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.

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

features

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

4.

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.

Wednesday, June 04, 2014

ADEM pearls

old paper, useful insights
Menge T, Hemmer B, Nessler S et al  Acute disseminated encephalomyelitis: an update. Arch Neurol 2005; 62: 1673-1680
 
1.  Consider a temporal relationship to a vaccine or infection.  If vaccine, especially MMR, also polioand European tick borne encephalitis vaccination

Monday, June 02, 2014

antiMOG seronegative NMO

Kitley J, Waters P, Woodhall M, et al. Neuromyelitis optica spectrum disorders with aquaphorin-4 and Myelin-oligodendrocyte glycoprotein antibodies: a comparative study.
 
see Levy M. Does aquaphorin-4-seronegative neuromyelitis optica exist? (editorial) JAMA Neurology 2014; 71:271-2.
 
Authors of both studies ferret out a subtype of seronegative NMO that is actually yet another disease.   Anti MOG positve patients with clinical features of NMO have a slightly different phenotype with features of ADEM also.  This group encompasses young males with severe episodes with better recoveries that are more likely to be monophasic, sometimes with simultaneous or rapidly sequential optic neuritis and transverse myelitis.. AntiMOG patients also had more conus involvement on spine MRI and more involvement of deep gray nuclei on brain MRI.  There were no patients with both anti MOG and anti AQU4 antibodies.  anti MOG antibodies are available at Neuroimmunology Testing Service, Oxford, England for 30 pounds).  "n" of the study was 10 aq-4 patients and 9 MOG AB patients. 
 
More clinical information:  4/9 anti MOG and 6/20 AQU$ AB patients had ON as initial invoolvement or part of ; anti MOG had more bilateral ON involvement (75 v. 33 %); both had severe ON when it did happen.  12/20 AQU$ 4 and 9/9 antiMOG had spinal cord involvement initially; Transverse myelitis differed with more bladder involvement in anti MOG patients as iniital symptom (33 v. 0 %) and more late sphincter disturbance in NMO ab patients.  Brain MRI was more likley to be ADEM like in MOG ab patients (44 %) v. 0 % in NMO. 

Wednesday, May 28, 2014

CJD and non CJD with neuronal markers

Grau-Rivera O, Sanchez-Valle R, Saiz A et al. Determination of neuronal antibodies in suspected and definite Creutzfeld-Jakob disease . JAMA Neurol 2014;71:74-78.

Take home points

1. A small but definite number of 346 patients with suspected CJD had anti neuronal antibody mimics but these six did not fulfil criteria for CJD. Found were NMDAR,LGI1 , CASPR2, aquaphorin 4, Tr(DNER alpha notch 4 epgf and unknown protein.

2. No patients among 46 with definite CJD had these neuronal markers.

These all were studied in CSF

Faciobrachial systolic seizures , correlate with anti VGKC and not CJD

Faciobrachial systolic seizures , correlate with anti VGKC and not CJDYoo J and Hirsch LJ. Limbic encephalitis associated with anti voltage gated potassium channel complex antibodies mimicking CJD. Jama Neurol 2014;71:79-82.

Case with following take home points:
FBDS are highly associated with ant VGKCC and not CJD and are treated with normal AED's

The two disorders otherwise may mimic each other

Anti VGKCC responds robustly to steroids

Both disorders can have elevated 14,3,3 in CSF

Absent restricted diffusion is a "red flag" against CJD

MRI of anti VGKCC is usually high T2 signal in uni or bilateral temporal lobes but they can also show cortical ribbon and basal ganglia changes mimicking CJD

FBDS mimic myoclonus but EEG confirms seizures

Spect scans show abnormal basal ganglia metabolism