Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients on anti-seizure medication necessity (or lack thereof) in the setting of PNES without comorbid epilepsy?
I discuss in detail and openly with the patients regarding the etiology of epileptic seizures in comparison with the current understanding of etiology in PNES and help them understand why traditional anticonvulsants won't work for PNES. I also explain that taking a medication that may not be indicat...
Would you generalize the data from the CHANCE-2 trial to a broader clinic population given that the study was specific to Han Chinese patients?
I believe the results of CHANCE-2 (Wang et al., PMID 34708996) are generalizable to non-Chinese populations. CHANCE (Wang et al., PMID 23803136), performed in China, and POINT (Johnston et al., PMID 29766750), performed worldwide but excluding China, produced strikingly similar results in dual antip...
How do you switch/cross-titrate regular Levodopa to Rytary in a patient with Parkinson's disease?
The manufacturer has a suggested conversion table in the package insert: https://rytary.com - pi.pdf (impaxlabs.com) However, many patients do not respond well using this table, so be prepared to make adjustments over the next few days. I find the duration of action varies from 4 to 8 hours and mot...
What workup do you do for patients who have PL-7 elevation when screening for myopathy?
In the literature, the PL-7 antibody has been associated with the antisynthetase syndrome and aside from myositis, interstitial lung disease (ILD). Patients with PL-7 autoantibodies are at high risk of ILD. Referral to pulmonary should be considered. One would also consider assessing pulmonary funct...
How do you interpret a mildly positive NT5C1A lab test in patients with hyperCKemia?
Seropositivity, in general, ought to support the clinical features of the given disease in the patient. In this instance, the patient should have selective medial forearm flexor weakness, quadriceps atrophy/weakness, and dysphagia (if in later stages). In the rare case that the phenotype has not yet...
For patients with MS on natalizumab, at what JC virus antibody titer do you consider switching DMTs?
I am comfortable continuing Tysabri as long as the JCV index remains below 0.9. I would discuss switching therapies or would consider extending-interval dosing (treating every 6 to 8 weeks, instead of every 4 weeks), if the index is between 0.9 and 1.5. I would not continue Tysabri if the index is a...
Does the overall conclusion of the CHANCE-2 trial make ticagrelor + ASA a worthwhile transition given the data showing cumulative hazard of stroke diverged during the first week and was subsequently similar, which suggests the benefit of ticagrelor over clopidogrel is seen predominantly soon after stroke?
Given the fact that clopidogrel costs 11 cents a day and ticagrelor costs almost $8/day and the fact that most patients will not be tested for slow CYP2c19 metabolizer (or have the results back in a timely fashion), it seems that the combination of ASA plus clopidogrel is the best option from a publ...
Is there a risk of CYP2C19 gene testing only being adopted by wealthier health systems, thereby creating a disparity gap in treatment?
I do not believe this test is widely available for use in clinical practice. There is a serum platelet assay that checks for P2Y12 receptor inhibition that is widely available and could be an alternative to CYP2C19 testing.
When do you order an EMG for evaluation of patients with movement disorders?
I can think of only two reasons to order EMG for my Movement disorders patients. There may be more but these I recall: Determine frequency when suspecting orthostatic tremor. I do not order it for any other type of tremor. A Parkinsonian patient having neck extensor weakness when I am evaluating fo...
When do you typically check vitamin B5 levels in patients with peripheral neuropathy?
I do order B5 level in people with burning feet and sometimes the result does show low level. I usually prescribe Sublingual vitamin B complex and folic acid as most of the time if a person is deficient in one, then they can have multiple vitamin deficiency, and we are not checking all in usual clin...