Phorest and Trees early November 2020

 

Phorest & Trees Sharing the things I’m reading (big or small) Many more trees this time. Enjoy!

CODING 2021

See attached for my long awaited summary of the upcoming coding changes. Admit it you’ve been waiting with baited breath.

Ground Round Discussion

There was some recent controversy surrounding the role of the Ground Electrode. I have attached Larry Robinson’s articles on the ground electrode as well as the forum discussion involving dr. Dumitru and Robinson. (I almost spat my lunch out on the screen while reading the last of dr. robinson’s hilarious posts.)

Who says VA aint GQ?

The NJ VA’s very own Dr. Rex Ma is the poster boy for AAP and VA/ECU attending Dr. John Norbury is the same for AANEM. Who says we VA docs can’t be GQ?

Is it ethical to test the asymptomatic limb?

I found the answer by Dr. Stalberg to this question to be all encompassing on the AANEM forum. If you find this stimulating, I encourage you to lurk on the forum and read our gods and demigods discuss practical stuff. Enjoy:   I think that there are often indications for bilateral studies, also with unilateral symptoms. As you indicated, for a side-comparison with age,height,temperature (BMI) matched values.( In our lab we have all reference values normalized for age, height, and keep control of temperature and distance, but still often make bilateral testing for neurography.) We find that absolut bilateral values may be within refernce limits, but the side difference is outside (lab ref values), It may be essential to rule out generalized EDX abnormalities, in spite of unilateral symptoms. (mononeuritis multiplex/pnp, CTS, ulnar entrapment…). Particular for neurography. If the patient has bilateral symmetrical symptoms, unilateral study may be enough to assess type of pathology. For EMG, the situation may be more tricky. Requires usually quantitation. Examples of recommended bilateral studies: MND question in a patients with one-sided symptoms, atypical radiculopathy and more…... As you see, I give different suggestions for neurography (CAMP ampl, and latency, F-latency and persistence, sensory amplitudes) and EMG. You asked if it ethical to make bilateral studies in unilateral symptoms. One can also ask if it “ethical” of professional to make just local studies and miss important subclinical information. Usually very easy to explain the strategy to the patient.

CRS Socket Design

No it doesn’t stand for “can’t remember s%$t” in this case. Attached is my summary of an atypical socket design that uses alternating pressure and release built into the casting process to allow for more efficient motion. The original article lightly touches on the physics but I thought it was very well written and easy to understand. I am in the midst of discussions with prosthetists who have actually (Thanks to Dr. Shenoy for the reference!).

Diabetes stuff

My deeper interest owing to my own diagnosis Reinforcement that speaking conversationally (I personally even go colloquially) with patients may improve outcomes.  Mismatches between oral glucose tolerance testing and A1c. False positives? Gila monster venom: Exenatide, (Byetta or Bydureon) CGM gets easier to obtain from the VA and DoD

Trees

Why we don’t use sterile water with our botox?...cuz it hoitz! Hi-tech bandage for wound care for my SCI friends When you’re at the VA, check out the Atlas of orthoses and Assistive devices. (Link likely won’t work outside the VA.) thanks dr. edmond. Also of interest is the Atlas of common pain syndromes (Attendings may like the Atlas of Uncommon Pain Syndromes) A patient of mine wanted a referral for “TMR” to address pain; I am quite familiar with its use in prosthetic control but not pain. If anyone has experience with this, please contact me. TMR consists of a nerve transfer of residual peripheral nerves to otherwise redundant target muscle motor nerves. When TMR is performed on an amputee, the residual peripheral nerve is mobilized and any neuroma is excised. The native motor nerve of the target muscle is then located through nerve stimulators and transected near the muscle. Lastly, the residual peripheral nerve is coapted to the motor nerve, close to its point of entry into the muscle. New knowledge of specific chemo induced CNS neurotoxicity: CD19-directed immunotherapies are clinically effective for treating B cell malignancies but also cause a high incidence of neurotoxicity. The result is that a subset of patients treated with chimeric antigen receptor (CAR) T cells or bispecific T cell engager (BiTE) antibodies display severe neurotoxicity, including fatal cerebral edema associated with T cell infiltration into the brain. Vocab: STRUT ACDC is back!