The American Academy of Neurology’s Palatucci Advocacy Leadership Forum

I was lucky enough to participate in the AAN’s 2014 Palatucci Advocacy Leadership Forum last weekend.

The forum provides a wonderful opportunity for neurologists to learn how to:

  • Promote state and federal legislation
  • Work with the media
  • Obtain financial support for research
  • Develop coalitions
  • Organize and reinvigorate state neurological societies
  • Lobby for fair reinbursement
  • Help Draft position statements that affect future legislation

The forum is named in honor of former UCSF Professor of Neurology and AAN Board of Directors Member Donald M. Palatucci, MD.

Attendees get to practice:

  • Creating effective action plans to identify issues and resolves problems
  • Sharpen their interview skills, work with reporters, and improve confidence on camera
  • Get an inside look at how governments work and how to get results

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Here are some examples of on-site activities and the accomplishments of forum alumni:

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Shouldn’t I have a brain MRI, doctor?

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Migraine is extremely common, with a lifetime incidence of 43% in women and 18% in men, and a median age of onset of 24-5.

The vast majority of headache patients have migraine and need a careful history & physical examination, followed by appropriate treatment, not a brain imaging study.

Studies have shown that a brain imaging study will disclose an “abnormality” in about 1% of unselected headache patients, similar (if not less) than asymptomatic test subjects.

Furthermore, there are potential complications involved with brain imaging:  Some patients are claustrophobic and require sedation, even a general anesthetic.  Many “abnormalities” are innocuous, unrelated to the headache and do not require treatment.  However, these headache patients with such  “incidentalomas”  are left with the conclusion that there is something wrong with them, and may be subjected to further unnecessary follow-up studies.  A few end  up getting unnecessary invasive tests, which actually hurt them.

However, not a day goes past without a migraine patient asking me for a brain imaging study, or for that matter a patient referred to the office worried about an “incidentaloma” identified on a brain imaging study which should never have been done in the first place.

That’s not to say brain imaging is always unnecessary in every headache patient.

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Carefully selected patients with the following “red flag” characteristics might still need a scan:

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This approach is supported by the American Academy of Neurology, whose position is that neuroimaging usually is not warranted for patients with migraine and normal neurologic examination, only for patients with atypical headache features.

Find out more about migraine and headache here.

On Aspirin or Warfarin for Stroke Prevention, Need Dental Work or Minor Surgical Procedure, What to do?

We have previously blogged about the importance of antiplatelet and anticoagulant drugs for stroke prevention.

Let’s say you are taking one of these drugs, and you need to have dental work, or a minor surgical procedure.  Is it safe to hold the drug?  What should you do?

Obviously you are weighing the risk of a recurrent stroke against the risk of complications from increased bleeding during the procedure.

A recent evidence based guideline from the American Academy of Neurology tries to address some of these concerns.

Here is what it says:

If you are taking aspirin, it’s probably OK to continue it while you undergo dental work, skin biopsy, cataract surgery, epidural injections, EMG, endoscopy, colonoscopy and prostate biopsies.

If you are taking warfarin, it’s probably OK to continue it while you undergo dental work, skin biopsy and EMG.

Otherwise, you might need to temporarily hold the aspirin or warfarin for the procedure.

Unfortunately, that is where the guidelines end – There is insufficient data to make formal recommendations about how long these medications should be held for, when they should be re-started, and if patients should be a on “bridging drug” (like Lovenox or heparin shots) while warfarin is held.   These are still decisions that have to made on a case by case basis after careful discussion with your doctor(s).

American Academy of Neurology Identifies 5 Questionable Practices

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It’s no secret that health care costs are escalating.

Although physicians value their independence, part of the problem here is the unregulated use of costly tests, medications and procedures, many of which are unproven and of questionable benefit.

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Evidence based medicine assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests in an attempt to help clinicians predict whether a treatment will do more good than harm.

However, less than 1 in 5 medical decisions in the USA are made based on evidence-based medicine.

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The American Academy of Neurology has recently taken a step in the right direction by publishing a list of 5 costly neurology practices which continue to be widely performed despite being of little proven benefit:

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1. Don’t perform electroencephalography (EEG) for headaches.

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2. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Syncope is caused by global cerebral hypoperfusion, not carotid artery disease, so even if a carotid stenosis is identified, it would be asymptomatic (see point number 5)

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3. Don’t use opioid or butalbital treatment for migraine except as a last resort.

Butalbital is effective short term treatment for migraine, but commonly leads to rebound, which ultimately exacerbates migraine.  Click here for more information about migraine.

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4. Don’t prescribe interferon-β or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of MS.

Interferon-β and glatiramer acetate, are effective for  relapsing phases of MS, but do not prevent the development of permanent disability in progressive forms of multiple sclerosis.  These medications cost more than $40,000 a year, and put a financial strain on the patients and their families to make the co-pays.  In some series as many as 10%-15% MS patients have progressive forms of the disease and yet are still taking one of these medications.

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5. Don’t recommend carotid endarterectomy (CEA) for all patients with asymptomatic carotid stenosis.

Surgery is of much less benefit for asymptomatic carotid stenosis, and should be reserved for those with a perioperative complication risk of less than 3% and a life expectancy of greater than 3 to 5 years. Click here for more information about surgery for carotid artery disease.

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Click here for more details.