Neurologic clinics
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Motor fluctuations and dyskinesias are common motor complications that manifest within the first few years from the initiation of therapy in patients with Parkinson disease. These complications negatively affect the quality of life and represent an important source of disability. ⋯ Patients who maintain a good response to levodopa but continue to experience disabling motor complications despite the best medical management may benefit from a regimen of subcutaneous apomorphine, ideally delivered by a subcutaneous pump, or deep-brain stimulation of the subthalamic nucleus or internal portion of the pallidum. Emerging therapies for motor complications are expected to further enhance continuous (physiologic) delivery of dopaminergic drugs and extend the reach of therapies beyond the dopaminergic system to influence not only the motor but also the vast range of nonmotor complications of this multisystemic disease.
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Eye movement abnormalities constitute an important clinical sign that can be a manifestation of dysfunction of cranial nerves III, IV, and VI (the 3 ocular motor nerves). Specific motility deficits often have highly localizing value within the neuroaxis, serving to refine a differential diagnosis and guide management. This article reviews the key anatomic concepts, clinical presentation, differential diagnosis, and management of ocular motor nerve palsies. Dysfunction of an ocular motor nerve must be distinguished from other causes of abnormal eye movements, such as myasthenia gravis or thyroid eye disease, which are outside the scope of this article.
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Virtually all abnormalities of the orbit can result in neuro-ophthalmic findings: optic neuropathies, motility disorders, and changes in sensation. Subtle orbital disease, presenting with neuro-ophthalmic findings, is frequently overlooked on initial evaluation. ⋯ This article focuses on those disorders more commonly encountered or that come with more serious consequences if misdiagnosed. Orbital trauma, hemorrhage, neoplasm, and inflammation are covered in some detail.
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A medical practice, whether operated by a solo physician or by a group, is a business. For a neurology practice to be successful, it must meet performance measures that ensure its viability. ⋯ Crucial medical practice metrics that should be measured are financial performance, staffing efficiency, physician productivity, and patient access. Such measures assist a physician or practice in achieving the goals and objectives that each determines are important to providing quality health care to patients.
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Neurosarcoidosis is a diagnostic consideration in diverse clinical settings. Efforts should be made to secure pathologic confirmation of systemic sarcoidosis; only rarely is central nervous system (CNS) pathologic confirmation available. CNS infection and malignancy should be reasonably excluded before making a diagnosis of CNS sarcoidosis. Corticosteroid therapy alone may not be sufficient to treat neurosarcoidosis; adjunct immunosuppressive agents are increasingly used to achieve an optimal clinical outcome.