Saturday, May 15, 2010

pearls symptoms management elliott froman

1. nocturia due to low compliance bladder-- consider DDAVP, urology eval to look at pelvic floor
2. always get urology exam to look at pelvic floor after you have gotten PVR
3. Phasic spasms are treated differently than tonic spasms or restless legs, try levitiracetam
4. check ferritin, not just in restless legs patients along with vitamin D, thyroid
5. fampridine flattens decay curve of temperature effects, fatigue
6. Vyvanse given for fatigue and cognitive slowing-- works.  hypertension uncommon but works
7.  4 AP the more truncal and postural instability, the likelier to respond to 4 AP
8.  Hold 4 AP if you have a fever, uti, sepsis due to risk of seizure
9. aceto L carnitine double effect of amantadine on fatigue, 2 nice studies, 1-2 grams bid buy bronson's vitamins online cheap, may even be able to go off provigil or amphetamines
10. tizanidine occassionally causes formed visual hallucinations not always require stopping drug, eg. "Indian shaman visiting her, like having a doctor at home"
11.  aerosolized ethyl chloride anesthetizes skin is best for injection pain.
12.  Neuropathic sensations after sensory myelitis, MS "hug" (aka anaconda sign), sharp burning rhythmic oscillating pain after defecation and sexual intercourse ("real neurologists do "heads and tails").  tried levitiracetam, it helped, think of phasic spasticity and saw dramatic benefit.  Thoracic squeezing continued clonazepam helped a little.  Used belladonna and opiate suprettes (b & o supp) completetely resolved defecation spasms.
13.  trigeminal neuralgia-- refractory-- suboccipital decompression first, then rhizotomy or gamma knife.  What are you decommpressing? Decompress but also scrape and cut trigeminal root. Decompression works better when done as first procedure.
14.  Causalgia on end of hand-- use topical compounded agents rather than systemic agents if topical and superficial-- compound almost any drug  GBN, mexilitene/clonidine/lidocaine
15.  Gait mechanics--swing limb advance is key causes toe drag, falling.   Medicare now pays for many walk aid and similar devices (fes- functional electrical stimulators).  prevent falls, decrease energy utilization
16.  poor hip thrust due to weak iliopsoas, clonus, tonic and phasic spasticity, tight gastroc,
17. genu encurvatrum (hyperextension of knee during standing) cure with AFO.  Dorsiflexion causes flexion of joint above.
18.  Edema-- everyone with weakness has it.  huge factor needs to be addressed buy at cheaply get 8-12 mm Hg "like a bilge pump" start at 15-20.  ten dollars a pair. leg is lighter and movement is aided not carrying a gallon of water in each leg.
19.  AFO pearls-- single piece (no articulation) is good for flail or dead foot.  Hinged or articulated brace are preferred more like normal movement only works if patient has some control.  FES is taking over for many. (Bioness or walkaid)
20.  Walkers-- use all wheel or all rolling walkers not ones with "skis" likes U step walker because it has adjustable tension on wheel so patient cannot festinate and has laser light can pattern gait cycle
21.  Pelvic obiquity hurts-- hip, gluteal girdle, takes energy, puts pressure on stance leg, AFO cures, also cures knee hyperextension.  If single piece need to tell orthotist how many degrees of  dorsiflexion (easier with articulated brace) start 5-7 degrees dorsiflexion with single piece
22.  Some people with ballet foot needs to start with botox before AFO for it to work
23.  Do 6 minute walk as well as 25 foot walk to test
24.  Bone loss in men and women--at demarcation of EDSS of 4 and beyond.  Get dexa scans every few years check femur hip and spine
25.  Vitamin D goal is 60-80 not lower level
26.  Dysautonomia in limbs (pain, cold, purple, edema) responds to ciolostazol (pletal) 50 bid or 100 bid affects platelets and relaxes smooth muscle.  May work in Asa resistant strokes too.  Viagra may also work for this, help acrocyanosis
27.  baclofen less sedating than tizanidine,need to monitor lft's.  Zanaflex is less sedating than tizanidine.  May use at night.
28.  hypertensive crisis may occur if stop tizanidine suddenly its an alpha two agonist big rebound effect
29.  Dantrolene last choice can be hepatotoxic need to check, different mechanism, not gaba B or alpha 2 but works on sarcoplasmic reticulum it works sometimes.
30.  Benzodiazepines are drug of choice for phasic spasticity usually clonazepam, some valium, and others GBN, levitiracetam
31.  Botox for focal spasticity especially tight heel cords before bracing
32.  Intrathecal baclofen can be dramatic-- use in patients you  really know well and can trust to do adjustments for nine months realistic expectations are key.
33.  Constipation--pay attention to fluid intake, physical activity, pelvic spasticity (benefit from antispasticity drugs or enemas), drugs  that constipate, bulking agents, softeners, mild osmotics esp magnesium, avoid harsh laxatives, dulcolax or glycerin suppositories.  Enemese plus has both glycerol, docusate (softening) and benzicaine for pain.
34.  Bladder dysfunction ubiquitous even in pediatrics 100 %. Bladder stores to do need 2 things need.  To store need competent sphincter annd relaxed detrusor, and to void need reflexive detrusor and ability to relax sphhincter.  Detrusor hyperreflexia with closed sphincter is commonest type of neurogenic bladder. Symptoms are frequency, urgency, urge leaking, and nocturia.   Dyssynergia of detrusor 2 types.  Both DSD have tight sphincter.  One has detrusor hyperreflexia, urgency, frequency and nocturia, other detrusor areflexia.  This occurs with longstanding disease and leads to high post void residuals.Take history and get a post void residual and if its high send to urologist.If PVR is less than 100 treat, if its greater > 150 send to urologist.  Couuld try relaxation, double void, triple void, vibrator, drugs like Cardura BEFORE intermittent catheterisation.  Patch has 70 % reduction of side effects.  Gel nique new rub on form of oxybutynin. Imipramine for enuresis.  Alpha one agonism ( helps tighten sphincter). If can't get urine out use alpha blocker, such as flomax.  These are sphincter drugs not bladder drugs.  DDAVP most effective drug for nocturia.  Only .1 to .4 at night to reduce urine and decrease voiding.  Don't use in daytime.  If have headache and confused, check sodium (hyponatremia).  Catheters hurt urethra.  Chronic-- consider suprapubic.  Bricker procedure or ileoostomy effective.  (diversion procedures)
35. and are 2 online sites to discuss sex
36. Eros clitoral device helps sensation, lubrication, threshold to orgasm its 400 dollars or so. Eroscillator is wall powered three speeds. Wall powered is better need high intensity to get thresholds.  Libigel is hormone therapy for women not yet approved.

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