Saturday, April 18, 2015

IV valproate inferior for acute migraine

Friedman BW, Garber L, Yoon A, et al.  Randomized trial of iv valproate vs.metoclopramide v. ketorolac for acute migraine.  Neurology 2014; 82:976-983.
Authors randomized 330 patients in ER to get 1000 mg, 10 mg, or 30 mg of respective drugs above over an iv drip over 15 minutes in a double blind trial.  On the primary measure of pain relief, valproate lost big to the other two drugs.  On secondary measures of needing a rescue medication, iv valproate also lost.
Comment-- great to have this knowledge but the two winning drugs each had relatively low sustained headache relief, 4 v. 11 v. 16 % with respective drugs above.  Also metoclopramide made people feel restless.

Wednesday, April 01, 2015


Foreman BM, Chassen J, Abou Khaled K, et al. Generalized periodic discharges in the critically ill:  a case control study of 200 patients.  Neurology 2012; 79:1951-1960
and editorial Jette N, Mosely BD. Generalized periodic discharges : More light shed on the old GPEDs Neurology 2012; 79: 1940-1.
Authors found GPD's in 4.5 % of 3000 patients undergoing cEEG.  These 200 patients  had brain injury (44%), acute systemic illness (38%), cardiac arrest (15%) and epilepsy (3%). 
27 % of GPD's had NCSE v. 8 % of controls.  However, GPD's were not associated with convulsive seizures. 
Authors/editorial notes that the distinction and semiology of GPD's v. triphasic waves is "challenging" even for board certified epileptologists. 
Take home messages, per the editorial are:
1) Patients with GPD's on routine EEG should undergo cEEG
2)  NCSE should be promptly treated when diagnosed to prevent mortality
3) Standard terminology and interrater reliability should be assessed within institutional readers.

Wednesday, March 25, 2015

code for tpa

If you physically administer tpa; code 37195
If you are present evaluating a acute stroke, bill as highest level code (if you meet all the 'bullet points').
Add a statment "patient is critical and unstable'; document time spent; if it is 30-74 min; add 99291

Idiopathic hypertrophic pachymeningitis

  Dumont AS, Clark AWm Sevick RJ, Myles ST. Idiopathic hypertrophic pachymeningitis:  A report of two cases and review of the literature.
Background-- Authors note entity was described by Charcot and Joffroy, and that there are three forms:  spinal, intracranial and craniospinal (latter is rarer). 
Past cases were often attributed to specific etiologies but most recent cases are idiopathic after investigation.  Authors case 1 underwent 2 surgeries for biopsy/decompression , had persistent pain and numbness, but was non progressive for 15 years after one early relapse.  The second one received steroids after biopsy with resolution of symptoms and MRI changes.  Authors argue based on above that the condition is not autoimmune. 
Literature review suggested a worse prognosis for patients with "inflammatory signs" (fever, high sed rate, CRP, or elevated WBC). 
Associations include infections: syphilis, TB, HTLV-1, fungi; may be presenting sign of adjacent ear or sinus infection.  Autoimmune associations include RA, orbital pseudotumor, multifocal fibrosclerosis, MCTD, Wegener's granulomatosis.    The 23 reports run the gamut from marked to slight improvement to deterioration and late recurrence or surgical death. 
For interest, Charcot's clinical descriptors divided the spinal form into distinct stages: first intermittent radicular pain that later became continuous; then muscle weakness and atrophy; then spastic paralysis and loss of sphincter control.  Radicular signs can be confined to the upper extremities and evolve over weeks to months or even a year. 
The cranial form frequently presents with a headache, cranial neuropathies and ataxia. 
Authors emphasize the need for pathologic confirmation.

Sunday, February 01, 2015

Encephalitis serological evaluation

Hiv 1 and 2
Mycoplasma pn

Tuesday, November 04, 2014

Definite central fourth nerve palsy

per Neil Miller

An ipsilateral or contralateral relative afferent pupillary defect (RAPD) unassociated with any decrease in visual acuity, reduced color vision, or visual defect, but with setting of an isolated fourth nerve palsy, RAPD indicated localization to brachium of superior colliculus and almost always indicates the fourth nerve paresis is central in origin.

Friday, October 17, 2014

Smartvest SQL

Chest wall oscillation approved for neuromuscular disease, 80 % paid by Medicare with assistance for rest.

originally for bronchiectasis

use for thirty minutes twice daily



topiramate tablets
divalproex delayed release tbalets
valproic acid capsules, USP
lamotrigine tablets
carbamazepine tablets
phenytoin extended release. 

receive a consistent product
use a specialty pharmacy form
MOBE referral kit available free with Rx.

Use Thrifty White Pharmacy # 61
eRx  NCPDP:3504138
fax 855 826 2596
phone 844 432 7891

Charging for items outside the traditional billing codes.

based on summary article by Orly Avitzur, Neurology Today based ona presentation by health care lawyer Daniel Brown.

New CPT codes for telephone/internet assessment when provided doctor to doctor by a consultant-- codes 99446-99449.  May be used for complex and urgent situations when face to face is not practical.  These are time based only codes and only available to consulting specialist.  MEDICARE DOES NOT PAY FOR THESE CODES, "check with commercial payors about their policies"

EMAIL (CPT code 98969 and 99444) and phone calls from patients (98966-98968 or 99441-99443) for after hours requests for routine refills of Rx and other requests.  Medicare does not cover these, because they are considered to be included in face to face.  With proper documentation, though you can add time of phone call to the time of the next visit IF its associated with the patient's next visit.  You can factor phone call into the time/complexity calculation of next visit.  Remember that using time , fifty percent of time must be face to face.   If a patient calls several moths after an appointment for an unrelated question, that could be considered a separate service.

Can doctor bill the patient directly for internet consults?  Answer is yes, but CMS "strongly encourages " and advanced beneficiary notice (ABN) before billing so patients can make an informed decision.  Also, MD must not duplicate a service performed at a subsequent visit, the components follow the descriptions in CPT code, and the services are adequately documented.

Bill for forms?  OK to bill for copying, filling forms for camp, or work UNLESS its part of that outpatient visit. 


Concise of brain antigens commonly tested

1.  NMDAR NR1  anti NMDAR encephalitis

2.  amphiphysin-- stiff person syndrome, encephalomyelitis,limbic encephalomyelitis, sensorimotor neuropathy

3.  ARHGAP 25, GRAF -- subacute inflammatory cerebellar ataxia

4. CASPR2 (contactin associated protein 2)-  Morvan syndrome, neuromyotonia, limbic encephalitis


6.  GAD 65-- stiff person syndrome, cerebellar syndrome, limbic encephalitis, epilepsy

7.  Ma2--  brainstem encephalitis, limbic encephalitis, cerebellar syndrome, polyneuropathy

8.  Yo-  brainstem encephalitis, cerebellar syndrome

9.  Ma1 -  brainstem encephalitis, limbic encephalitis, cerebellar syndrome, polyneuropathy

German study published in Ann Neurol July 23 show equal prevalence of these antibodies in healthy and diseased individuals.  Titers and Ig class distribution also were similar for above antigens.

NMDAR were found in 10-20 percent of normal individuals, and are higher among those who suffered influenza. 

Weinshenker-- Validity depends on pretest probability that patients have the illness.

Thursday, October 09, 2014

Hydroxyurea and HbF in sickle cell disease

Steinberg MH et al. Effect of hydroxyurea on mortality and morbidity in adult sickle cell anemia.    Risks and benefits up to 9 years of treatment. JAMA 1003; 289: 1645-51.  Weiner DL, et al. editorial: hydroxyurea and sickle cell disease. A chance for every patient.

HbF is inversely related to mortality in SCD, and can be increased with hydroxyurea.  Also cite Multicenter Study of hydroxyurea (MSH) in SCA (NEJM 1995; 332: 1317-1322).

299 SCA patients were randomized to hydroxyurea or placebo, morbidity was reduced by half, with no difference in mortality or stroke.  There was an open label extension of the trial on 233 patients (both arms) receiving hydroxyurea for 9 years (up to).  In this part of the study, mortality was reduced forty percent for patients receiving hydroxyurea (patient option to take or not).  Cumulative mortality corresponded with HBF levels esp .5 g/dL or higher. 

Machado Joseph disease

aka MJD, spinocerebellar ataxia type 3


adult onset, autosomal dominant
UMN and LMN signs resembling ALS may include tongue fasciculations, dystonia, rigidity, progressive external opthalmoplegia, and peripheral neuropathy.

Due to CAG triplicate repeat on chromosome 14q32.1

Cramping is far more common than in PN or SMA but not ALS and is relieved almost completely by mexilitene, supporting notion that is due to sodium conductance.

Cocaine related hallunications

Classically is the sensation of animal, bugs or insects moving under the skin (cocaine bugs or parasitosis). Other purely visual hallucinations that can occur include "snow lights" or the sensation of sunlight reflecting off snow crystals. Vibrating and pulsating geometric shapes, polyopia, and dysmorphia occur and resemble visual aura. Olfactory, tactile and gustatory hallucinations may occur. Photophobia, halos around lights, and gtrouble focusing may be due instead to pupillary mydriasis due to increased sympathetic tone.

Vienna conference return to play recommendations

Vienna conference return to play recommendations1.   Remove from game if any signs of concussion- any items missed on sideline exam
2.   No return to play in current game
3.   Medical evaluation after injury   a. rule out serious focal injury     b. neuropsychologic evaluation
4.   Stepwise return to play    a.  rest till asymptomatic      b.   light aerobic      c.  sport specific training     d.  noncontact practice      e. full contact practice     f. return to play

Shingles pearls

1. 1 in 3 people will develop HZ during their lifetimes.

2. The preeruption pain may be confused with MI , pleurisy, appendicitis, dental pain and many others.

3. Shell vial viral culture is most common test, but PCR is rapid, more sensitive and specific


Parkinsonism in cirrhotics

Burkhard PR et al. Arch Neurol 2003;60:521-528


Authors studied cirrhotics prospectively and found a unique Parkinsonian syndrome in 20 %.  Among 51 consecutive patients evaluated for liver transplant, 11 had Parkinsonism esp. stereotypical onset with generalized bradykinesia, dysarthira, postural instability, and prominent ACTION tremor.  Six had dystonia especially of face or feet.  Frontal findings were seen on neuropsych testing.  Levodopa resulted in improvement on UPDRS in 2 patietns.  CSF manganese was elevated in 3 patients in whom it was measured.  Allpatients had symmetric T1 abnormalities on MRI.  Liver transplantation reverses MRI findings.  Question arises of whether to chelate.