Background:The reduction in US stroke mortality has been attributed to declining stroke incidence. However, evidence is accumulating of a trend in declining stroke severity.Methods: We examined secular trends in stroke incidence, prevalence, and fatality in Framingham Study subjects aged 55-64 years in three successive decades beginning in 1953, 1963, and 1973.Results: No significant decline in overall stroke and transient ischemic attack incidence or prevalence occurred. In women, but not men, incidence of completed ischemic stroke declined significantly. Stroke severity, however, decreased significantly over time. Stroke with severe neurological deficit decreased in later decades, with a fall in rates of severe stroke cases in which patients were unconscious on admission to the hospital. There was no substantial change in the case mix of infarcts and hemorrhages and no decline in hemorrhage to account for the decline in severity. The proportion of isolated transient ischemic attacks increased significantly over the 30 years studied, yielding an apparent and significant decline in case-fatality rates in men only.Conclusions: Secular trends in stroke incidence and fatality did not follow a clear or definite pattern of decline. While a significant decline in stroke severity occurred over three decades, incidence of infarction fell only in women. The decline in total case fatality rates occurred only in men and resulted largely from an increased incidence of isolated transient ischemic attacks. The severity of completed stroke was significantly lower in the later decades under study. (Stroke 1992;23:1551-1555)

IMPORTANCE Biological sex and sociocultural gender represent major sources of diversity among patients, and recent research has shown the association of sex and gender with health. A growing body of literature describes widespread associations of sex and gender with cells, organs, and the manner in which individual patients interact with health care systems. Sex-and gender-informed medicine is a young paradigm of clinical practice and medical research founded on this literature that considers the association of sex and gender with each element of the disease process from risk, to presentation, to response to therapy. OBSERVATIONS Characteristics that underlie sex and gender involve both endogenous and exogenous factors that change throughout the life course. This review details clinical examples with broad applicability that highlight sex and gender differences in the key domains of genetics, epigenomic modifiers, hormonal milieu, immune function, neurocognitive aging process, vascular health, response to therapeutics, and interaction with health care systems. These domains interact with one another in multidimensional associations, contributing to the diversity of the sex and gender spectra. Novel research has identified differences of clinical relevance with the potential to improve care for all patients.CONCLUSIONS AND RELEVANCE Clinicians should consider incorporating sex and gender in their decision-making to practice precision medicine that integrates fundamental components of patient individuality. Recognizing the biological and environmental factors that affect the disease course is imperative to optimizing care for each patient. Research highlights the myriad ways sex and gender play a role in health and disease. However, these clinically relevant insights have yet to be systematically incorporated into care. The framework described in this review serves as a guide to help clinicians consider sex and gender as they practice precision medicine.

The care of patients with functional neurological disorders overlaps both the neurology and psychiatry specialties. It is often the case that neither provider thinks that he or she should be the treating clinician, and as a result, this patient group can suffer a substantial gap in care. Here, we illustrate a practical approach toward integration of care to appropriately treat patients with functional neurological disorders. DEFINITIONSThe chapter on somatic symptoms and related disorders in DSM-5 encompasses several psychiatric disorders for which the primary feature is a symptom related to a physical or health-related complaint. The diagnostic criteria for somatic symptom disorder require that the patient have one or more Which of the following reflects a DSM-5 criterion for conversion disorder (functional neurologic symptom disorder)?A. Symptoms of altered voluntary motor, cognitive, or sensory function. B. Clinical findings compatible with a recognized neurologic condition. C. Symptom onset following an identified stressor. D. Evidence of intentional production of neurologic symptoms. "Ms. A," a 29-year-old woman, was referred for a second neurologic opinion. Several months earlier, she woke with a pins-and-needles sensation involving both legs from the knees to the toes. The following day, she could not move her legs without help from her fiancé. Several hours later, she developed transient numbness of the left arm. Alarmed by her increasing symptoms, she presented to the emergency department. A brain and cervical MRI with gadolinium contrast showed no abnormalities. The patient was discharged with neurologic follow-up. Results of an electromyogram and nerve conduction study of the upper and lower extremities were normal. Later, because of increasing back and diffuse leg pain, the patient underwent a lumbar MRI, which also showed no abnormalities. She continued to experience lower extremity weakness and paresthesias as well as back and leg pain. No diagnosis was made. The patient had been unable to work since her symptoms began.Ms. A had a history of posttraumatic stress disorder related to a rape in college. She still endorsed presence of frequent nightmares and flashbacks related to the experience. She denied hypervigilance or avoidance related to her trauma. She denied any history of depression or other anxiety symptoms.On examination the patient had diffuse lower extremity weakness with variability of effort (the strength of her lower extremities did not consistently show the same response, as would be expected in a physiological motor deficit). Her reflexes were normal and there were no pathological reflexes. Sensation to pinprick was decreased in both legs without a sensory level or a dermatomal pattern (if a patient has a spinal cord abnormality, a sensory level would be an expected finding, or if there were cauda equina involvement, the sensory loss should conform to that of multiple sensory dermatomes). The patient's vibratory sense was diminished over the thoracic but not the lumbar vertebrae or in...

Neurological complications after labor and delivery are most often caused by compressive trauma related to childbirth and rarely related to neuraxial anesthesia/analgesia. However, it is important for anesthesiologists to be able to recognize the common manifestations of these neuropathies in order to distinguish them from more ominous causes of neurologic disease. In this article, we review the anatomy and etiology of postpartum thoracolumbar spinal cord, lumbar nerve roots, plexus, and lower extremity peripheral nerve injuries. We will focus on a practical approach to their diagnosis, management, and treatment. Cases will be used to illustrate diagnosis and management.