To update the 2011 American Academy of Neurology (AAN) guideline on the treatment of painful diabetic neuropathy (PDN) with a focus on topical and oral medications and medical class effects.
The ...authors systematically searched the literature from January 2008 to April 2020 using a structured review process to classify the evidence and develop practice recommendations using the AAN 2017 Clinical Practice Guideline Process Manual.
Gabapentinoids (standardized mean difference SMD 0.44; 95% confidence interval CI, 0.21-0.67), serotonin-norepinephrine reuptake inhibitors (SNRIs) (SMD 0.47; 95% CI, 0.34-0.60), sodium channel blockers (SMD 0.56; 95% CI, 0.25-0.87), and SNRI/opioid dual mechanism agents (SMD 0.62; 95% CI, 0.38-0.86) all have comparable effect sizes just above or just below our cutoff for a medium effect size (SMD 0.5). Tricyclic antidepressants (TCAs) (SMD 0.95; 95% CI, 0.15-1.8) have a large effect size, but this result is tempered by a low confidence in the estimate.
Clinicians should assess patients with diabetes for PDN (Level B) and those with PDN for concurrent mood and sleep disorders (Level B). In patients with PDN, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain (Level B) and consider factors other than efficacy (Level B). Clinicians should offer patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class (Level B) and not use opioids for the treatment of PDN (Level B).
OBJECTIVETo update the 2002 American Academy of Neurology (AAN) guideline regarding immunization and multiple sclerosis (MS).
METHODSThe panel performed a systematic review and classified articles ...using the AAN system. Recommendations were based on evidence, related evidence, principles of care, and inferences according to the AAN 2011 process manual, as amended.
MAJOR RECOMMENDATIONS (LEVEL B EXCEPT WHERE INDICATED)Clinicians should discuss the evidence regarding immunizations in MS with their patients and explore patientsʼ opinions, preferences, and questions. Clinicians should recommend that patients with MS follow all local vaccine standards, unless there are specific contraindications and weigh local vaccine-preventable disease risks when counseling patients. Clinicians should recommend that patients with MS receive the influenza vaccination annually. Clinicians should counsel patients with MS about infection risks associated with specific immunosuppressive/immunomodulating (ISIM) medications and treatment-specific vaccination guidance according to prescribing information (PI) and vaccinate patients with MS as needed at least 4–6 weeks before initiating patientsʼ ISIM therapy. Clinicians must screen for infections according to PI before initiating ISIM medications (Level A) and should treat patients testing positive for latent infections. In high-risk populations, clinicians must screen for latent infections before starting ISIM therapy even when not specifically mentioned in PI (Level A) and should consult specialists regarding treating patients who screen positive for latent infection. Clinicians should recommend against using live-attenuated vaccines in people with MS receiving ISIM therapies. Clinicians should delay vaccinating people with MS who are experiencing a relapse.
Faciobrachial dystonic seizures (FBDS) are the first adult-onset autoantibody-mediated epilepsy. Thompson et al. describe 103 patients with FBDS, and show that seizures are responsive to ...immunotherapy, with early seizure cessation reducing long-term disability and preventing cognitive impairment. Potential pathogenic mechanisms include complement fixation and LGI1-ADAM22 complex internalisation.
Abstract
Faciobrachial dystonic seizures and limbic encephalitis closely associate with antibodies to leucine-rich glioma-inactivated 1 (LGI1). Here, we describe 103 consecutive patients with faciobrachial dystonic seizures and LGI1 antibodies to understand clinical, therapeutic and serological differences between those with and without cognitive impairment, and to determine whether cessation of faciobrachial dystonic seizures can prevent cognitive impairment. The 22/103 patients without cognitive impairment typically had normal brain MRI, EEGs and serum sodium levels (P < 0.0001). Overall, cessation of faciobrachial dystonic seizures with antiepileptic drugs alone occurred in only 9/89 (10%) patients. By contrast, 51% showed cessation of faciobrachial dystonic seizures 30 days after addition of immunotherapy (P < 0.0001), with earlier cessation in cognitively normal patients (P = 0.038). Indeed, expedited immunotherapy (P = 0.031) and normal cognition (P = 0.0014) also predicted reduced disability at 24 months. Furthermore, of 80 patients with faciobrachial dystonic seizures as their initial feature, 56% developed cognitive impairment after 90 days of active faciobrachial dystonic seizures. Whereas only one patient developed cognitive impairment after cessation of faciobrachial dystonic seizures (P < 0.0001). All patients had IgG4-LGI1 antibodies, but those with cognitive impairment had higher proportions of complement-fixing IgG1 antibodies (P = 0.03). Both subclasses caused LGI1-ADAM22 complex internalization, a potential non-inflammatory epileptogenic mechanism. In summary, faciobrachial dystonic seizures show striking time-sensitive responses to immunotherapy, and their cessation can prevent the development of cognitive impairment.
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Multiple Sclerosis and Related Disorders provides evidence-based data and experience-based guidance for delivering quality long-term care to MS patients. Information on disease history, ...pathophysiology, and biology is included to provide clinicians with a framework for understanding current diagnosis, monitoring, and treatment strategies for these disorders. In addition to thoroughly reviewing the newest disease-modifying treatments, the authors have devoted significant focus to the symptoms that frequently manifest and their treatment options. Symptoms and functional limitations are the Ïface of the diseaseÓ for patients, and present their own set of challenges for practitioners. The book proceeds through diagnosis (initial symptoms, criteria and classification, imaging, lab tests, and differential diagnosis), approved treatments for the various MS types including emerging therapies where appropriate, symptom management, rehabilitative issues, general health and wellness, and an overview of MS clinical trials. Special populations, societal and family issues, and related disorders that are often mistaken for MS are also covered. Dedicated chapters on neuromyelitis optica and acute disseminated encephalomyelitis incorporate newer diagnostic criteria. Because comorbidities often make the management of MS-related disability more complex, the book addresses these comorbidities as part of a comprehensive management plan. To enhance the clinical utility, critical-to-know information and management pearls are boxed for quick reference and most chapters include lists of ÏKey PointsÓ for clinicians, and for patients and families. Illustrations, tables, graphs, assessment scales, and up-to-date MRI imaging inform the text throughout. The treatment chapters include specific recommendations where available and highlight areas of controversy. Illustrative cases go beyond the literature to amplify clinical recommendations and provide real-world guidance for practitioners. Illustrations, tables, graphs, assessment scales, and up- to-date MRI imaging inform the text throughout. Multiple Sclerosis and Related Disorders features: * Comprehensive clinical reference for all members of the MS care team * Focus on practical approaches to diagnosis, treatment, counseling, and rehabilitative strategies * Reviews the latest disease modifying therapies * Extensive chapters on symptom management and womenÌs issues in MS * Edited and written primarily by expert clinicians at Cleveland Clinic/Mellen Center * Evidence- and experience-based guidance * Dedicated chapters on neuromyelitis optica and acute disseminated encephalomyelitis incorporating newer diagnostic criteria * Includes treatment guidelines and numerous illustrations, tables, scales key information is highlighted for quick reference
Brain death evaluation during the pandemic Migdady, Ibrahim; Rae-Grant, Alexander; Greer, David M
Neurology,
2020-October-13, 2020-10-13, 20201013, Letnik:
95, Številka:
15
Journal Article
Recenzirano
Odprti dostop
Coronavirus disease 2019 (COVID-19) may pose unique challenges to clinicians attempting to diagnose brain death in patients infected with the SARS-CoV-2. Among these challenges is the risk of aerosol ...generation during the traditional apnea testing using the insufflation technique in addition to the risk of complications due to SARS-CoV-2-related lung disease. In this article, we discuss these challenges and provide further guidance to minimize such risks to ensure safety of healthcare professionals and other patients. We also emphasize the importance of maintaining the standards of brain death determination in this critical time.
Summary Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in autoimmune encephalitis research in the past 10 years ...have led to the identification of new syndromes and biomarkers that have transformed the diagnostic approach to these disorders. However, existing criteria for autoimmune encephalitis are too reliant on antibody testing and response to immunotherapy, which might delay the diagnosis. We reviewed the literature and gathered the experience of a team of experts with the aims of developing a practical, syndrome-based diagnostic approach to autoimmune encephalitis and providing guidelines to navigate through the differential diagnosis. Because autoantibody test results and response to therapy are not available at disease onset, we based the initial diagnostic approach on neurological assessment and conventional tests that are accessible to most clinicians. Through logical differential diagnosis, levels of evidence for autoimmune encephalitis (possible, probable, or definite) are achieved, which can lead to prompt immunotherapy.
Written by the lead author of the popular review book popular Ultimate Review for the Neurology Boards, Second Edition, this handy paperback is an essential tool for Board preparation and can be used ...independently or as a supplement to any review book. Ultimate Review for the Neurology Boards: Question and Answer Companion contains structured test questions, answers, and explanations designed to help the busy clinician prepare for the neurology boards, the AAN's RITE exam, or recertification. Using a Q&A format to test recall and sharpen skills, all areas covered on the boards are represented. The book opens with a set of test taking tips, and then breaks down the field of neurology into 23 chapters covering all the subjects tested on the boards including psychiatry. Each chapter contains from 8 to 30 multiple-choice questions, with answers and complete explanations. Ultimate Q&A is illustrated throughout, and includes a color plate section. The book closes with a practice test containing additional random questions and an appendix of high-yield facts, figures, and tables specifically selected for last-minute reinforcement before the exam.
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