Neurology Update - PowerPoint PPT Presentation

Loading...

PPT – Neurology Update PowerPoint presentation | free to download - id: 774041-NDYyN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Neurology Update

Description:

Neurology Update Paul Hart Neurologist Epsom + St Helier AMNU _at_ St George s Royal Marsden Hospital – PowerPoint PPT presentation

Number of Views:130
Avg rating:3.0/5.0
Slides: 43
Provided by: pbwo663
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Neurology Update


1
Neurology Update
  • Paul Hart
  • Neurologist
  • Epsom St Helier
  • AMNU _at_ St Georges
  • Royal Marsden Hospital

2
Neurology Update
  • Diseases
  • Parkinsons disease
  • Multiple Sclerosis
  • Epilepsy
  • Stroke
  • Dementia
  • Headache
  • ..

3
Neurology Update
  • Diseases
  • Parkinsons disease
  • Multiple Sclerosis
  • Epilepsy
  • Stroke
  • Dementia
  • Headache
  • .. Germline mosaicism of MPZ gene in
    Dejerine-Sottas syndrome (HMSN III) associated
    with hereditary stomatocytosis
  • Neuromuscul Disord. 1999 Jun9(4)232-8

4
Neurology Update
  • Diseases
  • Parkinsons disease
  • Multiple Sclerosis
  • Epilepsy
  • Stroke
  • Dementia
  • Headache
  • .. Germline mosaicism of MPZ gene in
    Dejerine-Sottas syndrome (HMSN III) associated
    with hereditary stomatocytosis
  • Neuromuscul Disord. 1999 Jun9(4)232-8
  • Neurology Top 10 Tips
  • Services
  • TWRs
  • Direct access investigations
  • Local provision
  • How to get the most out of your neurologist

5
Update - Parkinsons disease
  • Suspected PD
  • Unsuspected PD making the penny drop
  • PD review
  • Common
  • Increasing prevalence
  • Predicted to treble over the next 50 years
  • Age 50 10100,000
  • Age 80 200100,000
  • lt 80 confirmed at post-mortem !?

6
Classification of Movement Disorders
  • Akinetic
  • Idiopathic Parkinsons Disease
  • Parkinsons plus
  • MSA
  • PSP
  • DLB
  • CBD
  • Secondary Parkinsonism
  • Hyperkinetic
  • Chorea
  • Ballism
  • Tremors
  • Myoclonus
  • Wilsons disease
  • Dystonia
  • Tics Tourettes
  • Sleep related movement disorders
  • Ataxia
  • Dyskinesias
  • Psychogenic

7
Definition of idiopathic PD
  • Pathological diagnosis
  • depigmentation neuronal loss in substantia
    nigra
  • Intraneuronal inclusions- Lewy bodies

8
(No Transcript)
9
Clinical Features
  • Tremor
  • ULgtLL
  • Asymmetric
  • Rest tremor
  • Tongue lips chin
  • Rigidity
  • Akinesia
  • Postural instability
  • Gait
  • micrographia
  • Facial Hypomimia
  • Speech
  • Non-motor manifestations
  • Constipation
  • EDS
  • Anosmia
  • REM behaviour disorder
  • Depression
  • Dementia
  • Pain
  • Postural stability
  • Skin
  • Autonomic
  • .

10
Sleep
  • 75-90 PD sleep dysfunction
  • Insomnia
  • Sleep fragmentation
  • Sleep akinesia
  • Nocturia
  • Nocturnal panic attacks
  • RLS
  • Excesssive daytime somnolence
  • Drug induced psychosis 10-30
  • reduce parkinson meds
  • monitor response
  • neuroleptic trial quetiapine / clozapine /
    olanzapine
  • Mirtazapine
  • RIvastigmine

Neuropsychiatric problems
Depression and Dementia
11
A Clinical Diagnosis
  • Investigations Exclude Wilsons -young with
    tremor
  • MRI
  • DaT scan
  • Research
  • SPECT
  • PET

12
PD - Is it something else ?
  • Essential Tremor
  • Kinetic /- postural tremor
  • 4-12 Hz
  • UL, head, voice, LL, trunk, tongue
  • gt90 undiagnosed
  • 73 report significant disability
  • Treatment medical, botox, surgical
  • Parkinsons plus
  • MSA
  • PSP
  • LBD
  • CBD
  • Drug induced Parkinsonism
  • 12 of 328 patients referred to secondary care
  • Prochloperazine 32
  • Typical antipsychotics 42
  • atypical antipsychotics 18
  • Metoclopramide 11
  • Amiodarone 8
  • Lithium 8
  • Antihistamines 8
  • Promethazine and cinnarazine
  • Valproate 5

13
PD Treatment what when and how?
  • 1817 James Parkinson
  • Blood letting
  • Iatrogenic pus formation
  • 2011 Dopaminergic
  • Non dopaminergic
  • Symptomatic
  • Neuroprotective
  • Surgery Ablation DBS Brain Grafting
  • Preventative

14
Levo Dopa
  • Pros effective
  • Cons side effects
  • Early side effects NV, ?HR, ?BP
  • Late SE
  • motor fluctuations
  • dyskinesias
  • neuropsychiatric
  • Symptoms unresponsive to L-Dopa
  • postural instability
  • freezing phenomena
  • speech
  • sialorrhoea
  • depression and dementia
  • ANS - sweating, urinary frequency, constipation
  • sensory symptoms pain
  • Tremor
  • REM sleep behaviour disorder
  • (DATATOP trial n352 F/U 20 months /- 9)
  • Wearing off 50
  • Dyskinesias 33
  • Severe on-off 10
  • Hedonistic homeostatic dysregulation

15
Levodopa therapeutic manoeuvres
  • On with dyskinesia vs Off without dyskinesia
  • CR preparations
  • Hyperfractionate dosing schedule
  • COMT inhibitors - entacapone, tolcapone
  • Stalevo
  • Levodopa carbidopa entacapone
  • 50 / 12.5 / 200
  • Stalevo 50 75 100 125 150 200
  • MAO inhibitors - selegeline, rasagiline
  • Amantadine
  • Dopamine Agonists
  • Duo-dopa
  • Apomorphine pump

16
Agonists
  • No dyskinesia
  • potentially neuroprotective
  • delays use of levodopa
  • longer half life
  • no absorption delay/dietary effects
  • no metabolic conversion
  • Apomorphine
  • Pergolide
  • Cabergoline
  • Pramipexole
  • Ropinirole
  • Rotigitone
  • Side effects
  • Ankle oedema
  • Gambling
  • Sexual appetite

17
(No Transcript)
18
PD whats new
  • Genetics
  • Drugs
  • NSAIDs
  • Ibuprofen protective but not other NSIADs
  • N136,474
  • Stem cells

19
PD whats new - Genetics
  • 15 PD patients have an affected 1st degree
    relative
  • 5 due to mutation in one of several specific
    genes
  • alpha-synuclein (SNCA)
  • ubiquitin carboxy-terminal hydrolase L1 (UCH-L1)
  • parkin (PRKN)
  • leucine-rich repeat kinase 2 (LRRK2 or dardarin)
  • PTEN-induced putative kinase 1 (PINK1)
  • DJ-1
  • ATP13A2
  • In most cases, people with these mutations will
    develop PD.
  • All rare except LRRK2
  • 10 familial PD
  • 3 sporadic PD
  • Genome wide association studies
  • Complex late onset sporadic degenerative
  • 15 confirmed genes

20
Update Multiple Sclerosis
21
Update Multiple Sclerosis
  • Disease modifying therapies
  • CCSVI
  • Lifestyle effects
  • Sativex
  • NMO antibodies

22
Update Multiple Sclerosis
  • Refresher
  • Demyelination
  • Inflammation
  • Clinically isolated syndrome
  • Optic neuritis
  • Transverse myelitis
  • Brain stem
  • motor
  • Sensory
  • McDonald criteria 2001 2005 2010

23
McDonald criteria
  • Clinical presentation Additional data needed
    for MS diagnosis
  • Two or more attacks
  • objective clinical evidence of two or more
    lesions None
  • Two or more attacks
  • objective clinical evidence of one
    lesion Dissemination in space shown on
    MRI or Up to two MRI detected lesions
    typical of MS plus positive CSF or Await
    a further relapse suggestive of dissemination in
    space (ie affecting another part of the
    body)
  • One attack
  • objective clinical evidence of two or more
    lesions Dissemination in time demonstrated by
    MRI or Second clinical attack (relapse)
  • One attack
  • objective clinical evidence of one lesion
  • (known as 'clinically isolated
    syndrome') Dissemination in space
    demonstrated by MRI or Up to two MRI
    detected lesions typical of MS plus positive CSF
  • AND dissemination in time demonstrated by
    MRI or Dissemination in time demonstrated
    by MRI (ie new lesion seen on MRI at least 3
    months after the original scan) or Second
    clinical attack (relapse)
  • Insidious neurological progression suggestive
  • of multiple sclerosis (typical for primary
    progressive MS) Positive cerebrospinal fluid
  • AND
  • dissemination in space, shown on MRI
  • or Abnormal visual evoked potential plus
    abnormal MRI

24
Update Multiple Sclerosis
  • Treatment of MS
  • Relapses
  • Treatment
  • Oral methyprednisilone 500mg od - 5days
  • Prevention
  • DMTs
  • Treatment of symptoms
  • Fatigue
  • Amantadine
  • Modafinil
  • Depression
  • Spasticity
  • Baclofen
  • Tizanidine
  • Sativex
  • Bladder
  • Etc.

25
Update Multiple Sclerosis - DMTs
  • a group of compounds which alter the progression
    of MS
  • reduce the frequency and severity of relapses and
    slow the development of disability in some
    people.
  • Beta interferon 1a AVONEX im
  • REBIF sc
  • 1b BETAFERON sc
  • Fingolimod po
  • Glatiramer acetate COPAXONE sc
  • Different mechanism, similar effect
  • Natalizumab TYSABRI
  • A recombinant humanised monoclonal antibody
    produced in murine myeloma cells.
  • The specific mechanism(s) not fully defined.
    However, inhibition of leucocyte transmigration
    out of the vascular space.
  • Progressive Multifocal Leukoencephalopathy(PML)
    is an opportunistic infection caused by the JC
    virus that typically occurs in patients that are
    immunocomprimised.
  • Mitoxantrone

26
Update Multiple Sclerosis - DMTs
  • CCSVI
  • Zamboni
  • Stem cells
  • Lifestyle effects
  • Vitamin D
  • tobacco
  • diet
  • NMO antibodies
  • Neuromyelitis optica (Devics disease)
  • Aquaporin antibodies

27
Update Multiple Sclerosis - DMTs
  • CCSVI
  • Zamboni
  • Stem cells
  • Lifestyle effects
  • Vitamin D
  • tobacco
  • diet
  • NMO antibodies
  • Neuromyelitis optica (Devics disease)
  • Aquaporin antibodies
  • Other neurological antibodies
  • MUSK
  • VGKC
  • NMDA

28
Update Epilepsy
  • More New AEDs
  • Enhance slow activation of Na channels
  • Lacosamide
  • Rufinamide
  • Ca channel lockers carbonic anhydrase inhibitor
  • Zonisamide
  • Sudden unexplained death in epilepsy
  • Epilepsy SMR 1.6-9.3
  • Underlying disorder / status / accidents /
    suicide / Rx related death / SUDEP
  • 8-17 of deaths
  • Memory
  • Psychosocial

29
Update Stroke
  • Risk of stroke after TIA
  • Thrombolysis
  • PFO

30
Update
31
Overview
  1. Neurology - theres a lot of it about

32
Overview
  1. Neurology - theres a lot of it about
  2. Guidelines, QOFs, and more guidelines

33
Overview
  1. Neurology - theres a lot of it about
  2. Guidelines, QOFs, and more guidelines
  3. Do you suffer from Neurophobia ?

34
Overview
  • Theres a lot of it about
  • Guidelines, QOFs, and more guidelines
  • Neurophobia widespread

35
Neurological disorders are common
  • WHO
  • Neurological disorders a public health
    challenge
  • one of the greatest threats to public health
  • Mortality vs DALYs
  • Neurological disease accounts for 20 of
    admissions to general hospitals
  • More diagnoses than the rest of medicine put
    together

36
Guidelines, QOFs, etc..
  • NICE PD
  • NICE epilepsy
  • SIGN epilepsy
  • QOF epilepsy
  • Stroke and TIA
  • Headache
  • MS
  • And all the others.

37
Do you suffer from Neurophobia ?
  • A fear of neurosciences and clinical neurology
  • Jozefowicz 1994
  • Schon Hart et al 2002

38
Do you suffer from Neurophobia ?
  • A fear of neurosciences and clinical neurology
  • Jozefowicz 1994
  • Schon Hart et al 2002
  • Seeds Sown at medical school ?

39
We can cure it for you !
  • The Epsom and St Helier neurology Service
  • 100 patients seen by Consultant grade
  • 4 Consultant Neurologists
  • 2 Consultant Neurophysiologists
  • 4 specialist nurses
  • Neuro PT, OT etc
  • State of the art imaging facilities, EEG, EMG,
    PIU
  • 52 clinics per month
  • 94 of ward referrals seen on day of referral,
    99 within 48 hrs

40
Neurology top ten tips
  • TIAs never cause isolated loss of consciousness
  • Numb tingling hands are rarely due to neck
    pathology
  • Beware of medication overuse headache
  • Essential hypertension, sinusitis and eye strain
    do not cause chronic daily headache
  • Vertigo usually originates from the vestibular
    apparatus not the brain
  • Diplopia monocular ophthalmology, binocular
    neurology
  • Know which headaches are worth worrying about
  • Beware of misdiagnosing tremor
  • Radiological imaging is rarely helpful in
    illuminating headache or back pain
  • The neurological examination is hugely overvalued
    in non-neurologists

41
  • Our ethos ?
  • Referral guidelines ?
  • Communication
  • Tel 0208 296 3355
  • Fax 0208 296 3356

42
Neurology Update
  • Paul Hart
  • Neurologist
  • Epsom St Helier t 0208 296 3355
  • f 0208 296 3356
  • AMNU _at_ St Georges
  • Royal Marsden Hospital
About PowerShow.com