Friday, August 21, 2015

Drug choices for juvenile myoclonic epilepsy

valproic acid
topiramate
lamotrigine
levetiracetam
zonisamide


note these are the "broad spectrum drugs"
also note: valproic acid and topiramate are teratogenic

AED's and psychiatric function

Psychiatric function worse:


levetiracetam
topiramate
zonisamide
tiagabine
phenobarbital
periampanel


psychiatric function better


carbamazepine
valproic acid
lamotrigine
pregabalin

AED's compared head to head to standard therapy eg. carbamazepine

note this is a test done by EU>> FDA


favorably compare: 


oxcarbazepine
eslicarbazepine
lamotrigine
gabapentin
topiramate
levetiracetam
zonisamide


unfavorably compare (are inferior)


pregabalin
vigabatrin


test not done


tiagabine
lacosamide
ezogabine
perampanel

Enzyme inducers-- pearls

enzyme inducers adverse effects (partial) include


1.  decrease efficacy of oral contraception
2.  osteomalacia
3.  halve dose of many drugs, rendering them ineffective; this includes chemotherapeutic agents for children having CLL who have greater mortality on these drugs
4.  increase cholesterol
5.  Decrease testicular size

Narrow and broad spectrum antiepileptic drugs

Narrow spectrum


carbamazepine
oxcarbazepine
tiagabine
gabapentin
pregabalin


Broad spectrum


valproic acid
topiramate
lamotrigine
levetiracetam
zonisamide
parampanel

New Epilepsy classification

I  Genetic
II Focal
    a. Aware
    b  Unaware
III Mixed
IV Unknown
V Secondary generalized

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

GPDS and NCSE

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

Hsve
Cmv
Hiv 1 and 2
Vzv
Ebv
Toxo
Lyme
Mycoplasma pn
Leptospirosis
Legionella
Brucellosis
Chlamydia
Syphilis
Aspergillosis

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

www.smartvest.com
www.ICD9data.com

GALAXY PORTFOLIO FOR AED'S-- LOW PRICED DRUGS

UPSHER SMITH PORTFOLIO INCLUDES
TOPIRAMATE ER (QUDEXY) 25,50,100, 150 , 200 MG TABS (NOT DISCOUNTED)

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

advantages
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. 

Prior authorizations?  MEDICARE STRONGLY BELIEVES THAT IS AN UNREIMBURSED COST INCURRED BY THE PHYSICIAN

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

5.  MOG  -- ADEM, MS, CIS, NMO-SD

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.