LETTER #2 RE: The financial contribution of the multiple sclerosis specialist
JoshTorgovnick, MD, NYU Langone Medical Center, New York, NYdrjosh49@msn.com
Submitted August 16, 2017
I read the article by Dr. Berger1 with interest. The United States already has the most expensive medical care in the world without a comparable improvement in outcome. The Revised McDonald criteria are clear about the evaluation after 2 attacks: if dissemination in space and time and objective evidence of 1 lesion and good history for a second are present, no further testing is necessary.2 With a spinal cord lesion, a pattern-shift visual evoked response (PSVER) might be useful but I disagree with using a battery of evoked potential (EP) tests. Lumbar puncture should no longer be needed if history and MRI are typical. It is textbook3 that oral steroids, 1250mg of prednisone are equivalent to 1gm of solumedrol and patients can carry this on vacations or other travel and not need to be hampered by IVs. A baseline optical coherence tomography (OCT) is reasonable but no one knows how often to repeat it. Many patients with MS don't progress4 and identifying that group is more important than the financial benefits of which Dr. Berger speaks. Lastly, the history and physical live on and tests are still extensions of these.
Disclosures: The author reports no disclosures.
References:
1. Berger JR. The financial contribution of the multiple sclerosis specialist. Neurol Clin Pract 2017;7:246-255.
2. Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria. Ann Neurol 2011; 69:292-302.
4. Sartori A, Abdoli M, Freedman MS. Can we predict benign multiple sclerosis? Results of a 20-year long-term follow-up study. J Neurol 2017;264:1068-1075.
I read the article by Dr. Berger1 with interest. The United States already has the most expensive medical care in the world without a comparable improvement in outcome. The Revised McDonald criteria are clear about the evaluation after 2 attacks: if dissemination in space and time and objective evidence of 1 lesion and good history for a second are present, no further testing is necessary.2 With a spinal cord lesion, a pattern-shift visual evoked response (PSVER) might be useful but I disagree with using a battery of evoked potential (EP) tests. Lumbar puncture should no longer be needed if history and MRI are typical. It is textbook3 that oral steroids, 1250mg of prednisone are equivalent to 1gm of solumedrol and patients can carry this on vacations or other travel and not need to be hampered by IVs. A baseline optical coherence tomography (OCT) is reasonable but no one knows how often to repeat it. Many patients with MS don't progress4 and identifying that group is more important than the financial benefits of which Dr. Berger speaks. Lastly, the history and physical live on and tests are still extensions of these.
Disclosures: The author reports no disclosures.
References:
1. Berger JR. The financial contribution of the multiple sclerosis specialist. Neurol Clin Pract 2017;7:246-255.
2. Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 Revisions to the McDonald criteria. Ann Neurol 2011; 69:292-302.
3. Weiner HL, Stankiewicz JM, editors. Multiple Sclerosis: Diagnosis and Therapy. Wiley-Blackwell, 2012: p.197.
4. Sartori A, Abdoli M, Freedman MS. Can we predict benign multiple sclerosis? Results of a 20-year long-term follow-up study. J Neurol 2017;264:1068-1075.