Telemedicine in General Neurology: Interrater Reliability of Clinical Neurological Examination Via Audio-Visual Telemedicine.

INTRODUCTION: While there are several studies on reliability of telemedicine in assessing stroke scales, little is known about the validity of a general neurological examination performed via telemedicine. Therefore, we sought to test the agreement between bedside and remote examination in acute patients of the emergency room. METHODS: Acute patients at the emergency room of a 450-bed academic teaching hospital were included in this study. A clinical neurological examination consisting of 22 items was performed at bedside and also remotely via an audio-visual link by a different neurologist; both were experienced clinicians at the consultant level. Kappa statistics were calculated for each item of the examination. RESULTS: Forty three patients completed both examinations (mean age 58.3 years, 56% female). Patients were seen between 8 and 72 min after admission (mean 36.3 min). Total time for remote examination was 12.6 min (8-21 min) and 8.9 min (5-18 min) for bedside examination. K-coefficients ranged from 0.32 (muscle tone) - 0.82 (language) indicating a fair to excellent agreement in most items. CONCLUSIONS: Remote examination via an audio-visual link produces comparable results to bedside performance even in acute patients of the emergency room. Compared to the scarce data available, inter-observer agreement is about the same as that between 2 examiners at bedside. However, more studies on reliability and validity of clinical neurological examination are required.

Incidence of perioperative complications in total hip and knee arthroplasty in patients with Parkinson disease.

INTRODUCTION: The aim of this study is to evaluate the difference in perioperative complication rate in total hip, bipolar hemiarthroplasties and total knee arthroplasty in patients with Parkinson disease in trauma and elective surgery in our Musculoskeletal Center during a period of 10 years. MATERIAL AND METHOD: Between 2006 and 2016, 45 bipolar hemiarthroplasties in trauma surgery, 15 total knee and 19 total hip arthroplasties in patients with Parkinson's disease were performed. We divided the patients in two groups. Group I included trauma cases (45) and group II elective surgery cases (34). Complications were documented and divided into local minor and major complications and general minor and major complications. Fisher's exact test was used for statistical evaluation. RESULTS: In both groups, there was one local major complication (p > 0.05): In group I, there was one case of loosening of a K-wire which was removed operatively. In group II, there was one severe intraarticular bleeding requiring puncture of the hematoma. In group I, there were 38 general complications; in group II, there were 17 general complications. There was no statistical difference in complication rate (p > 0.05). CONCLUSION: Total hip arthroplasty, bipolar hemiarthroplasties and knee arthroplasty in patients with Parkinson disease is possible in elective and trauma surgery. Complication rate is higher in comparison with patients not suffering from Parkinson disease, but there is no difference in complication rate in elective and trauma surgery. Nevertheless, early perioperative neurological consultation in patients with Parkinson disease is recommended to minimize complications and improve early outcomes after arthroplasty.

A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association.

The aim of this new statement is to provide a comprehensive and evidence-based review of the scientific data evaluating the use of telemedicine for stroke care delivery and to provide consensus recommendations based on the available evidence. The evidence is organized and presented within the context of the American Heart Association's Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for the use of telemedicine in general neurological assessment and primary prevention of stroke; notification and response of emergency medical services; acute stroke treatment, including the hyperacute and emergency department phases; hospital-based subacute stroke treatment and secondary prevention; and rehabilitation.

Correction to: Telemedicine in general neurology: use of audiovisual consultation for on call back-up service in an acute care hospital.

The original version of this article unfortunately contained a mistake in the acknowledgement section.

Telemedicine in acute stroke: remote video-examination compared to simple telephone consultation.

BACKGROUND: Telemedicine is increasingly being used in acute stroke care. Some of the first studies and network projects are already applying remote audiovisual communication for patient evaluation. Formerly the telephone was the method of choice to contact experts for case discussion. We compared remote video-examination and telephone consultation in acute stroke care. METHODS: Two district hospitals were linked to stroke centers in Northern Bavaria. Patients with symptoms suggestive of an acute stroke were included. Remote video examination (RVE) was provided by live audiovisual communication and access to brain images; telephone consultation (TC) was done via standard telephone using a structured interview. There was a weekly rotation of the two methods. Demographic data and other data concerning process and quality of care as well as outcome 10 days after stroke were recorded and compared between the two groups. RESULTS: Within the study period 151 consultations were made in acute stroke patients (mean age 66.8 years). 77 patients were seen by RVE and 74 by TC. Total examination times were 49.8 min for RVE and 27.2 min for TC (p < 0.01). Patients were more frequently transferred to the stroke center after TC consultation (9.1 % vs. 14.9 %, p < 0.05) and had a higher mortality 10 days after stroke (6.8 % vs. 1.3 %, p < 0.05). Diagnosis made by TC had to be corrected more frequently (17.6 % vs. 7.1 %; p < 0.05). CONCLUSIONS: Creating a network improves stroke care by establishing cooperation between hospitals. Telephone consultation could be a simple method of telemedicine to support cooperation as it is easy and widely available. However, outcome parameters like mortality indicate that remote video examination is superior to TC. Therefore, full-scale audiovisual communication is recommended for remote consultation in acute stroke care.

Telemedicine in general neurology: use of audiovisual consultation for on call back-up service in an acute care hospital.

OBJECTIVE: While telemedicine is in expanding use in acute stroke care, little is known about its use in general neurology, especially in acute care. We sought to investigate the feasibility and possible effects of a telemedicine device within the neurological back-up service of an acute care hospital. METHODS: In a 450 bed academic teaching hospital an experienced neurologist (EN) is on call to support the junior doctor at the hospital. Support was possible whether by standard telephone advice (TA) or by audiovisual consultations (AVC). In AVC the expert used a mobile telemedicine device and so he could establish audiovisual contact from his home to the emergency room and examine newly admitted patients. Technical and patient details including timing and diagnosis were recorded. Video and audio quality as well as impact of AVC on diagnosis was rated by the EN. RESULTS: Out of about 1200 cases in off peak times, during the study period, 164 AVC including remote video examination were done (13.6%). Also 48 cases were documented by pure TA. Video quality was rated to a medium of 1.7, audio quality to 2.1. In 36 cases the audiovisual consultation was influenced by technical issues leading to cessation of AVC in 8 cases. Duration of teleconsultation was 17.3 min in AVC compared to 8.7 min for TA. The consultation diagnosis in AVC was confirmed in 74.4% of all cases compared to 57.7% in TA. AVC was rated as a valuable contribution to the diagnostic workup in 74.3% of all cases seen. In about 40% of all cases AVC was not possible due to technical or organizational reasons. CONCLUSIONS: Audiovisual consultation seems to be a feasible and useful support in routine neurology back-up service of an acute care hospital. Better mobility of devices and flexibility of service is needed to improve availability and quality of this valuable tool.

Hyperresponsiveness of platelets in ischemic stroke.

Platelet activation and aggregation are critical in the pathogenesis of acute ischemic cerebrovascular diseases. The aim of our study was to characterize platelet function in patients with acute ischemic stroke or transient ischemic attack (TIA), and to evaluate the effect of platelet activation on clinical outcome. One hundred thirty-eight consecutive patients with TIA (n = 74) or stroke (n = 64) were enrolled in this study. Platelet aggregation in response to ADP, epinephrine, arachidonic acid, or collagen, and expression of platelet activation receptors (CD62P, CD63, LIBS-1 and PAC-1) in the acute phase and at three months follow-up were evaluated. Platelets derived from stroke patients were more hyperaggregable in response to agonists in the acute phase compared to TIA patients (p[ADP] = 0.002, p[arachidonic acid] = 0.047, p[epinephrine] = 0.020). Platelet activation was enhanced in the acute phase irrespective of the severity of the disease (stroke or TIA) and returned to baseline levels three months later. Persistent elevated platelet activation at three months follow-up (PAC-1) was associated with increased incidence of recurrent stroke (median, [interquartile range] 3.4, [3.0-5.2] versus 2.9, [2.3-4.0], p = 0.048). In conclusion, platelets are hyperactive in acute stroke compared with TIA. A more intensified dual antiplatelet therapy may be of benefit for stroke patients.

24/7 Live Stream Telemedicine Home Treatment Service for Parkinson's Disease Patients.

BACKGROUND: Treatment of advanced-stage idiopathic Parkinson's disease (PD) is a demanding challenge, and in Germany, medication regimen adjustments are often made during inpatient stays. Admissions often follow an acute worsening of symptoms and functioning. In order to reduce long and expensive inpatient stays, and to provide more frequent consultations, a 24/7 live stream telemedicine home treatment service was established. METHODS: A pilot study was conducted in which laptops were distributed to 50 patients for 1 year to see whether such a service was feasible (in terms of patient participation and compliance) and whether this intervention affected the patient's condition, measured in UPDRS, Mini-Mental Status Examination (MMSE), 39-item Parkinson's Disease Questionnaire (PDQ39), and H & Y Scale. RESULTS: Seventy-two percent (36) of the patients were compliant and did not experience technical issues. Patients lived, on average, 198 ± 183 km away from the specialist clinic. In total, 264 video conversations took place with 6.9 ± 7.2 (0-29) calls per patient. We found a significant improvement in PDQ39 scores, but not in UPDRS, MMSE, or H & Y scores, at 1 year. CONCLUSIONS: Our data shows that 24/7 live stream telemedicine is feasible and can help to improve quality of life. However, a detailed preliminary review of the patient's willingness to use such a service should be made to obtain the best results. Improvement of the technical setup and network coverage would facilitate an improved service and increase efficiency.

Course of platelet activation and platelet-leukocyte interaction in cerebrovascular ischemia.

BACKGROUND AND PURPOSE: Platelet activation plays a crucial role in the pathophysiology of cerebral ischemia. The aim of this study was to investigate the contribution of platelet activation and leukocyte-platelet interactions to the disease. METHODS: One hundred thirty-five patients with transient ischemic attack (TIA) or stroke were enrolled in this single-center study. They underwent cranial computer tomography within 24 hours of clinical onset and after 3 months, and systemic venous blood samples were drawn. Platelet activation (CD62P expression), leukocyte activation (L-selectin expression), and the appearance of platelet-specific antigens on leukocytes as an index of platelet-leukocyte aggregation were measured by flow cytometric techniques in the acute state and at 3-month follow-up. RESULTS: Patients with a completed stroke or TIA had significantly increased circulating platelet-leukocyte aggregates, increased P-selectin expression on platelets, and decreased L-selectin expression in the acute state compared with the control group (healthy volunteers). No differences in regard to the tested activation markers could be detected between patients with stroke or TIA in the acute phase of the disease. However, platelet and leukocyte activations were normalized after 3 months in patients with TIA, whereas leukocyte activation (reduced L-selectin expression) remained in stroke patients. CONCLUSIONS: In patients with TIA and completed stroke, platelet and leukocyte activation is substantially enhanced in the acute phase of the disease. The sustained leukocyte activation observed in stroke but not in TIA patients at 3-month follow up might play a pathophysiological role in the course of the disease.

First aid in acute stroke : introducing a concept of first action to laypersons.

OBJECTIVE: First aid training is well established to teach the public how to recognize a medical emergency and take appropriate action. Though it is now handled as a high priority emergency stroke is not among the main topics of first aid. We investigated if first aid training may be useful for enhancing stroke awareness. METHODS: We developed a 15-20 minute teaching session about stroke as an emergency including signs and symptoms and first hands-on measures. The session was integrated in standard first aid training of the St John Ambulance of Germany and participants were asked to fill out a questionnaire regarding their knowledge about stroke. Subjects were questioned before the stroke lesson and again at the end of the training. RESULTS: 532 participants of the training responded to the questionnaire (mean age 28.6 years, 53.6% male). There was a significant increase in proportion of subjects correctly defining what stroke is (28.4% vs. 69.9%, p < 0,001) and in the mean number of stroke symptoms listed (1.52 vs. 3.35, p < 0,001) by the participants. The number of participants unable to list at least 1 symptom decreased significantly (12.8 vs. 3.6%, p<0.001). CONCLUSIONS: In our study a teaching lesson integrated in first aid training was effective in improving stroke knowledge of participants. First aid training should be used for stroke information complementary to other activities like mass media campaigns as it is effective, could reach younger people that are not primarily interested in stroke and provides connections to other health topics.

Mortality prediction in critical care for acute stroke: Severity of illness-score or coma-scale?

BACKGROUND AND PURPOSE: The use of early prognostic data provided by various scores in critically ill stroke patients remains unclear. We tested the performance of the Simplified Acute Physiology Score (SAPS) II in prediction of mortality of acute stroke patients in the NeuroCriticalCareUnit (NCCU). METHODS: During one year every patient admitted to the NCCUs at 2 University hospitals for cerebral ischemia (CI) or intracerebral hemorrhage (ICH) and intubated was included in this study. Data for SAPS (I)/II and the Glasgow Coma Scale (GCS) were collected, and mortality at 10 days, 90 days and 1 year was determined. Prognostic performance of all scores was tested by calculation of receiver operating curve (ROC) and by Cox regression analysis. RESULTS: 90 patients were included in the study, 49 with ICH and 41 with CI. Mortality after 10 days was 32.2%, after 3 months 58.9% and after 1 year 67.8%. Compared by their area under curve the predictive values were overall quite good for both SAPS (I) (0.77) and SAPS II (0.77) as well as GCS. Motor subscore was equal to total GCS (0.75 vs. 0.73). In Cox regression models all three scores were independent predictors of fatal outcome. CONCLUSION: SAPS II and SAPS (I) but also the GCS are valuable tools for prediction of short and long-term mortality in acute stroke patients treated in NCCU. The GCS as a predictor for mortality in stroke patients could be further simplified by using its subscore "best motor response" alone.

Use of a telestroke service for evaluation of non-stroke neurological cases.

Telemedicine is a growing field in many medical specialties. Within clinical neurosciences one of its largest applications is in acute stroke care. However, little is known about its value and effect in general neurology, despite stroke. In a retrospective survey of 1500 teleconsultations over a time period of 12 months from October 2008 to September 2009, from a large telestroke network in Germany, we evaluated 352 cases with a non-stroke diagnosis. Duration and methods of teleconsultation as well as neurological consultations at bedside and discharge diagnosis were analyzed and compared to stroke cases. Discharge diagnosis was not identical to teleconsultation diagnosis in 48.9% of all non-stroke cases compared to 12.5% of all stroke cases. Duration of teleconsultation was 26.5 min in non-stroke cases compared to 14.3 min for stroke cases. In non-stroke cases other parts of the neurological examination were added to the pure administration of a stroke scale. There were no significant differences between non-stroke cases with correct and incorrect consultation diagnoses concerning in-hospital mortality (4.6 vs. 5.0%) and length of hospital stay (8.3 vs. 7.6 days). We conclude that diagnostic accuracy and protocol routine is not as exact in non-stroke cases compared to acute stroke cases. Other neurologic conditions may need different algorithms for a telemedicine service. Thus experience from a telestroke service cannot be transferred to other neurologic conditions on a routine basis.