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Special Article
Mar 2012

The Evolution of Academic Neurology: New Information Will Bring New Meaning

Author Affiliations

Author Affiliations: Department of Neurosciences, University of California, San Diego, La Jolla (Dr Mobley); and Department of Neurology, University of Texas Southwestern Medical Center, Dallas (Dr Rosenberg).

Arch Neurol. 2012;69(3):308-314. doi:10.1001/archneurol.2011.1858

We are on the cusp of what promises to be an era of unprecedented progress in neurology. Even with current fiscal constraints and serious concerns about how health care will be organized and financed, in the next 2 decades progress in neurology and neurological science will create important new insights into understanding the brain as we decipher its disorders and discover and apply effective treatments.

The wealth of new information that will shed light on the structure, function, and dysfunction of the nervous system will drive progress and create unique challenges. This progress will build on as well as force changes in the way we train our students, recruit our faculty, conduct research, apply research findings to practice, and care for patients. Most importantly, the oncoming avalanche of new information, while challenging us to think and act differently, will make it possible as never before to understand and care for our patients.

New information will not just consist of gathering more data points (eg, the ability to resolve more precisely the images generated by neuroimaging tools) but will also come from the analysis and integration of that data. The integration of distinct data sets will allow us to uncover emergent properties of neurological systems. Finally, we will see the emergence of tools that help neurologists test hypotheses using existing data sets. In so doing, neurologists will gain significant new abilities to predict a patient's future clinical course and response to treatments.

The new tools that will be needed to harvest, integrate, and analyze information must become the topic of discussions within our community. Just collecting new information will not be enough; we will need entirely new computing methods and algorithms (http://ivory.idyll.org/blog/aug-11/cloud-not-the-solution.html) to support our ability to understand and care for the nervous system. Having stated the challenges, we are confident that we will meet them. Indeed, we see neurology serving at the leading edge of understanding and exploiting the new information age in neuroscience.

Below, we choose several topics where change is already evident or is likely to occur and where the oncoming changes will significantly impact neurologists, in our view for the good. Be warned that the views expressed are those of an optimist. We hope that readers will accept the view that optimism, rather than blinding one to obstacles to progress, can instead motivate one to uncover stumbling blocks and seek solutions.

The explosion of neuroinformation

Consider for a moment the examination room, or the hospital bed, in 2030. The neurologist, and the patient, will be able to access a body of knowledge exponentially larger than what exists today. Progress in basic neuroscience and the neurobiology of disease will have created a mountain of information; findings will span length and time scales on the order of 109.1 They will also span developmental time from conception to old age and tissue status from normal to pathological. Because neurologists will continue to confront problems that begin with genes and molecules, extend to changes in the properties in neuronal circuits, and result in changes in behavior, they must consider information collected across these many levels of analysis. In 2030, taking care of neurology patients will require neurologists to learn new ways of thinking and acting on information.

In the scenario presented, the patient may present to the neurologist with a new concern of headache. History taking and examination will be completed, but current methods for carrying out these functions are likely to be augmented by a host of new tools, especially for quantitatively measuring aspects of cognition, sensation, and movement. After reviewing any special studies, which are also likely to greatly exceed in precision and content that of current studies, the neurologist will be able to access in real time an extensive review of the literature that is informed not just by the data just collected from the patient's evaluation, but also from a wealth of information and insight that comes from the sequence of the patient's genome, prior results of earlier metabolic and genetic testing of the patient and all of his or her living relatives, and epidemiological studies in which each of these findings has been evaluated across very large patient databases over many years. As suggested earlier, powerful new algorithms will be developed that allow the neurologist to integrate over data sets and even to test hypotheses as to how the predictions from one are in accord or at odds with another. The clinician may then proceed to interact with a patient's “health avatar,” a unified model of a person's health profile consisting of an aggregate from multiple data sources, and perturb this model by adding the new concern.2 The neurologist will thus have carried out a data mining and analysis exercise that will take but minutes to perform yet yields a detailed view of the patient's neurological status, a “personalized neurological profile” that provides the template for “personalized neuromedicine.” The neurologist may then choose special studies suggested by the mining exercise, the results from which will be used to create an updated, comprehensive view of the patient's profile. In summary, much will be new in the patient encounter of 2030. What is most exciting and meaningful will be the ability to enhance patient care by accessing an armamentarium of information and powerful new diagnostic tools.

It perhaps goes without saying that we will also encounter increasing patient demands to partner in the evaluation process. Moreover, the new methods of collecting and evaluating information will create demands for privacy that may far exceed those encountered now.3 An important question then is how will neurologists create meaning for their patients, ie, how will they fully and correctly inform as well as protect their patients? Yet to be answered, the question mandates that neurologists equip themselves to understand and use the sources of information.

Informatics is the application of computational tools and concepts to the management of information. It begins with data collection, extends to data analysis, and features model building to predict and confirm relationships between bodies of information. Neuroinformatics is informatics applied to neuroscience.1 Technical advances, already extant through the creation of the Internet and sophisticated search engines, have and will increasingly enhance the ability to access information. We need a concerted effort by the discipline of neurology to prepare itself properly for the age of neuroinformation. We would do well to take notice of the important collaboration that led to the Neuroscience Information Framework.4

In another evolution of patient care, tools are already in hand that enhance the ability for neurologists and patients to communicate without geographic constraints,5 thus allowing for the extension of expertise to patients located remotely. Universal access to the Internet, or its equivalent, will make it possible for any physician and any patient to “see” each other and to consult in real time with any other physician. The effectiveness of providing care via “teleneurology” has been demonstrated for stroke6 as well as for chronic neurological conditions.5 By no means will “touching patients” become unimportant, but how we touch them is likely to change. In some cases, this will involve working with nonneurologist physicians who see patients with us via a “teleneurology” link. In others, new technologies that are just now in development will allow us to examine patients in ways that are equally informative and possibly far more comprehensive and quantitative.

Future training for neurologists

How to most effectively train neurologists has always been an important question. There is little doubt that we must continue to prepare trainees to engage in the basics—“the blocking and tackling”—of the discipline. Continued emphasis will be placed on skillful taking of the neurological history; conducting the examination; considering the anatomical, physiological, and etiological diagnoses; and choosing the appropriate special studies. But in the future, these basic skills will be informed and, ideally, complemented by significant advances in neuroscience and information technology. How will we equip the next generation of neurologists not only to cope with the mountain of information but to exploit it? We predict the following:

1. Training in neuroinformatics will be required. Neurology will take a special interest in neuroinformatics and neurology trainees will benefit by search engines that are specifically targeted for the care of neurology patients. Indeed, some of the most powerful tools will be designed by neurologists in concert with colleagues in computer science. Academic departments of neurology will jointly develop resources that make it possible for all neurology training programs to use these tools. Residents will become facile in their use, applying them effectively during and after the resident years.

2. Technical advances will change the training environment. In view of the likely proliferation of teleneurology, and enhancement of the technologies that support it, residents will be trained to make the best use of this mode of patient evaluation and care. Training in how best to interact effectively with physicians not trained in neurology will be important. Training via simulation will likely be used to develop residents' competency in many facets of neurological practice. Neurosimulation is the term for the establishment of a training environment in which clinical problem solving is done in a simulated environment. Yet in its infancy, simulation has been used effectively in the training of residents in neurocritical care7 and promises to be useful in situations where there is evident value in educating trainees to recognize and manage clinical problems without endangering patients. One can, for example, envision benefits from simulation of stroke diagnosis and management and the care of patients in status epilepticus.

3. The neurology residency will be lengthened. The combination of an increased burden of knowledge and a continuation in the reduction of resident duty hours are 2 factors that will mandate extending the duration of the residency. How long is an important question. There may be reluctance to engage in extra years of training but this will be mitigated by the demand for similar increases in duration of training in virtually every aspect of medicine.

4. Formal training will not end with the residency. Because the information explosion will continue unabated for the foreseeable future, and because new information will open new diagnostic and treatment modalities, intensive additional training in the postresidency years will become the rule. What form this takes is uncertain, but the current scheme that requires passing a board examination will almost certainly be modified to include ongoing formal training in the methods and concepts of basic and clinical neurology as well as neuroinformatics. Self-training regimens will be developed that build on the new technologies created for long-distance learning.

5. Neurology will become ever more superspecialized, encouraging new approaches to training. Another likely consequence of the avalanche of information will be for neurologists to narrow the focus of patients in their care. Already evident, this trend will become even more prominent.8

6. Neurology departments will collaborate to deliver training. The increasing complexity of the training mission may encourage departments of neurology to join in a consortium to develop a group of training programs, each of which provides unique expertise. While all departments will provide basic neurology education, highly specialized training that benefits from exceptional expertise in a particular department will be made available to trainees from other departments. It is easy to envision the creation of a national or international model for training in specific neurological subdomains. The resident of the future will thus have access to the “best and the brightest” in every domain of neurology. Importantly, the technology to support this enhancement is readily available now and only awaits the recognition of the benefits this model offers.

7. Training will be extended to a larger spectrum of neurology caregivers. Changes in training will likely affect more than residents, although they will continue to be at the core of the mission. Intensive training will be extended to other health professionals who will take an increasing role in the diagnosis and care of patients. The need to make neurology a larger part of the curriculum for primary caregivers is already on us, as is the benefit to neurology of highly trained nursing personnel.9 The work of neurologists will increasingly be carried out, with oversight, by ancillary personnel whose training in medicine and neurology is less extensive but whose skills allow them to shoulder a larger burden of routine and even specialized care. Training for these individuals will become an important aspect of a department's mission.

The academic neurology department of the future and its faculty

1. Neurology departments will thrive. We are well aware of the limits imposed by the departmental structure. Many have argued that it impedes learning across the various disciplines that inform our understanding of the brain and its disorders. They endorse an academic model where faculty from various disciplines work together in an institute to create new insights in a somewhat narrowly defined biological domain(s), bring expertise to solve a specific biological or pathological problem, or develop new technical capabilities and applications. Institutes can be valuable, but by their very nature they are prone to being short lived, fail to garner consistent faculty commitment and effort, and lack the atmosphere needed to train and nourish a faculty and provide the services required of neurologists. Though we will benefit from the interdisciplinary nature of institutes, and the creation of links between departments and institutes should be fostered, for now the department will remain the home for neurologists and their trainees.

2. Departments will benefit from intensive linkages with one another and with the neuroscience and greater university community at large. The most successful departments will collaborate with other departments of neurology and should explore methods to enhance interactions to support training, research, and care. Indeed, it may prove useful for departments to focus faculty recruitments to build expertise that complements the work of faculties in other departments of neurology. In this way, hard-won successes in brain science and care can be made available more widely and with greater benefit to the training and care missions.

In the same vein, departments that reach out to the broader neuroscience community will prosper, as will the scientists with whom they share information and research objectives. The faculty of the future will almost certainly reflect the need to more tightly link discoveries in neuroscience to the development of therapeutics. In some cases, these linkages will lead to increased recruitment of neurologists-neuroscientists. It is equally likely that departments will choose increasingly to recruit those with PhDs whose expertise in the neurobiology of disease equips them to play this role. Finally, one can imagine that departments will recruit individuals whose research and technical expertise fills the gaps between discovery, therapeutic development, and delivery of care. Included in this group may be neuroinformaticians, bioengineers, electrical engineers, and drug discovery experts.

3. Departments will find new ways to care for common disorders of the nervous system. The practice of general neurology will change appreciably in the face of the wealth of new information. The latter promises to satisfy the saying that “everything old is new again.” What we now see as a typical disorder, eg, migraine, will take on new significance as we learn that it arises from several distinct genetic and biological roots. As distinct subtypes of common disorders are defined, we will learn that treatments viewed as effective for most patients work especially well for some subsets but not for others. Indeed, generally effective treatments may be shown to be deleterious for certain subsets.

Departments will build a faculty that can continue to deal effectively with the many disorders frequently seen in general neurology clinics. Only now these individuals will be called on to understand and use the information that will be collected for common as well as rare disorders. General neurology thus promises to become even more interesting and challenging. The work of the general neurologist may create new paradigms for care and justify its recognition as a uniquely attractive subspecialty within the department.

4. Superspecialization will be needed to provide care for many patients. There can be little doubt of the pressure that will impact neurologists to limit the body of knowledge and the patients for whom they care. How departments answer the needs of patients is yet to be defined. Several models could emerge. In one, as under the existing trend, a neurologist would increasingly focus on a select disorder or group of disorders. In another, neurology practice would evolve to care for patients on the basis of the underlying disease pathogenesis of their disorder. This model is attractive because it builds rationally on new insights from studies of pathogenesis to create and apply methods for diagnosis and treatment. Distinct from the current model, it deals with physiological entities and cuts across existing disease boundaries. For example, a “channelopathy clinic” would see patients with a variety of clinical syndromes that result from changes in channel function.10 It is even possible that channelopathy clinics would become further specialized for different channel defects, eg, sodium vs calcium and potassium. In principle, both types of models could exist.

5. Departments of neurology will expand their domain of technical expertise. Neuroimaging is but one area in which rapid progress promises to provide neurologists with powerful tools to examine brain structure and function. Though a speculation, we may within the next decades be able to define precisely not just the loci of lesions but also the individual network elements that make possible behavioral and cognitive functions. The blossoming of research on the neurology of neuronal networks is extremely exciting and will come to inform clinical practice in many ways. One question is who “develops and owns” the technology. In our view, the answer must be departments of neurology and their faculty. Taking on this mantle will enhance our ability to create new paradigms for testing, new methods of analysis, and new approaches to treatment. Neurologists must put themselves at the cutting edge of technology development and use. Accordingly, we must recruit a faculty that allows us to play these roles. Including within our faculty those with expertise in the physical sciences, computer science, and electrical engineering would help us to stake our claim in this domain of neuroscience.

6. The boundaries between neurology and psychiatry will disappear. The walls that separate neurology from its sister disciplines do little to advance, and in many cases compromise, progress and patient care. For example, as we come to better understand chronic nervous system disorders, the co-occurrence of neurological and psychiatric symptoms is increasingly appreciated.11 We suspect that departments of neurology and psychiatry will continue to be distinct entities, but joint efforts involving neurologists and psychiatrists who are well informed, carefully organized, and highly collaborative will increasingly act to dissolve departmental barriers. Prior to the establishment of joint departments of neurology and psychiatry, changes in training, faculty recruitment, and research will provide increasing evidence of the similarities and linkages between their missions.

The bright future of neurology research

1. Collaboration across disciplines will be vital. The problems neurologists tackle will demand expertise that spans many levels of investigation. Departments will access this expertise through their own faculty as well as through collaboration with investigators in genetics, molecular and cellular biology, systems and cognitive neuroscience, computer science, neuroinformatics, pharmaceutical chemistry, and the business of health systems. Here again the possibility for collaboration across departments and universities can be exploited.

2. Collaborative efforts will create new systems for evaluating scholarly contributions. With the creation of research consortia, we will need to define more carefully how individuals contribute. At present, many universities count as significant only written evidence of scholarship and even then only when the individual's name is either first or last on the list of authors. The mode of evaluating scholarly work must create a system that honors fully all of the collaborators' efforts. Some journals already mandate documentation of individual contributions. In addition, new technologies should be exploited to demonstrate and communicate scholarly pursuits. Universities can play a leading role in encouraging the adoption of new technologies to properly document the contribution of individuals, in so doing to reward collaboration. Moreover, they can and must encourage the active “safe sharing” of data through forums that accelerate the movement of ideas between investigators. In this regard, a review of examples of how this can be done may be informative.12

3. As genomic sequencing provides ever more insights into genetic disease mutations and risk factors, we will see dramatic enhancements in our ability to understand, diagnose, and treat our patients. The sequencing of the human genome, and subsequent advances in human genetics, has created an enormous wealth of data on gene structure and function.13 In 2001, the human genome was sequenced by the National Institutes of Health Human Genome Institute led by Francis Collins14 and Celera led by Craig Venter.15 Three billion nucleotides in the human genome, encoding at least 21 000 genes, have been sequenced. Now that we have what has been called the “dictionary of life,” we are learning how to decipher it. An important aspect of this effort is exploring more fully the genomes of individuals and populations to understand genetic risk factors for common disorders as well as the genetic bases for rare disorders. Genome-wide association studies have found single-nucleotide polymorphisms or variations in genes that increase the risk for a number of neurological diseases, including Parkinson disease, Alzheimer disease, and multiple sclerosis. Deep sequencing of the human genome is now under way to find the “hidden inheritance” of genetic polymorphisms linked to these and much rarer neurological diseases.

4. Advances in understanding and treating brain disorders will benefit greatly from the ability to deeply phenotype as well as genotype our patients. Our ability to deeply phenotype the normal and abnormal nervous system is much less developed. While we recognize disease patterns, we know too little of the natural history of disorders and have only begun to invest in the discovery of biomarkers that could be used to diagnose diseases, detect their onset, and define treatment responses. In the future, a branch of neurology that could be labeled “neurophenomics” will focus on deeply phenotyping patients and linking these data with genetic and other data sets. The science of neurophenomics promises rich rewards for our discipline and our patients.

A powerful approach is one that makes possible direct correlations between phenotype and genotype. For example, Alzheimer disease expresses itself differently in different individuals, eg, the age at onset, rate of disease progression, and accompanying symptoms that include changes in motor behavior, psychosis, and vascular disease. The best estimate is that these various “endophenotypes” will be shown to correlate with specific single-nucleotide polymorphisms. Thus, we are likely to define Alzheimer disease types using specific sets of genotype-phenotype combinations or clusters. It is an interesting and rational possibility that such clusters will ultimately define the utility of specific therapies. Personalized genotype-phenotype therapies will then become standard. These predictions will likely apply to many if not all neurological diseases.

Beyond the focus on neurological disorders, we will also define more precisely genotype-phenotype correlations for normal brain function. Variations in temperament, mood, and mental abilities may all be found to be explained, in whole or in part, by genotype-phenotype clusters. The one area for research most likely to benefit our patients in the next 20 years, and beyond, may thus be deciphering the genetic bases for both normal and disordered brain function. With this will come entirely novel insights into how to care for our patients. But with it must also come a respect for individuals that avoids marginalizing or in any way compromising the well-being of those whose genotype suggests the possibility for undesired phenotypes. Neuroethicists may provide insights essential to manage this new aspect of neurology.

5. Technical advances will markedly increase our ability to phenotype our patients. We are fascinated by the many neurotechnological advances on the horizon.16,17 More effective materials and methods for catheterizing vessels, monitoring brain function, and using computer analysis to define brain signals are being developed. In one embodiment, we already have access to methods that make it possible to examine the activities of neuronal populations, predict the onset of unwanted circuit rhythms, and modify circuit activity to restore normal or near normal circuit function.16 Methods under development promise to make it possible to listen to a more precise collection of neurons and to monitor synaptic function both biochemically and electrophysiologically.17 In another advance, wearable electrode/sensor arrays are being developed. It will soon be possible to record in real-time electroencephalography, and possibly magnetoencephalography, using a simple cap whose dry sensors can feed data wirelessly to remote sites.18 Advanced methods for evaluating signals will be used to discern patterns and predict ever more precisely the onset of seizures and other electrical brain phenomena of interest.19

In an interesting development, investigators at the University of California, San Diego, are creating the MoBi Suit.18 The suit would cover a part or all of the body and wirelessly communicate electroencephalography data as well as information about movement (eg, limb movement, gait, and tremor), blood pressure, heart rate, and respiration. It would make possible the examination of patients in real time, 24/7 and remotely, thus allowing the neurologist to define precisely the problems encountered and the results of treatment. The suit promises to change the way we examine patients by making it possible to assess in great detail and quantitatively many of the elements of nervous system function, whether in person or at a distance. This tool will likely complement the ability to monitor and modify circuit rhythms using deep-brain stimulation. Imagine the neurologist of the future monitoring, remotely and in real time, the physiological status of basal ganglia circuits together with the details of motor function. Imagine further that he or she has the ability to reprogram stimulation parameters to enhance movement.

6. The research mission will increasingly inform health care systems and the business of neurology. A fundamental goal for research in a department of neurology is to enhance the well-being of patients. We are increasingly aware of the costs of care. While the trend toward increasing costs is unlikely to change in the next decades, research advances, especially those focused on early detection and the development of effective treatments for chronic disorders, will begin to decrease costs. At present, for example, Alzheimer disease and similar dementias impact the lives of upwards of 35 million patients globally, about 0.5% of the total population.20 In the United States, the number with Alzheimer disease is currently 5.4 million. At present, more than $180 billion are spent on care for US patients; with increasing disease prevalence, by 2050 the estimated cost of care will be more than $1 trillion (http://www.alz.org/documents_custom/2011_Facts_Figures_Fact_Sheet.pdf). Methods that allow for early diagnosis and treatment of Alzheimer disease will result in dramatic reduction in costs. Similarly, decreases in cost of care can be predicted for stroke, Parkinson disease, and neurological complications of diabetes and disorders of mental health. A future informed by research offers the promise of improved care at a much lower cost.

Translating discoveries of neuropathogenesis to the care of patients

Translational medicine consists of all those events and activities needed to apply fundamental basic science and/or clinical observations to the care of patients. Referencing the contribution of Sung and colleagues,21 current obstacles to this enterprise include fragmentation of expertise and effort, inefficiencies of practice, and lack of a systematic approach to defining and resourcing potential treatments. The results are that translation is troubled at 2 levels: from basic discovery to clinical trials and from success in clinical studies to practice.21 Models are needed to overcome these obstacles. To succeed, a model must create an infrastructure that effectively moves ideas across platforms populated by individuals with a variety of expertise using diverse technologies. Creating a new model—a system for innovation that understands, motivates, measures, and develops new methods for diagnosis and care—needs new thinking and new planning and will require the participation of not just academic institutions but all those other parties that harbor the expertise needed to move ideas to treatments. One such model has sparked much interest.22 Under the Distributed Partnering Model, an independent, multisponsored organization collaborates with the academic community in a risk-adjusted manner to discover, define, develop, and deliver innovative products. This model addresses not just the issue of culture but the structural issue of financing and executing translational projects that drive new therapies for patients.

A national effort to accelerate progress in translational neuroscience would link neurology departments to increases in the number of targets to pursue, inspire collaboration to create effective target assays, use a standard library of compounds for high throughput screening, and provide expertise in clinical research and trials needed in human studies. Though the issue of intellectual property would arise, there are existing models that have tackled this problem. It is an exciting possibility that departments of neurology could lead the effort to bring great neuroscience to great care for our patients.

The care of neurology patients

1. We will find ways to avoid information overload for our patients. The already vast amount of information to which patients have access will increase. The results can be perceived as both good and bad. The good news is that patients have far more information about neurological disorders and their treatment and have demonstrated the willingness to partner with the neurologist to understand their illness and modes of care. But without appropriate training, patients cannot critically review what they read and often cannot organize and interpret the information. The predictable result is that they are subject to misinformation, misinterpretation, and faulty reasoning about important aspects of their diagnosis and care. The solution is to provide information in well-known, carefully reviewed forums targeted to patients that provide up-to-date information. More generally, a variety of tools must be developed to assist patients to understand their diagnosis and prognosis. These tools will be increasingly useful as information about the natural history of disorders increases and predictive biomarkers are developed. The Internet is an ideal venue for communicating with patients; attempts are in process to create Web sites that build on rigorous, thoughtful scholarship. Neurologists should play an active role in creating such sites.

2. Personalized neuromedicine will be the norm. Clearly, we are on the verge of understanding our patients much better than ever before. The practice of personalized medicine will be the result of the research activities described earlier, especially the ability to link deep phenotyping with genotyping studies. As mentioned, it will be essential to protect the privacy of the information we collect and the results of the analyses we perform. The challenges to privacy are predicted to increase greatly.3

3. We will practice neurology with empathy and compassion. The increasing access to a variety of sources of information, and the likely increase in financial pressures on the clinical practitioner, may well compromise our ability to focus on the emotional needs of our patients. A recent report noted that a variety of stressors experienced by clinicians routinely diminished empathy among both trainees and physicians.23 In ongoing discussions, we have begun to consider what might be done to help physicians continue to place the overall well-being of the patient as paramount. In one approach, we have reviewed recent research on the neurological basis of empathy and compassion24 as well as studies examining the impact of meditation25 or focused training26 that provide fresh insights into how to provide physicians with skills to care for the emotional well-being of their patients and themselves. Training in empathic and compassionate care will be widely practiced within the next decade, or so we hope. Effective training will allow us to understand and connect closely with our patients without losing our objectivity in professional decision making.

Pursuing the manifest destiny of the neurological sciences

Currently, neurologists and psychiatrists study brain disorders and the care of those affected. Increasing success in understanding and treating disease will create the opportunity to increase attention to the questions that inspired many of us to commit our lives to neuroscience: “How does the brain make meaning?” “What is the neural circuit basis of reason, creativity, empathy, compassion, fear, hope?” and “How do diseases impact these fundamental aspects of brain function?” It is exciting to think that in time neurologists will increasingly seek to answer these questions. In so doing, we will extend the reach of our discipline far beyond what it is today.

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Article Information

Correspondence: William Mobley, MD, PhD, Department of Neurosciences, University of California, San Diego, 9500 Gilman Dr, CNCB Bldg, Room 100, La Jolla, CA 92093-0752 (williammobley7@gmail.com).

Accepted for Publication: August 29, 2011.

Published Online: November 14, 2011. doi:10.1001/archneurol.2011.1858

Author Contributions:Study concept and design: Mobley and Rosenberg. Drafting of the manuscript: Mobley and Rosenberg. Administrative, technical, and material support: Mobley and Rosenberg.

Financial Disclosure: Dr Rosenberg holds a US patent on amyloid β gene vaccines. He is the recipient of clinical trial grants from Janssen Inc and Pfizer Inc. He is the director of the University of Texas Southwestern Alzheimer Disease Center grant funded by the National Institutes of Health/National Institute on Aging (P30AG1230017-1).

Additional Contributions: Thanks to Richard Stoner, PhD, and Long Do, PhD, for critically reviewing the manuscript and helpful comments and to Shelley Herron for editing.

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