Answer: Neurologist salaries depend on the needs of the community, the geographic location, and the number of years of experience.
Neurology

$180,000
$228,000
$345,000

Median Salary by Years Experience – Job: Physician / Doctor, Neurologist (United States)

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Answer: The symptoms you describe could be due to a number of different factors. Your mother needs to see your family physician, a medical professional who can listen to her, examine her, and help evaluate her condition.

The family doctor is your entry point into the medical system and they can guide you towards medical specialists if appropriate – in psychiatry, neurology or other specialties. If you don’t have a family physician, I’d start with the local community mental health services.

If she is increasingly suicidal, I’d suggest taking her to the local emergency room. And if she, in fact, attempts suicide, immediately dial 911.

Answer: Cerebral aneurysms can be congenital, resulting from an inborn abnormality in an artery wall.  Cerebral aneurysms are also more common in people with certain genetic diseases, such as connective tissue disorders and polycystic kidney disease, and certain circulatory disorders, such as arteriovenous malformations (snarled tangles of arteries and veins in the brain that disrupt blood flow).

(2) The causes of cerebrovascular disease in children are legion, and no one risk factor predominates. Thus, not only is stroke less common in children, but the diversity of risk factors creates a heterogeneous patient population which hinders clinical research.

(3) Despite improved diagnostic techniques which make rapid, noninvasive diagnosis of cerebrovascular disease possible, many physicians still know very little about cerebrovascular disorders in children. This lack of awareness contributes to delayed diagnosis and in the near future will make it more difficult to use thrombolytic agents or other treatments which require early diagnosis and treatment.

Frequency of Pediatric Cerebrovascular Disease

Although cerebrovascular disorders occur less often in children than in adults, recognition of stroke in children has probably increased because of the widespread application of noninvasive diagnostic studies such as magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computed tomography (CT) and, in the neonate, cranial ultrasound studies.^1-3 These studies allow confirmation of a diagnosis that in previous years would not have been suspected or at least not recognized as a vascular lesion. Also, the number of patients with cerebrovascular lesions from certain risk factors may have increased as more effective treatments for some causes of stroke have allowed patients to survive long enough to develop vascular complications. Patients with sickle cell disease or with leukemia, for example, now have a longer life-expectancy, and during this time they may have a stroke.

Most of the pediatric cerebrovascular literature consists of single case reports or small groups of children with a common etiology. These reports offer some insight into the relative frequency of various causes of stroke and draw attention to individual risk factors, but their usefulness is otherwise limited. Larger series of children selected for a common anatomic lesion or a single cause offer additional insight into the unique features of cerebrovascular lesions in children,⁴ but patients collected from large medical centers may not be representative of all children with stroke. None of these studies can accurately judge the incidence of cerebrovascular disease in children.

Schoenberg and colleagues studied cerebrovascular disease in children of Rochester, Minnesota from 1965 through 1974.⁵ Excluding strokes related to intracranial infection, trauma or birth, they found three hemorrhagic strokes and one ischemic stroke in an average at risk population of 15,834, for an estimated average annual incidence rate of 1.89/100,000/year and 0.63/100,000/year for hemorrhagic and ischernic strokes respectively. Their overall average annual incidence rate for children through fourteen years of age was 2.52/100,000/year. In this population, hemorrhagic strokes occurred more often than ischemic strokes, while in the Mayo Clinic referral population, ischemic strokes were more common. The risk of childhood cerebrovascular disease in this study is about half the risk for neoplasms of the central nervous system of children, but neonates and children with traumatic lesions are excluded. Despite our impression that cerebrovascular disorders are recognized more often in children than in previous years, Broderick and colleagues⁶ found an incidence of 2.7 cases/1 00,000/year, similar to the figure reported by Schoenberg and colleagues.⁵ In the Canadian Pediatric Ischemic Stroke Registry incidence of arterial and venous occlusion is estimatedtobe 1.2/100,000 children/year.

The frequency of several individual risk factors for stroke in children is known, but in most instances, the occurrence of secondary cerebrovascular disease is so variable that it is difficult to assess the relative contribution of each risk factor to the problem of cerebrovascular disease as a whole. In one report which included both children and young adults, children were less likely than young adult stroke patients to have identifiable risk factors and more often fall victim to infectious or inflammatory disorders.⁷ The implication is that children may have additional, as yet unknown, risk factors.

Etiology of Stroke in Children

Probably the most fundamental difference between cerebrovascular diseases in children and adults is the wide array of risk factors seen in children versus adults ( Table 1).⁸Congenital heart disease and sickle cell disease, for example, are common causes of stroke in children, while atherosclerosis is rare in children. No cause can be detected in about a fifth of the children with ischemic infarction, yet many of these children seem to do well. The recognized causes of cerebrovascular disorders in children are numerous ( Table 1 ), and the probability of identifying the cause depends on the thoroughness of the evaluation. A probable cause of cerebral infarction was identified in 184 of 228 (79%) children in the Canadian Pediatric Ischemic Stroke Registry ( Figure 1 ). The source of an intracranial hemorrhage is even more likely to be found.⁸

The most common cause of stroke in children is probably congenital or acquired heart disease. In the Canadian Pediatric Ischemic Stroke Registry, heart disease was found in 40 of 228 (19%) of the children with arterial thrombosis. Many of these children are already known to have heart disease prior to their stroke, but in other instances a less obvious cardiac lesion is discovered only after a stroke. Complex cardiac anomalies involving both the valves and chambers are collectively the biggest problem, but virtually any cardiac lesion can sometimes lead to a stroke. Of particular concern are cyanotic lesions with polycythemia, which increase the risk of both thrombosis and embolism.

Both the frequency and the cause of pediatric stroke may depend somewhat on both the geographic location and the specific hospital setting. The Canadian Pediatric Ischemic Stroke Registry, for example, lists only 5 children (2%) with cerebral infarction due to sickle cell anemia. A large metropolitan hospital in the United States might care for this many patients in a year, but early estimates⁹ that cerebral infarction occurred in 17% of people with sickle cell disease proved far higher than the 4-5% figure derived from more representative samples in Jamaica and in Africa.^10,11

Pre-hospital Emergency Care

Lack of general awareness of cerebrovascular disorders in children probably delays medical attention for children with cerebrovascular disorders. It is not unusual, for example, for children with a cerebral infarction to be brought to a physician several days after the onset of symptoms. In contrast, family members are usually well aware of the significance of an acute neurological impairment in older individuals, and these patients are typically seen by a physician earlier than children with a similar lesion.

Data from the Canadian Pediatric Ischemic Stroke Registry indicate that 48-72 hours often elapse between the onset of symptoms of arterial occlusion and a child’s diagnosis (Table 2).¹²Venousocclusion was discovered a bit more quickly than arterial occlusion, at least in younger children, perhaps because of the common occurrence of epileptic seizures in children with venous thrombosis. This seems to be fairly typical of the pattern seen in the United States as well. The typical adult with anew onset neurological deficit from cerebrovascular disease undoubtedly sees a physician much sooner. It is likely that this delay in the diagnosis of children reflects a lack of awareness by both physicians and families that cerebrovascular disease occurs in children. To the extent that treatment might be improved by earlier evaluation and treatment, prompt recognition and treatment could improve management.

Treatment and Rehabilitation

No randomized controlled treatment trials have been completed in children with stroke; many of the procedures increasingly used in children with cerebrovascular disease have been adapted from studies in adults. Accumulating experience with antithrombotic and anticoagulant treatment in children suggests that these agents can be safely used in children, though their efficacy and proper dose still need to be established by controlled trials. Thrombolytic agents should be as effective in children as in adults, but the safety data are inadequate for children and the timing and dosage need to be determined for children and adolescents.

(2) Safety: In addition to the potential complications of chronic aspirin use seen in adults, children taking daily aspirin could have an increased risk of developing Reye’s syndrome. Evidently the risk of Reye’s syndrome is fairly small, due perhaps to the low aspirin dose typically used in children. Despite the increasingly common use of aspirin in children with stroke, we were unable to find in the literature even one child who developed Reye’s syndrome while taking prophylactic aspirin. One 65 year-old, however, developed Reye’s syndrome while taking aspirin for stroke prophylaxis, but he also took additional aspirin for influenza.¹³

(3)Efficacy: Adaily aspirin dose of 2-3 mg/Kg/day causes an antiplatelet effect, though it remains to be seen whether this dose of aspirin is clinically effective in children.

by treatment, and what is the risk of inducing a hemorrhage because of anticoagulation? Much like the situation in adults, heparin should be used in children thought to have a high risk of recurrence and a low risk of secondary hemorrhage.

(2) Safety: There are no large scale trials of heparin in children with ischemic stroke, but increasing clinical experience suggests that children can be treated along the same lines as adult patients with

reasonable safety.^8,14,15 Combined experience with over 100 pediatric patients treated for systemic clots with low molecular weight heparin indicates a good safety profile and dose finding feasibility.¹⁶ No significant hemorrhagic complications occurred in these initial 100 children’s.¹⁸

(3) Efficacy: The value of anticoagulation in children is difficult to assess without more information. Anticoagulation is commonly used in children with arterial dissection, dural sinus thrombosis, coagulation disorders, or a high risk of embolism.^8,15 It also seems reasonable to anticoagulate a child with progressive deterioration or during the initial evaluation of a new cerebral infarction.⁸ The loading dose of heparin is 75 units/Kg intravenously followed by 20 units/Kg/hour for children over one year of age (or 28 units/Kg/hour below one year of age). The target APTT to 60-85 is seconds.¹⁴

Adult stroke patients who receive low molecular weight heparin for ten days starting within 48 hours.of diagnosis have a better outcome,¹⁷ and it may be possible to adapt this approach for children. Low molecular weight heparin (Lovenex, Rhone-Poulenc) can be given to children subcutaneously in two divided doses of 1 mg/Kg/dose (or in neonates, 1.5 mg/Kg every 12 hours).

(2) Safety: Clinical experience suggests that warfarin can be used in children and adolescents with reasonable safety. The concern that active children could have an increased risk of hemorrhage due to trauma seems to be largely unfounded, though it is recommended that they avoid activities which carry an especially high risk of injury (e.g., contact sports).

(3) Efficacy: The rationale for using warfarin in children with cerebrovascular disorders follows closely the approach used in adults. Thus, major uses of warfarin treatment in children include congenital or acquired heart disease, hypercoagulable states, arterial dissection, and dural sinus thrombosis. An INR of 2.0 to 3.0 is appropriate for most children on warfarin; for children with mechanical heart valves the INR should be 2.5 to 3.5.

infarction, because 75% of the children have serious sequelae including neurologic deficit, epilepsy, or death. While there is little information about the use of thrombolytic agents in children with stroke, enough work has been done with adult patients that the technique could possibly be adapted for selected children.

(2) Safety: Urokinase and streptokinase are used infrequently in children with cerebrovascular disease, but no serious complications occurred in the few children treated for dural sinus thrombosis. Thrombolytic therapy for children with non-cerebral thrombotic complications has recently been evaluated. Pooled literature analysis of 203 children treated with thrombolytic agents (including 39 patients who received tPA) indicated that the thrombus was cleared in 80% of the children, but 54% had minor bleeding (not requiring transfusion) and one child suffered an intracranial hemorrhage. In 29 consecutive children treated with tPA (0.5 rng/`Kg) at Toronto’s Hospital for Sick Children, the clot was dissolved in 79%, but almost a fourth of these children had bleeding which required transfusion.^19,20 Given this high rate of serious bleeding after systemic tPA and the lack of studies demonstrating improved outcome, we can not recommend tPA except in the setting of a controlled clinical trial.

(3) Efficacy: The delayed diagnosis which so often occurs in children with ischemic stroke reduces the likelihood that a child with an ischemic stroke will be seen early enough to benefit from thrombolytic agents. Intravascular urokinase or streptokinase have been used with apparent success in a few children with dural sinus thrombosis, 8,21-23 but there is even less experience with these agents in children with arterial thrombosis. The available data are insufficient to comment on the effectiveness of any of the thrombolytic agents in children with ischemic stroke. Certainly they would be expected to produce unacceptable roles of bleeding as seen in adults if given more than 4-6 hours after onset of stroke.

Safety: Although the risk can be reduced by iron chelation, iron toxicity from repeated blood transfusions remains a major problem. Cohen and colleagues 24 proposed a less aggressive transfusion program to maintain the hemoglobin S near 50%; this regimen required an average of 31% less transfused blood and still no infarctions occurred. Miller and colleague had similar results, although their follow-up period was shorter. This new approach needs to be studied further.

Efficacy: Although no randomized clinical trials were ever done, years of clinical experience have produced general agreement that periodic transfusion greatly reduces the risk of ischemic cerebral infarction due to sickle cell disease. A patient who has had one stroke has about a 90% risk of having additional infarctions. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) is now investigating the use of transcranial Doppler (TCD) to identify children at greatest risk for their first cerebral infarction due to sickle cell disease. This study could prove that periodic transfusions reduce the risk of ischemic infarction in children with sickle cell disease and that TCD can be used to identify those at greatest risk.

Directions for Research

Given the paucity of information about many aspects of childhood stroke, what is the best approach to the diagnosis and management of stroke in children? How should our methods in children differ from those used in adults? Until more information on childhood stroke is available, we must of necessity continue to adapt the knowledge obtained from adult stroke patients. Itshould not be necessary to repeat in children all the work already done in adults, but we do need to identify areas which are age specific.

In some respects, our study of stroke in children recapitulates some of the early work in adult stroke patients. Databases such as the Canadian Pediatric Ischemic Stroke Registry will continue to provide data on the causes of childhood stroke as well as the patients’ treatment and outcome. Under the best of circumstances, such databases are limited by the fact that the correct diagnosis may not be recognized or reported to the registry. Larger case series which concentrate on one cause of stroke or one anatomic lesion need to be published. Epidemiologic studies need to be reassessed to reflect better diagnostic techniques and the increased recognition of stroke in children by physicians.

Several specific causes of cerebrovascular disease are relatively common in children and have a high enough risk of stroke to make collaborative trials feasible. There are several potentially productive areas to study. Research should initially focus on the more common disorders or on children with risk factors which are usually identified before a stroke occurs:
(a) The Stroke Prevention Trial in Sickle Cell Anemia (STOP) trial now underway could serve as a model for studies of childhood stroke from other causes. Sickle cell disease is common in some medical centers, and cerebral infarction frequent enough to make a study feasible. Early diagnosis and treatment probably improve the patient’s outlook. Additional multicenter trials for patients with sickle cell disease could also address the use of hydroxyurea or other drugs in stroke prevention.

(b) Sinovenous thrombosis seems to occur relatively more often in children than other cerebrovascular lesions and can now be identified quickly and noninvasively with MRI/MRA. Collaborative studies to evaluate systemic anticoagulation and/or thrombolysis should be feasible, particularly if similar trials in adults continue to show promise.

Cardiac disease remains the most common cause of ischemic cerebral infarction in children. Most of these children have congenital heart lesions which are identified well before an infarction occurs, and ischemic infarction may occur frequently enough to warrant controlled trials of prophylactic agents or of neuro-protective agents during surgery when the risk of stroke is higher. Thrombolytic agents could play a greater role in children with heart disease because their families could be taught to recognize the significance of an acute neurologic deficit.

Moyamoya is an uncommon condition but it could be studied via a collaborative approach. Most patients in the recent literature have had various surgical procedures designed to increase blood flow to the brain. But no controlled trials have ever been done to assess these operations, and there is some evidence that the natural history of untreated moyamoya may be less devastating than sometimes suggested. In one group of 27 children, 5 patients had no sequelae, 9 had only headache or transient ischemic symptoms, and 7 had mild intellectual or motor impairment. Only 6 of the 27 had a poor outcome: 1 death, 2 who required continuous care, and 3 who required special schooling or institutionalization. Only 11 of these 27 patients had surgery.²⁶ The fact that so many patients do well without intervention makes it difficult to evaluate treatment in the absence of controlled trials.

Several pediatric hospitals offer extracorporeal membrane oxygenation (ECMO), a technique which requires ligation of the right carotid artery. In some centers, the carotid artery is eventually reconstructed once ECMO is no longer needed.²⁷ These children provide an opportunity to study the long term effects of altered cerebral circulation and, for the children whose carotid is reopened, to explore the effects of carotid artery trauma on the development of atherosclerosis.

Summary

Increased awareness of these disorders by the public, and by medical personnel will potentially improve accessibility of pediatric stroke patients to newer forms of thrombolytic and neuroprotective agents. Increased awareness by research teams and research funding agencies will provide the means for the intervention trials critically necessary to realize that potential.

References

1. Wiznitzer M, Ruggieri PM, Masaryk TJ, Ross JS, Modic MT, Berman B: Diagnosis of cerebrovascular disease in sickle cell anemia by magnetic resonance angiography. J Pediatr 1 990; 1 1 7:551-555.
2. Ball WS: Cerebrovascular occlusive disease in childhood. Neuroimaging Clin N Amer 1994;4:393-421.
3. Koelfen W, Wentz U, Freund M, Schultze C: Magnetic resonance angiography in 140 neuropediatric patients. Pediatr Neurol 1 995; 1 2:31-38.
4. Brower MC, Rollins N, Roach ES: Basal ganglia and thalamic infarction in children (In press). Arch Neurol 1996;53:
5. Schoenberg BS, Mellinger JF, Schoenberg DG: Cerebrovascular disease in infants and children: A study of incidence, clinical features, and survival. Neurology 1978;28:763-768.
6. Broderick J, Talbot T, Prenger E, Leach A, Brott T: Stroke in children within a major metropolitan area: The surprising importance of intracerebral hemorrhage. J Child Neurol 1 993;8:250-255.
7. Kerr LM, Anderson DM, Thompson JA, Lyver SM, Call GK: Ischemic stroke in the young: Evaluation and age comparison of patients six months to thirty-nine years. J Child Neurol 1 993;8:266-270.
8. Roach ES, Riela AR: Pediatric Cerebrovascular Disorders. 2^nd ed. New York: Futura, 1995, 359 pp.
9. Portnoy BA, Herion JC: Neurological manifestations in sickle-cell disease – with a review ofthe literature and emphasis on the prevalence of hemiplegia. Ann Intern Med 1972;76:643-652.
10. Adeloye A, Odeku EL: The nervous system in sickle cell disease. Afr J Med 1970; 1:33-48.
11. Balkaran B, Char G, Morris JS, Thomas PW, Serjeant BE, Serjeant GR: Stroke in a cohort of patients with homozygous sickle cell disease. J Pediatr 1992;120:360-366.
12. deVeber GA, Adams M, Andrew M: Canadian Pediatric Ischemic Stroke Registry (Abstract). Can J Neurol Sci 1995;22:S24.
13. Peters U, Wiener GJ, Gilliam J, Van Nord G, Geisinger KR, Roach ES: Reye’s syndrome in adults: A case report and review of the literature. Arch Intern Med 1986;146:2401-2403.
14. Michelson AD, Bovill E, Andrew M: Antithrombotic therapy in children. Chest 1995;108:506S-522S.
15. deVeber G, Andrew M, Adams M, et al: Treatment of pediatric sinovenous thrombosis with low molecular weight heparin (Abstract). Ann Neurol 1 995;38:532.
16. Massicotte P, Adams M, Marzinotta V, Brooker L, Andrew M: Low molecular weight heparin in pediatric patients with thrombotic disease: A dose finding study (In press). J Pediatr 1996.
17. Kay R, Sing Wong K, Ling Yu Y, et al: Low-molecular weight heparin for the treatment of acute ischemic stroke. N Engl J Med 1995;333:1 588-1 593.
18. Andrew M, Marzinorto V, Brooker LA, et al: Oral anticoagulant therapy in pediatric patients: A prospective study. Thromb Haemostas 1 994;71:265-269.
19. Leaker M, Massicot-te MP, Brooker L, Andrew M: Thrombolytic therapy in pediatric patients: A comprehensive review of the literature (In press). Thromb Haemostas 1996.
20. Leaker M, Nitschmann E, Benson L, Mitchell L, Andrew M: Thrombolytic therapy in pediatric Thromb Haemostas 1996;73:948.
21. Higashida RT, Helmer E, Halbach VV, Hieshima GB: Direct thrombolytic therapy for superior sagittal sinus thrombosis. A J N R 1989;10:S4-S6.
22. Wong VK, LeMesurier J, Franceschini R, Heikali M, Hanson R: Cerebral venous thrombosis as a cause of neonatal.seizures. Pediatr Neurol 1987;3:235-237.
23. Griesemer DA, Theodorou AA, Berg RA, Soera TD: Local fibrinolysis in cerebral venous thrombosis. Pediatr Neurol 1994;10:78-80.
24. Cohen AR, Martin MB, Silber JH, Kim HC, Ohene-Frempong K, Schwartz E: A modified transfusion program for prevention of stroke in sickle cell disease. Blood 1992;79:1657-1661.
25. Miller ST, Jensen D, Rao SP: Less intensive long-term transfusion therapy for sickle cell anemia and cerebrovascular accident. J Pediatr 1 992; 1 20:54-57.
26. Kurokawa T, Tomita S, Ueda K, et al: Prognosis of occlusive disease of the circle of Willis (moyamoya disease) in children. Pediatr Neurol 1985; 1:274-277.
27. Taylor BJ, Seibert JJ, Glasier CM, VanDevanter SH, Harrell JE, Fasules JW: Evaluation of the reconstructed carotid artery following extracorporeal membrane oxygenation. Pediatrics 1992;90:568-572.

* Modified from Roach and Riela. Pediatric Cerebrovascular Disorders, New York. Futura Publishing Co., 1995.

Figure 1: Effect of Age At Event On Mean Diagnosis Time* (O-18 yrs.; N=80)

*data from the Canadian Pediatric Ischemic Stroke Registry

Source: National Institute of Neurological Disorders, 2010

Although ASD varies significantly in character and severity, it occurs in all ethnic and socioeconomic groups and affects every age group.  Experts estimate that three to six children out of every 1,000 will have ASD.  Males are four times more likely to have ASD than females.

What are some common signs of autism?

How is autism diagnosed?

What causes autism?

What role does inheritance play?

Do symptoms of autism change over time?

How is autism treated?

What research is being done?

For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute’s Brain Resources and Information Network (BRAIN) at:

BRAIN
P.O. Box 5801
Bethesda, MD 20824
(800) 352-9424

http://www.ninds.nih.gov

Information also is available from the following organizations:

Source: National Institute of Neurological Disorders and Stroke, 2010

Physicians work in one or more of several specialties, including, but not limited to, anesthesiology, family and general medicine, general internal medicine, general pediatrics, obstetrics and gynecology, psychiatry, and surgery.

Anesthesiologists focus on the care of surgical patients and pain relief. Like other physicians, they evaluate and treat patients and direct the efforts of their staffs. Through continual monitoring and assessment, these critical care specialists are responsible for maintenance of the patient’s vital life functions—heart rate, body temperature, blood pressure, breathing—during surgery. They also work outside of the operating room, providing pain relief in the intensive care unit, during labor and delivery, and for those who suffer from chronic pain. Anesthesiologists confer with other physicians and surgeons about appropriate treatments and procedures before, during, and after operations.

Family and general physicians often provide the first point of contact for people seeking healthcare, by acting as the traditional family physician. They assess and treat a wide range of conditions, from sinus and respiratory infections to broken bones. Family and general physician typically have a base of regular, long-term patients. These doctors refer patients with more serious conditions to specialists or other healthcare facilities for more intensive care.

General internists diagnose and provide nonsurgical treatment for a wide range of problems that affect internal organ systems, such as the stomach, kidneys, liver, and digestive tract. Internists use a variety of diagnostic techniques to treat patients through medication or hospitalization. Like general practitioners, general internists commonly act as primary care specialists. They treat patients referred from other specialists and, in turn, they refer patients to other specialists when more complex care is required.

General pediatricians care for the health of infants, children, teenagers, and young adults. They specialize in the diagnosis and treatment of a variety of ailments specific to young people and track patients’ growth to adulthood. Like most physicians, pediatricians work with different healthcare workers, such as nurses and other physicians, to assess and treat children with various ailments. Most of the work of pediatricians involves treating day-to-day illnesses—minor injuries, infectious diseases, and immunizations—that are common to children, much as a general practitioner treats adults. Some pediatricians specialize in pediatric surgery or serious medical conditions, such as autoimmune disorders or serious chronic ailments.

Obstetricians and gynecologists (OB/GYNs) specialize in women’s health. They are responsible for women’s general medical care, and they also provide care related to pregnancy and the reproductive system. Like general practitioners, OB/GYNs attempt to prevent, diagnose, and treat general health problems, but they focus on ailments specific to the female anatomy, such as cancers of the breast or cervix, urinary tract and pelvic disorders, and hormonal disorders. OB/GYNs also specialize in childbirth, which includes treating and counseling women throughout their pregnancy, from giving prenatal diagnoses to assisting with delivery and providing postpartum care.

Psychiatrists are the primary mental healthcaregivers. They assess and treat mental illnesses through a combination of psychotherapy, psychoanalysis, hospitalization, and medication. Psychotherapy involves regular discussions with patients about their problems; the psychiatrist helps them find solutions through changes in their behavioral patterns, the exploration of their past experiences, or group and family therapy sessions. Psychoanalysis involves long-term psychotherapy and counseling for patients. In many cases, medications are administered to correct chemical imbalances that cause emotional problems.

Surgeons specialize in the treatment of injury, disease, and deformity through operations. Using a variety of instruments, and with patients under anesthesia, a surgeon corrects physical deformities, repairs bone and tissue after injuries, or performs preventive surgeries on patients with debilitating diseases or disorders. Although a large number perform general surgery, many surgeons choose to specialize in a specific area. One of the most prevalent specialties is orthopedic surgery: the treatment of the musculoskeletal system. Others include neurological surgery (treatment of the brain and nervous system), cardiovascular surgery, otolaryngology (treatment of the ear, nose, and throat), and plastic or reconstructive surgery. Like other physicians, surgeons also examine patients, perform and interpret diagnostic tests, and counsel patients on preventive healthcare.

Other physicians and surgeons work in a number of other medical and surgical specialists, including allergists, cardiologists, dermatologists, emergency physicians, gastroenterologists, ophthalmologists, pathologists, and radiologists.

Work environment. Many physicians—primarily general and family practitioners, general internists, pediatricians, OB/GYNs, and psychiatrists—work in small private offices or clinics, often assisted by a small staff of nurses and other administrative personnel. Increasingly, physicians are practicing in groups or healthcare organizations that provide backup coverage and allow for more time off. Physicians in a group practice or healthcare organization often work as part of a team that coordinates care for a number of patients; they are less independent than the solo practitioners of the past. Surgeons and anesthesiologists usually work in well-lighted, sterile environments while performing surgery and often stand for long periods. Most work in hospitals or in surgical outpatient centers.

Many physicians and surgeons work long, irregular hours. In 2008, 43 percent of all physicians and surgeons worked 50 or more hours a week. Nine percent of all physicians and surgeons worked part-time. Physicians and surgeons travel between office and hospital to care for their patients. While on call, a physician will deal with many patients’ concerns over the phone and make emergency visits to hospitals or nursing homes.

Physicians examine patients, obtain medical histories, and order, perform, and interpret diagnostic tests.

Training, Other Qualifications, and Advancement

The common path to practicing as a physician requires 8 years of education beyond high school and 3 to 8 additional years of internship and residency. All States, the District of Columbia, and U.S. territories license physicians.

Education and training. Formal education and training requirements for physicians are among the most demanding of any occupation—4 years of undergraduate school, 4 years of medical school, and 3 to 8 years of internship and residency, depending on the specialty selected. A few medical schools offer combined undergraduate and medical school programs that last 6 or 7 years rather than the customary 8 years.

Premedical students must complete undergraduate work in physics, biology, mathematics, English, and inorganic and organic chemistry. Students also take courses in the humanities and the social sciences. Some students volunteer at local hospitals or clinics to gain practical experience in the health professions.

The minimum educational requirement for entry into medical school is 3 years of college; most applicants, however, have at least a bachelor’s degree, and many have advanced degrees. In 2008, there were 129 medical schools accredited by the Liaison Committee on Medical Education (LCME). The LCME is the national accrediting body for M.D. medical education programs. The American Osteopathic Association accredits schools that award a D.O. degree; there were 25 schools accredited in 31 locations in 2008.

Acceptance to medical school is highly competitive. Most applicants must submit transcripts, scores from the Medical College Admission Test, and letters of recommendation. Schools also consider an applicant’s character, personality, leadership qualities, and participation in extracurricular activities. Most schools require an interview with members of the admissions committee.

Students spend most of the first 2 years of medical school in laboratories and classrooms, taking courses such as anatomy, biochemistry, physiology, pharmacology, psychology, microbiology, pathology, medical ethics, and laws governing medicine. They also learn to take medical histories, examine patients, and diagnose illnesses. During their last 2 years, students work with patients under the supervision of experienced physicians in hospitals and clinics, learning acute, chronic, preventive, and rehabilitative care. Through rotations in internal medicine, family practice, obstetrics and gynecology, pediatrics, psychiatry, and surgery, they gain experience in the diagnosis and treatment of illness.

Following medical school, almost all M.D.s enter a residency—graduate medical education in a specialty that takes the form of paid on-the-job training, usually in a hospital. Most D.O.s serve a 12-month rotating internship after graduation and before entering a residency, which may last 2 to 6 years.

A physician’s training is costly. According to the Association of American Medical Colleges, in 2007 85 percent of public medical school graduates and 86 percent of private medical school graduates were in debt for educational expenses.

Licensure and certification. To practice medicine as a physician, all States, the District of Columbia, and U.S. territories require licensing. All physicians and surgeons practicing in the United States must pass the United States Medical Licensing Examination (USMLE). To be eligible to take the USMLE in its entirety, physicians must graduate from an accredited medical school. Although physicians licensed in one State usually can get a license to practice in another without further examination, some States limit reciprocity. Graduates of foreign medical schools generally can qualify for licensure after passing an examination and completing a U.S. residency. For specific information on licensing in a given State, contact that State’s medical board.

M.D.s and D.O.s seeking board certification in a specialty may spend up to 7 years in residency training, depending on the specialty. A final examination immediately after residency or after 1 or 2 years of practice is also necessary for certification by a member board of the American Board of Medical Specialists (ABMS) or the American Osteopathic Association (AOA). The ABMS represents 24 boards related to medical specialties ranging from allergy and immunology to urology. The AOA has approved 18 specialty boards, ranging from anesthesiology to surgery. For certification in a subspecialty, physicians usually need another 1 to 2 years of residency.

Other qualifications. People who wish to become physicians must have a desire to serve patients, be self-motivated, and be able to survive the pressures and long hours of medical education and practice. Physicians also must have a good bedside manner, emotional stability, and the ability to make decisions in emergencies. Prospective physicians must be willing to study throughout their career to keep up with medical advances.

Advancement. Some physicians and surgeons advance by gaining expertise in specialties and subspecialties and by developing a reputation for excellence among their peers and patients. Physicians and surgeons may also start their own practice or join a group practice. Others teach residents and other new doctors, and some advance to supervisory and managerial roles in hospitals, clinics, and other settings.

Employment

Physicians and surgeons held about 661,400 jobs in 2008; approximately 12 percent were self-employed. About 53 percent of wage–and-salary physicians and surgeons worked in offices of physicians, and 19 percent were employed by hospitals. Others practiced in Federal, State, and local governments, educational services, and outpatient care centers.

According to 2007 data from the American Medical Association (AMA), 32 percent of physicians in patient care were in primary care, but not in a subspecialty of primary care. (See table 1.)

According to the AMA, the New England and Middle Atlantic States have the highest ratios of physicians to population; the South Central and Mountain States have the lowest. Physicians tend to locate in urban areas, close to hospitals and education centers. AMA data showed that in 2007, about 75 percent of physicians in patient care were located in metropolitan areas while the remaining 25 percent were located in rural areas.

Job Outlook

Employment is expected to grow much faster than the average for all occupations. Job opportunities should be very good, particularly in rural and low-income areas.

Employment change. Employment of physicians and surgeons is projected to grow 22 percent from 2008 to 2018, much faster than the average for all occupations. Job growth will occur because of continued expansion of healthcare-related industries. The growing and aging population will drive overall growth in the demand for physician services, as consumers continue to demand high levels of care using the latest technologies, diagnostic tests, and therapies. Many medical schools are increasing their enrollments based on perceived new demand for physicians.

Despite growing demand for physicians and surgeons, some factors will temper growth. For example, new technologies allow physicians to be more productive. This means physicians can diagnose and treat more patients in the same amount of time. The rising cost of healthcare can dramatically affect demand for physicians’ services. Physician assistants and nurse practitioners, who can perform many of the routine duties of physicians at a fraction of the cost, may be increasingly used. Furthermore, demand for physicians’ services is highly sensitive to changes in healthcare reimbursement policies. If changes to health coverage result in higher out-of-pocket costs for consumers, they may demand fewer physician services.

Job prospects. Opportunities for individuals interested in becoming physicians and surgeons are expected to be very good. In addition to job openings from employment growth, openings will result from the need to replace the relatively high number of physicians and surgeons expected to retire over the 2008-18 decade.

Job prospects should be particularly good for physicians willing to practice in rural and low-income areas because these medically underserved areas typically have difficulty attracting these workers. Job prospects will also be especially good for physicians in specialties that afflict the rapidly growing elderly population. Examples of such specialties are cardiology and radiology because the risks for heart disease and cancer increase as people age.

Projections Data About this section

Earnings

Earnings of physicians and surgeons are among the highest of any occupation. According to the Medical Group Management Association’s Physician Compensation and Production Survey, median total compensation for physicians varied by their type of practice. In 2008, physicians practicing primary care had total median annual compensation of $186,044, and physicians practicing in medical specialties earned total median annual compensation of $339,738.

Self-employed physicians—those who own or are part owners of their medical practice—generally have higher median incomes than salaried physicians. Earnings vary according to number of years in practice, geographic region, hours worked, skill, personality, and professional reputation. Self-employed physicians and surgeons must provide for their own health insurance and retirement.

Source: Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-11 Edition, Physicians and Surgeons, 2010

What doctor should I see if I feel that my short term memory is decreasing? Thank you.
(From Neurology.com Q&A)

Answer:

You should start your line of inquiry with your primary care physician to assess whether your symptoms are due to normal aging or not. Everyone forgets things from time to time, and your physician can provide a more thorough assessment of what is considered normal aging.

You should certainly consider a doctor who is familiar with Alzheimer’s disease (AD) in particular. He or she can help with your concerns, and if needed, direct you toward a specialist. You can also find resources through the Alzheimer’s Association website.

It’s a good idea for you to look into this issue, because if you do have concerns, it helps to address them earlier, rather than later.

Why is early diagnosis important?
Early diagnosis is beneficial for several reasons. Having an early diagnosis and starting treatment in the early stages of AD can help preserve function for months to years, even though the underlying AD process cannot be changed.

Having an early diagnosis also helps patients and their families:

• plan for the future
• make living arrangements
• take care of financial and legal matters
• develop support networks

Finally, an early diagnosis can provide greater opportunity for people with AD to get involved in clinical trials. Clinical trials are research studies in which scientists test the safety, side effects, or effectiveness of a medication or other intervention.

Normal Cognitive Aging, Cognitive Decline, and AD: What’s the Difference?
Improvements in public health, medical care, nutrition, and living standards have resulted in our now living longer than ever before. Many older adults enjoy active, productive lives, but they also face the risk of memory and other cognitive problems. This challenge has provided a major impetus for research into healthy cognitive aging. Scientists—and the public—want to know how and why some people remain cognitively healthy all their lives while others do not. Answers to these questions also can help researchers understand what goes wrong in AD or other neurodegenerative diseases and can point the way to interventions that might maintain successful brain and cognitive aging.

As knowledge about the spectrum of stages from healthy cognitive aging to AD grows, it has become increasingly evident that no clear distinctions separate a healthy brain and a diseased brain. Most people develop some plaques and tangles in their brains as they get older, but not everyone develops cognitive problems, MCI, or AD. At what point does an age-related process become a disease-causing process? Several studies published in 2008 and 2009 explored this question.

• Researchers at the University of Pittsburgh School of Medicine conducted PiB PET scans to image amyloid deposits in the brains of 43 adults, 65 to 88 years old, who did not have clinical AD or MCI (Aizenstein et al., 2008). The 9 participants with beta-amyloid deposits in at least one brain region performed as well on cognitive tests as the 29 participants who had no amyloid deposits and the 5 participants with “intermediate” evidence of amyloid deposits. The finding that an older person with “significant amyloid burden” can be cognitively normal suggests either that some people may have a high level of cognitive reserve or that beta-amyloid deposition alone does not explain cognitive impairment. Another possibility is that some of these individuals will go on to develop AD, even though they are cognitively normal to start. In that case, PiB PET may be useful in identifying AD before clinical symptoms appear. These findings mirror those previously found in post-mortem studies, where the brains of some people with normal cognition were found to have significant amyloid deposits.
• A team of scientists at the Banner Alzheimer’s Institute in Phoenix, Arizona, conducted PiB PET scans in 28 cognitively normal older people, correlating the results with the presence of the APOE ε4 gene (Reiman et al., 2009). The researchers found higher levels of beta-amyloid deposits in people with one and two copies of the APOE ε4 gene than in those without this version of the gene. These results echo earlier findings showing that APOE ε4 carriers have higher levels of amyloid in their brains at death than do people without this risk factor. Findings from these two studies suggest the possible usefulness of PiB PET scans to detect AD before clinical signs and symptoms appear. This will be crucial for testing promising prevention therapies.
  Longitudinal studies also are being conducted to determine the long-term consequences of beta-amyloid deposits in brain and whether they invariably lead to AD.
• University of California Berkeley scientists looked at the relationship between extent of brain amyloid deposits (measured using PiB PET scans), hippocampal volume (measured using MRI), and episodic memory (for example, memory of times or places) in three groups: cognitively healthy participants in the Berkeley Aging Cohort, cognitively healthy participants in the AD Neuroimaging Initiative (ADNI), and ADNI participants with MCI (Mormino et al., 2009). In the Berkeley Aging Cohort participants and ADNI participants with MCI, brain amyloid deposits were associated with smaller hippocampal volumes and worse episodic memory. In the healthy ADNI participants, brain amyloid deposits were associated with smaller hippocampal volumes but normal episodic memory. The researchers conducted analyses suggesting that beta-amyloid deposition, hippocampal atrophy, and declines in episodic memory occur sequentially in elderly subjects, with beta-amyloid deposition being the triggering event. In other words, declining episodic memory in older individuals may be caused by hippocampal atrophy induced by beta-amyloid.

Source: National Institute on Aging, 2010

Items including a tuning fork, flashlight, reflex hammer, ophthalmoscope, and needles are used to help diagnose brain tumors, infections such as encephalitis and meningitis, and diseases such as Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis (ALS), and epilepsy.  Some tests require the services of a specialist to perform and analyze results.

X-rays of the patient’s chest and skull are often taken as part of a neurological work-up.  X-rays can be used to view any part of the body, such as a joint or major organ system.  In a conventional x-ray, also called a radiograph, a technician passes a concentrated burst of low-dose ionized radiation through the body and onto a photographic plate.

Since calcium in bones absorbs x-rays more easily than soft tissue or muscle, the bony structure appears white on the film.  Any vertebral misalignment or fractures can be seen within minutes.  Tissue masses such as injured ligaments or a bulging disc are not visible on conventional x-rays.  This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.

Fluoroscopy is a type of x-ray that uses a continuous or pulsed beam of low-dose radiation to produce continuous images of a body part in motion.  The fluoroscope (x-ray tube) is focused on the area of interest and pictures are either videotaped or sent to a monitor for viewing.  A contrast medium may be used to highlight the images.  Fluoroscopy can be used to evaluate the flow of blood through arteries.

Source: National Institute of Neurological Disorders and Stroke, 2010

Cerebral aneurysm (also known as an intracranial or intracerebral aneurysm) is a weak or thin spot on a blood vessel in the brain that balloons out and fills with blood.  The bulging aneurysm can put pressure on a nerve or surrounding brain tissue.  It may also leak or rupture, spilling blood into the surrounding tissue (called a hemorrhage).  Some cerebral aneurysms, particularly those that are very small, do not bleed or cause other problems.  Cerebral aneurysms can occur anywhere in the brain, but most are located along a loop of arteries that run between the underside of the brain and the base of the skull.

What causes a cerebral aneurysm?

How are aneurysms classified?

Who is at risk?

What are the dangers?

What are the symptoms?

How are cerebral aneurysms diagnosed?

How are cerebral aneurysms treated?

Can cerebral aneurysms be prevented?

What is the prognosis?

What research is being done?

For example, blood and blood product tests can detect brain and/or spinal cord infection, bone marrow disease, hemorrhage, blood vessel damage, toxins that affect the nervous system, and the presence of antibodies that signal the presence of an autoimmune disease.  Blood tests are also used to monitor levels of therapeutic drugs used to treat epilepsy and other neurological disorders.  Genetic testing of DNA extracted from white cells in the blood can help diagnose Huntington’s disease and other congenital diseases.

Analysis of the fluid that surrounds the brain and spinal cord can detect meningitis, acute and chronic inflammation, rare infections, and some cases of multiple sclerosis.  Chemical and metabolic testing of the blood can indicate protein disorders, some forms of muscular dystrophy and other muscle disorders, and diabetes.  Urinalysis can reveal abnormal substances in the urine or the presence or absence of certain proteins that cause diseases including the mucopolysaccharidoses.

Genetic testing or counseling can help parents who have a family history of a neurological disease determine if they are carrying one of the known genes that cause the disorder or find out if their child is affected.  Genetic testing can identify many neurological disorders, including spina bifida, in utero (while the child is inside the mother’s womb).  Genetic tests include the following:

• Amniocentesis, usually done at 14-16 weeks of pregnancy, tests a sample of the amniotic fluid in the womb for genetic defects (the fluid and the fetus have the same DNA).  Under local anesthesia, a thin needle is inserted through the woman’s abdomen and into the womb.  About 20 milliliters of fluid (roughly 4 teaspoons) is withdrawn and sent to a lab for evaluation.  Test results often take 1-2 weeks.
• Chorionic villus sampling, or CVS, is performed by removing and testing a very small sample of the placenta during early pregnancy.  The sample, which contains the same DNA as the fetus, is removed by catheter or fine needle inserted through the cervix or by a fine needle inserted through the abdomen.  It is tested for genetic abnormalities and results are usually available within 2 weeks.  CVS should not be performed after the tenth week of pregnancy.
• Uterine ultrasound is performed using a surface probe with gel.  This noninvasive test can suggest the diagnosis of conditions such as chromosomal disorders

Specific tests in a neurological examination include:

• Examination of posture
• Decerebrate
• Decorticat
• Hemiparetic
• Abnormal movements
• Seizure
• Fasciculations
• Cerebellar testing
• Dysmetria
• Finger-to-nose test
• Ankle-over-tibia test
• Dysdiadochokinesis
• Rapid pronation-supination
• Ataxia
• Assessment of gait
• Nystagmus
• Intension tremor
• Staccato speech
• Tone
• Spasticity
• Pronator drift
• Rigidity
• Cogwheeling (abnormal tone suggestive of Parkinson’s disease)
• Gegenhalten – is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force. More common in dementia.
• Romberg test to examine proprioception or cerebellar function
• Resting tremors
• Sensory
• Light touch
• Pain
• Temperature
• Vibration
• Position sense
• Graphesthesia
• Stereognosis, and
• Two-point discrimination (for discriminative sense)
• Extinction

Sources: National Institute of Neurological Disorders and Stroke; Wikipedia