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In This Issue of JAMA Neurology
July 2019


JAMA Neurol. 2019;76(7):737. doi:10.1001/jamaneurol.2018.2996

Between 40% and 50% of patients with Parkinson disease (PD) experience anxiety and depression. While clinical practice guidelines support exercises for PD rehabilitation, existing evidence of yoga for stress and symptom management is scarce. In this randomized clinical trial of 138 patients with PD, half were randomized to mindfulness yoga and half to a stretching and resistance training exercise plan. Kwok and coauthors found that patients in both groups experienced improved mobility, and patients in the mindfulness yoga program showed additional benefits on measures of psychological distress, spiritual well-being, and health-related quality of life, with comparable benefits related to motor dysfunction and mobility. Yoga that teaches mindfulness along with physical activity may be well suited for stress and symptom management in patients with PD.

Embolic strokes of undetermined source make up about 20% of all ischemic strokes. While oral anticoagulation is highly effective at preventing atrial fibrillation–related stroke recurrence, the benefits outside of this indication are unclear. The NAVIGATE ESUS randomized clinical trial demonstrated no difference in the rate of recurrent ischemic stroke in patients with a recent embolic stroke of undetermined source randomized to either rivaroxaban or aspirin, but in a secondary analysis including 7112 patients, Healey and coauthors examined the effects of randomized treatments in subgroups of patients. In patients with a left atrial diameter of more than 4.6 cm, the risk of ischemic stroke was lower among the rivaroxaban group compared with the aspirin group, suggesting a possible benefit of rivaroxaban in the 9% of patients with a left atrial diameter of more than 4.6 cm, who presumably have a higher risk of subsequently developing atrial fibrillation.

Continuing Medical Education

Patients who experience a transient ischemic attack or minor acute ischemic stroke are at short-term risk of developing recurrent ischemic stroke. In a secondary analysis of the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke double-blind randomized clinical trial at 269 sites, 4881 patients with high-risk transient ischemic attack or minor acute ischemic stroke received aspirin and were randomized within 12 hours of symptom onset to receive clopidogrel or placebo. Tillman and coauthors found that short-term treatment with clopidogrel plus aspirin was more effective for patients after transient ischemic attack or minor ischemic stroke than aspirin alone but was associated with an increased risk of hemorrhages. In this report, most major hemorrhages were extracranial and treatable.

Author Audio Interview

Biomarkers of Alzheimer disease (AD) currently require invasive and expensive tests or scans that are not widely available; plasma neurofilament light (NfL) appears to be promising. In a large multicenter cohort study using data from 1583 individuals in the Alzheimer’s Disease Neuroimaging Initiative study database, Mattsson and coauthors found that longitudinal measurements of plasma NfL levels increase over time in sporadic AD, even in the prodromal and preclinical stages of the disease. Using cerebrospinal fluid and neuroimaging techniques, these increases correlate with both baseline and longitudinal measures of other disease markers of AD. Together, the results indicate that plasma NfL level is a useful noninvasive marker to track neurodegeneration in AD and may potentially be useful both in clinical practice and in drug trials aimed at reducing neurodegeneration in AD.