RESUMO
The US health care crisis is of great concern to American neurologists. The United States has the world's most expensive health care system yet one-sixth of Americans are uninsured. The cost and volume of procedures is expanding, while reimbursement for office visits is declining. Pharmaceutical costs, durable goods, and home health care are growing disproportionately to other services. Carriers spend more for their own administration and profit than on payments to physicians. This first article on the US health care system identifies problems and proposes solutions, many of which are championed by the American Academy of Neurology through its legislative and regulatory committees.
Assuntos
Atenção à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Custo Compartilhado de Seguro , Atenção à Saúde/economia , Atenção à Saúde/métodos , Atenção à Saúde/estatística & dados numéricos , Feminino , Humanos , Lactente , Masculino , Imperícia/estatística & dados numéricos , Prontuários Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Médicos , Dinâmica Populacional , Mecanismo de Reembolso , Estados Unidos , Adulto JovemRESUMO
In the search for a universal, high quality, affordable health care system, Americans seek to identify and correct a series of current problems. In part one of this two-part series, we presented problems along with some suggested actions. This second part presents other health care systems in Europe and Canada. These different systems provide universal care and at a lower cost than in the United States. Further domestic proposals are presented from the Massachusetts plan and positions from US presidential candidates. These systems and proposals raise ideas about possible changes in the US health care system. Knowledge of these issues and other health care systems will help foster a meaningful dialog about changes in the US health care system.
Assuntos
Atenção à Saúde , Reforma dos Serviços de Saúde , Política de Saúde , Modelos Organizacionais , Programas Nacionais de Saúde/organização & administração , Planejamento em Saúde Comunitária , Atenção à Saúde/economia , Atenção à Saúde/métodos , Atenção à Saúde/estatística & dados numéricos , Apoio ao Planejamento em Saúde , Humanos , Programas Nacionais de Saúde/economia , Estados UnidosRESUMO
The authors reviewed charts of 78 myelopathy patients who underwent spinal angiography for possible arteriovenous malformations (AVMs). Twenty-two patients had an AVM. No neurologic complications from angiography were observed. MRI findings of increased T2 signal or flow voids were strongly associated with AVMs. Spinal angiography should be performed in all patients with unexplained myelopathy after neurologic evaluation and an MRI demonstrating increased T2 signal or flow voids.
Assuntos
Malformações Arteriovenosas/diagnóstico por imagem , Doenças da Medula Espinal/diagnóstico por imagem , Medula Espinal/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Malformações Arteriovenosas/complicações , Criança , Feminino , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Medula Espinal/irrigação sanguínea , Doenças da Medula Espinal/complicaçõesRESUMO
Electrical impedance myography (EIM) is a new technique with potential for the noninvasive bedside assessment of myopathy. EIM was performed on the quadriceps of 10 patients with inflammatory myopathy and 10 normal subjects. The major EIM parameter, the spatially averaged phase, was 35% lower in the myositis patients and correlated with whole-body (r = 0.765, p = 0.01) and quadriceps (r = 0.673, p = 0.03) strength.
Assuntos
Eletrodiagnóstico/métodos , Músculo Esquelético/fisiopatologia , Miosite/diagnóstico , Miosite/fisiopatologia , Impedância Elétrica , Estimulação Elétrica/métodos , Eletrodiagnóstico/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração Muscular/fisiologia , Debilidade Muscular/diagnóstico , Debilidade Muscular/etiologia , Debilidade Muscular/fisiopatologia , Miografia/instrumentação , Miografia/métodos , Valor Preditivo dos Testes , Músculo Quadríceps/fisiopatologiaRESUMO
We report a patient with hydrocephalus who developed levodopa responsive parkinsonism and severe bradyphrenia associated with shunt malfunction and revision. Magnetic resonance imaging revealed periaqueductal edema involving medial substantia nigra. [18F]dopa positron emission tomography demonstrated reduced uptake in the caudate and putamen with relative sparing of the posterior putamen. Hydrocephalus associated with shunt malfunction can cause a distinct parkinsonian syndrome with greater dysfunction of projections from the medial substantia nigra to anterior striatum than in idiopathic Parkinson's disease.
Assuntos
Hidrocefalia/complicações , Transtornos Parkinsonianos/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Derivação Ventriculoperitoneal , Adulto , Antiparkinsonianos/uso terapêutico , Mapeamento Encefálico , Carbidopa/uso terapêutico , Núcleo Caudado/fisiopatologia , Ventrículos Cerebrais/fisiopatologia , Combinação de Medicamentos , Falha de Equipamento , Humanos , Hidrocefalia/fisiopatologia , Hidrocefalia/cirurgia , Hipocinesia/tratamento farmacológico , Hipocinesia/fisiopatologia , Levodopa/uso terapêutico , Imageamento por Ressonância Magnética , Masculino , Exame Neurológico , Transtornos Parkinsonianos/tratamento farmacológico , Tomografia por Emissão de Pósitrons , Complicações Pós-Operatórias/tratamento farmacológico , Putamen/fisiopatologiaRESUMO
Tremor is a symptom of many disorders, including Parkinson's disease, essential tremor, orthostatic tremor, cerebellar disease, peripheral neuropathy and alcohol withdrawal. Tremors may be classified as postural, rest or action tremors. Symptomatic treatment is tailored to the tremor type. Combination therapy with carbidopa and levodopa remains the first-line approach for parkinsonian tremor. Essential tremor may be amenable to propranolol or primidone. Propranolol may be useful in treating alcohol withdrawal tremor, and isoniazid may control the cerebellar tremor associated with multiple sclerosis. Clonazepam may relieve orthostatic tremor. Other agents are also available for the treatment of tremor. When medical therapy fails to control the tremor, surgical options such as thalamotomy, pallidotomy and thalamic stimulation should be considered in severe cases. Thalamic stimulation, the most recent of these surgical approaches, offers the advantage over ablative procedures of alleviating tremor without the creation of a permanent lesion.
Assuntos
Tremor/etiologia , Tremor/terapia , Diagnóstico Diferencial , Humanos , Tremor/classificação , Tremor/tratamento farmacológico , Tremor/fisiopatologia , Tremor/cirurgiaRESUMO
This study investigates the relationship of the Unified Parkinson's Disease Rating Scale (UPDRS) to the patient's perception that they are "on". Following the first dose of medication, patients reported that they were "on" when their UPDRS-III reached a mean of 8+/-2, representing a decrease of 67+/-8% from their early morning rating. Patients reported that they were "off" when their UPDRS-III score increased to 20+/-5, representing an increase of 50+/-12% from their initial "on" score. A 67% improvement in the baseline UPDRS-III score may be useful in defining "on".
RESUMO
Mortality due to WG has been significantly decreased by cytotoxic therapy with cyclophosphamide and glucocorticoids. Several studies have addressed different treatment regimens, particularly different maintenance regimens, in order to reduce the potential for cyclophosphamide-induced toxicity. Relapse may be precipitated by the chronic carrier-state of S aureus in the nasopharynx, and is sometimes heralded by rising c-ANCA titers. The treatment of the relapse is determined by the severity of its manifestations. Options for maintenance therapy include methotrexate and azathioprine. The value of therapy with TMSx for maintenance of remission still is uncertain, although its use 3 times a week is recommended for Pneumocystis prophylaxis. The ACR guidelines for monitoring drug toxicity should be followed when treating WG.
Assuntos
Anti-Inflamatórios/uso terapêutico , Antirreumáticos/uso terapêutico , Ciclofosfamida/uso terapêutico , Granulomatose com Poliangiite/tratamento farmacológico , Anticorpos Anticitoplasma de Neutrófilos/sangue , Granulomatose com Poliangiite/diagnóstico , Granulomatose com Poliangiite/epidemiologia , Granulomatose com Poliangiite/imunologia , Humanos , Recidiva , Indução de Remissão , Sensibilidade e Especificidade , Esteroides , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Adult-onset focal dystonias (AFD) are common disorders that are often misdiagnosed and incorrectly treated. Their presentation is readily recognized, and botulinum toxin has become the agent of choice for treating these disorders. Most of the focal dystonias include cervical dystonia, blepharospasm, oromandibular dystonia, spasmodic dysphonia, and limb dystonia, specifically writer's cramp. Their onset is either idiopathic, familial, or post-traumatic, and the pathophysiology of the focal dystonias is not currently known. Local injections of botulinum toxin into the affected area result in chemical denervation of the muscle, resulting in a weakness of the muscles that are involved in the sustained contractions. This weakness alleviates the painful contraction of the dystonia. In this paper we present a case study of the most common type of focal dystonia, cervical dystonia. The etiology in this case was post-traumatic, and significant improvement resulted after treatment with botulinum toxin type A.