neurology

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The Pursuit of Gender Equality: A WISE Idea

Siddharth Sehgal, MD

Each year, the second Sunday of May is observed as Mother’s Day. This day provides an opportunity to celebrate and honor the mothers in our lives. Mothers make many sacrifices to ensure that their kids lead healthy and successful lives. They continually strive to balance their family and professional responsibilities. Women often put their careers on hold in order to raise their families. Even though there has been some improvement in recognition of gender bias issues inside workplaces, women are more likely to face family related interruptions in their careers1. This social construct along with the culture of bias and discrimination in the workplace has led to women being grossly underrepresented in positions of leadership and influence, healthcare being no exception to this phenomenon. Lower salaries, a work culture that favors men, and sexual harassment are some grave challenges that women encounter in their professional lives. There has been a growing awareness of this problem in the last few years, thanks to efforts lead by organizations such as TIME’S UP.

Within the field of academic Neurology, there has been a growing call to recognize these issues related to gender disparity2. Women are underrepresented both as recruited subjects in neurological clinical trials and also as project leaders for those clinical trials. A recent observational study found that only about 31% of all academic Neurology positions are held by women; this disparity widens as the academic rank increases with only 13.8% of Neurology professors being women3. Men also appear to have a higher rate of academic publications than women, with larger gaps seen at junior faculty positions. Similar gender inequities have been noted in other specialties including neurosurgery, orthopedic surgery and radiology4. However, this disparity cannot be explained by a lack of female representation in medical schools. American Association of Medical Colleges data from 2017 revealed that female students accounted for 50.7% of all enrollees in medical schools, which is a 9.6% increase since 20155.

Similar to the business world, social media has played an important role in increasing recognition and reporting of gender disparities within the field of Neurology. Women Neurologists Group (WNG) was formed in 2015 as a closed Facebook group, which now has more than 2,000 members and also has more than 1,000 followers on Twitter (@WNGtweets). This group of “Women neurologists networking and supporting each other” provides a platform for women neurologists to discuss, among other topics, issues related to maintaining the family-work balance. According to Dr. Kathrin Lafaver (@LaFaverMD, Assistant Professor of Neurology at University of Louisville) who is one of the founding members of the group, this forum has provided a safe space for women to share their experiences and opinions about a variety of subjects including the problem of gender disparity and it’s potential solutions6. The American Academy of Neurology set up a task force to study the underlying causes of gender disparity in the field and put forth recommendations to tackle this problem. As part of this initiative, the academy established a “Women leading in Neurology” program in 2017 which aims to help women neurologists gain the appropriate leadership skills to advance their careers and attain top tier positions within their field.

Gender disparity in healthcare is obviously not an issue unique to the United States and is becoming recognized around the world. Last year, the European Stroke Organization (ESO) established WISE (Women Initiative for Stroke in Europe), with its main goal of improving stroke care for women across Europe. The group aims to increase awareness about stroke risk factors and symptoms  in women and to ensure gender equity when it comes to stroke care in the continent. One of the objectives of the group is to support women clinicians and researchers in the field of stroke medicine and to help them attain leadership positions. The group organized their second annual WISE stroke leadership workshop earlier this week in conjunction with the ESO conference in Milan, Italy. During this workshop, Dr. Natalia Rost (@nsanar Professor of Neurology, Harvard University) represented the STROKE journal and provided a call for action to increase female leadership in the field of academic stroke neurology. She advocated for increased transparency within academic departments, recognizing achievements and contributions of women scientists and promoting diversity within scientific committees and editorial boards7. These are important steps toward establishing a culture of equality and fairness within the field of medicine.

While there is a clear commitment within neuroscience and the medical community at large to promote diversity inside academic and clinical arenas; a lot still needs to be done to help women maximize their potential as clinicians, educators and researchers. At this time of the year when we celebrate Mother’s day, let’s all pledge to support the women in our lives so that they can attain all the personal and professional success that they deserve.

 

References:

  1. https://www.pewresearch.org/fact-tank/2015/03/10/women-still-bear-heavier-load-than-men-balancing-work-family/
  2. Silver JK, Bank AM, Slocum CS, Blauwet CA, Bhatnagar S, Poorman JA, et al. Women physicians underrepresented in American Academy of Neurology recognition awards. Neurology. 2018;91:e603–e614
  3. McDermott M, Gelb DJ, Wilson K, Pawloski M, Burke JF, Shelgikar AV, et al. Sex differences in academic rank and publication rate at top- ranked US neurology programs. JAMA Neurol. 2018;75:956–961
  4. Jagsi, Reshma et al. Sex, Role Models, and Specialty Choices Among Graduates of US Medical Schools in 2006–2008. Journal of the American College of Surgeons , Volume 218 , Issue 3 , 345 – 352
  5. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/5c/26/5c262575-52f9-4608-96d6-a78cdaa4b203/2017_applicant_and_matriculant_data_tables.pdf
  6. https://journals.lww.com/neurotodayonline/FullText/2018/07190/Neurologists_on_Social_Media__The_Women.13.aspx
  7. Charlotte Cordonnier, Shelagh B. Coutts, Karen C. Johnston, Natalia S. Rost. Crucial Role of Women’s Leadership in Academic Stroke Medicine You Can’t Be What You Can’t See. https://doi.org/10.1161/STROKEAHA.118.024788
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Statins for Chronic Subdural Hemorrhage: Pleiotropy and Pathophysiology

Neal Parikh, MD

HMG-CoA reductase inhibitors, or statins, are widely used for lipid lowering to risk the risk of cardiovascular disease. Based on the suspected pleiotropic effects of statin medications, such as their anti-inflammatory and endothelial stabilization effects, trials of statin medications for non-cardiovascular indications have proliferated.

Statin medications have been tested for indications ranging from acute respiratory distress syndrome (ARDS) to chronic obstructive pulmonary disease (COPD). Statin therapy was not shown to be beneficial for these indications. So, I was pleasantly surprised to come across a JAMA Neurology publication reporting on a randomized trial of statin therapy for chronic subdural hemorrhage.

Subdural hemorrhage is a common and morbid condition in older individuals. To date, the primary treatment has been neurosurgical. Neurologists are involved in the care of these patients primarily to control seizures.

Jiang and colleagues report the results of a Phase II, randomized, placebo-controlled, double-blind, multi-center trial in which 169 patients with chronic subdural hematoma were randomized to receive atorvastatin or a placebo.1 They followed these patients for up to 24 weeks, and measured hematoma volume, rates of surgery, and clinical outcomes.

Although the size of the study population limits certainty in the results, their results were remarkably consistent across several outcomes, both radiographic and clinical: patients randomized to atorvastatin did better. Remarkably, patients randomized to atorvastatin also less frequently required surgery.

If confirmed, the results of this study speak to the pleiotropic effect of statin medications and inform our understanding of chronic subdural hemorrhage pathophysiology – perhaps further implicating inflammation and endothelial dysfunction. In addition to being clinically useful, these results underscore the value of persistence in clinical investigation.

 

1Jiang et al. Safety and Efficacy of Atorvastatin for Chronic Subdural Hematoma in Chinese Patients. JAMA Neurology. 2018 [E-pub ahead of print].

 

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.
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Stroke Advances In 2017: An Overview, Reflections, And A Call To Action

Neal Parikh, MD

2017 gave us numerous dramatic advances in stroke neurology. We were treated to compelling data regarding the favorability of patent foramen ovale closure in well-selected individuals with cryptogenic stroke.1,2,3 Endovascular therapy matured with the extension of the treatment time window.4 We even saw promising rehabilitation data regarding surgical nerve transfer for chronic spastic arm paralysis.5 Conversely, some widely used therapies such as head positioning6 and oxygen supplementation7 were shown to be ineffective. The list of figurative leaps goes on.
 
As an early career neurologist in a vascular neurology fellowship, I found myself reflecting on the year’s advances, in part to find my place in the field. While thoroughly inspired by the major advances of 2017, I couldn’t help but dwell on the findings of a secondary analysis of the Insulin Resistance Intervention After Stroke (IRIS) trial.
 
The IRIS trial randomized non-diabetic patients with stroke or TIA to pioglitazone or placebo and followed them for several cardiovascular outcomes.8 The primary analysis was published in 2016; patients randomized to pioglitazone had a lower risk of recurrent stroke or heart attack.
 
In a secondary analysis published in Neurology in 2017, Katherine Epstein and colleagues evaluated the association of smoking cessation and recurrent stroke, myocardial infarction, and death.9 In an observational design, they followed individuals who were smoking at the time of their index stroke and quit, and compared them to individuals who did not quit. The 5-year risk of stroke, MI, or death was 16% in quitters versus 23% in non-quitters (adjusted hazard ratio 0.66). Quitters had half the risk of death compared to non-quitters.
 
Granted, this was observational data. Individuals who were motivated to quit smoking may have made other healthy decisions. And, these results are not ground breaking either – we know that smoking cessation is “the most important thing one can do for one’s health” (as we are taught to tell patients in medical school).
 
Regardless, the results are memorable. While advances in acute stroke care, surgical interventions, and novel pharmacotherapies are a testament to scientific ingenuity, we must not neglect the low-hanging fruit. Are neurologists trained to effectively aide in smoking cessation? What are the best tools for this purpose? Are such services adequately incentivized? Some argue that advances in stroke systems of care may now yield more public health gains than scientific advances. If we accept this notion, we must acknowledge that it does not apply exclusively to the acute stroke treatment arena.
 
Included in the AHA/ASA’s Life’s Simple 7 paradigm, and a focus of the FDA’s newest public education campaign entitled “Every Try Counts”,10 smoking cessation deserves our fullest attention. To support these programs and to empower our patients to quit, we must identify and incorporate the best tools available into our practice.  

References

  1. Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent Foramen Ovale Closure or Anticoagulation vs Antiplatelets after Stroke. NEJM. 2017:377;1011-1021.
  2. Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. NEJM. 2017:377;1022-1032.
  3. Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, et al. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. NEJM. 2017:377;1033-1042.
  4. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 Hours After Stroke with a Mismatch between Deficit and Infarct. NEJM. 2018:378;11-21.
  5. Zheng MX, Hua XY, Feng JT, Li T, Lu YC, Shen YD, et al.
  6. Anderson CS, Arima H, Lavados P, Billot L, Hacket ML, Olavarria VV, et al. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. NEJM. 2017:376;2437-2447.
  7. Roffe C, Nevatte T, Sim J, Bishop J, Ives N, Ferdinand P, et al. Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke: The Stroke Oxygen Study Randomized Clinical Trial. JAMA. 2017:318;1125-1135.
  8. Kernan WN, Viscoli CM, Furie KL, Young LH, Inzucchi SE, Gorman M, et al. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. NEJM. 2016:374;1321-31.
  9. Epstein KA, Viscoli CM, Spence JD, Young LH, Inzucchi SE, Gorman M, et al. Smoking cessation and outcome after ischemic stroke or TIA. Neurology. 2017:89;1723-1729.
  10. Every Try Counts Campaign. Food and Drug Administration. https://www.fda.gov/tobaccoproducts/publichealtheducation/publiceducationcampaigns/everytrycountscampaign/default.htm

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @ NealSParikhMD and contributes to Blogging Stroke as a blogger.