Virtual vs In-Person Neurologic Ambulatory Care

Dr. Matthew Barrett talks with Dr. Elan Louis about the incidence and prevalence of mild cognitive impairment and dementia in essential tremor and what these findings may mean for patient care and future research. Read the related article in Neurology®. Disclosures can be found at Neurology.org.

Dr. Katie Krulisky talks with Dr. Kelsey Smith about the impact of menopause on women with epilepsy, including therapeutics and clinical management during midlife. Read the related article in Neurology®Clinical Practice. Disclosures can be found at Neurology.org. Podcast Transcript: Dr. Jose Merino: This is Jose Merino, Editor-in-Chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening and have a great week. Dr. Katie Krulisky: Hello, and welcome to this episode of the Neurology Podcast. This is Katie Kruliski from the VA and University of Utah in Salt Lake City, Utah. Today, I have the pleasure of talking with Kelsey Smith. She's a neurologist and epileptologist at Mayo Clinic in Rochester, Minnesota. We will be discussing her recent paper published in the Neurology Clinical Practice Journal titled The Menopause Transition and Epilepsy: A Focus on Therapeutics. Welcome, Kelsey, and thank you for joining us. Dr. Kelsey Smith: Thank you so much for having me. I'm really excited to be here today to talk about this paper and this really important topic. Dr. Katie Krulisky: Yes. Your paper highlighted a staggering statistic, that women spend approximately 40% of their lives post-menopause. That shook me when I was reading this for a presentation on management of women in epilepsy. Being a woman, I felt totally blindsided by the statistic. I've never thought about it this way. I feel like so much of the emphasis of our clinical practice in epilepsy is choosing the right medications for pregnancy. And there is a lack of information and focus on women in perimenopause and post-menopause, even though a much larger percentage of the lifespan is spent in this phase. Let's go ahead and start with the clinical scenario. A 45-year-old woman with focal epilepsy is having some symptoms attributed to perimenopause and is interested in pursuing hormonal treatments. As her epileptologist, what is your approach to counseling her based on the current available data? Dr. Kelsey Smith: And when it comes to patients like this, it's a very important topic. And the first thing is that it really requires both an individualized and multidisciplinary approach. So I think first as an epileptologist, I want to understand all I can about her epilepsy, what the current seizure control is, what the current therapy is, what the epilepsy's been like over other life stages if she's had epilepsy no earlier, to understand how seizures may have been during menstrual cycles to know if there's kind of a hormonal driver of seizures that's been noticed through the lifespan. And then also I really want to understand about her menopause symptoms. What are the symptoms that are really bothering her that she's hoping to start the hormonal therapy for? And are those symptoms things like vasomotor symptoms or sleep disturbances? And are those actually also influencing her current seizure control? If the vasomotor symptoms are waking her up at night and she's not getting good rest, is this lowering the seizure threshold and actually driving worse seizure control? Understanding all of this background's really important. And then to discuss with her what the data is about menopausal hormonal therapy and how it's related to epilepsy, how that data is really limited. And so we don't have a lot of data to go off of to provide counseling in this scenario. And all the studies that have really looked at this topic are really quite old, over 20 years old and have not used the same formulations of menopause hormonal therapy we use nowadays. And a lot of these studies didn't even use the anti-seizure medicines that we use nowadays. It's important to work with a patient like this and really let her know that despite the limited data, that epilepsy itself should not be a strict contraindication to considering menopausal horm

Dr. Margarita Fedorova talks with Dr. Pascal Geldsetzer about how the herpes zoster vaccination may have neuroprotective effects, potentially delaying or preventing dementia. Read the related article in The Lancet Neurology. Disclosures can be found at Neurology.org. Podcast Transcript: Dr. José Merino: This is José Merino, editor-in-chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening and have a great week. Dr. Margarita Fedorova: Hi, this is Margarita Fedorova and I'm a neurology resident at the Cleveland Clinic. Today, we're exploring a study that speaks to an idea that's been building for a few years now, that vaccination itself might be neuroprotective. I'm here with Pascal Geldsetzer, a physician and epidemiologist at Stanford University. Pascal is the author on a paper published in the February 2026 issue of Lancet Neurology titled "Herpes Zoster Vaccination and Incident Dementia in Canada: An Analysis of Natural Experiments." What makes the study different is how they got at the question. When Ontario started publicly funding the shingles vaccine, eligibility came down almost entirely to date of birth. People born a few weeks on one side of a cutoff could get the vaccine for free, and people born a few weeks on the other side could not. That left Pascal and his colleagues with two groups of older adults who should be alike in essentially every way, except their access to the vaccine. And they asked whether those groups went on to develop dementia in different rates. We wanted to bring Pascal to the podcast because this is a question our patients are already asking us in clinic, and because vaccination is one of the few things we can offer an older adult that might actually protect the brain. Pascal, welcome to the podcast. Dr. Pascal Geldsetzer: Thank you very much for having me. Dr. Margarita Fedorova: Let's start with a take-home message. If I'm rounding with a team tomorrow and I get to teach them one thing from your paper, one thing I want them to still remember six months from now, what should that be? Dr. Pascal Geldsetzer: I think it is that for shingles vaccination and dementia, we now have a body of evidence from observational data that we're usually never able to obtain in terms of the fact that we are able to get at cause and effect in a much more plausible way than we are usually able to. And we can say here now that shingles vaccination may well have a delaying or preventing effect on the dementia disease process. Dr. Margarita Fedorova: Before we get into your study, give us the background. We tend to think about dementia in terms of amyloid, tau, vascular risk, and lifestyle. Where do vaccines come into it? And is this really a shingles story or is it something broader about vaccination and brain health in older adults? Dr. Pascal Geldsetzer: Yeah, so unfortunately we don't know exactly. And so of course, broadly speaking, it could be either through reducing reactivations of the chickenpox virus or varicella zoster virus, which we know is a neurotropic virus, which we know reactivates throughout life. And so reducing these reactivations and probably accompanying neuroinflammatory processes may well have benefits. But there may also be a broader potentially virus-independent immune mechanism at play here that may also apply to other vaccines than just shingles vaccination. So we don't really understand the mechanism yet. It's a very interesting and fascinating area of research and hopefully we'll learn more in the future. Dr. Margarita Fedorova: We already knew from a lot of prior work that shingles vaccine was associated with a lower risk of dementia, but in the paper you were direct that those earlier studies can't really speak to cause and effect, and that's a really big part of why this one matters. What goes wrong when we sim

Dr. Jason Crowell talks with Dr. John McDonough about the historical and economic factors shaping the US healthcare system and why understanding these systemic forces matters for neurologists and patient care. Read the related article in The Harvard Gazette. Disclosures can be found at Neurology.org. Podcast Transcript: Dr. Jose Merino: This is Jose Merino, Editor-in-Chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening and have a great week. Dr. Jason Crowell: Hey, this is Jason Crowell from Norton Neuroscience Institute in Louisville, Kentucky. Thanks for listening to today's Neurology Podcast. Most of our audience members are practicing neurologists, you're in training or you're in an academic setting or in private practice. And for those of us who are in practice, we are well aware of the challenges of helping our patients access drugs, getting prior authorizations approved, the other areas of friction that exist in our healthcare system. And I would say that whether we realize it or not, these areas of friction are symptoms of larger choices about how our hospitals and clinics operate. And so to help us think about these things, today we've invited John McDonough to join us. John is a professor of public health practice at the Harvard T.H. Chan School of Public Health. We recently read an article about John's work published August 18th, 2026 in the Harvard Gazette and wanted to invite him to join us today. So John, thank you so much for your time. Dr. John McDonough: Pleasure to be here with you, Jason. Thanks for inviting me. Dr. Jason Crowell: So John, in this piece that I read in the Harvard Gazette that was describing some of the work you've done, you point to a specific historical pivot around 1980 when US healthcare spending grew at a pace that's disconnected from the rest of the industrialized world. And that was 40 to 50 years ago, so most of our audience does not have experience with the practice of medicine prior to that time. The title of your upcoming book is America's Wrong Turn: US Healthcare in the Neoliberal Era. Can you help summarize what you mean by this wrong turn that happened? And also, can you just give us some background about what you mean by this neoliberal era? Dr. John McDonough: So I've been influenced by a Yale political scientist, Stephen Skowronek, who suggests that there's a helpful way to look at American political economic history, not through the lens of individual presidential terms like say the Nixon era or the Reagan era or the Obama era, but to look at larger multi-decade politico economic eras where there are dominant political strains. And Skowronek says we've had five of these eras over the 250 years. But just to talk about the two most modern ones that are most relevant to our discussion here. The first one started in 1933 with Franklin Delano Roosevelt's inauguration as president in the midst of the Great Depression. And inaugurating an era that became known as the New Deal era, which was an era of muscular federal and state governmental leadership and guidance in terms of steering the economy toward greater productivity, toward higher wages, toward all different kinds of innovations like social security and Medicare and Medicaid. That era didn't end when FDR died. It went on until 1980 when it collapsed in the end of the Jimmy Carter presidency with upset and anger over what was then called stagflation, the Iran hostage crisis, the gas crisis from the Middle East with OPEC. So it was succeeded in 1980 with the inauguration of Ronald Reagan. And Ronald Reagan came in openly talking about let's move away from the New Deal era. It's not working anymore. We have to go forward. And that era was in some ways, people call it the neoliberal era because it was an era defined by a set of economists like Milton Fried

Dr. Shuvro Roy talks with Dr. Daniel Daneshvar about the prevalence of CTE at death among NFL players and the association between CTE severity and the risk of dementia. Read the related article in the BMJ. Disclosures can be found at Neurology.org. Podcast Transcript: Dr. Jose Merino: This is Jose Merino, Editor-in-Chief of the Neurology family of journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening, and have a great week. Dr. Shuvro Roy: Hi, this is Shuvro Roy from the University of Washington, and welcome to today's Neurology Podcast. We'll be covering a study titled Prevalence of Chronic Traumatic Encephalopathy and Death in National Football League Players: A Retrospective Population-Based Cohort Study from 2008 to 2001, published in BMJ. We're joined by lead author Daniel Daneshvar, Chair of Spaulding Rehabilitation at Harvard Medical School. Dan, thanks for joining us. Dr. Daniel Daneshvar: Great to be here. Thanks for having me. Dr. Shuvro Roy: So Dan, this study has already received widespread national attention, but please give us the headline. What did you find and what's the number one thing that you want listeners to remember? Dr. Daniel Daneshvar: So this was a study looking at how commonly this specific neurodegenerative disease called chronic traumatic encephalopathy or CTE, how commonly this occurs in a cohort with a lot of repeated traumatic brain injury exposure, namely former National Football League professional football players. And what we found was that between the years of 2016 and 2021, so for that five-year period, the absolute minimum prevalence of CTE at death in this group was 25%. The absolute maximum was 98%, and the true rate is somewhere in that range. Now, for context, in the general population in community cohort studies, the prevalence of this pathology is somewhere south of 1%. Dr. Shuvro Roy: And what does this study add to our current understanding of CTE and neurologic disease associated with head trauma? Dr. Daniel Daneshvar: So we've long known that individuals who have experienced repeated traumatic brain injury exposure, whether through sports like NFL, NHL players, professional soccer players, whether through occupational exposures like in the military or as in individuals who experience intimate partner violence, we've long known that these individuals have higher rates of neurodegenerative disease. But what we haven't known is just how much higher that rate is. And what this study has shown us is first off that this is alarmingly high in former professional football players at death. And then the second thing that this study shows us is that this pathology is unsurprisingly very linked to clinical symptoms, including with more severe disease, cognitive impairment that's so severe it results in dementia, meaning impairment in someone's ability to perform activities of daily living, including feeding, bathing, dressing, grooming, toileting, those kinds of things. Dr. Shuvro Roy: As you pointed out, your primary finding was that there was this maximum versus minimum prevalence, which ranged from anywhere from 98% to 25%, so obviously a wide range. But to help us understand this study, can you walk us through that methodology, the minimum and maximum prevalence approach? Why a range rather than a single estimate? And you mentioned that the number is likely somewhere in between. Where do you think that true number sits, if we even can estimate? Dr. Daniel Daneshvar: So to understand why there's a range, it's helpful to understand how we got to these numbers. And so when we looked at the individuals who had CTE who played in the NFL across three brain banks, mostly the BU CTE Center, but also the Mount Sinai Brain Bank and the UCSF Alzheimer's Disease Center Brain Bank, when we combined all NFL players across these brain banks, we found that N