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Rachel Gottlieb-Smith, MD, MHPE Profile picture
@RGottliebSmith
Jan 13, 2022 • 9 tweets • 7 min read • Read on X
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1/🧵
What's your favorite anti-seizure medication (ASM)?

If you said levetiracetam (LEV), you're not alone.

Why do so many #neurologists ♥️ LEV? A #tweetorial.

#MedStudentTwitter #NeuroTwitter #MedTwitter @MedTweetorials
2/
 What's so good about LEV? First, some #pharmacology:

✅ Fast PO absorption
✅ 1:1 PO:IV 💉
✅ Few med interactions
✅ Can load for status epilepticus

pubmed.ncbi.nlm.nih.gov/31029217/ Image
3/
 And lots of clinical uses:

1⃣ Focal and generalized seizures
2⃣ From 👶 to 🧓
3⃣ Often used in 🤰 (category C): pubmed.ncbi.nlm.nih.gov/28472982/
4⃣ Good for status epilepticus (60 mg/kg, up to 4500 mg) - similar efficacy to phenytoin & valproic acid:
pubmed.ncbi.nlm.nih.gov/32203691/
4/
 When doesn't LEV work as well?

1⃣ Absence epilepsy - only 1/4 seizure free pubmed.ncbi.nlm.nih.gov/30458657/
2⃣ Neonatal seizures - 40-60 mg/kg not as effective as phenobarbital 20 mg/kg
pubmed.ncbi.nlm.nih.gov/32385134/
3⃣ Infantile spasms - 🚫 use LEV, for Tx options:
pubmed.ncbi.nlm.nih.gov/34266919/ ImageImage
5/
 & maybe I should have been writing this about lamotrigine (LTG) instead...

4⃣ Newly diagnosed focal epilepsy
pubmed.ncbi.nlm.nih.gov/33838757/
LEV not as good as LTG:
◾️ Time to achieve 12-month seizure freedom longer for LEV
◾️ LEV more likely to fail due to adverse reactions ImageImage
6/
 But LEV is typically well tolerated. Some possible side effects:

◾️ Sedation (usually less v. other ASMs)
◾️ Headaches
◾️ Mood & behavior change - sometimes vitamin B6 can help: pubmed.ncbi.nlm.nih.gov/33823377/
◾️ Rare psychosis

🔑 Metabolized by kidneys: dose adjust for 🔻 renal fcn
7/
 Short tangent for the new(er) kid on the block: brivaracetam

*⃣ LEV's cousin
*⃣ Similar mechanism: binds to synaptic vesicle protein 2A
*⃣ May be better for adverse behavioral effects:
pubmed.ncbi.nlm.nih.gov/33839453/
*⃣ 🔺 cost (goodrx.com)
8/
 So is LEV your favorite ASM? 💊

If not, comment on which is your favorite (and why!) 👇
9/
 Key points:
🔑 LEV is a broad spectrum Tx for focal and generalized epilepsy (w/ a few caveats)
🔑 Can be used across all ages & in 🤰
🔑 Usually well tolerated
🔑 Vitamin B6 may help w/ mood & behavior side effects

• • •

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More from @RGottliebSmith

Rachel Gottlieb-Smith, MD, MHPE Profile picture
Jul 8, 2022
1/🧵
Ever look at an #EEG & wonder what the 🧠 squiggles mean?

This #twEEGtorial is for you

#MedTwitter #NeuroTwitter #EEGTwitter #Tweetorial
2/
 Let’s start with some background:

💡 #EEG = electroencephalogram
💡 What an EEG does: records electrical activity in the 🧠
3/
 You might then 🤔: how does the 🧠 create ⚡️?

A bit of neuroscience: 🧠 cells called neurons generate ⚡️ through the flow of charged ions (sodium & potassium) across their membranes

An EEG on the scalp can't detect the ⚡️ of a single neuron, but can when neurons are in sync
Read 16 tweets
Rachel Gottlieb-Smith, MD, MHPE Profile picture
May 21, 2022
1/
 The only good thing to come of finding this on my leg last week: I learned enough to write a #tweetorial about it

A 🧵/twitter PSA about what to do if a tick comes for you – & what neuro presentations you can see w/ tick-borne illnesses

#MedTwitter #NeuroTwitter #IDTwitter
2/
 After time outside in a non-wooded area, I found this on my leg. I didn’t realize what it was, so I grabbed it & flung it off... only to then find a very active, crawling tick on my counter. 😱

So after freaking out for a moment (or 2), I had to figure out what to do with it.
3/
 Memories from med school flashed into my head of what you’re SUPPOSED to do:

1⃣ Remove tick w/ tweezers
2⃣ Grab close to skin & pull tick off without twisting so it doesn’t break apart
3⃣ Disinfect

Since I had already accidentally messed up 1⃣ & 2⃣, I started w/ 3⃣
Read 17 tweets
Rachel Gottlieb-Smith, MD, MHPE Profile picture
Apr 15, 2022
1/🧵
What’s going on in the 🧠 that causes motion sickness – and what’s the link with #migraine?

A #tweetorial about motion sickness, the importance of matching, and why serotonin matters

#MedTwitter #NeuroTwitter
2/
 First, let’s review some structures of the vestibular system that help us sense body movement:

1⃣ Semicircular canals = angular acceleration
2⃣ Otoliths (utricle & saccule) = linear acceleration & head tilt

📷: cell.com/current-biolog…
3/
 The 🧠 combines this vestibular input with visual 👀 & proprioceptive input to assess motion

➡️ This is where the importance of matching comes in

...So what happens when the inputs don't match?
Read 10 tweets
Rachel Gottlieb-Smith, MD, MHPE Profile picture
Feb 13, 2022
1/
 #MedTwitter: ever learn a mnemonic that you can’t remember 5 minutes later? 🙋‍♀️

What makes a mnemonic useful (or not)?

A 🧵 about the good – and the bad – of mnemonics

#MedEd #NeuroTwitter #Tweetorial
2/
 First, some background:

Mnemonic = relating to memory

Mnemonic devices/techniques (often called mnemonics for short) = memory aids or strategies that help with recall

Goal: transition info from working memory to long-term memory (and then be able to retrieve it later!)
3/
 Let’s review 3 mnemonic techniques:

1⃣ Method of loci AKA “memory palace”
▪️ Type of imagery mnemonic
▪️ Info mentally placed at important landmarks along an imagined path ➡️ recall by re-tracing the route
▪️ Vivid images are helpful

Image from pubmed.ncbi.nlm.nih.gov/33613393/
Read 11 tweets
Rachel Gottlieb-Smith, MD, MHPE Profile picture
Feb 3, 2022
1/12
How does botulinum neurotoxin (BoNT) work to improve chronic migraine? 🤔

⚡️ Spoiler: it's probably not what you think!

A 🧵 about BoNT & #migraine

#MedTwitter #NeuroTwitter #tweetorial
2/
 Let's start with a definition: what makes a migraine "chronic?"

◾️ Headache occurs at least 1⃣5⃣ days per month
◾️ Of which at least 8⃣ have features of migraine headache
◾️ For 3⃣ months or more

From: Int'l Classification of Headache Disorders ichd-3.org/1-migraine/1-3…
3/
 And a bit of history: botulinum neurotoxin (BoNT) came to be studied for chronic migraine after anecdotes suggested that BoNT injections to treat wrinkles also helped with headaches!
Read 12 tweets
Rachel Gottlieb-Smith, MD, MHPE Profile picture
Jan 22, 2022
1/
 What's the best strategy for effective - and time efficient - teaching in clinic?

A 🧵 for 4⃣ teaching strategies when 🕗 is limited (& how they might be used in #neurology)

#MedEd #NeuroTwitter

pubmed.ncbi.nlm.nih.gov/18276715/
pubmed.ncbi.nlm.nih.gov/29383053/
2/
 1⃣ One-minute preceptor (initially called: 5-step microskills)
pubmed.ncbi.nlm.nih.gov/1496899/

5 steps & examples 👇

Pros:
✅ Assess learner's knowledge
✅ 👍 & constructive feedback "built in"
✅ Clinical reasoning
✅ Good for novice learners

Cons:
⛔️ "1 min" is a bit unrealistic
3/
 2⃣ SNAPPS
pubmed.ncbi.nlm.nih.gov/14507619/

Pros:
✅ Very learner-driven
✅ Aligns well w/ traditional presentation model
✅ Clinical reasoning

Cons:
⛔️ May not work as well for novice learners
Read 7 tweets

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