Tuberous sclerosis complex (TSC) is a rare neurocutaneous disorder of mTOR pathway dysregulation resulting from pathogenic variants in the TSC1 or TSC2 genes. Expression of this disorder may involve abnormal tissue growth and dysfunction within the brain, kidneys, heart, lungs, eyes, skin, bones, and teeth. Neurological manifestations can include subependymal giant cell astrocytomas (SEGAs), high rates of infantile spasms, drug-resistant epilepsy, developmental delay, cognitive impairment, autism spectrum disorder, and other neurobehavioral manifestations. Here we review the potential clinical manifestations of TSC by system, recommended diagnostic and surveillance testing, genetic testing, currently available therapeutic options, and considerations for education and social support resources given the unique challenges of this multi-system disorder.

Status epilepticus is a neurologic emergency defined as a seizure that lasts longer than 5 minutes. This is the most common neurologic emergency in children, and it is associated with significant morbidity and mortality. Initial seizure management focuses on stabilization of the patient, followed by medication to terminate the seizure. Benzodiazepines, levetiracetam, fosphenytoin, valproic acid and other antiseizure medications can effectively halt status epilepticus. There is a narrow but important differential diagnosis, including prolonged psychogenic nonepileptic seizure, status dystonicus, and nonconvulsive status epilepticus. Focused laboratory testing, neuroimaging, and electroencephalography can be useful in the evaluation of status epilepticus. Sequelae include focal neurologic deficits, cognitive impairment, and behavioral problems. Pediatricians play an important role in the early recognition and treatment of status epilepticus, thereby preventing the acute and chronic harm that can be associated with status epilepticus.

Status epilepticus is a neurologic emergency defined as a seizure that lasts longer than 5 minutes. This is the most common neurologic emergency in children, and it is associated with significant morbidity and mortality. Initial seizure management focuses on stabilization of the patient, followed by medication to terminate the seizure. Benzodiazepines, levetiracetam, fosphenytoin, valproic acid and other antiseizure medications can effectively halt status epilepticus. There is a narrow but important differential diagnosis, including prolonged psychogenic nonepileptic seizure, status dystonicus, and nonconvulsive status epilepticus. Focused laboratory testing, neuroimaging, and electroencephalography can be useful in the evaluation of status epilepticus. Sequelae include focal neurologic deficits, cognitive impairment, and behavioral problems. Pediatricians play an important role in the early recognition and treatment of status epilepticus, thereby preventing the acute and chronic harm that can be associated with status epilepticus.

Writing the counterpoint article to Pedro Weisleder's commentary on moral injury among medical practitioners has been challenging, largely because I tend to agree with much of what my friend has to say.1 I am also at a considerable disadvantage because, unlike Dr. Weisleder, I am not a trained ethicist. Thus, I have few options in this debate but to provide a smattering of personal observations in an effort to ensure a balanced perspective. There is considerable research on burnout among physicians, but moral injury is not as well studied. Physicians are often reluctant to acknowledge concerns about moral injury lest they appear inadequate or weak. Their hesitancy to speak may also be related to a denial of personal vulnerability or to the long-standing stigma surrounding mental health disorders among physicians, a broader problem for another day's discussion. One point that is seldom mentioned in contemporary discussions of physician burnout and moral injury is that medicine is an intrinsically difficult profession. How could it be otherwise when we so often deal with untreatable diseases, death, disability, social and family turmoil, and patient financial ruin? It is wrong to assume that only modern physicians face soul-scarring difficulties. Previous generations of physicians had far fewer effective therapies and so more often had to preside over hopeless situations or resort to worthless medications or mutilating amputations in an often-futile attempt to save someone's life. Additionally, physicians once faced a socially accepted dual standard of care that was far worse than the present gap between individuals with commercial health care insurance and those with limited coverage: it was once considered completely acceptable for physicians to simply ignore sick poor people. Indeed, physicians who provided a free cattle-call clinic for a few hours each month were usually considered noble for doing so. Surely these circumstances would have engendered moral injury to many caring, thoughtful physicians of the time. While the recently articulated concept of moral injury makes it easier to recognize the outsized role that our health care system plays in creating physician distress, it is naïve to blame burnout and moral injury solely on the institutions of medicine. Being a physician has always been challenging, and it is likely to remain so even if we can address some of the systemic issues. I have often pondered why some physicians seem to fare so much better than others when facing situations that typically lead to moral injury and burnout. Even within the same medical specialty, in the same institution, and with the same workload, some people remain grounded and productive while others falter and decompensate. From my own admittedly anecdotal observations, the diverse responses of physicians to professional adversity may be partly explained by intangible individual qualities such as resilience, perfectionism, compulsiveness, strength of purpose, and clarity of expectations. This comment is certainly not intended to absolve our institutions from responsibility by shifting blame to the physicians who deal with the woes of organized medicine on a daily basis. It should never be acceptable to make medical practice more difficult than necessary, even for physicians who seem to be thriving. But it is also wrong to ignore these individual physician differences, if only because they could offer practical avenues for helping a distressed colleague. Each physician has unique qualities that will inevitably influence how they react to professional adversity as well as how they respond to proposed solutions. Some physicians are drawn to medicine because it offers a sense of accomplishment and prestige within their community and their family, while others are attracted by the higher income medical practice offers. None of these motives provides a sustainable reason to become a physician. Medicine is and always has been a tough career. Anyone who thinks otherwise is likely to be ill-prepared for what is, even under ideal circumstances, an often physically and emotionally grueling lifestyle. Regardless of whether the challenges we face stem from the practice of medicine per se, from ill-advised institutional policies, or from a combination of these factors, we should perhaps acknowledge that some people simply do not have the temperament or resilience to thrive in medicine. Are we sure that we physicians do not contribute to the problems we face, even to a slight degree? The health care system would come to a complete standstill if enough physicians conclude that enough is enough and demand change. The legitimate systemic issues that Dr. Weisleder describes exist in the context of physicians who are collectively unable or unwilling to demand changes. Presumably, this means that many physicians are not totally dissatisfied with their current circumstances or, more likely, are insufficiently dissatisfied to risk their otherwise comfortable existence in an effort to exact change. Even individual physicians may bear some responsibility. While many of us complain about the workload and the lack of time needed to promote personal well-being, few are willing to accept part-time employment that might promote well-being and still allow an income that many nonphysicians would envy. Not all physician jobs would allow such a change, of course, but some of us make a conscious decision in favor of higher compensation instead of opting for a position with more personal time but lower income. The entrepreneurial nature of the United States health care system predictably incentivizes financial gain, both for institutions and for individual physicians. Efforts to control the resulting high costs, in turn, often lead to questionable documentation requirements and wasted physician time spent pleading for approval of necessary diagnostic studies or treatments. Major institutions shamelessly cherry-pick lucrative procedures, depriving less affluent facilities of needed funds and exacerbating care disparities.2 Our piecemeal reimbursement system both rewards and normalizes these behaviors. Altruistic practitioners who entered medicine to help people are often caught in this profit-driven meat grinder, typically with little meaningful input into far-reaching decisions that affect patient care and contribute to physician burnout. But as Dr. Weisleder points out, physician burnout is a worldwide problem, so the unique difficulties of the US health care system cannot be the sole reason for it. How can we address these pervasive issues to make life easier for physicians? Laying the entire problem at the feet of the physicians is certainly unfair. But it is also unwise to ignore the individual traits that contribute to burnout and limit our ability to cope with moral injury, if only because these individual characteristics may provide improvement opportunities that are far more plausible than overhauling the entire health care system. Celebrating successes, promoting self-compassion, improving self-awareness, and inasmuch as possible aligning personal values with work duties may help some of us avoid a vortex of pessimism.3 We need to cultivate resilience, realistic expectations, and strength of purpose. Doing so will not eliminate the individual or systemic difficulties of medical practice, but it just might enable some physicians to deal with these difficulties more constructively. E. Steve Roach: Conceptualization; project administration; writing—original draft; writing—review and editing. The author is the editor-in-chief of the Annals of the Child Neurology Society. The opinions expressed in this essay are those of the author and do not reflect the official policy of the Child Neurology Society.

The essence of science: ask an impertinent question, and you are on the way to a pertinent answer. Jacob Bronowski Prepublication peer review of scientific manuscripts is used by most legitimate scientific publications. Skillful peer reviews represent a valuable contribution to the field by improving the quality of scientific research communication and promoting scientific integrity. Peer review of scientific manuscripts was introduced in 1733 by the Royal Society of Edinburgh. In 1752, a committee of the Royal Society of London began prepublication reviews for the society's Philosophical Transactions.1 In 1893, the British Medical Journal began using outside referees for noneditorial articles.2 However, prepublication peer review of medical and scientific manuscripts did not become standard until the mid-1900s, led by the introduction of manuscript review by JAMA and Science in the 1940s and Lancet in 1976.2 The peer review process was likely facilitated by the advent of photocopy technology.3 The overlapping goals of peer review are to provide editors with an assessment of the veracity and potential significance of the submission and to help the author improve the quality of the manuscript. However, there are sometimes benefits to a reviewer as well, such as improved manuscript preparation skills, exposure to new concepts and ideas, and opportunities for improved professional standing. A number of studies have analyzed the effectiveness of manuscript peer review, the potential effects of reviewer bias, and the authors' satisfaction with the review process.4-7 Despite the acknowledged importance of manuscript peer review, information about how to do it effectively is scant, and formal training in manuscript reviewing is usually limited. There are many different ways to complete a manuscript review, but what follows is a primer on effective manuscript peer review by an editor with years of reviewing and editing experience. Does the manuscript pass the "smell test"? As a reviewer, you are the content expert, and editors will appreciate your placing a study into context. Are earlier publications being ignored or trivialized? Well-crafted manuscripts offer a clear explanation of their purpose, ideally in the introduction. If the reviewer struggles to grasp the manuscript's importance, so will the readers. Rare is not the same thing as novel. Manuscripts occasionally have important implications that are not recognized by the authors. More often, the authors suggest novelty when little exists. Not all novelty is equally meaningful. I am usually unimpressed with "geographic" manuscripts ("we describe the first patient with West Nile encephalitis in all of Wyoming"), "making people aware" manuscripts (describing something that is uncommon but already well-known), "masquerading as" manuscripts, incremental data reports (adding a few more patients to last year's published summary), and manuscripts whose sole novelty is a new variant of an already well-characterized gene. Does the title convey an adequate sense of the study's contents? Just as the abstract should provide an overview of the manuscript's contents, a title should telegraph the story an article will tell. Cute catchy titles may be lost on individuals who are less familiar with English idioms, so it is best to limit such titles to commentaries and editorials. It is generally better to avoid abbreviations in titles unless they are so widely used that they are universally recognized. Pay close attention to the abstract. The abstract is the only part of an article that many people will read, so it should provide enough details to be useful independent of the remaining article. Does it provide context for the article? Does it contain substantive data or gloss over the results? Are there meaningful conclusions, and are these adequately supported by the information presented? There are few things more disappointing than an abstract that concludes "the data will be discussed." Are the figures technically adequate and the tables well-organized? Overly complicated tables or figures are difficult to interpret and ineffective. A few carefully selected, high-quality illustrations are preferable to multiple illustrations depicting the same findings. Many journals allow online supplemental data files, and these are an excellent way to provide more detailed information while streamlining the main article. Do the figure legends provide enough information to allow a reader to interpret the figure without extensive reference to the other text? Are the methods described in sufficient detail to allow one to understand the results and, potentially, to independently confirm the data? Do the statistical methods seem appropriate? If you have concerns about the statistical methods but feel uncomfortable trying to verify them, it is fine to suggest a separate statistical review to the editor. Does the discussion adequately credit earlier work? Is there a clear delineation of what the current study adds to our understanding of the topic? Are the study's limitations mentioned? Are the manuscript's conclusions adequately supported by the information presented? It is not reasonable, for example, to suggest that all patients with celiac disease be tested for hearing loss in a report of two such patients. Can the manuscript be shortened without omitting important information? The shift toward electronic publication has made strict manuscript word limits less important, but removing bloated text is still a good way to improve a manuscript's focus and readability. Mercifully, reviewers are not expected to correct grammatical errors or identify plagiarism. However, it is useful to mention writing that is so bad that it impairs understanding of the manuscript or is likely to defy correction. It is rather poor form to criticize an author's spelling and grammar in review comments that are filled with misspellings and grammatical errors. While editors do not expect a reviewer to personally verify every bibliography entry, it is sometimes helpful to spot-check a few of the citations for completeness, accuracy, and importantly, whether the cited article actually states what the authors suggest. Primary peer-reviewed sources are generally preferable to textbooks, abstracts, chapters, or websites. Are the citations reasonably accessible to the readers? Citing an obscure publication is sometimes necessary, but references that are not readily available to the readers are not very helpful. Does the manuscript document approval or waiver of approval by the institution's research ethics committee? Does the study maintain equipoise? Dunking children with Dravet syndrome into a hot bath to see if increased body temperature triggers seizures is problematic (yes, I once rejected such a manuscript) even in the unlikely event of its being approved by an ethics committee. Are clinical trials properly registered? Are potential conflicts of interest adequately disclosed? The most obvious conflicts are typically the economic ones, such as the corporate sponsorship of the study itself, employment of an author by the corporate sponsor, or financial incentives to the authors.8 Other conflicts are more subtle, and even the appearance of conflict can be problematic. If properly disclosed, conflicts of interest do not always preclude publication. A good approach is to err on the side of over-disclosure. As a reviewer, be mindful of your own potential conflicts. Are you able to consider authors' work fairly and objectively? It is best not to review manuscripts written by relatives, close colleagues, trainees, mentors, or individuals from your own institution. Not all conflicts disqualify a reviewer. Having a direct financial interest in the outcome of the study under consideration is disqualifying, while receiving an occasional honorarium from the sponsor for work unrelated to the study at hand may be acceptable. At a minimum, the reviewer should disclose potential conflicts to the editor. What is missing from the manuscript? It is reasonable to ask for text clarification, another table or figure, or additional data that will improve the manuscript. However, it is probably too late at this stage to demand fundamental study redesigns or the collection of extensive new data. Missing data that impair a study's analysis should at a minimum be listed as a study limitation. Begin the review comments with a one- or two-sentence summary of the manuscript. This sets the stage for the critique that follows and assures the authors that the reviewer has at least read the manuscript. Even if you recommend rejection, try to provide helpful, actionable suggestions for improving a manuscript. Assuming that the authors are sufficiently motivated to fully address the reviewers' suggestions, the manuscript they submit to a different journal will often be vastly improved. Organize your comments to the authors as a numbered list. This makes it much easier for the editors to grasp the essential points of the review and facilitates an author's creation of a point-by-point response to these comments when revising the manuscript. The authors' point-by-point response, in turn, makes it easier for you and the editors to assess the revised manuscript. Typically, some reviewer concerns are more serious than others, and grouping the major and the minor concerns is useful and takes little additional time. Point out inconsistencies. Do the data differ in the text, figures, and tables? Are the conclusions more robust than the data support? Are elements of the discussion contradictory? Does the information in the abstract contradict the text comments? Do the study's results and conclusions contradict earlier studies, and are these differences adequately documented and explained? Are the manuscript's limitations and potential biases adequately acknowledged? All studies have flaws. These do not necessarily invalidate the manuscript's conclusions or prevent its publication, but a clear summary of the study's limitations is necessary. Avoid making comments to the authors about whether the manuscript should be published. There are many factors that go into a publication decision, such as the other reviewer's opinion, the editor's opinion, a statistical review, the quality of the writing, and the plagiarism analysis. Most journals receive more submissions than can be accepted, so some manuscripts must be declined only because they are perceived to be less important than other submissions. A recommendation in favor of publication in the comments to the author makes it more difficult for the editors to tactfully decline a manuscript. A clearly stated publication recommendation to the editor, in contrast, is quite useful. You cannot always support an author's approach and conclusions, but you can always be kind. Remember that even a substandard manuscript represents a fellow human being's sincere effort and earnest hopes, however modest. Before harshly ridiculing their effort, imagine how you would feel if a reviewer characterized your work as "an utter waste of time and effort" or stated that they "wouldn't wrap fish in this paper." Such hurtful comments serve no useful purpose, and many editors remove overly harsh remarks before sharing the comments with the authors. I also stop inviting these individuals to serve as reviewers. This manuscript is very well-written, making its lack of significance all the more apparent. It is wonderful to read a truly great paper, but this is not one of those. There is much less here than meets the eye. This manuscript contains new and important information. Unfortunately, the new parts are not very important. It is unclear whether the results are confusing or merely confused. Manuscript peer reviewers are the unsung heroes of science. They make an important contribution to the advancement of the field, anonymously donating their time and expertise to improve other people's work. As annoying as reviewer comments can be to the authors, most manuscripts benefit greatly from the review and revision process. Many people whose own work has benefited greatly from the insights and suggestions of anonymous peer reviewers cannot be bothered to pay it forward and help other authors. Finding qualified, willing peer reviewers is the single biggest challenge for most medical editors. Please consider the importance of the peer review process the next time you are asked to serve. E. Steve Roach: Conceptualization; project administration; writing original draft; manuscript review and editing. The author is the editor-in-chief of the Annals of the Child Neurology Society, but the expressed opinions do not reflect the official policy of the Child Neurology Society.

Status epilepticus is a neurologic emergency defined as a seizure that lasts longer than 5 minutes. This is the most common neurologic emergency in children, and it is associated with significant morbidity and mortality. Initial seizure management focuses on stabilization of the patient, followed by medication to terminate the seizure. Benzodiazepines, levetiracetam, fosphenytoin, valproic acid and other antiseizure medications can effectively halt status epilepticus. There is a narrow but important differential diagnosis, including prolonged psychogenic nonepileptic seizure, status dystonicus, and nonconvulsive status epilepticus. Focused laboratory testing, neuroimaging, and electroencephalography can be useful in the evaluation of status epilepticus. Sequelae include focal neurologic deficits, cognitive impairment, and behavioral problems. Pediatricians play an important role in the early recognition and treatment of status epilepticus, thereby preventing the acute and chronic harm that can be associated with status epilepticus.

The first year of Annals of the Child Neurology Society (ACNS) has been marked by extraordinary progress, and we pause here to review and celebrate the journal's successful launch. As an official journal of the Child Neurology Society, ACNS offers a venue for clinical and translational research articles, clinically relevant basic science articles, patient reports, teaching vignettes, and quality improvement articles. It also provides a forum for discussion of important professional issues and factors that affect the care of children with neurological disease. The society maintains its traditional relationship with Annals of Neurology, with its focus on more basic research. Several years ago, the American Neurological Association created Annals of Clinical and Translational Neurology (ACTN), and the addition of ACNS by the Child Neurology Society forms an Annals “family” of journals that together support a wide range of scholarly endeavors. We have a great collaborative relationship with the editors of Annals of Neurology, and authors of manuscripts that cannot be accepted by Annals are offered consideration by ACNS or ACTN. We expect this transfer option to eventually become an important source of articles for ACNS. The first few months were spent building the journal's infrastructure. It takes considerable behind‐the‐scenes time and effort to create policies, websites, social media accounts, the editorial board, a detailed guide for authors, letter templates, and an initial reviewer database. ACNS features several innovative initiatives, including a monthly Editor's Choice article that is highlighted in an email to the society's members, a trainee mentoring program for novice writers, and ACNS Fast Track, a rapid review cycle designed to generate an initial publication decision within two weeks of submission. The first articles began to appear in December 2022. The initial ACNS articles have been remarkably good, led by a series of excellent review articles by pioneers in the field. The first article after the opening editorial was Harvey Sarnat's eloquent review of axonal pathfinding and guidance in the development of the nervous system, a basic science topic with obvious clinical relevance. Curtis Coughlin and Sidney Gospe contributed an outstanding summary of pyridoxine dependency. These authors were instrumental in unraveling the clinical features, genetics, and molecular mechanisms of pyridoxine dependency, so not surprisingly, their review is a tour de force. Nordli and Galan provide a detailed case‐based review of magnetoencephalography, a valuable tool for identifying an epileptogenic zone and for pinpointing language, motor, and visual functions in relation to a brain lesion. Fernández and Peters provide an intriguing glimpse of potential clinical uses of artificial intelligence and algorithm‐driven machine learning to process data and improve performance. The ACNS research articles have also been outstanding, although we cannot highlight all of them. Roberts and colleagues analyzed prospective observational data from 276 babies in their Neonatal Seizure Registry, concluding that inability to tolerate oral feedings by the time of

Legacy is everything. Honor what is good in the past, fuel what is promising in the future, and you will bring meaning and substance to the present. Nina Schor The ideal approach for child neurology training has become a topic of controversy in recent years, with strong opinions from both sides of the discussion often generating more heat than light. What follows is a dispassionate analysis of our child neurology training requirements. My intent is to facilitate constructive discussion and reframe the questions, not to take sides. We owe it to our trainees and to the children entrusted to us to create the best possible child neurology training. As a neurologist who still sees adult patients, I am not opposed to adult neurology training for child neurologists. The question is not whether a year of adult neurology training still has value for child neurologists, but whether requiring a full year continues to represent the best use of the residents' time given the major changes in the field in the half century since the basic training requirements were initially established. Similarly, it may be appropriate to discuss the optimal amount of preliminary pediatric training for child neurologists. We wrote the rules and they followed us. We set what, in the three years, these young people who were going to be trained in pediatric neurology would do. They would spend a year on the adult neurology service, learning neurology with people who could talk back to them and give them histories. Then we developed a year in which they would understand all of the diagnostic techniques. Electroencephalogram, the air tests, that sort of business, which was important. Then finally, they would take care of the children with neurologic problems. They would have the basic background now. This was on top of their own pediatric training, which we had nothing to do with except to be sure it was a good one. This became the method of training pediatric neurologists. The American Board of Psychiatry and Neurology (ABPN) was founded in 1934, and separate training and certification programs for neurologists and psychiatrists began in 1946. In 1959, Sidney Carter became the first child neurologist to serve as an ABPN director. That same year, the ABPN began to include child neurology topics in its certification examination, which at the time consisted of an eight-hour oral examination.2 During the next eight years, a written examination with child neurology topics was introduced, and in 1967, the oral examination was scaled back to four hours, one of which focused on child neurology. In 1969, the ABPN created its “Special Qualification in Child Neurology” category, awarding 106 “grandfather” certificates to individuals who were already focusing on child neurology.2 There have been a number of modifications to the child neurology certification process since it began. The oral examination was eventually reduced to three hours and later replaced entirely with an expanded written examination. Time-limited certification was introduced. The option of dual certification in pediatrics and in neurology remains, although fewer and fewer trainees opt to pursue certification in pediatrics.3 Two infrequently used alternate certification pathways allowing one year of general pediatrics training to be replaced by either internal medicine or pre-approved neuroscience research were approved, of course without the option of certification in general pediatrics. The six-year neurodevelopmental pediatrics track was approved as a separate pathway. Thus, the certification process has not been stagnant, but the requirement for 12 months of clinical adult neurology training has remained intact. A decade or so ago, the Child Neurology Society's (CNS) leadership and the society's representatives on the Neurology Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) initiated a discussion about the child neurology training requirements that culminated in a series of curriculum modifications in 2014.4 Before then, the focus of the adult neurology training for child neurology residents was largely at the discretion of the individual programs, and some child neurology residents spent most of the time on inpatient rotations. To complicate things further, adult-focused rotations such as adult neurophysiology, neuroradiology, and neuropathology could not be used to satisfy part of the adult neurology requirement because the activities did not include direct care of the patients. The 2014 update specified six months of hospital-based rotations, three months of outpatient experience, and three months of adult-focused electives. Additionally, adult specialty rotations could now include some portion of child neurology, provided that the predominant focus of the rotation remained on adult neurology. Programs were encouraged, but not required, to defer some of the adult neurology rotations into the second and third years of neurology training. By most accounts, these recent modifications have been well received (despite the initial grumbling in some quarters that the changes would degrade the training experience and ruin long-established traditions). However, the introduction of these simple changes in the training requirements may have defused the larger question: Does a child neurology trainee really need a full year of adult neurology and two full years of general pediatric training to become a competent child neurologist? Whatever one thinks of the current training and certification requirements, one has to admit that the field has changed tremendously in the last half century. When the initial requirements were implemented, child neurology was generally viewed as a subspecialty of neurology rather than a separate discipline. There were few child neurologists when certification began, and many of these individuals saw adults as well as children. Most early training programs had relatively few child neurology faculty members, creating a dependence on the adult neurology faculty for basic instruction. An often-mentioned justification for the year of adult neurology training is how difficult it is to learn history taking and anatomic localization skills while evaluating children. While this notion is somewhat plausible, not all adults are cooperative and not all children are hopelessly uncooperative. What may have been more important for the trainees was the sheer number of adults with focal neurological lesions and the frequency with which the diagnosis was confirmed by autopsy. Today's resident is still likely to encounter more patients with focal lesions on the adult wards than in pediatrics, but the advent of modern neuroimaging techniques made it relatively easy to confirm lesion locations in children. Numerous other advances now compete for curriculum time, although some of these are applicable to both adults and children. In the last half century, our understanding of stroke in children, the neurological problems of neonates, epilepsy management, and neuroimmunology has improved dramatically. Advances in genetics now allow precise diagnosis of rare disorders and, increasingly, sophisticated treatments utilizing gene therapy or specific mechanism-based treatments derived from a deep understanding of the molecular biology of genetic diseases. The need to introduce trainees to these and other advances now drives the need to reassess time-honored approaches. Adult neurology training clearly had value for child neurologists when the certification process began a half century ago, and most of us believe that it remains useful. It may be easier to hone neurological localization skills in adults, and the ability to quickly amass useful experience in disorders like stroke that are more common in adults seems worthwhile. While people will disagree, there may also be some value in the very rite of passage that we are discussing: becoming part of a larger network of neurology colleagues through shared experiences. Perhaps we should ask the question in a fashion that is more constructive: What is the best return on investment for the 12 months now spent on adult neurology training? In a recent survey of child neurology residency directors, 73% of the respondents thought that child neurology residents need fewer than 12 months of adult neurology training.5 Prominent among the topics needing additional training emphasis listed by program directors and residents were genetics, neuroimmunology, fetal-neonatal neurology, neuromuscular diseases, and developmental disorders.6 Similarly, 70% of the surveyed program directors favored increased program flexibility for the adult neurology training requirements.5 Carter's original scheme allowed a year for adult neurology and another year to learn diagnostic tests, which at the time would have included cerebrospinal fluid analysis, electroencephalography, cerebral angiography, and pneumoencephalography.1 One wonders how Carter would have allocated these 24 months had his trainees needed to learn about neonatal neurology, autoimmune neurological disorders and gene therapy, neuro-oncology, and numerous then-unknown genetic disorders. Modern trainees also need to know about computed tomography, magnetic resonance imaging, cranial ultrasound, polysomnography, magnetoencephalography, and a myriad of genetic diagnostic tests. Trainees have three years to accumulate all the information and experience that are needed to become an independent practitioner of child neurology. In one survey, only 2.9% of the child neurologists who were certified by the ABPN between 2001 and 2010 now care for adults, and the majority of the respondents estimated that they used their adult training “less than weekly.”7 Are the adult neurology months so valuable that they trump rotations such as pediatric neuro-ophthalmology, pediatric neuromuscular disease, clinical genetics, or pediatric neuroimmunology? Viewing the issue as a question of relative value makes it easier to consider the potential effects of both change and the failure to change. Reasonable people can disagree on the best approach to training. Whether in favor of change or in support of the status quo, individuals with strongly held beliefs tend to express their views more forcefully, but it does not follow that their opinions are more correct. Neither should we automatically assume that survey data indicate the optimal approach; if a thousand people speak nonsense, it remains nonsense. Perhaps we can agree that none of us has all the answers when it comes to clinical training, that each program may have unique needs and capabilities within the framework of the core requirements, and that it is not heresy to periodically formally assess whether changes are needed. Most child neurologists who attained ABPN certification between 2001 and 2010 would favor reducing the length of adult neurology training to six months.7 Most child neurology program directors favor increased program flexibility in the required adult neurology training.7 Child neurology residents indicate that adult neurology training negatively affects their wellness, mood, and work-life balance, particularly when all 12 months of adult neurology training are completed during the PGY3 year. They also acknowledge a small positive effect on their sense of autonomy.8 In most programs, child neurology residents share the night and weekend adult neurology call duties during adult neurology rotations, including the non-clinical rotations in many programs.4 Neither the ACGME nor the ABPN specifically requires child neurology residents to participate in adult neurology night call, and a few programs, including my own, do not require their residents to do so. Is adult night call an essential part of child neurology training? Is such duty advisable given the increasing complexity of the patients and the technology in many hospitals? Does the activity contribute to the resident's future competency as a child neurologist? Providing adequate supervision and readily available backup should make it safe for child neurology residents to participate in adult neurology night call. But surveyed residents feel unsafe because of inadequate supervision, perceive a lack of career relevance, and report a lack of prioritization of education.8 It seems likely that some supervising adult neurologists assume a certain level of background knowledge and basic training in adult medicine on the part of the on-call residents, most of whom completed an internal medicine internship before starting their neurology training. How quickly and effectively can the supervising neurologist adjust these assumptions when supporting residents without the preliminary internal medicine training? How willing are they to provide additional resident support if it requires more after-hours involvement in the patient's care? What is the competence return on investment for the time a child neurology resident spends caring for patients with conditions that they will not often see in the future? In my own program, we halted adult neurology night call after concluding that the activity did not provide enough long-term educational value to compensate for the possible practice risk and the negative effect on resident wellness. The change has had a stunningly positive effect on the residents' morale and sense of well-being. Time will tell whether we have hindered our residents' long-term professional development, but we do not think so. We should have suitable training standards for both adult and pediatric neurology residents, with requirements designed to ensure that all trainees of accredited programs achieve a basic level of clinical competence. But residency programs have varying needs and capabilities, and 70% of surveyed program directors favored increased program flexibility for the adult neurology training requirements.5 Some training programs could probably produce competent child neurologists without allocating a full year to adult neurology, while other programs may continue to benefit from a more robust contribution from adult neurology colleagues. Is there a way to introduce more flexibility in the training requirements without jeopardizing the overall quality of the training? In the case of the adult training for child neurologists, for example, might it be possible to specify both a minimum and a maximum number of adult neurology months, perhaps six and 12 months? [Correction added on 18 February 2023, after first online publication: In the preceding sentence, ‘five’ was changed to ‘six’.] With this approach, a program would be required to provide at least six months of adult neurology training, but could opt instead to maintain the current 12 months. A major reduction of the required adult neurology training would result in loss of the “special competence” certification designation. Since fewer than 3% of child neurologists provide general adult neurology care,7 it seems unlikely that this change would upset very many people. A more practical consideration is the effect that reduced exposure to adult neurology would have on the trainees' ability to pass the current neurology certification examination, which is already weighted toward adult neurology topics. Is this concern a reason to maintain the status quo or a reason to develop a more focused test? These issues should be part of any discussion. And by the mid-1960s, it was not clear which specialty—neurology or pediatrics—would absorb child neurology. Dialogs developed between the members of the American Board of Pediatrics—Randolph Byers of Harvard and Ralph Platou—and the ABPN. This was to see who was going to be the big papa. Representing adult neurology was Frank [Francis] Forster and me. Based on the necessity for formal training in neuroanatomy and neurophysiology for pediatric neurologists, obviously lacking in a pediatric residency, these discussions led to the development of certification in 1967 by the ABPN, with a designation of Special Competence in Child Neurology. So when you got your certificate, this is what it said. And you were really trained in two fields. Peace was made because pediatrics could have it and neurology could have it…. The ability to do this made peace between the higher-ups in neurology and in pediatrics. The pediatricians—the big-shot pediatricians didn't give a damn about neurology. And the big-shots in neurology didn't give a damn about pediatrics. That's a cold way to put it, but that wasn't about who was going to get the end people involved and where were the new people coming from. Much of the recent discussion about child neurology training has focused on the number of months of adult neurology training. Strangely, the question of whether one really needs two years of general pediatric training to be a competent child neurologist seldom arises, even though many of the arguments for reducing the time spent on adult neurology training would seem to apply equally to the general pediatrics training. The lure of dual board certification has diminished as fewer and fewer physicians pursue board certification in pediatrics and many of those who do opt against recertification. To some extent, we have already answered the question of whether two years of general pediatrics training are essential to becoming a competent child neurologist. The individuals who complete a single year of general pediatrics as a part of the internal medicine-pediatrics track or the research track are not eligible for certification in general pediatrics, but there is little evidence that they have difficulty passing the neurology board examination or that they lack clinical competence in child neurology. We know little about whether the training time deters people from becoming a child neurologist, but the duration of training seems to be less important than the influence of a role model or an intellectual interest in the topic. However, the residency length may diminish the number of child neurologists who complete fellowship training. Ninety-three percent of adult neurologists complete a post-residency fellowship, while only 56% of child neurology residents do additional training.9 Does anyone seriously think that our lower fellowship numbers are unrelated to the existing five-year training requirements? This again raises the issue of relative value. What would serve a child neurologist better, the current two years of general pediatric training or a single year coupled with a later year of specialized training in neurology? Could our traditional training requirements unwittingly promote lack of diversity within the profession? There is evidence that limited exposure to neuroscience and clinical neurology may contribute to a lack of diversity within neurology.10 But medical education is expensive, and groups that are poorly represented in child neurology tend to be the same groups that have been historically excluded from wealth-building endeavors. A recent analysis of 2014–2019 Association of American Medical Colleges resident data demonstrated that Black residents were significantly more likely to have debts than other individuals (e.g., 60% versus 35% with pre-medical education loans and 50% versus 25% with consumer debt). Several other groups were also more likely to have debt than were White and Asian trainees.11 It seems reasonable to ask whether an additional year with a low resident's salary could disproportionately affect students who are more indebted. What is the optimal amount of adult neurology training for child neurology residents? Is it possible to allow child neurology training programs more flexibility when deciding the amount of adult neurology training? Should each program reassess the need for their child neurology residents to cover adult neurology night call? Could our traditional training requirements unwittingly contribute to the lack of diversity within the profession? Is there a case for shortening the traditional preliminary pediatric training? Perhaps we could allow individuals who complete a clinical fellowship following residency to qualify for ABPN certification with one year of general pediatrics training, similar to the current research fellowship track. Could there be untoward economic consequences to these changes, such as limitation of the scope of practice or the curtailment of employment opportunities? Are these concerns offset by increased resident wellness and improved preparation for future practice? Because several organizations play key roles in child neurology training, revising the requirements would likely necessitate a series of initiatives rather than a single process as discussed here. These discussions need not occur simultaneously. Ultimately, it does not matter what any one person thinks, because the issues are far too important to be decided by a few individuals with the loudest voice or a readily available editorial platform. We need leaders who are wise enough to seek a consensus and strong enough to push for needed changes. This is my challenge to you, the leaders of the profession: create a series of high-level panels of all reasonable stakeholders to analyze and address these complicated questions, then work to implement any changes the groups recommend. Whether we choose to act or to sit idly on the sidelines will be our legacy. Tradition is wonderful, but every half century or so, we need to systematically analyze whether we are doing things the best way. E. Steve Roach: Conceptualization; data curation; formal analysis; funding acquisition; methodology; project administration; writing – original draft; writing – review and editing. The author is the editor-in-chief of the Annals of the Child Neurology Society, but the expressed opinions do not reflect the official policy of the Child Neurology Society.

We thank Dr. Klunk for his thoughtful comments about our essay.1Pavlakis S. Roach E.S. Follow the money: childhood health care disparities magnified by COVID-19.Pediatr Neurol. 2021; 118: 32-34Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar We wanted to make people think and to stimulate discussion, and it is great to see that we succeeded. We focused on the effect of predatory hospital business practices on health care delivery and how the COVID-19 pandemic magnified the negative effects of these practices. Whether one considers universal health care to be a basic right or merely a desirable goal, predatory business practices by some health care organizations represent an obstacle to the provision of efficient and affordable health care for all. While one may reasonably argue whether health care should be considered a right, it would be foolish to question its status as a commodity, at least in the entrepreneurial health care system that exists in the United States. Perhaps a less provocative approach would be to compare health care to a public utility, such as electric, water, or sewer services. It is generally acknowledged that public utilities provide essential services that should be consistently maintained and reasonably affordable for most people. Like health care, public utilities are provided by a mixture of municipal and corporate entities. As with health care, it is a highly desirable goal for everyone to have consistent access to reasonably priced electricity, but few would characterize the availability of unlimited free electricity as a universal human right. The extent of oversight of public utilities varies from location to location, but the regulations and the limited monopoly granted to utility companies minimize the sort of predatory business practices that are increasingly common in health care. Utility price increases often must be justified and approved by an oversight panel. Utility companies are usually granted a franchise for a given region, but in exchange, they are expected to provide consistent service to all customers in their service area, not just the affluent neighborhoods. In regions where electric companies are allowed to compete for the same customers via price competition, the customers may initially save a bit of money but can later experience less reliable service and ultimately higher costs. Some areas of medicine are already starting to embrace public utility economics. Coverage contracts for emergency departments, neonatal intensive care units, and radiology services work in part because they provide a near-exclusive franchise for the provided services. Consequently, these physicians can care for all children, even if some of them have limited resources. Imagine trying to make these schemes work economically if most of the affluent patients were selectively treated by their private physician, leaving the contracted physicians with an ever-diminishing pool of paying patients. Our recent essay called out shameful predatory practices that drain essential resources from less affluent facilities and illustrated how the pandemic exacerbated the existing funding disparities. It currently makes little practical difference whether one considers universal health care to be a right or merely a desirable aim because we are presently so far removed from achieving either that the immediate journey is likely to be the same. Public relations campaigns designed to make corporate cherry-picking seem so noble are, in the end, nothing more than putting lipstick on a pig. Reply to Letter From KlunkPediatric NeurologyVol. 128PreviewI agree with Dr. Roach. Currently most large hospital systems are organized as "nonprofit organizations" and compete with limited regulation. There are antitrust laws affecting the health care marketplace, but monopolistic, or at least oligopolistic, tendencies flourish. These occur in advertising and predatory practices and in buying out competitors. Capitalism is allowed to function without much regulation, and many of the most vulnerable people are adversely affected. Full-Text PDF Health Care: Neither Right, Privilege nor CommodityPediatric NeurologyVol. 128PreviewIn a March editorial, Pavlakis and Roach wrote, "As long as health care is considered a commodity instead of a basic right, it will be susceptible to market forces and to efforts to maximize profits."1 While appealing, labeling health care as a right without acknowledgement of what that right entails, how it generates reciprocal obligations, and how that label frames advocates for other approaches to improving healthcare as unsupportive of human rights is fraught. This approach precludes discussion of the desirability of a universal health care system (UHS); instead, declaring it must be so. Full-Text PDF

Knowledge is of two kinds: we know a subject ourselves, or we know where we can find information upon it. This editorial marks the formal beginning of the Annals of the Child Neurology Society (ACNS), an official journal of the Child Neurology Society (CNS). Since its founding in 1972, the CNS membership has increased steadily and the needs of its members have become more diverse. This is an extraordinarily productive era for the study of childhood neurological disorders, and the steady stream of exciting discoveries make this an ideal time for the society to launch its clinically focused journal. The CNS will maintain its traditional relationship with Annals of Neurology, with its focus on more basic research. Several years ago, the American Neurological Association created Annals of Clinical and Translational Neurology, and the addition of ACNS by the CNS forms an Annals “family” of journals that together support a wide range of scholarly endeavors. Creation of ACNS is arguably the most important venture for the society in many years. All new journals face challenges both expected and unexpected, and the fledgling journal will need time to grow and mature. But the CNS needs a clinically focused journal, and we will succeed. ACNS provides a venue for clinically focused articles and for society business. We will publish clinical and translational research articles, epidemiology studies, case series, case reports, educational image vignettes, quality improvement articles, letters, and commentaries on medicine or societal factors that affect the care of children with neurological disease. Clinically relevant basic science articles are encouraged. Manuscripts must undergo rigorous peer review and revision before acceptance. We have assembled an outstanding editorial team (Table 1) and a diverse editorial board whose members have broad expertise in child neurology as well as in important areas such as neuroradiology and neurosurgery (Table 2). The editorial board includes both established leaders in the field and up-and-coming colleagues who represent the future of the profession. While centered in North America, ACNS has editorial board representatives from Africa, South America, Asia, Europe, and the Middle East. ACNS is owned by the CNS and will be published via a contract with Wiley, much like the arrangement for Annals of Neurology between the American Neurological Association and Wiley. The society maintains editorial control of ACNS, selecting the publishing partner, choosing the editor-in-chief, and approving associate editors and editorial board members. At least 65% of the editorial board members must be CNS members in good standing. The ACNS editorial team will make the final determination of a manuscript′s suitability for publication. The articles in open access journals are freely available to anyone with internet access and, consequently, reach a larger audience and tend to be cited more often than equivalent articles in subscription journals. Both open access and subscription-based journals, however, have production costs. Medical journals have for many years been funded by subscription fees and product advertising. The positive aspect of this funding method is that the authors are not asked to share the cost of publication. On the down side, these journals are only available to individuals with an individual subscription or access to a medical library. The landscape for funding medical journals has shifted dramatically in recent years. Most readers now read articles online after searching for information about a specific topic. With little opportunity for effective ad placement, the revenue from medical journal advertising has plummeted. More and more journals are reducing expenses by eliminating their costly and environmentally unsound print editions. Some subscription journals have adopted a hybrid model, mixing open access articles whose authors pay a publication fee and traditional restricted access articles with no publication fee. Some authors may have difficulty paying open access fees, so despite the trend toward open access journals, there will continue to be a role for subscription-based journals. We have developed a number of ways to mitigate the publication fees. CNS members will receive a 20% discount on reviews and research articles. The society will pay the fees for articles whose first author is a junior CNS member. They will ask that award lectures and society-supported symposium presentations be followed by a companion manuscript for ACNS and will pay the costs of these articles. Wiley allows free or reduced publication fees for articles from authors living in countries with limited resources. Preliminary inquiries about the suitability of topics or other queries should be directed to the editor-in-chief, Dr. E. Steve Roach, at [email protected] or to the appropriate associate editor via [email protected]. For information about manuscript preparation, submission, or publication costs, please visit the ACNS website at https://www.annalscns.com. Follow ACNS on Twitter (@AnnalsCNS).

Dr. James Francis "Jim" Toole (Figure 1) died peacefully at age 96 in his Winston-Salem, North Carolina home on September 12, 2021. Toole was a veteran academic neurologist and a pioneer in the study of cerebrovascular disease. Jim Toole was educated at Princeton University and Cornell Medical College. In 1949, he began an internship and internal medicine residency at the Hospital of the University of Pennsylvania, but his training was abruptly interrupted in 1951 by his call to active military duty and deployment to the Korean War as a forward lines MASH unit officer. He was awarded a Bronze Star for helping to lead his surrounded battalion through enemy lines to safety in the dead of night. After his Korean service, Toole returned to Philadelphia to complete training in internal medicine and then neurology, interrupted only by a one-year stint as a Fulbright Fellow at the National Hospital, Queen Square. Toole joined the faculty of the Bowman Gray School of Medicine (later the Wake Forest University School of Medicine) in 1962, and soon thereafter he was named the first Walter C. Teagle Professor of Neurology. He served as Professor and Chair of the Department of Neurology for twenty years and founded one of the first stroke centers in the country. He remained in Winston-Salem for his entire career, interrupted only by a sabbatical year at the Scripts Institute in La Jolla, California. The small department recruited excellent faculty members and attracted trainees from across the United States and from Japan, Estonia, Canada, Korea, India, Russia, and the Middle East, several of whom later became prominent academic neurologists in their own right. The first edition of Cerebrovascular Disorders by James Toole and colleague Aneel Patel1Toole JF Patel A.N. Cerebrovascular Disorders. McGraw-Hill, New York1967Google Scholar appeared in 1967, several years before the advent of computed tomography. It was a beautifully written treatise, illustrated with dozens of anatomical drawings, cerebral arteriograms, and pathological specimens. The first edition solidified stroke as a topic worthy of study and established Toole as a leader in this new field. Each new edition added new diagnostic techniques and reflected an improving understanding of the pathophysiology of stroke. Various editions of Toole's book were translated into Russian, Japanese, Spanish, Portuguese, Chinese and German. The sixth and final edition appeared in 2010 as Toole's Cerebrovascular Disorders, written as a tribute by three of Toole's protegees. Most contemporaries considered Toole's book to be the first textbook to focus on cerebrovascular disorders, but, as a keen student of medical history, Toole himself referred to his book as the first stroke book "in the modern era" in recognition of Johann Jacobus Wepfer's 1658 treatise Apoplexia. Today there are numerous other stroke textbooks, but as the first modern textbook on the topic, Toole's book was hugely influential because it introduced stroke to many in the next generation of neurologists, individuals who would go on to make major contributions to the field. Toole also edited or co-edited several other books on stroke and other topics, including three volumes on cerebrovascular disorders for the comprehensive Handbook of Clinical Neurology, a stroke guide for patients and families, the proceedings of the 1968 Princeton Stroke Conference, a book on vascular dementia, and two books on diagnostic procedures. One of Toole's earliest contributions to the study of cerebrovascular disease was his description of the subclavian steal syndrome.2Toole JF. Reversed vertebral artery flow and cerebral vascular insufficiency.Ann Intern Med. 1964; 61: 159-162Google Scholar His first stroke-related research effort was a simple longitudinal patient registry designed to provide outcome data following a stroke. This single institution study was a far cry from the large, multicenter clinical trials that have revolutionized the treatment of stroke in recent years, but it provided much-needed basic information, such as the factors that influence recovery and return to work following a stroke and the observation that most people who survive an initial ischemic stroke are more likely to die from cardiac disease than from a subsequent stroke.3Howard G Till JS Toole JF Matthews C Truscott BL. Factors influencing return to work following cerebral infarction.JAMA. 1985; 253: 226-232Google Scholar Toole and his Wake Forest colleagues refined the use of non-invasive carotid ultrasound in the diagnosis of cervical carotid atherosclerosis, then established its validity versus catheter angiography. Their ultrasound validation studies provided the noninvasive diagnostic tool that was needed to justify a study comparing carotid endarterectomy to best medical management in individuals with asymptomatic carotid artery stenosis – the seminal Asymptomatic Carotid Artery Stenosis (ACAS) trial.4Endarterectomy for asymptomatic carotid artery stenosisExecutive Committee for the Asymptomatic Carotid Atherosclerosis Study.JAMA. 1995; 273: 1421-1428Google Scholar The ACAS data suggested that asymptomatic individuals with a 60% or greater reduction in carotid artery lumen diameter benefitted from elective endarterectomy, at least in centers with a modest operative complication rate. Toole was the principal investigator for the multicenter Vitamin Intervention for Stroke Prevention (VISP) trial.5Toole JF Malinow MR Chambless LE et al.Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial.JAMA. 2004; 291: 565-575Google Scholar It had earlier been established that elevated plasma homocysteine levels correlated with an increased ischemic stroke risk, and it was well known that administration of folic acid, vitamin B6, and vitamin B12 could lower the homocysteine levels and reduce the risk of vascular complications in individuals with the genetic condition homocystinuria. Although VISP demonstrated a moderate reduction of the plasma homocysteine levels in the vitamin group, there was no reduction in the likelihood of recurrent stroke in the following two years. Given the years-long process of atherosclerosis development, however, longer term vitamin supplementation might still prove to be useful. Toole also made major contributions to organized neurology both nationally and internationally, serving on committees too numerous to list here and elected to leadership roles in multiple organizations. He served as a council member, secretary-treasurer, and president of the American Neurological Association. He also served as the president of the World Federation of Neurology, the American Society of Neuroimaging, and the International Stroke Society. He served as the editor-in chief of the Journal of Neurological Sciences for eight years and was a member of the editorial boards of Stroke, Annals of Neurology, Annals of Internal Medicine, and several other journals. Toole was a lifelong student of history, particularly the history of medicine and how medical illnesses of world leaders could have affected the events of history. In the preface to the third edition of Cerebrovascular Disorders, for example, Toole noted that the Western leaders Franklin Roosevelt, Joseph Stalin, and Winston Churchill all experienced cerebrovascular disease. By the time of their 1945 Yalta meeting, Churchill had already experienced a series of small strokes. Three months later, Roosevelt died following a massive brain hemorrhage, and Stalin died from stroke a few years later. Could vascular-related cognitive impairment have adversely affected the men's decisions? In response to a challenge by former President Jimmy Carter to the American Academy of Neurology, Toole established a working group to develop protocols to identify presidential impairment as provided in the Twenty-fifth Amendment to the US Constitution, attempting to balance public disclosure and patient confidentiality. The group included physicians, lawyers, historians, politicians, and others, along with input from former presidents Jimmy Carter and Gerald Ford. The group's recommendations, compiled in the book Presidential Disability6Toole JF Joynt RJ Presidential Disability. University of Rochester Press, Rochester, New York2001Google Scholar by James F. Toole and fellow-neurologist Robert J. Joynt, were adopted by the Clinton Administration. In San Francisco after returning from Korea, wearing his smart white Navy dress uniform, Toole met Patricia Wooldridge, the daughter of a family friend. They were married in October, 1952, beginning a partnership that endured for 69 years (Figure 2). Independent minded and highly accomplished in her own right, Patricia was a life-long partner who offered unfailing encouragement and support as well as the occasional dissenting opinion. Jim and Patricia raised four talented children, adding a wonderful personal legacy to a professional legacy that few people can match.

Please welcome the next Editor-In-Chief of Pediatric Neurology, Yasmin Khakoo, MD. She will officially become the journal’s third editor in January, 2022, but she has already been busy learning the manuscript submission system, getting a handle on articles in the pipeline, and no doubt making plans for new initiatives. E. Steve Roach: Reflections From the Editor-In-Chief of Pediatric NeurologyPediatric NeurologyVol. 125PreviewAt end of this year, E. Steve Roach will stand down as the Editor-in-Chief of Pediatric Neurology. Dr. Roach became the Journal's second Editor-in-Chief in January, 2013. He inherited a well-established journal from founding Editor Kenneth Swaiman and turned it into a highly respected journal with a dramatically improved impact factor that has become a flagship journal of our field. Dr. Roach achieved this feat by building a home for novel research and educational content, amassing a most talented editorial board, and launching innovative programs. Full-Text PDF