Continuum : lifelong learning in neurology
-
Continuum (Minneap Minn) · Feb 2012
Case ReportsDifficult decisions: managing chronic neuropathic pain with opioids.
The decision to use opioids to treat chronic neuropathic pain is complex and somewhat controversial. Although opioid therapy may be appropriate for some patients with chronic neuropathic pain, physicians must implement strategies to reduce opioid abuse, addiction, and diversion. ⋯ Fortunately, specific recommendations for the safe and effective use of opioids are now available in several recently published guidelines. The best practices embodied in these guidelines should be considered for widespread adoption by both individual providers and health care systems.
-
Continuum (Minneap Minn) · Oct 2011
Hypoxic-ischemic brain injury and prognosis after cardiac arrest.
: Cardiac death is the leading cause of death in the United States, and patients who have out-of-hospital cardiac arrest have only a 1% to 10% survival rate, despite improvements in advanced life support. The neurologic sequelae of hypoxic-ischemic brain injury after cardiac arrest vary from subtle cognitive impairment to coma, persistent vegetative state, and brain death. Neurologists are commonly asked to prognosticate neurologic outcome after cardiac arrest. ⋯ : Neurologic prognostication after cardiac arrest remains challenging because of the sedation and neuromuscular blocking agents given to patients who undergo therapeutic hypothermia. A multimodal algorithmic approach (clinical, electrophysiologic, and possibly serum biomarker testing) is suggested for cardiac arrest patients treated with hypothermia, but further research is needed to determine more accurate prognostic predictors.
-
: Persistent elevation of intracranial pressure (ICP) can lead to cerebral ischemia, brain herniation, and possibly death. Understanding the fundamental mechanism that contributes to the rise in ICP and recognizing the specific intracranial compartment involved (brain, CSF, or blood) can lead to early diagnosis and effective treatment. This article reviews the conceptual approach to a patient with elevated ICP. ⋯ : Increased ICP is a neurologic emergency that requires immediate intervention. However, the treatment itself is not without risk; thus, the risks and benefits of medical and surgical intervention must be carefully evaluated and individualized for each patient.
-
Psychiatric and cognitive disorders in persons with epilepsy (PWE) are often overlooked or undertreated. Studies have shown that they occur in all types of epilepsy, but they are especially prominent when epilepsy is severe and multiple antiepileptic drugs are used. In particular, the clinician should be vigilant about the coexistence of depression with epilepsy. ⋯ The clinician should be aware that some PWE have increased risk for suicide. The phenomenon of sudden unexplained death in epilepsy occurs at the highest rate in persons with uncontrolled seizures, especially generalized convulsive seizures. For now, optimizing seizure control appears to be the best way to reduce the risk for this still mysterious and catastrophic event.
-
Dopaminergic agents remain the principal treatments for patients with Parkinson disease (PD). In many patients, however, a combination of relatively resistant motor symptoms, motor complications such as dyskinesias, or nonmotor symptoms such as dysautonomia may lead to substantial disability in spite of dopaminergic therapy. This chapter will review both dopaminergic and nondopaminergic therapies for motor and nonmotor symptoms in PD. ⋯ In addition, there has been an increasing interest in agents targeting nonmotor symptoms, such as dementia and sleepiness. As patients with PD live longer and acquire additional comorbidities, addressing these nonmotor symptoms has become increasingly important. In this chapter, the major antiparkinsonian dopaminergic compounds will be reviewed, followed by a patient-focused guide to implementation of these treatments as part of an overall management plan.