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Ge S, Dune L, Liu M, Fu G, Ma H, Hu J, Lin X, Li J. Feasibility of therapeutic Chinese massage (tui na) for peripheral neuropathy among people with human immunodeficiency virus: findings of a pilot randomized controlled trial. Front Neurol 2023; 14:1148150. [PMID: 38107641 PMCID: PMC10722432 DOI: 10.3389/fneur.2023.1148150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 10/25/2023] [Indexed: 12/19/2023] Open
Abstract
Background Peripheral neuropathy (PN) is prevalent in people with human immunodeficiency virus (PHIV) with no Food and Drug Administration-approved treatment. Therapeutic Chinese massage (TCM) is a promising noninvasive and non-harmful intervention for HIV-related PN. However, relevant research is lacking. The purpose of this study is to evaluate the feasibility of TCM for HIV-related PN. Method We conducted a pilot, single-centered, two-arm, double-blinded, randomized controlled trial. Twenty eligible PHIV were recruited primarily from the AIDS Foundation Houston, Inc. in Texas and were randomly assigned into two groups. Ten participants in the intervention group received three weekly 25-min TCM sessions by a certified TCM therapist. The remaining ten control group participants received the same therapist's three weekly 25-min placebo massage sessions on their lower extremities. The outcome was the feasibility of this study as measured by recruitment and completion rates, participant safety, and treatment adherence and compliance, as well as the effect size of the intervention. Results The study population comprised 20 PHIV (mean age 55.23). This study showed high feasibility as measured by a high rate of recruitment, a 100% rate of completion, and zero serious adverse events. As we inquired 21 respondents for eligibility for the study, all except one had HIV-related PN. All respondents were willing to participate in the study and adhered to the group assignment after they enrolled in the study. The participants' baseline pain was at a medium to a high level (6.30 [2.15] out of 10). Conclusion Chinese massage is a feasible intervention in PHIV. Future relevant randomized controlled trials are expected. Clinical trial registration https://clinicaltrials.gov/, NCT05379140.
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Affiliation(s)
- Song Ge
- Department of Natural Sciences, University of Houston-Downtown, Houston, TX, United States
| | - Linda Dune
- Department of Natural Sciences, University of Houston-Downtown, Houston, TX, United States
| | - Minhui Liu
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Guojing Fu
- Department of Tuina, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Haixia Ma
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Jiale Hu
- Department of Nurse Anesthesia, College of Health Professions, Virginia Commonwealth University, Richmond, VA, United States
| | - Xuechun Lin
- Hubei Key Laboratory of Food Nutrition and Safety, Department of Nutrition and Food Hygiene, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Junxin Li
- Johns Hopkins University School of Nursing, Baltimore, MD, United States
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Yitbarek GY, Addis WD, Dagnaw FT, Ayehu GW, Melese BD, Amare TJ, Mulu AT, Bayih WA, Ashagrie BK, Zewde EA, Munye T, Chanie ES, Ebabu W, Alemayehu SA, Arage G, Teshome AA. Magnitude of Peripheral Sensory Neuropathy and Associated Factors Among HIV/AIDS Clients Receiving Care at Public Health Institutions, Northwest Ethiopia. Mol Pain 2022; 18:17448069221089593. [PMID: 35266800 PMCID: PMC9016588 DOI: 10.1177/17448069221089593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: In the mid-1990s, the development of combination antiretroviral
therapy converted HIV infection into a chronic condition, with newly diagnosed
patients now living longer than the general population. HIV affects both the
central and peripheral nerve systems, resulting in a variety of clinical
problems, including peripheral neuropathy, which is a common neurological
consequence. Despite this, there is a scarcity of data on the extent of
peripheral sensory neuropathy and its underlying factors in Ethiopia,
necessitating this study. Objective: The primary goal of this study is to assess
the degree of peripheral sensory neuropathy and its related factors among
HIV/AIDS clients on follow up at public health institutions in Northwest
Ethiopia. Methodology: Institution based cross-sectional study was conducted
from November 1 to 30 December 2020 at selected south Gondar zone public health
institutions ART clinic. Multistage sampling technique was used to select the
study participants. Standardized Questioner adapted from other study was used to
collect the data. Moreover, Brief Peripheral Neuropathy Screening tool (BPNS)
was used to assess peripheral sensory neuropathy. The data were entered with
epi-data manager version 4.4 and analyzed using STATA version 16. Result: A
total of 555 adult PLWHIV agreed to participate in the study, resulting in a
response rate of 96.8%. The prevalence of Peripheral sensory neuropathy was
32.25, 95% CI (28.28, 36.26). The participant’s age, DM comorbidity, viral load
level, and disease clinical stage were all found to have a statistically
significant association with peripheral sensory neuropathy. Conclusion:
Peripheral sensory neuropathy was incredibly common. Accordingly, peripheral
sensory neuropathy was found considerably associated with age, viral load level,
stage of the disease, and DM comorbidity. It is vital to integrate routine
peripheral sensory neuropathy screening strategies for clients who are on ART
follow up for prevention and early identification of the problem.
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Kuka WP, Shah J, Alam U, Shah R, Sokhi DS. Clinical Characteristics of Peripheral Neuropathy in Kenyan Patients with HIV Infection Compared with Patients with Concurrent HIV Infection and Diabetes Mellitus. Diabetes Ther 2022; 13:441-451. [PMID: 35157232 PMCID: PMC8934803 DOI: 10.1007/s13300-022-01205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Persons living with human immunodeficiency virus (HIV) are living longer and at risk of non-communicable diseases, including diabetes mellitus (DM). Both HIV and DM place patients at risk of peripheral neuropathy (PN). Our aim was to demonstrate the prevalence and characteristics of PN in our population of patients with HIV infection compared with concomitant HIV and DM. METHODS A prospective cross-sectional study was performed at the Aga Khan Hospital in Nairobi, Kenya. Data were collected on demographics and characteristics of DM and HIV. Symptoms and signs of PN were evaluated by Neuropathy Symptom Score, Neuropathy Disability Score, and 10 g monofilament testing. RESULTS Two groups were recruited, each consisting of 68 patients: (1) HIV only, (2) HIV and DM. The median age of patients was 51 years (IQR 42.8-58.6) and 55% were male. Median duration for HIV was 10 years (IQR 5-12) with a median CD4 count of 524 cells/mm3 (IQR 369-731). Median duration for DM was 1 year with a median glycosylated hemoglobin of 6.7% (IQR 6.6-7.6). Sixty-nine percent of patients with HIV had suppressed viral loads, and 9 patients (6.6%) had a history neurotoxic antiretroviral therapy use. PN was detected in 11 (16%) HIV-only patients, and in 17 (25%) participants who had both HIV and DM (Fisher exact test chi-square = 0.4). Univariate analysis demonstrated older age, high body mass index, and long duration of HIV were associated with an OR of 1.07 (95% CI 1.02-1.11), 1.21 (95% CI 0.46-3.11), and 1.07 (95% CI 0.99-1.15) in the overall group, respectively. CONCLUSION Our study demonstrates a higher but non-significant prevalence of PN in patients with both HIV and DM when compared to HIV alone. HIV disease control had no association with PN presence.
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Affiliation(s)
- Werimo Pascal Kuka
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya.
| | - Jasmit Shah
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya
| | - Uazman Alam
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
- Diabetes and Endocrinology Research, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Reena Shah
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya
| | - Dilraj Singh Sokhi
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya
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Himmelgreen D, Romero-Daza N, Heuer J, Lucas W, Salinas-Miranda AA, Stoddard T. Using syndemic theory to understand food insecurity and diet-related chronic diseases. Soc Sci Med 2020; 295:113124. [PMID: 32586635 DOI: 10.1016/j.socscimed.2020.113124] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 12/28/2022]
Abstract
Syndemic Theory (ST) provides a framework to examine mutually enhancing diseases/health issues under conditions of social inequality and inequity. ST has been used in multiple disciplines to address interacting infectious diseases, noncommunicable diseases, and mental health conditions. The theory has been critiqued for its inability to measure disease interactions and their individual and combined health outcomes. This article reviews literature that strongly suggests a syndemic between food insecurity (FI) and diet-related chronic diseases (DRCDs), and proposes a model to measure the extent of such interaction. The article seeks to: (1) examine the potential syndemic between FI and DRCDs; (2) illustrate how the incorporation of Life History Theory (LHT), into a syndemic framework can help to highlight critical lifeperiods when FI-DRCD interactions result in adverse health outcomes; (3) discuss the use of mixed methods to identify and measure syndemics to enhance the precision and predictive power of ST; and (4) propose an analytical model for the examination of the FI-DRCD syndemic through the life course. The proposed model is more relevant now given the significant increase in FI globally as a result of the ongoing COVID-19 pandemic. The differential impact that the pandemic appears to have among various age groups and by other demographic factors (e.g., race, gender, income) offers an opportunity to examine the potential FI-DRCD syndemic under the lens of LHT.
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Affiliation(s)
- David Himmelgreen
- Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA; USF Center for the Advancement of Food Security & Healthy Communities, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA.
| | - Nancy Romero-Daza
- Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA; USF Center for the Advancement of Food Security & Healthy Communities, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA
| | - Jacquelyn Heuer
- Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA; USF Center for the Advancement of Food Security & Healthy Communities, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA
| | - William Lucas
- Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA
| | - Abraham A Salinas-Miranda
- USF Center of Excellence in MCH Education, Science & Practice, University of South Florida, 13201 Bruce B. Downs Blvd, UPC 523, Tampa, FL, 33612, USA
| | - Theresa Stoddard
- Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107, Tampa, FL, USA
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Saylor D, Nakigozi G, Nakasujja N, Robertson K, Gray RH, Wawer MJ, Sacktor N. Peripheral neuropathy in HIV-infected and uninfected patients in Rakai, Uganda. Neurology 2017; 89:485-491. [PMID: 28679596 PMCID: PMC5539731 DOI: 10.1212/wnl.0000000000004136] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the prevalence, risk factors, and functional impairment associated with peripheral neuropathy in a prospective cohort of adults in rural Uganda. METHODS Eight hundred participants (400 HIV- and 400 antiretroviral-naive HIV+) in the Rakai Community Cohort Study underwent detailed neurologic evaluations including assessment of neuropathy symptoms, functional measures (Patient Assessment of Own Functioning Inventory and Karnofsky Performance Status scores), and neurologic evaluation by a trained medical officer. Neuropathy was defined as ≥1 subjective symptom and ≥1 sign of neuropathy on examination. Neuropathy risk factors were assessed using log binomial regression. RESULTS Fifty-three percent of participants were men, with a mean (SD) age of 35 (8) years. Neuropathy was present in 13% of the cohort and was more common in HIV+ vs HIV- participants (19% vs 7%, p < 0.001). Older age (relative risk [RR] 1.04, 95% confidence interval [CI] 1.02-1.06), female sex (RR 1.49, 95% CI 1.04-2.15), HIV infection (RR 2.82, 95% CI 1.86-4.28), tobacco use (RR 1.59, 95% CI 1.02-2.48), and prior neurotoxic medication use (RR 2.08, 95% CI 1.07-4.05) were significant predictors of neuropathy in the overall cohort. Only older age was associated with neuropathy risk in the HIV+ (RR 1.03, 95% CI 1.01-1.05) and HIV- (RR 1.06, 95% CI 1.02-1.10) cohorts. Neuropathy was associated with impaired functional status on multiple measures across all participant groups. CONCLUSIONS Peripheral neuropathy is relatively common and associated with impaired functional status among adults in rural Uganda. Older age, female sex, and HIV infection significantly increase the risk of neuropathy. Neuropathy may be an underrecognized but important condition in rural Uganda and warrants further study.
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Affiliation(s)
- Deanna Saylor
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Gertrude Nakigozi
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Noeline Nakasujja
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kevin Robertson
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ronald H Gray
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J Wawer
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ned Sacktor
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Woldeamanuel YW, Kamerman PR, Veliotes DGA, Phillips TJ, Asboe D, Boffito M, Rice ASC. Development, Validation, and Field-Testing of an Instrument for Clinical Assessment of HIV-Associated Neuropathy and Neuropathic Pain in Resource-Restricted and Large Population Study Settings. PLoS One 2016; 11:e0164994. [PMID: 27764177 PMCID: PMC5072607 DOI: 10.1371/journal.pone.0164994] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 10/04/2016] [Indexed: 02/02/2023] Open
Abstract
HIV-associated sensory peripheral neuropathy (HIV-SN) afflicts approximately 50% of patients on antiretroviral therapy, and is associated with significant neuropathic pain. Simple accurate diagnostic instruments are required for clinical research and daily practice in both high- and low-resource setting. A 4-item clinical tool (CHANT: Clinical HIV-associated Neuropathy Tool) assessing symptoms (pain and numbness) and signs (ankle reflexes and vibration sense) was developed by selecting and combining the most accurate measurands from a deep phenotyping study of HIV positive people (Pain In Neuropathy Study–HIV-PINS). CHANT was alpha-tested in silico against the HIV-PINS dataset and then clinically validated and field-tested in HIV-positive cohorts in London, UK and Johannesburg, South Africa. The Utah Early Neuropathy Score (UENS) was used as the reference standard in both settings. In a second step, neuropathic pain in the presence of HIV-SN was assessed using the Douleur Neuropathique en 4 Questions (DN4)-interview and a body map. CHANT achieved high accuracy on alpha-testing with sensitivity and specificity of 82% and 90%, respectively. In 30 patients in London, CHANT diagnosed 43.3% (13/30) HIV-SN (66.7% with neuropathic pain); sensitivity = 100%, specificity = 85%, and likelihood ratio = 6.7 versus UENS, internal consistency = 0.88 (Cronbach alpha), average item-total correlation = 0.73 (Spearman’s Rho), and inter-tester concordance > 0.93 (Spearman’s Rho). In 50 patients in Johannesburg, CHANT diagnosed 66% (33/50) HIV-SN (78.8% neuropathic pain); sensitivity = 74.4%, specificity = 85.7%, and likelihood ratio = 5.29 versus UENS. A positive CHANT score markedly increased of pre- to post-test clinical certainty of HIV-SN from 43% to 83% in London, and from 66% to 92% in Johannesburg. In conclusion, a combination of four easily and quickly assessed clinical items can be used to accurately diagnose HIV-SN. DN4-interview used in the context of bilateral feet pain can be used to identify those with neuropathic pain.
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Affiliation(s)
- Yohannes W. Woldeamanuel
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Neurology, Addis Abäba University School of Medicine, College of Health Sciences, Addis Abäba, Ethiopia
- Advanced Clinical Consultation & Research Center, Addis Abäba, Ethiopia
- * E-mail:
| | - Peter R. Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Demetri G. A. Veliotes
- Division of Neurology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tudor J. Phillips
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
- The Pain Relief Unit, The Churchill Hospital, Oxford, United Kingdom
| | - David Asboe
- The Pain Relief Unit, The Churchill Hospital, Oxford, United Kingdom
| | - Marta Boffito
- HIV Medicine and Sexual Health, Chelsea and Westminster Hospital, London, United Kingdom
| | - Andrew S. C. Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
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Microglial content-dependent inhibitory effects of calcitonin gene-related peptide (CGRP) on murine retroviral infection of glial cells. J Neuroimmunol 2015; 279:64-70. [PMID: 25670002 PMCID: PMC4325278 DOI: 10.1016/j.jneuroim.2015.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 12/17/2014] [Accepted: 01/26/2015] [Indexed: 12/22/2022]
Abstract
C57BL/6 (B6) mice develop peripheral neuropathy post-LP-BM5 infection, a murine model of HIV-1 infection, along with the up-regulation of select spinal cord cytokines. We investigated if calcitonin gene-related peptide (CGRP) contributed to the development of peripheral neuropathy by stimulating glial responses. An increased expression of lumbar spinal cord CGRP was observed in vivo, post-LP-BM5 infection. Consequently, in vitro CGRP co-treatments led to a microglial content-dependent attenuation of viral loads in spinal cord mixed glia infected with selected doses of LP-BM5. This inhibition was neither caused by the loss of glia nor induced via the direct inhibition of LP-BM5 by CGRP.
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Abstract
The vast majority of people living with human immunodeficiency virus (HIV) infection reside in resource-limited settings. As compared with resource-rich settings, there are important differences in the epidemiology and outcomes of HIV infection in resource-limited settings. Nonetheless, little HIV neurology research occurs in these regions. We will first review clinical, epidemiological, and translational HIV neurology research originating from resource-limited settings. We will then discuss the barriers to conducting neurologic research, such as limited human resources, diagnostics, and access to medications. Finally, we will review existing initiatives to build capacity for research in resource-limited settings. Despite the barriers, there is growing interest in and opportunities for collaborative international neurologic research. Including diverse viral and human populations from across the globe in research opens possibilities for important implementation science, clinically oriented science, and basic science discoveries.
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Affiliation(s)
- Ana-Claire Meyer
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
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