September 2011 Archives

UpToDate via Smartphone

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Fairview subscribes to UpToDate and with a few tweaks, you can access it from your iPhone or Android device. Here is what to do:

1. Turn on Wifi in your phone's settings. By default your smartphone may only be set to use a cellular connection, but we need to connect to the Fairview wireless network.
2. Connect to FV_WLAN1 using your Fairview username and password (same as you use to log into Epic). iPhone is pretty straightforward. Android will ask you to set a password for the connect (use whatever password you like) and then take you to the screen where you can enter your Fairview username and password.
3. Go to www.uptodate.com and you should be good to go.

As a reminder, all UMN resources (except UpToDate) can be accessed from anywhere using your UMN username and password (you will be prompted when you need to enter it).

We also have a number of mobile apps available. You can either look at the general list or the Neurology specific one I created.

You can always contact me with any questions that come up.

Recommended article on delirium

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Dr. Rodriguez recommended the article "Delirium in Older Persons" for all residents as a nice overview of the etiology, management, and prevention of delirium.

Questions from Rounds, 9/23/11

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What is the prognostic value of follow-up MRIs in a patient with myoclonus status epilepticus?

I was not able to find any articles that looked at the prognostic values of follow-up MRIs and very few even reported that multiple MRIs were performed. I did, however, find a number of articles that reported on the prognosis of patients with MSE.

Thömke reported on 50 patients with MSE. 24 patients died within 4 days, 21 within 5-12 days, and 5 survived in a persistent vegetative state. The article includes a review of cases of positive outcome.

Zandbergen conducted a prospective cohort study of 407 patients, 7 of whom were diagnosed with MSE (and 5 with SE). There were no positive outcomes at the 1 month mark.

Wijdicks reported on 40 patients with MSE, none of whom awakened, improved in motor status, or survived.

Arbelaez provides an overview of imaging in patients with global cerebral anoxia at <24 hours, 24 hours-13 days, and 14-20 days.

Els discusses the prognistic value of DWI in patients with global cerebral hypoxia, especially compared to traditional MRI.

Finally, I wanted to direct you to the AAN's Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review), which provides a nice overview of prognostic factors.

Differential from diffusion-weighted imaging

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I received a question about resources to help with diagnosis involving diffusion-weighted imaging. Needless to say, this is a huge topic, but here are two sources that might help.

Imaging tutorial: differential diagnosis of bright lesions on diffusion-weighted MRI. (no PDF available, this is online only)
Diffusion-weighted MR imaging of the brain (in particular, I would look at the chapter "How to use this book," which groups similar image patterns together to ease diagnosis)

Questions from Rounds, 9/16/11

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How often does HSV encephalitis manifest without increased white blood cells counts?

Although most articles cite increased counts as a cardinal sign of HSV encephalitis, many also acknowledge that sometimes levels remain normal One recent article found that 11% of patients diagnosed did not have abnormal levels. This article also provides a nice set of tables comparing signs/symptoms and findings among the types of encephalitis.

What nutritional deficiencies can lead to neurological disease, specifically myelopathies?

A nice overview of deficiency diseases can be found in Chapter 61 of Neurology in Clinical Practice. The two causes that came up the most in my searching were B12 deficiency and copper deficiency, both of which can arise from several causes including strict diets, inherited defects, and gastric bypass surgery.

Questions from Rounds, 9/9/11

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Can transient global amnesia result from a temporal lobe bleed?

I found two case reports of TGA due to temporal/frontal lobe hemorrhage. Both cases had sudden and acute onset with imaging later disclosing a hemorrhage. Symptoms resolved in 3 and 18 hours respectively.

Transient global amnesia due to left temporal hemorrhage
Transient global amnesia and left frontal hemorrhage

There is a recent case report of a patient developing TGA following a 5000 IU bolus of unfractionated heparin on day 4 post-mitral valve replacement. TGA appeared within an hour of his receiving the bolus. TGA continued as subsequent boluses were given and mental state returned to normal with 24 hours of treatment being reversed. A comment to the editor suggested that transient epileptic amnesia may be a more appropriate diagnosis.

Stimulus-induced myoclonic jerks

I was able to find one article which discussed the voluntary nature of some myoclonic-like jerks.

Voluntary stimulus-sensitive jerks and jumps mimicking myoclonus or pathological startle syndromes

Physiology of psychogenic movement disorders is recent review that provides more details and moves beyond myoclonus.

Stroke as adverse event of intra-arterial chemotherapy for gliomas

Stroke rates appear to vary depending on agent used. Neither of the below studies reported stroke rates for the control (non-intraarterial) groups. Neither used bevacizumab, which itself can carry a 5% risk of serious thromboembolic events.

3.6-4.8% stroke rate
A randomized comparison of intra-arterial versus intravenous BCNU, with or without intravenous 5-fluorouracil, for newly diagnosed patients with malignant glioma.

2.1% stroke rate
Results of a randomized trial comparing intra-arterial cisplatin and intravenous PCNU for the treatment of primary brain tumors in adults


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