Controlled Clinical Studies Controlled Clinical Studies of Adjunctive Therapy with Immediate-Release Oxcarbazepine in Adults Previously Treated with Other AEDs: Table 4 lists adverse reactions that occurred in at least 2% of adult patients with epilepsy treated with immediate-release oxcarbazepine or placebo with concomitant AEDs and that were numerically more common in the patients treated with any dosage of immediate-release oxcarbazepine than in placebo. As immediate-release oxcarbazepine and Oxtellar XR® were not examined in the same trial, adverse event frequencies cannot be directly compared between the two formulations.

Table 4: Adverse Reaction Incidence in a Controlled Clinical Study of Immediate Release Oxcarbazepine with Concomitant AEDs in Adults* Immediate-Release Oxcarbazepine Dosage (mg/day): OXC 600 (N=163); OXC1200 (N=171); OXC2400 (N=126); Placebo (N=166). Body as a Whole: Fatigue: 15%, 12%, 15%, 7%; Asthenia: 6% 3%, 6%, 5%; Edema Legs: 2%, 1%, 2%, 1%; Weight Increase: 1%, 2%, 2%, 1%; Feeling Abnormal: 0%, 1%, 2%, 0%. Cardiovascular System: Hypotension: 0%, 1%, 2%, 0%.

Digestive System: Nausea: 15%, 25%, 29% 10%; Vomiting: 13%, 25%, 36%, 5%; Pain Abdominal: 10%, 13%, 11%, 5%; Diarrhea: 5%, 6%, 7%, 6%; Dyspepsia: 5%, 5%, 6%, 2%; Constipation: 2%, 2%, 6%, 4%; Gastritis: 2%, 1%,2%,1%. Metabolic and Nutritional Disorders: Hyponatremia: 3%, 1%, 2%,1%. Musculoskeletal System: Muscle Weakness: 1%, 2%, 2%, 0%; Sprains and Strains: 0%, 2%, 2%, 1%. Nervous System: Headache: 32%, 28% 26%, 23%; Dizziness: 36%, 32%, 49%, 13%; Somnolence: 20%, 28%, 36%, 12%; Ataxia: 9%, 17%, 31%, 5%; Nystagmus: 7% 20%, 26% 5%; Gait Abnormal: 5%, 10%, 17%, 1%; Insomnia: 4%, 2%, 3%, 1%; Tremor: 3% 8%, 16%, 5%; Nervousness: 2%, 4%, 2%, 1%; Agitation: 1%,1%, 2%, 1%; Coordination Abnormal: 1%, 3%, 2%, 1%; EEG Abnormal: 0%, 0%, 2%, 0%; Speech Disorder: 1%, 1%, 3%, 0%; Confusion: 1%, 1%, 2%, 1%; Cranial Injury NOS: 1%, 0%, 2% 1%; Dysmetria: 1%, 2%, 3%, 0%; Thinking Abnormal: 0%, 2%, 4%, 0%. Respiratory System: Rhinitis: 2%, 4%, 5%, 4%; Skin and Appendages: Acne: 1%, 2%, 2%, 0%; Special Senses: Diplopia: 14%, 30%, 40%, 5%; Vertigo: 6%, 12%, 15%, 2%; Vision Abnormal: 6%, 14%, 13%, 4%; Accommodation Abnormal: 0%, 0%, 2%, 0%. *Events in at least 2% of patients treated with 2400 mg/day of immediate-release oxcarbazepine and numerically more frequent than in the placebo group.

Other Reactions Observed in Association with the Administration of Immediate-Release Oxcarbazepine In the paragraphs that follow, the adverse reactions, other than those in the preceding tables or text, that occurred in a total of 565 children and 1574 adults exposed to immediate-release oxcarbazepine and that are reasonably likely to be related to drug use are presented. Events common in the population, events reflecting chronic illness and events likely to reflect concomitant illness are omitted particularly if minor.

They are listed in order of decreasing frequency. Because the reports cite reactions observed in open-label and uncontrolled trials, the role of immediate-release oxcarbazepine in their causation cannot be reliably determined.

Body as a Whole: fever, malaise, pain chest precordial, rigors, weight decrease.

Cardiovascular System: bradycardia, cardiac failure, cerebral hemorrhage, hypertension, hypotension postural, palpitation, syncope, tachycardia.

Digestive System: appetite increased, blood in stool, cholelithiasis, colitis, duodenal ulcer, dysphagia, enteritis, eructation, esophagitis, flatulence, gastric ulcer, gingival bleeding, gum hyperplasia, hematemesis, hemorrhage rectum, hemorrhoids, hiccup, mouth dry, pain biliary, pain right hypochondrium, retching, sialoadenitis, stomatitis, stomatitis ulcerative.

Hematologic and Lymphatic System: thrombocytopenia.

Laboratory Abnormality: gamma-GT increased, hyperglycemia, hypocalcemia, hypoglycemia, hypokalemia, liver enzymes elevated, serum transaminase increased.

Musculoskeletal System: hypertonia muscle.

Nervous System: aggressive reaction, amnesia, anguish, anxiety, apathy, aphasia, aura, convulsions aggravated, delirium, delusion, depressed level of consciousness, dysphonia, dystonia, emotional lability, euphoria,

extrapyramidal disorder, feeling drunk, hemiplegia, hyperkinesia, hyperreflexia, hypoesthesia, hypokinesia, hyporeflexia, hypotonia, hysteria, libido decreased, libido increased, manic reaction, migraine, muscle contractions involuntary, nervousness, neuralgia, oculogyric crisis, panic disorder, paralysis, paroniria, personality disorder, psychosis, ptosis, stupor, tetany.

Respiratory System: asthma, bronchitis, coughing, dyspnea, epistaxis, laryngismus, pleurisy.

Skin and Appendages: acne, alopecia, angioedema, bruising, dermatitis contact, eczema, facial rash, flushing, folliculitis, heat rash, hot flushes, photosensitivity reaction, pruritus genital, psoriasis, purpura, rash erythematous, rash maculopapular, vitiligo, urticaria.

Special Senses: accommodation abnormal, cataract, conjunctival hemorrhage, edema eye, hemianopia, mydriasis, otitis externa, photophobia, scotoma, taste perversion, tinnitus, xerophthalmia.

Urogenital and Reproductive System: dysuria, hematuria, intermenstrual bleeding, leukorrhea, menorrhagia, micturition frequency, pain renal, pain urinary tract, polyuria, priapism, renal calculus, urinary tract infection.

Other: Systemic lupus erythematosus.

Laboratory Tests Serum sodium levels below 125 mmol/L have been observed in patients treated with immediate-release oxcarbazepine. Experience from clinical trials with immediate-release oxcarbazepine indicates that serum sodium levels return toward normal when the dosage is reduced or discontinued, or when the patient was treated conservatively (e.g., fluid restriction).

Laboratory data from clinical trials suggest that immediate-release oxcarbazepine use was associated with decreases in T4, without changes in T3 or TSH. Postmarketing and Other Experience The following adverse reactions have been observed in named patient programs or post-marketing experience with immediate-release oxcarbazepine or Oxtellar XR®. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Body as a Whole: multi-organ hypersensitivity disorders characterized by features such as rash, fever, lymphadenopathy, abnormal liver function tests, eosinophilia, and arthralgia Cardiovascular System: atrioventricular block Digestive System: pancreatitis and/or lipase and/or amylase increase Hematologic and Lymphatic Systems: aplastic anemia Immune System Disorders: anaphylaxis Metabolism and Nutrition Disorders: hypothyroidism and syndrome of inappropriate antidiuretic hormone secretion (SIADH) Skin and Subcutaneous Tissue Disorders: erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, Acute Generalized Exanthematous Pustulosis (AGEP) Musculoskeletal, Connective Tissue and Bone Disorders: There have been reports of decreased bone mineral density, osteoporosis and fractures in patients on long-term therapy with immediate-release oxcarbazepine.

DRUG INTERACTIONS Effect of Oxtellar XR on Other Drugs It is recommended that the plasma levels of phenytoin be monitored during the period of Oxtellar XR titration and dosage modification. A decrease in the dosage of phenytoin may be required.

Effect of Other Drugs on Oxtellar XR If Oxtellar XR and strong CYP3A4 inducers or UGT inducers (e.g., rifampin, carbamazepine, phenytoin, and phenobarbital) are administered concurrently, it is recommended that the plasma levels of MHD be monitored during the period of Oxtellar XR titration. Dosage adjustment of Oxtellar XR may be required after initiation, dosage modification, or discontinuation of such inducers.

Hormonal Contraceptives Concurrent use of immediate-release oxcarbazepine with hormonal contraceptives may render these contraceptives less effective. Studies with other oral or implant contraceptives have not been conducted.

USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Exposure Registry There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to AEDs, such as Oxtellar XR, during pregnancy.

Encourage women who are taking Oxtellar XR during pregnancy to enroll in the North American Antiepileptic Drug (NAAED Pregnancy Registry) by calling 1-888-233-2334 or visiting http://www.aedpregnancyregistry.org/.

Risk Summary There are no adequate data on the developmental risks associated with the use of Oxtellar XR® in pregnant women; however, Oxtellar XR® is closely related structurally to carbamazepine, which is considered to be teratogenic in humans. Data on a limited number of pregnancies from pregnancy registries suggest that oxcarbazepine monotherapy use is associated with congenital malformations (e.g., craniofacial defects such as oral clefts, and cardiac malformations such as ventricular septal defects). Increased incidences of fetal structural abnormalities and other manifestations of developmental toxicity (embryolethality, growth retardation) were observed in the offspring of animals treated with either oxcarbazepine or its active 10-hydroxy metabolite (MHD) during pregnancy at doses similar to the maximum recommended human dose (MRHD).

In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. The background risk of major birth defects and miscarriage for the indicated population is unknown.

Clinical Considerations An increase in seizure frequency may occur during pregnancy because of altered levels of the active metabolite of oxcarbazepine. Monitor patients carefully during pregnancy and through the postpartum period.

Data Human Data Data from published registries have reported craniofacial defects such as oral clefts and cardiac malformations such as ventricular septal defects in children with prenatal oxcarbazepine exposure.

Animal Data When pregnant rats were given oxcarbazepine (30, 300, or 1000 mg/kg/day) orally throughout the period of organogenesis, increased incidences of fetal malformations (craniofacial, cardiovascular, and skeletal) and variations were observed at the intermediate and high doses (approximately 1.2 and 4 times, respectively, the MRHD on a mg/m2 basis).

Increased embryofetal death and decreased fetal body weights were seen at the high dose. Doses ≥300 mg/kg were also maternally toxic (decreased body weight gain, clinical signs), but there is no evidence to suggest that teratogenicity was secondary to the maternal effects.

In a study in which pregnant rabbits were orally administered MHD (20,

100, or 200 mg/kg/day) during organogenesis, embryofetal mortality was increased at the highest dose (1.5 times the MRHD on a mg/m2 basis). This dose produced only minimal maternal toxicity.

In a study in which female rats were dosed orally with oxcarbazepine (25, 50, or 150 mg/kg/day) during the latter part of gestation and throughout the lactation period, a persistent reduction in body weights and altered behavior (decreased activity) were observed in offspring exposed to the highest dose (0.6 times the MRHD on a mg/m2 basis). Oral administration of MHD (25, 75, or 250 mg/kg/day) to rats during gestation and lactation resulted in a persistent reduction in offspring weights at the highest dose (equivalent to the MRHD on a mg/m2 basis).

Lactation Risk Summary Oxcarbazepine and its active metabolite (MHD) are present in human milk after oxcarbazepine administration. The effects of oxcarbazepine and its active metabolite (MHD) on the breastfed infant or on milk production are unknown. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Oxtellar XR and any potential adverse effects on the breastfed infant from Oxtellar XR or from the underlying maternal condition.

Females and Males of Reproductive Potential Contraception Use of Oxtellar XR with hormonal contraceptives containing ethinylestradiol or levonorgestrel is associated with decreased plasma concentrations of these hormones and may result in a failure of the therapeutic effect of the oral contraceptive drug. Advise women of reproductive potential taking Oxtellar XR who are using a contraceptive containing ethinylestradiol or levonorgestrel to use additional or alternative non-hormonal birth control.

Pediatric Use The safety and effectiveness of Oxtellar XR® in pediatric patients 6 years of age and older for the treatment of partial-onset seizures is supported by: 1) An adequate and well-controlled safety and efficacy study of Oxtellar XR® in adults that included pharmacokinetic sampling, 2) A pharmacokinetic study of Oxtellar XR® in pediatric patients, which included patients 6 to less than 17 years of age, 3) Safety and efficacy studies with the immediate-release formulation in adults and pediatric patients.

Oxtellar XR® is not approved for pediatric patients less than 6 years of age because the size of the tablets are inappropriate for younger children.

Geriatric Use Following administration of single (300 mg) and multiple (600 mg/day) doses of immediate-release oxcarbazepine to elderly volunteers (60-82 years of age), the maximum plasma concentrations and AUC values of MHD were 30%-60% higher than in younger volunteers (18-32 years of age). Comparisons of creatinine clearance in young and elderly volunteers indicate that the difference was due to age-related reductions in creatinine clearance. Consider starting at a lower dosage and lower titration. Close monitoring of sodium levels is required in elderly patients at risk for hyponatremia.

Renal Impairment There is a linear correlation between creatinine clearance and the renal clearance of MHD. The pharmacokinetics of Oxtellar XR® has not been evaluated in patients with renal impairment. In patients with severe renal impairment (creatinine clearance <30 mL/min) given immediate-release oxcarbazepine, the elimination half-life of MHD was prolonged with a corresponding two-fold increase in AUC. In these patients initiate Oxtellar XR® at a lower starting dosage and increase, if necessary, at a slower than usual rate until the desired clinical response is achieved.

In patients with end-stage renal disease on dialysis, it is recommended that immediate-release oxcarbazepine be used instead of Oxtellar XR®.

Hepatic Impairment The pharmacokinetics of oxcarbazepine and MHD has not been evaluated in severe hepatic impairment, and therefore is not recommended in these patients.

DRUG ABUSE AND DEPENDENCE Abuse The abuse potential of Oxtellar XR® has not been evaluated in human studies.

Oxtellar XR® is not habit forming, and is not expected to encourage abuse.

Dependence Intragastric injections of oxcarbazepine to four cynomolgus monkeys demonstrated no signs of physical dependence as measured by the desire to self-administer oxcarbazepine by lever pressing activity.

OVERDOSAGE Human Overdose Experience Isolated cases of overdose with immediate-release oxcarbazepine have been reported. The maximum dose taken was approximately 48,000 mg.

All patients recovered with symptomatic treatment. Nausea, vomiting, somnolence, aggression, agitation, hypotension, and tremor each occurred in more than one patient. Coma, confusional state, convulsion, dyscoordination, depressed level of consciousness, diplopia, dizziness, dyskinesia, dyspnea, QT prolongation, headache, miosis, nystagmus, overdose, decreased urine output, and blurred vision also occurred.

Treatment and Management There is no specific antidote for Oxtellar XR® overdose. Administer symptomatic and supportive treatment as appropriate. Options include removal of the drug by gastric lavage and/or inactivation by administering activated charcoal.

CLINICAL PHARMACOLOGY Patients with Renal or Hepatic Impairment The effects of renal or hepatic impairment have not been studied for Oxtellar XR®.

Based on investigations with immediate-release oxcarbazepine, there is a linear correlation between creatinine clearance and the renal clearance of MHD. When immediate-release oxcarbazepine is administered as a single 300 mg dose in renally-impaired patients (creatinine clearance <30 mL/min), the elimination half-life of MHD is prolonged to 19 hours, with a two-fold increase in AUC. Dosage adjustment is recommended in these patients.

The pharmacokinetics and metabolism of immediate-release oxcarbazepine and MHD were evaluated in healthy volunteers and hepatically impaired subjects after a single 900 mg oral dose. Mild-to-moderate hepatic impairment did not affect the pharmacokinetics of immediate-release oxcarbazepine and MHD. The pharmacokinetics of oxcarbazepine and MHD have not been evaluated in severe hepatic impairment, and therefore it is not recommended in these patients.

Pregnant Women Due to physiological changes during pregnancy, MHD plasma levels may gradually decrease throughout pregnancy.

Drug Interaction Studies

In Vitro: Oxcarbazepine can inhibit CYP2C19 and induce CYP3A4/5 with potentially important effects on plasma concentrations of other drugs. In addition, several AEDs that are cytochrome P450 inducers can decrease plasma concentrations of oxcarbazepine and MHD. Oxcarbazepine was evaluated in human liver microsomes to determine its capacity to inhibit the major cytochrome P450 enzymes responsible for the metabolism of other drugs. Results demonstrate that oxcarbazepine and its pharmacologically active 10-monohydroxy metabolite (MHD) have little or no capacity to function as inhibitors for most of the human cytochrome P450 enzymes evaluated (CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, CYP4A9, and CYP4A11) with the exception of CYP2C19 and CYP3A4/5.

Although inhibition of CYP3A4/5 by oxcarbazepine and MHD did occur at high concentrations, it is not likely to be of clinical significance. The inhibition of CYP2C19 by oxcarbazepine and MHD, is clinically relevant.

In vitro, the UDP-glucuronyl transferase level was increased, indicating induction of this enzyme. Increases of 22% with MHD and 47% with oxcarbazepine were observed. As MHD, the predominant plasma substrate, is only a weak inducer of UDP-glucuronyl transferase, it is unlikely to have an effect on drugs that are mainly eliminated by conjugation through UDP-glucuronyl transferase (e.g., valproic acid, lamotrigine).

In addition, oxcarbazepine and MHD induce a subgroup of the cytochrome P450 3A family (CYP3A4 and CYP3A5) responsible for the metabolism of dihydropyridine calcium antagonists, oral contraceptives and cyclosporine resulting in a lower plasma concentration of these drugs.

Several AEDs that are cytochrome P450 inducers can decrease plasma concentrations of oxcarbazepine and MHD. No autoinduction has been observed with immediate-release oxcarbazepine.

As binding of MHD to plasma proteins is low (40%), clinically significant interactions with other drugs through competition for protein binding sites are unlikely.

In Vivo: Other Antiepileptic Drugs Potential interactions between immediate-release oxcarbazepine and other AEDs were assessed in clinical studies. The effect of these interactions on mean AUCs and Cmin are summarized in Table 5.

Table 5: AED Drug Interactions with Immediate-Release (IR) Oxcarbazepine AED Coadministered (daily dosage); IR-Oxcarbazepine (daily dosage); Influence of IR-Oxcarbazepine on AED Concentration Mean Change (90% Confidence Interval); Influence of AED on MHD Concentration (Mean Change, 90% Confidence Interval). Carbamazepine (400-2000 mg): 900 mg, nc1, 40 % decrease [Cl: 17% decrease, 57% decrease]; Phenobarbital (100-150 mg): 600-1800 mg, 14% increase [Cl: 2% increase, 24% increase]; 25% decrease [Cl: 12% decrease, 51% decrease]. Phenytoin (250-500 mg): 600-1800 >1200-2400, nc1,2 up to 40% increase3 [Cl: 12% increase, 60% increase], 30% decrease [Cl: 3% decrease, 48% decrease]. Valproic Acid (400-2800 mg): 600-1800, nc1, 18% decrease [Cl: 13% decrease, 40% decrease]. Lamotrigine (200 mg): 1200, nc1, nc1.

1 nc denotes a mean change of less than 10%; 2Pediatrics; 3 Mean increase in adults at high doses of immediate-release oxcarbazepine Hormonal Contraceptives Coadministration of immediate-release oxcarbazepine with an oral contraceptive has been shown to influence the plasma concentrations of two components of hormonal contraceptives, ethinylestradiol (EE) and levonorgestrel (LNG). The mean AUC values of EE were decreased by 48% [90% CI: 22-65] in one study and 52% [90% CI: 38-52] in another study. The mean AUC values of LNG were decreased by 32% [90% CI: 20-45] in one study and 52% [90% CI: 42-52] in another study.

Other Drug Interactions Calcium Antagonists: After repeated coadministration of immediate-release oxcarbazepine, the AUC of felodipine was lowered by 28% [90% CI: 20-33]. Verapamil produced a decrease of 20% [90% CI: 18-27] of the plasma levels of MHD after coadministration with immediate-release oxcarbazepine.

Cimetidine, erythromycin and dextropropoxyphene had no effect on the pharmacokinetics of MHD after coadministration with immediate-release oxcarbazepine. Results with warfarin show no evidence of interaction with either single or repeated doses of immediate-release oxcarbazepine.

NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis In two-year carcinogenicity studies, oxcarbazepine was administered in the diet at doses of up to 100 mg/kg/day to mice and by gavage at doses of up to 250 mg/kg/day to rats, and the pharmacologically active 10-hydroxy metabolite (MHD) was administered orally at doses of up to 600 mg/kg/day to rats. In mice, a dose-related increase in the incidence of hepatocellular adenomas was observed at oxcarbazepine doses ≥70 mg/kg/day or approximately 0.1 times the maximum recommended human dose (MRHD) on a mg/m2 basis. In rats, the incidence of hepatocellular carcinomas was increased in females treated with oxcarbazepine at doses ≥25 mg/kg/day (0.1 times the MRHD on a mg/m2 basis), and incidences of hepatocellular adenomas and/or carcinomas were increased in males and females treated with MHD at doses of 600 mg/kg/day (2.4 times the MRHD on a mg/m2 basis) and ≥250 mg/kg/day (equivalent to the MRHD on a mg/m2 basis), respectively. There was an increase in the incidence of benign testicular interstitial cell tumors in rats at 250 mg oxcarbazepine/kg/day and at ≥250 mg MHD/kg/day, and an increase in the incidence of granular cell tumors in the cervix and vagina in rats at 600 mg MHD/kg/day.

Mutagenesis Oxcarbazepine increased mutation frequencies in the Ames test in vitro in the absence of metabolic activation in one of five bacterial strains. Both oxcarbazepine and MHD produced increases in chromosomal aberrations and polyploidy in the Chinese hamster ovary assay in vitro in the absence of metabolic activation. MHD was negative in the Ames test, and no mutagenic or clastogenic activity was found with either oxcarbazepine or MHD in V79 Chinese hamster cells in vitro. Oxcarbazepine and MHD were both negative for clastogenic or aneugenic effects (micronucleus formation) in an in vivo rat bone marrow assay.

Impairment of Fertility In a fertility study in which rats were administered MHD (50, 150, or 450 mg/kg) orally prior to and during mating and early gestation, estrous cyclicity was disrupted and numbers of corpora lutea, implantations, and live embryos were reduced in females receiving the highest dose (approximately two times the MRHD on a mg/m2 basis).

RA-OXT-BS-PV2

Today’s Opening Luncheon Kicks off Four Days of Exhibit Hall Happenings continued from cover

industry representatives, but you can expect to: Connect with other health

organizations throughout the Association Neighborhood Discover emerging technologies within the Technology Pavilion Keep up-to-date on what’s new at Publishers Row Gather career resources and more during the Career Fair Preview the latest products and services at Vendor Booths Experience an array of dynamic events at the Innovation Hub Grab a cup of joe and mingle at the Exhibit Hall Buzz Cafes

Keep your devices charged

in the comfort of the Exhibit Hall Charging Lounges Take a break and unwind at the Exhibit Hall Picnic Area Unwind twice daily with Wine and Paint Sessions Play daily bingo or take part in fun food plating competitions 

Don’t Miss These Special Events!

Opening Luncheon

Sunday, 11:30 a.m.–1:00 p.m.

Sponsored by Sunovion Pharmaceuticals, Inc. Exhibit Hall Networking Reception

Monday, 4:00 p.m.–6:00 p.m.

Sponsored by EMD Serono, Inc.

Brainstorm: A Competition for the

Innovator in All of Us Monday, 4:00 p.m.–5:30 p.m.

Bingo

Daily, 1:00 p.m.–2:00 p.m.

Food Plating Competitions

Monday–Wednesday, 12:15 p.m.–12:45 p.m.

Medical Improv

Daily, 3:00 p.m.–3:30 p.m.

Wine and Paint

Daily, 12:00 p.m.–1:00 p.m.

Daily, 2:00 p.m.–3:00 p.m. 

Join New EHR Synapse Online Community The AAN has created a new Synapse™ Online Community devoted to discussions and information sharing on electronic health records (EHR). Members can post questions and get advice from colleagues on all things EHR, whether it’s general information or related to a specific EHR software. Success stories can be shared for colleagues to implement in their own practices.

The community’s document library can be explored to discover additional helpful resources.

The EHR Synapse Online Community is a private community; join by emailing practice@aan.com. 

30

Sunday, May 5, 2019 • AANextra

NIH Seeks Your Input on BRAIN Initiative’s Strategic Plan All Annual Meeting attendees are invited to learn about and provide input for the second half of the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, the large-scale public-private effort aimed at revolutionizing our understanding of the human brain launched in 2013. The event, Updating the NIH BRAIN Initiative: A Dialogue with the AAN, will be on Monday, May 6, from 8:00 a.m. to 9:00 a.m. in The Grand Experience— Grand Hall, Stage 2.

Representatives of the Working Group of the Advisory Committee to the NIH Director, known as the ACD BRAIN Initiative Working Group 2.0, will present information on the progress and advances of the BRAIN Initiative within the context of the original BRAIN 2025 report and solicit feedback from attendees. The working group will also be identifying key opportunities to apply new and emerging tools to transform our understanding of brain circuits and designating valuable areas of continued technology development.

Koroshetz

The presentation will include:

Welcome and Overview Walter J. Koroshetz, MD, FAAN / Director National Institute of Neurological Disorders and Stroke

Perspective from BRAIN Researcher Working with Clinical Patients Aysegul Gunduz, PhD / University of Florida

Panel Introductions and Remarks

Panelist Discussion and Audience Engagement

James Eberwine, PhD / Co-chair, BRAIN Neuroethics Subgroup

Perspective from BRAIN Clinician-researcher

Gabriel Lazaro-Munoz, PhD, JD, MBE / Baylor College of Medicine; with Koroshetz

Laura B. Dunn, MD / Stanford University

Panelist Discussion and Audience Engagement For more information, visit BrainInitiative.NIH.gov. 

LEARN ABOUT A NEW ORAL TREATMENT FOR MULTIPLE SCLEROSIS Visit Booth ©2019 EMD Serono, Inc. All rights reserved.

Printed in the USA US/NPR/0319/0198 03/19

2313

THE FIRST FDA-APPROVED TREATMENT INDICATED FOR ADULTS WITH TARDIVE DYSKINESIA (TD)1

ONE CAPSULE, ONCE DAILY1 Convenient, once-daily dosing without complex titration1

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• INGREZZA 80 mg provided rapid and significant reductions in TD severity by 6 weeks1,2 —with continued reductions in TD severity through 48 weeks1,3 • Generally well tolerated in clinical trials across a broad range of adult TD patients1,2 • Selectively inhibits VMAT2, with no appreciable binding affinity for serotonergic or dopaminergic receptors1 • Offers convenient, once-daily dosing without complex titration1 VMAT2, vesicular monoamine transporter 2.

Not an actual patient

I S I T T D O R A C U T E E P S ? | TA K E T H E T D C H A L L E N G E AT B O OT H # 9 0 0 EPS, extrapyramidal symptoms.

W W W. I N G R E Z Z A H C P. C O M

Important Information INDICATION & USAGE

INGREZZA® (valbenazine) capsules is indicated for the treatment of adults with tardive dyskinesia.

IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS

INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA. Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.

WARNINGS & PRECAUTIONS Somnolence

INGREZZA can cause somnolence. Patients should not perform activities requiring mental alertness such as operating a motor vehicle or operating hazardous machinery until they know how they will be affected by INGREZZA.

QT Prolongation

INGREZZA may prolong the QT interval, although the degree of QT prolongation is not clinically significant at concentrations expected with recommended dosing. INGREZZA should be avoided in patients with congenital long QT syndrome or with arrhythmias associated with a prolonged QT interval. For patients at increased risk of a prolonged QT interval, assess the QT interval before increasing the dosage.

ADVERSE REACTIONS

The most common adverse reaction (≥5% and twice the rate of placebo) is somnolence. Other adverse reactions (≥2% and >placebo) include: anticholinergic effects, balance disorders/falls, headache, akathisia, vomiting, nausea, and arthralgia.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit MedWatch at www.fda.gov/medwatch or call 1-800-FDA-1088.

Please see the adjacent page for brief summary of Prescribing Information and visit www.INGREZZAHCP.com/PI for full Prescribing Information.

REFERENCES: 1. INGREZZA [package insert]. San Diego, CA: Neurocrine Biosciences, Inc; 2018. 2. Hauser RA, Factor SA, Marder SR, et al. KINECT 3: a phase 3 randomized, double-blind, placebo-controlled trial of valbenazine for tardive dyskinesia. Am J Psychiatry. 2017;174(5):476-484. 3. Factor SA, Remington G, Comella CL, et al. The effects of valbenazine in participants with tardive dyskinesia: results of the 1-Year KINECT 3 extension study. J Clin Psychiatry. 2017;78(9):1344-1350.

©2019 Neurocrine Biosciences, Inc. All Rights Reserved. CP-VBZ-US-0525v2 5/19

for oral use

Brief Summary: for full Prescribing Information and Patient Information, refer to package insert.

INDICATIONS AND USAGE

Endocrine Disorders: blood glucose increased General Disorders: weight increased Infectious Disorders: respiratory infections Neurologic Disorders: drooling, dyskinesia, extrapyramidal symptoms (non-akathisia) Psychiatric Disorders: anxiety, insomnia During controlled trials, there was a dose-related increase in prolactin. Additionally, there was a dose-related increase in alkaline phosphatase and bilirubin, suggesting a potential risk for cholestasis.

Postmarketing Experience

INGREZZA® is indicated for the treatment of adults with tardive dyskinesia.

CONTRAINDICATIONS

INGREZZA is contraindicated in patients with a history of hypersensitivity to valbenazine or any components of INGREZZA. Rash, urticaria, and reactions consistent with angioedema (e.g., swelling of the face, lips, and mouth) have been reported.

WARNINGS AND PRECAUTIONS Somnolence

INGREZZA can cause somnolence. Patients should not perform activities requiring mental alertness such as operating a motor vehicle or operating hazardous machinery until they know how they will be affected by INGREZZA.

QT Prolongation INGREZZA may prolong the QT interval, although the degree of QT prolongation is not clinically significant at concentrations expected with recommended dosing. In patients taking a strong CYP2D6 or CYP3A4 inhibitor, or who are CYP2D6 poor metabolizers, INGREZZA concentrations may be higher and QT prolongation clinically significant. For patients who are CYP2D6 poor metabolizers or are taking a strong CYP2D6 inhibitor, dose reduction may be necessary. For patients taking a strong CYP3A4 inhibitor, reduce the dose of INGREZZA to 40 mg once daily.

INGREZZA should be avoided in patients with congenital long QT syndrome or with arrhythmias associated with a prolonged QT interval. For patients at increased risk of a prolonged QT interval, assess the QT interval before increasing the dosage.

The following adverse reactions have been identified during post-approval use of INGREZZA that are not included in other sections of labeling. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Immune System Disorders: hypersensitivity reactions (including allergic dermatitis, angioedema, pruritis, and urticaria) Skin and Subcutaneous Tissue Disorders: rash

DRUG INTERACTIONS

Drugs Having Clinically Important Interactions with INGREZZA Table 2: Clinically Significant Drug Interactions with INGREZZA Monoamine Oxidase Inhibitors (MAOIs) Clinical Implication: Concomitant use of INGREZZA with MAOIs may increase the concentration of monoamine neurotransmitters in synapses, potentially leading to increased risk of adverse reactions such as serotonin syndrome, or attenuated treatment effect of INGREZZA. Prevention or Avoid concomitant use of INGREZZA with MAOIs. Management:

ADVERSE REACTIONS

Examples: isocarboxazid, phenelzine, selegiline Strong CYP3A4 Inhibitors Clinical Implication: Concomitant use of INGREZZA with strong CYP3A4 inhibitors increased the exposure (Cmax and AUC) to valbenazine and its active metabolite compared with the use of INGREZZA alone.

Increased exposure of valbenazine and its active metabolite may increase the risk of exposure-related adverse reactions.

Prevention or Reduce INGREZZA dose when INGREZZA is coadministered with a strong CYP3A4 inhibitor.

Management:

The following adverse reactions are discussed in more detail in other sections of the labeling: • Hypersensitivity • Somnolence • QT Prolongation

Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Variable and Fixed Dose Placebo-Controlled Trial Experience The safety of INGREZZA was evaluated in 3 placebo-controlled studies, each 6 weeks in duration (fixed dose, dose escalation, dose reduction), including 445 patients. Patients were 26 to 84 years of age with moderate to severe tardive dyskinesia and had concurrent diagnoses of mood disorder (27%) or schizophrenia/ schizoaffective disorder (72%). The mean age was 56 years.

Patients were 57% Caucasian, 39% African-American, and 4% other. With respect to ethnicity, 28% were Hispanic or Latino. All subjects continued previous stable regimens of antipsychotics; 85% and 27% of subjects, respectively, were taking atypical and typical antipsychotic medications at study entry.

Adverse Reactions Leading to Discontinuation of Treatment A total of 3% of INGREZZA treated patients and 2% of placebo-treated patients discontinued because of adverse reactions.

Common Adverse Reactions Adverse reactions that occurred in the 3 placebo-controlled studies at an incidence of ≥2% and greater than placebo are presented in Table 1.

Table 1:

Adverse Reactions in 3 Placebo-Controlled Studies of 6-week Treatment Duration Reported at ≥2% and >Placebo

Adverse Reaction1

Examples: Strong CYP3A4 Inducers Clinical Implication:

paroxetine, fluoxetine, quinidine

Prevention or Management:

Concomitant use of strong CYP3A4 inducers with INGREZZA is not recommended. rifampin, carbamazepine, phenytoin, St. John’s wort1

Digoxin concentrations should be monitored when co-administering INGREZZA with digoxin. Increased digoxin exposure may increase the risk of exposure related adverse reactions. Dosage adjustment of digoxin may be necessary.

INGREZZA (n=262) (%)

Placebo (n=183) (%)

General Disorders Somnolence (somnolence, fatigue, sedation)

10.9%

4.2%

Examples: Digoxin Clinical Implication:

Nervous System Disorders Anticholinergic effects (dry mouth, constipation, disturbance in attention, vision blurred, urinary retention)

5.4%

4.9%

Prevention or Management:

Balance disorders/fall (fall, gait disturbance, dizziness, balance disorder)

4.1%

2.2%

Headache Akathisia (akathisia, restlessness)

3.4% 2.7%

Gastrointestinal Disorders Vomiting Nausea Musculoskeletal Disorders Arthralgia 1

Examples: itraconazole, ketoconazole, clarithromycin Strong CYP2D6 Inhibitors Clinical Implication: Concomitant use of INGREZZA with strong CYP2D6 inhibitors may increase the exposure (Cmax and AUC) to valbenazine’s active metabolite compared with the use of INGREZZA alone. Increased exposure of active metabolite may increase the risk of exposurerelated adverse reactions.

Prevention or Consider reducing INGREZZA dose based on tolerability when INGREZZA is coadministered with a strong CYP2D6 inhibitor.

Management:

2.7% 0.5%

1

Concomitant use of INGREZZA with a strong CYP3A4 inducer decreased the exposure of valbenazine and its active metabolite compared to the use of INGREZZA alone. Reduced exposure of valbenazine and its active metabolite may reduce efficacy.

Concomitant use of INGREZZA with digoxin increased digoxin levels because of inhibition of intestinal P-glycoprotein (P-gp).

The induction potency of St. John’s wort may vary widely based on preparation.

Drugs Having No Clinically Important Interactions with INGREZZA Dosage adjustment for INGREZZA is not necessary when used in combination with substrates of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2E1, or CYP3A4/5 based on in vitro study results.

OVERDOSAGE

Human Experience 2.6% 2.3%

0.6% 2.1%

2.3%

0.5%

Within each adverse reaction category, the observed adverse reactions are listed in order of decreasing frequency.

Other Adverse Reactions Observed During the Premarketing Evaluation of INGREZZA

Other adverse reactions of ≥1% incidence and greater than placebo are shown below. The following list does not include adverse reactions: 1) already listed in previous tables or elsewhere in the labeling, 2) for which a drug cause was remote, 3) which were so general as to be uninformative, 4) which were not considered to have clinically significant implications, or 5) which occurred at a rate equal to or less than placebo.

The pre-marketing clinical trials involving INGREZZA in approximately 850 subjects do not provide information regarding symptoms with overdose.

Management of Overdosage No specific antidotes for INGREZZA are known. In managing overdose, provide supportive care, including close medical supervision and monitoring, and consider the possibility of multiple drug involvement. If an overdose occurs, consult a Certified Poison Control Center (1-800-222-1222 or www.poison.org).

For further information on INGREZZA, call 84-INGREZZA (844-647-3992).

Distributed by: Neurocrine Biosciences, Inc. San Diego, CA 92130 INGREZZA is a registered trademark of Neurocrine Biosciences, Inc. CP-VBZ-US-0203v3 08/18

Make Your Way to the Grand Hall for the Grand Experience continued from cover Throughout the week attendees can expect find: Scientific platform sessions Scientific award presentations with a Q&A panel

with past recipients of the following: John Dystel Prize for Multiple Sclerosis Research Monday, 3:30 p.m.

Potamkin Prize for Research in Pick's, Alzheimer's, and Related Diseases Tuesday, 3:30 p.m.

Sheila Essey Award: An Award for ALS Research Wednesday, 3:30 p.m.

Education Award Presentations including the

A.B. Baker Award for Lifetime Achievement in Neurologic Education and the Frank A. Rubino Award for Excellence in Clinical Neurology Teaching Wednesday, 1:00 p.m.–1:45 p.m.

Academic medicine offerings Small-group conversations about career roles and stages Mentoring sessions Trainee opportunities Casual lounge areas for relaxing and networking

In addition, the Grand Experience will host two of the meeting’s most popular experiential learning areas: Navigating Your Career / Stage 3

Regardless of where you are in your professional journey, you’ll want to stop by this area for essential tips, tools, and resources to power your success. Those from academic departments will want to look for Academic Medicine Track programming. Additional new programs cover subspecialty career paths; issues that arise during early-, mid-, and latecareer stages; and Spanish-language presentations. For the first time, some talks will offer CME.

Research Corner / Stage 2

Discover how you can shape the future of research— no matter where you’re at in your research career. Improve your knowledge and skills through practical tools and resources you won’t find anywhere else at the Annual Meeting. Trainees interested in careers in research should look for new morning courses in the Futures in Neurological Research track. The area will also offer practical “How To” talks that explore tangible steps for identifying research questions, funding your research, publishing and presenting research, talking to your biostatician, what to do if your paper isn’t accepted, and more.

Photo Credit: Paul Loftland

For more information, visit AAN.com/view/ELAs. 

34

Sunday, May 5, 2019 • AANextra

NOW

AVA ILABLE

Finally, there’s a whole new path to explore

Booth 2129 Follow the footprints in the exhibit hall and discover EPIDIOLEX® (cannabidiol) Cv

Greenwich Biosciences is growing innovation Step into the growing and manufacturing process with a virtual reality experience at the booth.

Visit EPIDIOLEXhcp.com for more information

©2019 Greenwich Biosciences Inc. All rights reserved. EPX-04965-0319

Behavioral Interviewing: Tell a Compelling Story with Your Answer If you’ve been to a job interview lately—as either the candidate or the interviewer—then you may be familiar with a style of question called “behavioral.” Behavioral interview questions are based on a principle of psychology which states, in essence, that how a person has acted in the past under certain conditions is a predictor of how he or she will respond in the future to the same conditions.

Hence, when interviewers say, “Tell us about a patient you’ve treated who was difficult to relate to, and how you handled the situation,” what they’re really asking is: “How will you handle our difficult-to-manage patients?” So, you might wonder, why don’t they simply ask the question they really want answered? Because that would be too easy for the candidate to manipulate. A doctor could just answer with some kind of neat process, or claim that managing difficult patients hasn’t been a problem. It’s much harder to “game the answer” when asked to give an example.

You can see why behavioral questions have taken root over the past decade or so: Interviewers love being able to assess candidates through the lens of their behavior. Unfortunately, not all interviewers are skilled in interpreting the answers; nor are candidates necessarily good storytellers. As the candidate, you can’t do much about your interviewer’s level of skill, but you certainly can increase your own. Here are five steps to help you develop compelling answers for behavioral interview questions.

STEP 1. I dentify good stories in advance of the interview.

This can seem tricky at first—how can you prepare an answer without knowing the question? You won’t be heartened to know there are lists floating around of the top 100 behavioral interview questions. One hundred! That’s obviously far too many stories to prepare before a meeting, especially when the typical interview may contain no more than three or four of this style of question.

How would you ever know which questions they might ask? A better strategy is to reverse-engineer the problem: Instead of anticipating the question, start by identifying your ideal stories.

To do this, think deeply about the past five or eight years, to refresh your memory of internships, residency, fellowships, and any other training or field experience that you’ve had. Now ask yourself: When did you persevere during a challenging situation?

When were your efforts pivotal to creating a successful outcome?

When did you think of an improvement to a process or system that created good results for your team?

Once you have a few examples in mind of times when your work was particularly successful, you’ll have the basis for good stories.

STEP 2. Draft out each story in a STAR pattern.

STAR is a popular acronym which stands for Situation, Task, Action, Result. It’s a tool that can help you keep track of the parts of your story, and ensure that you have enough content to make an impact, while also guiding you to tell the story clearly. Here’s an example from a neurology fellow whose patient would not follow a treatment protocol, and how the physician handled the problem.

SITUATION: Patient continues activities that are harmful, and is not adopting behaviors that are healthy. The patient’s family is distraught and is asking for help convincing the patient to cooperate with the treatment plan.

TASK: The physician has several concerns to keep in mind, including patient confidentiality, the patient’s right to selfdetermination, the clinic’s liability, the overall goal of providing good care, etc.

36

Sunday, May 5, 2019 • AANextra

ACTION: As a fellow still in training, the physician decided to bring the case forward for discussion and review, with the goal of receiving advice for handling the situation. The question of mental health care and therapy support for the patient was raised by the fellowship director, which gave the physician the idea of providing resources to the patient to access this assistance. The idea of a care conference with the family was also raised to let them express their concerns in the patient’s presence. The physician decided to take these steps.

RESULT: The patient listened to the family’s concerns but also provided some insight about being uncooperative—behavior which was actually rooted in trying to maintain control. Although the patient turned down the option for mental health counseling, the care conference provided enough foundation for communication that the patient agreed to cooperate more fully. The doctor’s relationship with the patient also improved.

STEP 3. Shape the story to be more compelling when it’s spoken aloud.

Although the STAR story above is certainly clear, it’s not very relatable. It reads (and would sound) like a bare-bones recitation, which is hardly compelling in an interview. Here’s one way this STAR draft might sound when revised to be more conversational: “When I was in my first month as a fellow, one of my first cases in outpatient care was a gentleman whose epilepsy treatment plan called for a fairly high level of personal responsibility. He was a smart man and not someone who seemed self-destructive, but he was pretty much rejecting every part of the plan. He’d agree to things in the clinic, then go home and do the opposite. I was already trying to figure out what to do when I started getting calls and emails from his family. His wife, especially, was very concerned and she was asking for a lot of detail about my conversations with him. I knew I couldn’t go down that path with her, but I needed to do something to manage the situation, while also trying to get him the care he needed. I decided to bring the case up with my fellowship director and I got some good advice. She reminded me of ways I could use a care conference and also brought up the idea of resources he could tap into for mental health counseling that

might help him sort out his feelings about his epilepsy. In the end, we had a half-victory in that he agreed to the care conference, but he didn’t want to try the counseling. The conference was a home run, though, because it gave his family an opportunity to really open up about what his behavior was doing to them, and it prompted him to accept some parts of the treatment plan. I was also gratified to have a better relationship with him after that, I think because he trusted me and knew I was trying to provide good care while also listening to him.”

Although that story may look long when you see it printed as one big paragraph, when you time it out, you’ll see that it takes only a few minutes to tell. Adding pauses and intonation changes will increase the length but will be worth the tradeoff.

That’s because a more natural sounding delivery will be memorable and interesting to the interviewer.

STEP 4. Anticipate questions your story could answer.

A good story will give you the foundation for at least five or six different behavioral questions. Knowing this, you can prepare a handful of stories, perhaps five, with the confidence that you’ll be able to answer 25 or 30 different questions, just by reshaping the first few sentences of the story. For example, the story above could be used in its current form to answer, “Tell us about a difficult patient that you treated.” But with a little reshaping, it could also be used to answer, “When have you used a collaborative care process with a patient?” or “What have you done to gain a patient’s trust?” or even, “Tell us a situation you’re proud of from your fellowship.”

STEP 5. Practice, practice, practice.

While you can’t be certain which questions your interviewers will ask, you can still practice telling your stories. The ideal process involves three steps: Typing the story into a word processing program so you can shape it easily; then writing it by hand so it lodges more firmly in your memory; and finally, saying it out loud a few times until you feel comfortable navigating the different parts of the story without getting lost. As you already know, the goal isn’t to memorize to the point of sounding rehearsed. But not practicing at all increases the risk of forgetting key points— or forgetting the story altogether. The middle ground is to be comfortable enough telling your story without notes that you know you won’t freeze when a question is asked.

As a final tip, remember that no matter how prepared you are, the interviewer could still ask a question you don’t have an answer for. If that happens, you can always punt: “I’ll need to come back to that question, as I’m drawing a blank for the moment.” Or even, “I don’t have an example that relates exactly, but I did have a situation come up with some similarities. When I was in my first month as a fellow, one of my first cases in outpatient care was a gentleman whose epilepsy treatment plan…” Sometimes it’s not so important that the story matches the question, as long as the story itself is informative and well-spoken. Try it and see: If you master the art of answering behavioral questions, you’ll experience a transformative effect in your interview process. 

Enhance Your Annual Meeting Experience with Annual Meeting On Demand This comprehensive, CME-accredited digital library offers: • 500+ hours* of presentations—watch like you’re there in person with slides and synchronized audio with PDF and mp3 files available for download • 200+ programs and syllabi available** • Convenience—learn from your desk or on the go • Integrated CME testing with over 240 hours of CME eligible content (earn up to 242.75 AMA PRA Category 1 Credits™)

New for 2019!

• Lower Price—By moving Annual Meeting On Demand to the AAN’s Online Learning Center, we’ve been able to lower the purchase price.

• Simplified, Convenient Access—Access through the Online Learning Center, along with other AAN learning content.

• Complimentary Earbuds—Pre-order by May 10, 2019, and receive free wireless earbuds, while supplies last.

Pre-order by May 10, 2019, and Save $150 on 2019 Annual Meeting On Demand!

Onsite: Visit the eLearning Networking and Innovation Space at the Annual Meeting for any Annual Meeting On Demand or other online learning questions.

Order Online: AAN.com/view/AMOD2019

* Specific presentations within a session may not be available based on permissions granted by the presenter. ** With the move to an online offering, hard drives will not be provided.

AAN Industry Roundtable Celebrates 25 Years The AAN has long recognized the value of collaborating with industry. Since its founding in 1994, the Industry Roundtable (IRT), with more than 100 pharmaceutical, medical device, and imaging companies, has partnered with the AAN to share vision, intellect, and financial resources with the focus on improving the quality of patient care.

Prior to 1994, industry involvement in the AAN consisted primarily of support of entertainment, Satellite Symposia, and exhibits. As policies regarding industry involvement in medical societies changed, so, too, did the relationship between the AAN and industry.

The AAN benefits from industry support of many continuing medical programs, publications, conferences, public education opportunities, and more—either through financial or hardware/software contributions. In turn, the IRT provides a unique forum for industry partners to stay connected and informed of priorities in neurology and to offer their insights in areas of mutual interest.

Hosey

“Within the AAN and the IRT relationship, we look for areas where our objectives and resources align, then we work together with transparency,” said AAN Board Member Jonathan P. Hosey, MD, FAAN, physician liaison to the AAN’s IRT. “We are sincerely grateful for this support that furthers the field of neurology and helps improve the lives of patients living with neurologic diseases.”

Thank you to our 1994 founding members

Abbott Laboratories Allergan, Inc. Armour Pharmaceutical Company Athena Neurosciences, Inc. Berlex Laboratories Bristol-Myers Squibb Company Burroughs Wellcome Co. Cerenex Pharmaceuticals, Division of Glaxo Inc. Ciba-Geigy Corporation The DuPont Merck Pharmaceutical Company GATE Pharmaceuticals Hoechst- Roussel Marion Merrell Dow Inc. Nicolet Biomedical, Inc. Parke-Davis Sandoz Pharmaceuticals Corporation Syntex Laboratories TEVA Corporation The Upjohn Company

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Sunday, May 5, 2019 • AANextra

Thank you to our current members*: AbbVie, Inc. ACADIA Pharmaceuticals Inc. Acorda Therapeutics Inc. Adamas Pharmaceuticals, Inc. Akcea Therapeutics Alder BioPharmaceuticals, Inc. Alexion Pharmaceuticals Allergan, Inc. Amgen Amneal Specialty, a division of Amneal Pharmaceuticals LLC Avanir Pharmaceuticals, Inc. AveXis, Inc. Biogen Celgene Corporation CSL Behring Eisai Inc. Eli Lilly and Company EMD Serono, Inc.

Genentech, a Member of the Roche Group Greenwich Biosciences, Inc. IPSEN Biopharmaceuticals Inc. Lundbeck Medtronic, Inc. Merck & Co., Inc. Mitsubishi Tanabe Pharma America, Inc. Neurelis, Inc. Neurocrine Biosciences Novartis Pharmaceuticals Corporation Ovid Therapeutics Philips Sanofi Genzyme SK life science, a subsidiary of SK biopharmaceuticals Sunovion Pharmaceuticals Inc. Supernus Pharmaceuticals, Inc. Teva CNS Viela Bio  *as of March 25, 2019

Want to learn more about AJOVY® (fremanezumab-vfrm) injection?

Visit booth #1729 or AJOVYhcp.com

© 2019 Teva Pharmaceuticals USA, Inc. FRE-41483 March 2019

What Are Your Colleagues Saying?

Share your thoughts at #AANAM. Join the conversation!

#AANAM Waldyr Santos, MD / Salvador, Brazil “Why do you attend the AAN Annual Meeting?”

“There are huge reveals of everything in neurology and you get deep in any subject you’d like to spend more time on. My areas of interest are peripheral neuropathy and movement disorders. I want to hear talks by A. Gordon Smith and Joseph Jankovic. I also want to attend some courses on stroke, as there have been so many advances. I always come at 7:00 and leave after the last talk. My wife wants to come and I say, ‘No way—you’re just distracting me! You want to meet me for lunch or go to dinner!

Abeera Ali, MD / Birmingham, AL Resident “Why did you come to the Annual Meeting?”

“I’ve always been on patient rotation and couldn’t attend. This year I was like, ‘No, I have to go this year.’

Next year I will be graduating and in a non-academic setting, so I need to get set with my continuing education. My main thing is CME and connecting with other people in private practice and hearing everyone else’s perspective.”

Heber Varela, MD / Miami, FL “Why did you come to the Annual Meeting this year?”

“It’s the biggest meeting, so I can get all of the updates. It has everything I need in terms of clinical development. I moved into private practice. I’m more neuromuscular but also general neurology, so I need to know about everything. The other reason I came was because the AAN website has been very useful to me, especially the recertification course, so I thought I would come to the meeting.”

Angelique Manasseh / Garden City, MI Fourth-year medical student “What have you experienced so far?”

“I went to two sessions for medical students this morning about what to look for in a residency and what they are looking for. Those two alone were worth the trip! They really gave me the most valuable advice I’ve gotten to date on career issues in medical school! And then they were available to meet one-on-one with us at the end. Plus, I had a 30-minute mentorship meeting already this morning.”

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Sunday, May 5, 2019 • AANextra

INDUSTRY THERAPEUTIC UPDATE FROM GENENTECH, A MEMBER OF THE ROCHE GROUP FROM

Horses to Zebras

New Perspectives in Common and Rare Neurologic Diseases

Monday, May 6, 2019 7:00 pm – 9:15 pm Independence Ballroom Philadelphia Marriott Downtown 1201 Market St, Philadelphia, PA

P R O G R A M FA C U LT Y M O D E R AT O R

Paulo Fontoura, MD, PhD

Global Head Clinical Development, Neuroscience Genentech and Roche Basel, Switzerland ALZHEIMER’S DISEASE

Jeffrey L. Cummings, MD, ScD

Research Professor UNLV School of Allied Health Sciences Director Center for Neurodegeneration and Translational Neuroscience Director Emeritus Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas, NV HUNTINGTON’S DISEASE

Victor Sung, MD

Clinical Director of UAB Huntington’s Disease Clinic Associate Professor of Neurology UAB Division of Movement Disorders Birmingham, AL S P I N A L M U S C U L A R AT R O P H Y

Although every neuromuscular and neurodegenerative disease is unique, approaches to treating these conditions have clear commonalities. In this program, the faculty will review recent advancements in neurology that may in turn help us advance the management of common and rare neurologic diseases.

John W. Day, MD, PhD

Professor of Neurology, Pediatrics, and Pathology Director Neuromuscular Division and Clinics Stanford University School of Medicine Palo Alto, CA ADVOCACY MEMBER

Mary Dunkle

Senior Advisor National Organization for Rare Disorders (NORD®) Danbury, CT

For more information and to preregister for this program, please visit www.horses2zebras.com Complimentary dinner will be served.

Please note that seating is limited and priority admission will be given to preregistrants

Meals may be reportable under country, federal, state, and local jurisdictions. If you are a licensed healthcare professional in NJ, VT, or MN, please separately identify yourself to the registration staff at the symposium. Tables without food service will be available.

This non-CME program is intended for healthcare professionals only. CME credits will not be given for attendance. © 2019 Genentech USA, Inc. All rights reserved. NRD/030519/0028

Please note: This event is not part of the official AAN Annual Meeting activities or endorsed by the AAN.

Neuroscience in the Clinic Sessions Kick Off Today with Childhood Epilepsy

Today’s Invited Science Examines Infectious Diseases and Global Health

A week of always-popular Neuroscience in the Clinic sessions kicks off today at 3:30 p.m. in 204 C with a talk on Child Neurology: Emerging Understanding of the Epilepsy-Movement Disorder Spectrum Across the Lifespan. The two-hour sessions feature a mix of scientists and clinicians actively engaged in lively case discussions to integrate scientific research with clinical application. Scientists will provide background on a case and clinicians will apply the case to a patient. Sessions will feature abstract presentations related to the topic and end with a panel discussion. Speakers and topics for the first session include:

Today’s Invited Science Session from 1:00 p.m. to 3:00 p.m. in 105 AB on infectious diseases and global health will feature authors giving presentations of top abstracts presented at subspecialty meetings. The session is presented in partnership with the World Federation of Neurology. Select abstracts will emphasize basic, clinical, and translational science as they evolve toward a more complete understanding of infectious disease and global health with the overall goal of developing more effective prevention and treatment.

3:30 p.m.–3:45 p.m.

Introduction and Case Presentation Erika Fullwood Augustine, MD, FAAN, Rochester, NY

3:45 p.m.–4:15 p.m.

Proposed Pathophysiological Framework for the Epilepsy-Movement Disorder Spectrum Roberto Erro, MBBS, PhD, Fisciano, Campania, Italy

4:15 p.m.–4:45 p.m.

Clinical Features and Diagnosis in Epilepsy-Movement Disorder Overlap Syndromes Erika Fullwood Augustine, MD, FAAN, Rochester, NY

4:45 p.m.–5:00 p.m.

Abstract Presentation: Frequency and Phenotypic Spectrum of KMT2B Mutations in Childhood-onset Dystonia: Results from a Single-center Cohort Study Paulina Gonzalez Latapi, MD, Chicago, IL

5:00 p.m.–5:15 p.m.

Abstract Presentation: Effects of ATP1A3 Mutations on Default Mode Network Connectivity Christopher T. Whitlow, Winston Salem, NC

5:15 p.m.–5:30 p.m.

Discussion Faculty

The remaining week’s topics and times are: Interpretations of Genetic Results

Monday, 1:00 p.m.–3:00 p.m.

Stem Cells

Tuesday, 1:00 p.m.–3:00 p.m.

Immunotherapies in Neurological Disease

Wednesday, 1:00 p.m.–3:00 p.m.

Wearable Technology

Wednesday, 3:30 p.m.–5:30 p.m.

The Brain Across the Menstrual Cycle

Thursday, 3:30 p.m.–5:30 p.m. 

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Sunday, May 5, 2019 • AANextra

Abstracts and authors include: 1:00 p.m.–1:05 p.m.

Welcome to Invited Science Kiran Thakur, MD, New York, NY John D. England, MD, FAAN, New Orleans, LA

1:05 p.m.–1:20 p.m.

Acute Encephalitis Syndrome in Eastern Uttar Pradesh, India: Changing Etiological Understanding Manoj Murhekar, MBBS, MD, New Delhi, India

1:20 p.m.–1:35 p.m.

Molecular and Serological Discovery in CNS Infectious Diseases Nischay Mishra, PhD, New York, NY

1:35 p.m.–1:50 p.m.

Clinical and Epidemiological Features of Enterovirusassociated Acute Flaccid Myelitis Kevin Messacar, MD, Aurora, CO

1:50 p.m.–2:05 p.m.

EV-D68: Lessons from Murine Models and Neuronal Cell Culture Kenneth L. Tyler, MD, FAAN, Aurora, CO

2:05 p.m.–2:35 p.m.

Tapping into CNS Reservoirs: Single Cell RNA Sequencing of CSF in HIV Serena Spudich, MD, New Haven, CT

2:35 p.m.–3:00 p.m.

Viral Triggers of Autoimmune Encephalitis Josep O. Dalmau, MD, PhD, FAAN, Barcelona, Spain 

Find the Latest Research at Today’s Poster Session Today’s poster session runs from 11:30 a.m. to 6:30 p.m., with author standby taking place daily between 5:30 p.m. and 6:30 p.m. To help you navigate your way to the breakthrough research of most interest to you, each of the five sessions in this year’s hall are arranged in 10 topic-related “neighborhoods.” The example below shows how making your way to your favorite poster is now as easy as 1-2-3.

In addition, tours of similar-themed posters will occur daily during the poster hall’s open hours to help visitors focus in on their areas of interest.

Publication Code Example: P1.2-003 P1 = Poster Session Number 2 = Neighborhood 003 = Poster Board Number

Check out what’s in each neighborhood during today’s poster session: 

Poster Session 1 1. Aging, Dementia, Cognitive, and Behavioral Neurology: 1-001 to 1-031 2. Autoimmune Neurology; MS and CNS Inflammatory Disease: 2-001 to 2-107 3. Cerebrovascular Disease and Interventional Neurology: 3-001 to 3-066 4. Neuromuscular Disease and Clinical Neurophysiology (EMG): 4-001 to 4-039 5. Epilepsy/Clinical Neurophysiology (EEG): 5-001 to 5-035 6. Neuro-oncology; Child Neurology and Developmental Neurology: 6-001 to 6-070 7. Autoimmune Neurology/MS and CNS Inflammatory Disease ePosters: 7-001 to 7-010 8. Movement Disorders: 8-001 to 8-053 9. Neuro-ophthalmology/Neuro-otology; General Neurology; Research Methodology, Education, and History; Neuroscience Research Prize Recipients: 9-001 to 9-084 10. Headache: 10-001 to 10-026

1 2 3

1-001-1-031

2-001-2-107

3-001-3-066

4 5 6

4-001-4-039

5-001-5-035

6-001-6-070

7

7-001-7-010

ePosters

8 9 10

8-001-8-053

9-001-9-081

10-001-10-026

Expanded Symposium Offers Robust Opportunities for Medical Students Through funding from the Conrad N. Hilton Foundation, the popular Medical Student Symposium returns for a second year to the 2019 Annual Meeting with an updated and expanded program designed to offer medical students an even more immersive and engaging exploration of the many exciting neurology career options and unparalleled networking opportunities.

The inaugural event at last year’s meeting in Los Angeles was a huge success, with more than 200 attendees, half of those being scholarship recipients. For

2019, students can once again expect to experience physician-led treatment and diagnosis demonstrations, meet with physicians from various subspecialties, and take part in a fun pop culture session where students can see how neurology is portrayed in pop culture and then hear about neurologists’ experiences treating patients with similar conditions.

“Many of the students attending this symposium are able to do so through AAN scholarships made possible by a grant from the Conrad N. Hilton Foundation,” said A. Gordon Smith, MD, FAAN, chair

of the Education Committee and principal investigator on the Hilton grant.

“We are excited to offer these activities so that Smith medical students can experience the exciting advances in neuroscience and meet a diverse group of inspiring neurologists. We hope that many will choose to enter our field.” 

Sunday, May 5, 2019 • AANextra

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What Excited You Today at #AANAM?

SUNDAY, MAY 5 11:30 A.M.–1:00 P.M. Locations: Exhibit Hall C (limited quantities available at Broad Street Atrium)

Boxed Lunch Menu

Join the conversation at #AANAM Justin Martello @MartelloMD

You know you’ve made it when you made the #AANAM Twitter wall!

Lunch Options Option I:

Smoked Turkey Wrap with Brie and Cranberry Mayo Chips Fruit

Option II Vegan/Vegetarian/ Gluten Free:

Grilled Eggplant and Hummus Wrap Chips Fruit

Almuerzos con Colegas

12:00 p.m.–12:45 p.m.

Exhibit Hall, zona de almuerzo Reunámonos a comer con colegas hispanoparlantes del mundo para charlar sobre temas de interés común. Temas de hoy: Perlas clínicas y solicitando una residencia o subespecialidad en neurología.

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Sunday, May 5, 2019 • AANextra

Kasra John Sarhadi @kasrajohn

First 12 hours of #AANAM and already figured out what I want to do for the rest of my life?

I’d call that a successful day 1.

Jennifer Molano @JRVMol

#AANAM #JoyRounds - It’s officially day one!! So many joyful moments already, including running into two of the newest members of the Live Well Lead Well (LWLW) family after my morning talk.

What joyful moments have you had today? @AANMember

DISCOVER EMERGING SCIENCE IN NEUROLOGY FROM GENENTECH Sunday, May 5th 12:15 pm and 3:15 pm

Tuesday, May 7th 12:00 pm | 1:00 pm | 2:00 pm | 3:00 pm

Genentech Pipeline Presentation

Neuromyelitis Optica Spectrum Disorder Presentation

Dr Susan Begelman, MD, FACC

Dr Adil Javed, MD, PhD

Vice President, Spectrum Medical Unit | US Medical Affairs | Genentech Inc. San Francisco, California

Associate Professor of Neurology The University of Chicago Chicago, Illinois

Monday, May 6th 12:30 pm and 2:30 pm

Wednesday, May 8th 12:00 pm | 1:00 pm | 2:00 pm | 3:00 pm

Spinal Muscular Atrophy Presentation Dr Claudia A. Chiriboga, MD, MPH

Multiple Sclerosis Presentation

Professor of Neurology and Pediatrics Division of Pediatric Neurology Columbia University Medical Center New York, New York

Dr Mark Cascione, MD Tampa Neurology Associates South Tampa Multiple Sclerosis Center Tampa, Florida

Monday, May 6th 11:30 am and 3:30 pm Huntington’s Disease Presentation Dr Victor Sung, MD Associate Professor, UAB Department of Neurology, Division of Movement Disorders Director, UAB/HDSA Huntington’s Disease Center of Excellence Birmingham, Alabama

Come to booth 2329 to learn about Genentech Neurology or visit us at roche.com/neuroscience

© 2019 Genentech USA, Inc. All rights reserved. OCR/021919/0046a 04/19

+

LEADERSHIP IN NEUROSCIENCE. A LEGACY of helping patients.

When you are a pioneer, you go places that others haven’t.

You take risks that others wouldn’t. You dare to think that the impossible isn’t.

Since 1978, Biogen has pioneered new thinking and new therapies to help patients worldwide. And it’s why Biogen continues to investigate treatments for some of neuroscience’s biggest challenges, including multiple sclerosis, spinal muscular atrophy, Parkinson’s disease, and Alzheimer’s disease.

Discover more at Biogen.com ©2019 Biogen. All rights reserved. 04/19 FCH-US-5110