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Volume 3, No 3 - Summer 2006

Volume 3, No 3 - Summer 2006

Table of Contents

Ensuring Management of Vascular Risk Factors After Stroke Management Update
Ischemic stroke patients are at high risk for subsequent cardiovascular events. Despite this, an unacceptably high proportion of these patients do not receive treatment with evidence-based, guideline-recommended, vascular risk-reduction therapies when exposed to conventional care. The golden opportunity to most favorably influence the vascular future of stroke patients is at the initial encounter in the hospital or in the postdischarge setting. As such, there has been profound interest in identifying effective strategies and systems that increase the use of evidence-based therapies in the hospital and outpatient settings, to reduce the substantial morbidity and mortality that can result from recurrent vascular events after stroke. One strategy is the implementation of a stroke hospitalization quality-improvement program geared at optimizing appropriate drug therapy before discharge, intensifying patient education, and ensuring vigilant follow-up with early recognition and management of problems. Available evidence suggests that hospital-based systems can markedly improve medical care and education of hospitalized ischemic stroke patients, and increase longer-term patient adherence in the community. [Rev Neurol Dis. 2006;3(3):93-100]
Motor Fluctuations in Parkinson’s Disease Treatment Review
Parkinson’s disease is characterized by progressive slowness in activities of daily living and is the most common cause of parkinsonism, whose symptoms include resting tremor, cogwheel rigidity, and bradykinesia. The introduction of levodopa and its positive effect on motor dysfunction in Parkinson’s disease has allowed neurologists to focus on motor fluctuations. “End-of-dose wearing-off” and “morning akinesia” are terms to describe the transition between a patient’s relatively normal motor performance when levodopa is effective and when it has transiently lost its effect on motor responses and parkinsonian symptoms reemerge. The choices available to alleviate these motor fluctuations range from altering the patient’s levodopa/carbidopa dosing schedule to the addition of other agents to the regimen, including dopamine receptor agonists, catechol-O-methyltransferase inhibitors, monoamine oxidase inhibitors, and amantadine, as well as implementing dietary changes. Therapeutic decisions can be difficult because older agents have not been compared in head-to-head trials to determine which drugs are better than others and the order in which they should be tried or added to the levodopa regimen; however, all of the available treatments provide a good possibility of benefit to the patient. Deep brain stimulation surgery is an option for patients with medically intractable severe motor fluctuations. [Rev Neurol Dis. 2006;3(3):101-108]
Clinical Scales for Comatose Patients: The Glasgow Coma Scale in Historical Context and the New FOUR Score Diagnosis and Prognosis Update
The Glasgow Coma Scale (GCS) has been the gold standard for assessing the level of consciousness in patients with significant brain injury. Prior efforts to modify or replace this scale have been unsuccessful because no scale could improve on its simplicity and practical usefulness. This review provides a historical perspective on coma scales and introduces a new and simple, but more comprehensive, scale: the Full Outline of UnResponsiveness (FOUR) Score, which has been recently validated. The FOUR Score has 4 components with “4” as a maximal score for each item. The individual components are eye responses (eye opening and eye tracking), motor responses (responses to pain and following simple hand commands), brainstem reflexes (pupil, cornea, and cough reflexes), and respiration (breathing rhythm and respiratory drive in ventilated patients). The FOUR Score is a further improvement on previous scales for classifying and communicating impaired consciousness. [Rev Neurol Dis. 2006;3(3):109-117]
Neuromuscular Diseases Meeting Review
Highlights of the 58th Annual Meeting of the American Academy of Neurology, April 1-8, 2006, San Diego, CA
Mechanisms of Mind Meeting Review
Highlights of the 17th Annual Meeting of the American Neuropsychiatric Association, February 18-21, 2006, San Diego, CA
Stroke Reviewing the Literature