Implementation of a Teleneurology Clinic in Zambia during the COVID-19 Pandemic.

OBJECTIVE: The objective of this study was to assess the feasibility, acceptability, and benefits of a teleneurology clinic serving adults usually attending a neurology outpatient clinic in Lusaka, Zambia during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Televisits were offered to patients scheduled for neurology appointments between March and July 2020 using the telephone, WhatsApp video, or Zoom calls based on patient accessibility. Visit outcomes were documented, and patient and neurologist satisfaction surveys were completed. RESULTS: Of 323 patients, 195 (60%) were reachable by telephone, 179 of these were alive, and 74% (133/179) of those alive agreed to a televisit. Stroke (30%), seizures (20%), and headache (16%) were the most common diagnoses seen via televisit. Most televisits (80%) were by telephone call, 14% by WhatsApp video call, and 6% by Zoom. Nearly one-third (30%) of the patients were stable and discharged from the clinic, 32% only required medication refills, and 19% required an in-person visit. Sixty patients (out of 85 reachable and 71% response rate) and 7 of 9 neurologists (78% response rate) completed satisfaction surveys. Neurologists reported greater assessment confidence with Zoom, but confidence was high for all modalities. Patients preferring televisits (75%, 45/60) noted reduced expense and time requirements, whereas those preferring in-person visits (22%, 13/60) cited the desire for physical examinations. Overall, 98% of patients and 100% of neurologists were satisfied with televisits. INTERPRETATION: Teleneurology visits were acceptable and feasible for adults attending an outpatient neurology clinic in Zambia and their neurologists. They offer a promising supplement to in-person visits in resource-limited settings, even when video-conference capabilities and electronic medical records are absent. ANN NEUROL 2022;91:445-454.

[Adaptation of headache units in Andalusia to the COVID-19 pandemic. Analysis of the Andalusian Neurology Society's Headache Study Group]. / Adaptación de las unidades de cefalea de Andalucía a la pandemia por COVID-19. Análisis del Grupo de Estudio de Cefaleas de la Sociedad Andaluza de Neurología.

INTRODUCTION: The SARS-CoV-2 pandemic has given rise to a major change in healthcare and brought teleconsultation to the forefront. In neurology, headaches are the most frequent reason for visits. AIM: To assess the impact of the COVID-19 pandemic on the structure of headache units in Andalusia and the adaptations made to healthcare that are potentially useful innovations that can continue to be developed when the pandemic is over. MATERIALS AND METHODS: Cross-sectional observational study using an online survey of neurologists responsible for headache units and specialised consultations in Andalusia. RESULTS: During the state of alarm, all respondents used teleconsultation. The vast majority (92.8%) maintained some face-to-face activity, mostly for invasive techniques and new patients, using individual protection measures and as a way to avoid crowds. Half of them (50%) maintained botulinum toxin administrations at the scheduled times and 78.6% continued to prescribe monoclonal antibodies against calcitonin gene-related peptide. Altogether 78.5% are generally satisfied with the use of teleconsultation and 57.1% think it could be quite useful in the future. The main advantages reported were avoiding the need for the patient to travel and time savings; the disadvantages were the absence of physical examinations and difficulties in communicating. The most frequently expressed need for improvement was the use of video-calls. CONCLUSIONS: Some of the changes adopted during this time could continue to be useful in the future and, in the case of headaches, teleconsultation could be used as an option for following up patients who have already been diagnosed and do not require any invasive techniques.

TITLE: Adaptación de las unidades de cefalea de Andalucía a la pandemia por COVID-19. Análisis del Grupo de Estudio de Cefaleas de la Sociedad Andaluza de Neurología.Introducción. La pandemia por SARS-CoV-2 ha supuesto un gran cambio en la atención sanitaria y ha dado protagonismo a la teleconsulta. En neurología, las cefaleas constituyen el motivo más frecuente de consulta. Objetivo. Evaluar el impacto de la pandemia por COVID-19 en la estructura de las unidades de cefaleas de Andalucía y las adaptaciones asistenciales potencialmente útiles tras ella. Materiales y métodos. Estudio observacional transversal mediante encuesta en línea a los neurólogos responsables de las unidades y consultas monográficas de cefaleas de Andalucía. Resultados. Durante el estado de alarma, todos los encuestados usaron teleconsulta. El 92,8% mantuvo alguna actividad presencial, fundamentalmente para técnicas invasivas y pacientes nuevos, utilizando medidas de protección individual y para evitar aglomeraciones. El 50% mantuvo las administraciones de toxina botulínica en los tiempos adecuados y el 78,6% siguió prescribiendo anticuerpos monoclonales frente al péptido relacionado con el gen de la calcitonina. El 78,5% se encuentra globalmente satisfecho con el uso de la teleconsulta y el 57,1% considera que podría ser bastante útil de cara al futuro. Las principales ventajas expresadas fueron evitar el desplazamiento de los pacientes y el ahorro de tiempo; los inconvenientes, la ausencia de exploración física y la dificultad de comunicación. La necesidad de mejora más expresada fue el uso de videollamada. Conclusiones. Algunos de los cambios adoptados en este tiempo podrían seguir siendo útiles en el futuro y, en el caso de las cefaleas, la teleconsulta se podría emplear como opción para el seguimiento de pacientes ya diagnosticados y que no requieran técnicas invasivas.

Improving Patient Outreach by Defining Telehealth Suitability in a Tertiary Huntington's Disease Clinic.

BACKGROUND: The COVID-19 pandemic has increased the need for remote healthcare options among patients with Huntington's disease (HD). However, since not every HD patient is suitable for telehealth, it is important to differentiate who can be seen virtually from who should remain as in-person. Unfortunately, there are no clinical guidelines on how to evaluate HD patients for telehealth eligibility. OBJECTIVE: To standardize the teleneurology selection process in HD by implementing a screening tool that accounts for patient-specific factors. METHODS: We organized various indications and contraindications to teleneurology into a flowchart. If any indications or contraindications were met, patients were assigned to telehealth or maintained as in-person, respectively. If no indications or contraindications were met, patients were given the option of telehealth or in-person for their upcoming appointments. In two implementation cycles, we tested this screening tool among all HD patients scheduled for clinic visits, aided by chart review and phone interview. RESULTS: In a cohort of 81 patients, telehealth acceptance among eligible patients increased from 45.0%to 83.3%. Frequency of telehealth visits increased from a pre-intervention baseline of 12.8%to 28.2%. CONCLUSION: Teleneurology utilization among HD patients more than doubled across our study. Our intervention promotes consistency and patient-centeredness in HD clinical care and streamlines the overall telehealth selection process. Future studies can seek to reduce telehealth no-shows and also evaluate the utility of the motor and psychiatric criteria included in our screening tool.

Gene-Targeted Therapies in Pediatric Neurology: Challenges and Opportunities in Diagnosis and Delivery.

BACKGROUND: Gene-targeted therapies are becoming a reality for infants and children with diseases of the nervous system. Rapid scientific advances have led to disease-modifying or even curative treatments. However, delays and gaps in diagnosis, inequitable delivery, and the need for long-term surveillance pose unresolved challenges. OBJECTIVE AND METHODS: The goal of the Child Neurology Society Research Committee was to evaluate and provide guidance on the obstacles, opportunities, and uncertainties in gene-targeted therapies for pediatric neurological disease. The Child Neurology Society Research Committee engaged in collaborative, iterative literature review and committee deliberations to prepare this consensus statement. RESULTS: We identified important challenges for gene-targeted therapies that require resource investments, infrastructure development, and strategic planning. Barriers include inequities in diagnosis and delivery of therapies, high costs, and a need for long-term surveillance of efficacy and safety, including systematic tracking of unanticipated effects. Key uncertainties regarding technical aspects and usage of gene-targeted therapies should be addressed, and characterization of new natural histories of diseases will be needed. Counterbalanced with these obstacles and uncertainties is the tremendous potential being demonstrated in treatments and clinical trials of gene-targeted therapies. CONCLUSIONS: Given that gene-targeted therapies for neurological diseases are in their earliest phase, the pediatric neurology community can play a vital role in their guidance and implementation. This role includes facilitating development of infrastructure and guidelines; ensuring efficient, equitable, and ethical implementation of treatments; and advocating for affordable and broad access for all children.

The Impact of COVID-19 on Neuro-Ophthalmology Office Visits and Adoption of Telemedicine Services.

BACKGROUND: The COVID-19 public health emergency (PHE) has significantly changed medical practice in the United States, including an increase in the utilization of telemedicine. Here, we characterize change in neuro-ophthalmic care delivery during the early COVID-19 PHE, including a comparison of care delivered via telemedicine and in office. METHODS: Neuro-ophthalmology outpatient encounters from 3 practices in the United States (4 providers) were studied during the early COVID-19 PHE (March 15, 2020-June 15, 2020) and during the same dates 1 year prior. For unique patient visits, patient demographics, visit types, visit format, and diagnosis were compared between years and between synchronous telehealth and in-office formats for 2020. RESULTS: There were 1,276 encounters for 1,167 patients. There were 30% fewer unique patient visits in 2020 vs 2019 (477 vs 670) and 55% fewer in-office visits (299 vs 670). Compared with 2019, encounters in 2020 were more likely to be established, to occur via telemedicine and to relate to an efferent diagnosis. In 2020, synchronous telehealth visits were more likely to be established compared with in-office encounters. CONCLUSIONS: In the practices studied, a lower volume of neuro-ophthalmic care was delivered during the early COVID-19 public health emergency than in the same period in 2019. The type of care shifted toward established patients with efferent diagnoses and the modality of care shifted toward telemedicine.

American Academy of Neurology Telehealth Position Statement.

Telehealth services complement in-person neurologic care. The American Academy of Neurology supports patient access to telehealth services regardless of location, coverage for telehealth services by all subscriber benefits and insurance, equitable provider reimbursement, simplified state licensing requirements easing access to virtual care, and expanding telehealth research and quality initiatives. The roles and responsibilities of providers should be clearly delineated in telehealth service models.

Electrodiagnostic assessment of the autonomic nervous system: A consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology.

Evaluation of disorders of the autonomic nervous system is both an art and a science, calling upon the physician's most astute clinical skills as well as knowledge of autonomic neurology and physiology. Over the last three decades, the development of noninvasive clinical tests that assess the function of autonomic nerves, the validation and standardization of these tests, and the growth of a large body of literature characterizing test results in patients with autonomic disorders have equipped clinical practice further with a valuable set of objective tools to assist diagnosis and prognosis. This review, based on current evidence, outlines an international expert consensus set of recommendations to guide clinical electrodiagnostic autonomic testing. Grading and localization of autonomic deficits incorporates scores from sympathetic cardiovascular adrenergic, parasympathetic cardiovagal, and sudomotor testing, as no single test alone is sufficient to diagnose the degree or distribution of autonomic failure. The composite autonomic severity score (CASS) is a useful score of autonomic failure that is normalized for age and gender. Valid indications for autonomic testing include generalized autonomic failure, regional or selective system syndromes of autonomic impairment, peripheral autonomic neuropathy and ganglionopathy, small fiber neuropathy, orthostatic hypotension, orthostatic intolerance, syncope, neurodegenerative disorders, autonomic hyperactivity, and anhidrosis.

Sleep disorders in patients with functional dyspepsia: A multicenter study from the Korean Society of Neurogastroenterology and Motility.

BACKGROUND AND AIM: The few studies concerning the association between sleep disorders and functional dyspepsia (FD) have yielded inconsistent results. We compared the prevalence of sleep disorders in patients with FD and healthy controls, and evaluated whether FD was independently associated with sleep disorders, and the risk factors for sleep disorders in patients with FD. METHODS: This prospective, multicenter, cross-sectional study was conducted from August 2014 to December 2017 at 12 hospitals in South Korea. The inclusion criterion was the presence of FD (for ≥18 years) according to the Rome III criteria. Healthy controls were recruited from among patients who visited the Health Examination Center for check-ups. RESULTS: In total, 526 subjects were prospectively enrolled in this study (201 with FD and 325 healthy controls). The prevalence of sleep disorders was significantly higher among the patients with FD than among the healthy controls (41.8% vs 18.8%, P = 0.000). In a multivariate analysis, FD (odds ratio [OR] = 1.851; 95% confidence interval [CI] 1.194-2.870; P = 0.006), female sex (OR = 1.672; 95% CI 1.063-2.628; P = 0.026), and anxiety (OR = 3.325; 95% CI 2.140-5.166; P = 0.000) were independent risk factors for sleep disorders in the overall cohorts. In patients with FD only, low body mass index, heartburn, and anxiety were independent risk factors for sleep disorders in a further multivariate analysis. CONCLUSION: Sleep disorders were common in patients with FD. FD was significantly associated with sleep disorders in our patient population, irrespective of the presence of heartburn or psychiatric disorders.

Clinical practice guidelines for the management of adult diffuse gliomas.

To follow the revision of the fourth edition of WHO classification and the recent progress on the management of diffuse gliomas, the joint guideline committee of Chinese Glioma Cooperative Group (CGCG), Society for Neuro-Oncology of China (SNO-China) and Chinese Brain Cancer Association (CBCA) updated the clinical practice guideline. It provides recommendations for diagnostic and management decisions, and for limiting unnecessary treatments and cost. The recommendations focus on molecular and pathological diagnostics, and the main treatment modalities of surgery, radiotherapy, and chemotherapy. In this guideline, we also integrated the results of some clinical trials of immune therapies and target therapies, which we think are ongoing future directions. The guideline should serve as an application for all professionals involved in the management of patients with adult diffuse glioma and also a source of knowledge for insurance companies and other institutions involved in the cost regulation of cancer care in China and other countries.

Racial and gender disparities in neurology.

INTRODUCTION: The USA is a diverse society with representation from different ethnic and racial backgrounds, resulting in under-represented minorities (URMs) in various specialties of medicine. Our objective was to find the statistical ratio of URMs in the academic faculty of neurology. METHODS: This was a retrospective analysis of the American Association of Medical College database. The database covered neurology faculty members from 2006 to 2017. RESULTS: This study shows a significant change in racial representation in faculty ranks over the last 12 years. At chairperson rank, white people decreased from 86.4% to 79.8% whereas Asian, Hispanic and multiple races (non-Hispanic) simultaneously increased from 6.4% to 9.3%, 0.9% to 3.1% and 1.8% to 4.7%, respectively. At the professor rank, white people decreased from 87.4% to 81.6%, while Asians and Hispanics increased from 7.1% to 10.5% and from 0.7% to 2.1%, respectively. At the rank of associate professor, white people decreased from 81.1% to 68.3% whereas Asians, Hispanics and unknown races increased from 10.3% to 19.0%, 1.6% to 3.1% and from 2.1% to 3.5%, respectively. For the rank of assistant professor, white people decreased from 64.7% to 56.9% and Asians increased from 20.5% to 25.9%. Gender differences (men vs women) for the ranks of chairperson, professor, associate professor, assistant professor and instructors were 90.3% and 9.7%, 83.1% and 16.9%, 67.1% and 32.9%, 56.8% and 43.2%, and 48.1% and 51.9%, respectively. CONCLUSION: Over a period of 12 years the racial proportion in academic neurology has changed, but it is not proportionate to their respective increase in the population of the USA. Moreover, the portion of female faculty increased, but they are still under-represented in leadership roles. This racial and gender disparity can be addressed by well-planned interventions.

Shaping a data-driven era in dementia care pathway through computational neurology approaches.

BACKGROUND: Dementia is caused by a variety of neurodegenerative diseases and is associated with a decline in memory and other cognitive abilities, while inflicting an enormous socioeconomic burden. The complexity of dementia and its associated comorbidities presents immense challenges for dementia research and care, particularly in clinical decision-making. MAIN BODY: Despite the lack of disease-modifying therapies, there is an increasing and urgent need to make timely and accurate clinical decisions in dementia diagnosis and prognosis to allow appropriate care and treatment. However, the dementia care pathway is currently suboptimal. We propose that through computational approaches, understanding of dementia aetiology could be improved, and dementia assessments could be more standardised, objective and efficient. In particular, we suggest that these will involve appropriate data infrastructure, the use of data-driven computational neurology approaches and the development of practical clinical decision support systems. We also discuss the technical, structural, economic, political and policy-making challenges that accompany such implementations. CONCLUSION: The data-driven era for dementia research has arrived with the potential to transform the healthcare system, creating a more efficient, transparent and personalised service for dementia.

Migraine and Headache Care in the Republic of Ireland: History and a Vision for the Future Influenced by the COVID-19 Pandemic.

BACKGROUND: The care and management of migraine/headache patients in the Republic of Ireland over the last 25 years are summarized in this article. METHODS: Collaboration between voluntary patient organizations (the Migraine Association of Ireland or MAI), primary care services, and hospital/community shared healthcare professionals (most notably the headache specialist nurse), is highlighted as one of the key features of this management strategy in an underfunded and under-resourced public healthcare system. CONCLUSION: The migraine/headache community in Ireland is small, but they have been dedicated in their commitment to improving care for their patients for more than 2 decades. As a result, they have been successful in recent years, both nationally and internationally, in terms of financial funding and support for their multidisciplinary and collaborative approach.

Keeping the team together: Transformation of an inpatient neurology service at an urban, multi-ethnic, safety net hospital in New York City during COVID-19.

The COVID-19 pandemic dramatically affected the operations of New York City hospitals during March and April of 2020. This article describes the transformation of a neurology division at a 450-bed tertiary care hospital in a multi-ethnic community in Brooklyn during this initial wave of COVID-19. In lieu of a mass redeployment of staff to internal medicine teams, we report a novel method for a neurology division to participate in a hospital's expansion of care for patients with COVID-19 while maintaining existing team structures and their inherent supervisory and interpersonal support mechanisms.

[Specialised headache units, a feasible alternative in Spain]. / Unidades especializadas de cefalea, una alternativa viable en España.

INTRODUCTION: Visits due to headaches are the most frequent cause of demand for neurological treatment in primary care and neurology services. Headache units improve the quality of care, reduce waiting lists, facilitate access to new treatments of proven efficacy and optimise healthcare expenditure. However, these units have not been implemented on a widespread basis in Spain due to the relatively low importance attributed to the condition and also the assumption that such units have a high cost. AIM: To define the structure and minimum requirements of a headache unit with the intention of contributing to their expansion in hospitals in Spain. SUBJECTS AND METHODS: We conducted a consensus study among professionals after reviewing the literature on the structure, functions and resources required by a headache unit designed to serve an area with 350,000 inhabitants. RESULTS: Eight publications were taken as a reference for identifying the minimum resources needed for a headache unit. The panel of experts was made up of 12 professionals from different specialties. The main resource required to be able to implement these units is the professional staff (both supervisory and technical), which can mean an additional cost for the first year of around 107,287.19 euros. CONCLUSIONS: If we bear in mind the direct and indirect costs due to losses in labour productivity per patient and compare them with the estimated costs involved in implementing these units and their expected results, everything points to the need for headache units to become generalised in Spain.

TITLE: Unidades especializadas de cefalea, una alternativa viable en España.Introducción. Las consultas por cefalea son el motivo más frecuente de demanda de atención de causa neurológica en la atención primaria y en los servicios de neurología. Las unidades de cefalea mejoran la calidad asistencial, reducen las listas de espera, facilitan el acceso a nuevos tratamientos de eficacia contrastada y optimizan el gasto sanitario. No obstante, la implantación de estas unidades no está extendida en España debido a la relativa importancia atribuida a la patología y a la suposición de que su coste es elevado. Objetivo. Definir la estructura y los requerimientos mínimos de una unidad de cefalea con la intención de contribuir a su extensión en los hospitales de España. Sujetos y métodos. Estudio de consenso entre profesionales tras la revisión de la bibliografía sobre la estructura, las funciones y los recursos de una unidad de cefalea para un área de 350.000 habitantes. Resultados. Se tomaron como referencia ocho publicaciones para la identificación de recursos mínimos necesarios de una unidad de cefalea. El panel de expertos estuvo integrado por 12 profesionales de diferentes especialidades. El principal recurso para la implementación de estas unidades son profesionales (superiores y técnicos), lo que puede suponer un coste adicional para el primer año de alrededor de 107.287,19 euros. Conclusiones. Si consideramos los costes directos e indirectos debidos a las pérdidas por productividad laboral por paciente y los comparamos con los costes estimados de implantación de estas unidades y su expectativa de resultados, todo apunta a que es necesaria la generalización de unidades de cefalea en España.