3 Question Warm-Up
1. H o w do the features o f acute dystonia differ from tardive dyskinesia?
2. W h ich medication is used more than any other in the treatm ent o f Parkinson patients?
3. W h a t is the m axim um am ount o f tim e a TLA. may last?
4. W hat is the classic presentation of Guillain-Barre syndrome (GBS)?
° Symmetric muscle weakness that progresses over days to 4 weeks (usually 2 weeks) Usually beginning in the distal legs but may begin in the arms or facial muscles in 10% of cases
__________________________ requiring mechanical ventilation in ___________of cases
__________________________ and/or oropharyngeal weakness in __________ which may include bilateral facial muscle paralysis
° Autonomic dysfunction in 70% - usually________________________
° Absent or depressed deep tendon reflexes
° Little if any change in sensation
° No fever at the onset of symptoms
° GBS may be preceded by:
Campylobacter jejuni diarrheal illness (about 20% of cases) HIV infection
5. How is the diagnosis of Guillain-Barre syndrome made in a patient with ascending muscle paralysis?
° Characteristic clinical presentation
° CSF analysis (elevated protein and normal WBCs)
° Electrodiagnostic studies: nerve conduction studies and electromyography (EMG) reveal
PERIPHERAL DISORDERS 6. W hat is the prognosis of a patient with Guillain-Barre syndrome?
° Spontaneous regression and complete recovery by 1 year in 80-90%
° Relapse in 10%
° Prolonged disease with delayed or incomplete recovery in 5-10%
° Death despite ICU care in 5%
7. W hat is the treatment of Guillain-Barre syndrome?
° Hospitalization for respiratory monitoring including vital capacity, BP monitoring, cardiac monitoring (telemetry) and daily abdominal auscultation for ileus
° Mechanical ventilation required in 30% of patients
° ICU monitoring for autonomic dysfunction required in 20% of patients Equally effective at shortening time to independent walking by iSQfb Combining the two offers no additional benefit
° _______________________ are N O T recommended in the treatment of GBS.
Previously the mainstay of therapy; new studies show absolutely no benefit.
8. W hat is required to make the diagnosis of Bell’s palsy?
Clinical diagnosis:
° Diffuse involvement of the entire facial nerve —> facial muscle paralysis (upper and lower) Rule out Lyme disease b y _________________ : tick bite, heart block, arthritis, vertigo, hearing loss
Rule out Otitis media b y__________________
Rule out stroke b y _______________________
° Acute onset (1-2 days) —> progressively worsening weakness for 3 weeks —» recovery within 6 months
° Anything other than the above presentation requires imaging (CT and/or M RI) and screening blood tests to rule out other pathology
| 2 4]
W hat is the treatm ent for Bell’s palsy?
° Eye care to prevent corneal trauma Artificial tears hourly while awake Lubricating ointment qHS Patch covering the eye at night
° Glucocorticoids (e.g., prednisone 60mg daily x 1 week)
° +/- Valacyclovir lOOOmg tid x 1 week (acyclovir provides no additional benefit over glucocorticoids)
End of Session Quiz
10. W h a t test can help m ake the diagnosis o f myasthenia gravis?
11. H o w does Lam bert-Eaton syndrome differ from myasthenia gravis (M G ) on history and physical exam?
12. W h a t are the treatm ent options for benign essential tremor?
13. A 35-year-old w om an presents w ith ptosis and diplopia that worsens throughout the day. W h a t is the underlying problem?
14. W h a t is a classic presentation o f Guillain-Barre syndrome?
15. H o w do you treat Guillain-Barre syndrome?
16. H o w can Bell’s palsy be easily differentiated from a m otor cortex stroke?
NEOPLASMS AND SLEEP
s ' . i ■ • - v ... '■ mw® ® " m ■ ■ " $3 Question Warm-Up
1 W h a t two medications could be used for prophylaxis against meningococcal meningitis?
2. W h a t two classes o f medication could be used both to treat chronic hypertension and also to prevent recurrent migraines?
3. H ow do edrophonium, neostigmine and pyridostigmine work in the treatment o f myasthenia gravis?
. W hat are the differences between nightmares and night terrors?
° Nightmares - during REM sleep, patients that appear to wake up are actually awake
° Night terrors - during non-REM sleep, patients that appear awake (and are frightened/
screaming, tachycardic and diaphoretic) are actually not fully awake, difficult to arouse and usually fall right back to sleep after the episode
W hat is required to make the diagnosis of narcolepsy?
° _______________________ (sudden loss of muscle tone) only occurs in narcolepsy and is virtually diagnostic when present
° Other causes of excessive daytime sleepiness are ruled out
Overnight polysomnogram (to r/o O SA and periodic limb movement disorder) Rule out sedating medications as a cause
° Multiple Sleep Latency Test - when given 4-5 opportunities to nap every 2 hours, narcolepsy patients fall asleep in less than 8 minutes
W hat is the treatm ent for narcolepsy?
° Avoidance of drugs that cause sleepiness
° Scheduled naps (once or twice a day for 10-20 minutes)
° Stimulants - _______________________ is first-line
° Support group attendance
° I f cataplexy —* venlafaxine, fluoxetine or atomoxetine
W hat medications are common in the treatm ent of insomnia? W hat makes each one unique?
M elatonin Non-addictive, O T C , vivid dreams, safe for < 3 months Valerian O T C herbal remedy, studies show no benefit
A ntihistam ines (diphenhydramine, doxylamine)
Commonly used by patients first-line, associated with poor sleep quality, not for long-term use, anticholinergic side effects (avoid in the elderly)
Trazodone Antidepressant, decreases sleep latency, small risk of priapism
TC A s
(amitriptyline, doxepin)
Antidepressant, small risk of arrhythmias (obtain EKG prior to use), anticholinergic side effects (avoid in the elderly)
Addictive, short-term only (< 35 days)
Zolpidem Zaleplon
Act at the benzo receptor, short-term only (< 35 days), rebound insomnia when discontinued
Eszopiclone May be used long-term
Ramelteon Non-addictive because it works at melatonin receptors instead of G A B A /benzo receptors, avoid if hepatic insufficiency, long-term studies are lacking
NEOPLASMS ANDSLEEP 8. Restless Leg Syndrome
° The sensation of unpleasant paresthesias that compels the patient to have voluntary, spontaneous, continuous leg movements that temporarily relieve the sensations. The discomfort worsens at rest, in the evening and/or during sleep. Sensation of “spiders or ants” on/in K et/calf muscles.
° Usually a primary, idiopathic disorder
° Secondary RLS can result from iron deficiency, end-stage renal disease, diabetic neuropathy, Parkinson disease, pregnancy, rheumatic diseases (RA), varicose veins, caffeine intake.
° Treatment: pramipexole or ropinirole qHS (or levodopa/carbidopa), iron replacement, avoidance of caffeine, clonazepam qHS, gabapentin, opioids