Safety and Feasibility of Cervical and Thoracic Transcutaneous Spinal Cord Stimulation to Improve Hand Motor Function in Children With Chronic Spinal Cord Injury.

OBJECTIVE: In adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI. MATERIALS AND METHODS: In this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3-C4 and C6-C7) and thoracic (T10-T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks. RESULTS: All seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20-70 mA and thoracic site = 25-190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS. CONCLUSIONS: We indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT04032990.

Using Teleneurology to Deliver Chronic Neurologic Care to Rural Veterans: Analysis of the First 1,100 Patient Visits.

BACKGROUND: A challenge confronting the United States is delivery of quality specialty healthcare to citizens living in rural areas. INTRODUCTION: The Veterans Administration (VA) developed a large national telehealth network to address 5.2 million rural veterans. New Mexico's Albuquerque VA Neurology Service developed a teleneurology program for their rural veterans. This article analyzes our first 1,100 teleneurology patient visits. MATERIALS AND METHODS: Veterans living in remote areas of New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 16 rural VA community-based outpatient clinics (CBOCs) following an initial evaluation at the Albuquerque VA neurology outpatient clinic. Surveys were sent after all teleneurology visits focused on quality of care, ease of communication, satisfaction, and staff's ability to deliver same quality care as in person. Problems encountered, differences between face-to-face clinics and teleneurology, and cost savings were examined. RESULTS: Regarding the 701 (64%) returned surveys, we found 90% perceived they received good care, 91% felt there was good communication, 88% liked the convenience, and 87% reported they desired to continue teleneurology care. Ninety-six percent reported saving time, money, or both through CBOC visits instead of driving to Albuquerque. DISCUSSION: All providers felt that they could deliver excellent care through teleneurology. We found emergency room visits for neurologic problems was similar for both groups. CONCLUSIONS: Our rural veteran patients and neurology staff overwhelmingly found high quality patient care can be delivered via teleneurology for a variety of chronic neurologic problems and was comparable to care delivered in neurology face-to-face clinics.

Teleneurology: successful delivery of chronic neurologic care to 354 patients living remotely in a rural state.

BACKGROUND: Delivery of specialty healthcare to rural citizens in the United States remains largely unmet. The Veterans Health Administration is in a unique position to deliver specialty care to rural Veterans because it is mandated to deliver medical care to all eligible Veterans regardless of residence. To accomplish this, the VHA developed large national telehealth networks that provided over 1 million episodes of care in 2012. We investigated whether clinical video telehealth technologies can provide quality efficient neurologic follow-up care to Veterans living in the rural southwest United States. PATIENTS AND METHODS: Veterans with chronic neurologic conditions living remotely in New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 11 rural community-based outpatient clinics following initial evaluation at the Albuquerque, NM, neurology outpatient clinic. RESULTS: Over a 2-year period, 87% of 354 consecutive patients returned a performance improvement satisfaction questionnaire. Ninety percent of the patients were fully satisfied with their visit, and 92% felt teleneurology saved them time and money. We calculated an average time savings of 5 h and 325 miles driven, plus at least $48,000 total cost savings. Ninety-five percent reported they wanted to continue their neurologic care by teleneurology. CONCLUSIONS: Our study confirms earlier pilot studies of successful follow-up care through telemedicine. Our patients were highly satisfied with the convenience and quality of their teleneurology visit, and the neurology providers were convinced that neurologic care to both teleneurology and clinic follow-up patients was equivalent. Teleneurology to rural Veterans can provide quality neurologic care and overwhelming patient satisfaction and save considerable time and money.

Name-based demographic inference and the unequal distribution of misrecognition.

Academics and companies increasingly draw on large datasets to understand the social world, and name-based demographic ascription tools are widespread for imputing information that is often missing from these large datasets. These approaches have drawn criticism on ethical, empirical and theoretical grounds. Using a survey of all authors listed on articles in sociology, economics and communication journals in Web of Science between 2015 and 2020, we compared self-identified demographics with name-based imputations of gender and race/ethnicity for 19,924 scholars across four gender ascription tools and four race/ethnicity ascription tools. We found substantial inequalities in how these tools misgender and misrecognize the race/ethnicity of authors, distributing erroneous ascriptions unevenly among other demographic traits. Because of the empirical and ethical consequences of these errors, scholars need to be cautious with the use of demographic imputation. We recommend five principles for the responsible use of name-based demographic inference.

Durability of Improved Trunk Control Following Activity-Based Locomotor Training in Children With Acquired Spinal Cord Injuries.

BACKGROUND: A recent study in pediatric spinal cord injury (SCI) demonstrated activity-based locomotor training (ABLT) improved trunk control, measured by the Segmental Assessment of Trunk Control (SATCo). It is not known whether improved trunk control is maintained and, if so, for how long. OBJECTIVES: The purpose was to determine the durability of improvements in trunk control after ABLT is stopped. We hypothesized that SATCo scores at follow-up would not significantly regress (a) beyond the score measured at discharge and (b) to the initial SATCo pre-ABLT level. METHODS: Patients were assessed pre ABLT, after completing an episode of care, and upon returning to the clinic 1 or more months without ABLT. Durability is a score change less than 3, which is the measurement error of the SATCo. RESULTS: Twenty-eight children (10 females; 4 ± 2.5 years old) completed at least 40 sessions of ABLT and returned for the follow-up 8 ± 7 months (range, 1-38) after the episode of care. Trunk control improved 6 ± 3/20 points with ABLT (p < .0001). At the follow-up, average SATCo score decreased 2 ± 2/20 points, and the follow-up SATCo score was 4 ± 3 points higher than pre ABLT (p < .0001). There was no correlation between the change in SATCo scores and changes in age, weight, height or elapsed time between discharge and follow-up. CONCLUSION: Improvements in trunk control due to ABLT were maintained, indicating ABLT is neurotherapeutic. Although not achieving complete recovery of trunk control, the immediate effects and sustained improvements provide support for a clinical shift to neurotherapeutic approaches and for continued research to achieve enhanced recovery.

Noninvasive spinal stimulation safely enables upright posture in children with spinal cord injury.

In children with spinal cord injury (SCI), scoliosis due to trunk muscle paralysis frequently requires surgical treatment. Transcutaneous spinal stimulation enables trunk stability in adults with SCI and may pose a non-invasive preventative therapeutic alternative. This non-randomized, non-blinded pilot clinical trial (NCT03975634) determined the safety and efficacy of transcutaneous spinal stimulation to enable upright sitting posture in 8 children with trunk control impairment due to acquired SCI using within-subject repeated measures study design. Primary safety and efficacy outcomes (pain, hemodynamics stability, skin irritation, trunk kinematics) and secondary outcomes (center of pressure displacement, compliance rate) were assessed within the pre-specified endpoints. One participant did not complete the study due to pain with stimulation on the first day. One episode of autonomic dysreflexia during stimulation was recorded. Following hemodynamic normalization, the participant completed the study. Overall, spinal stimulation was well-tolerated and enabled upright sitting posture in 7 out of the 8 participants.

Wound botulism from heroin skin popping.

Following the introduction of black tar heroin mainly from Mexico in the 1980s, cases of wound botulism dramatically increased in the western United States. Contamination with spores of Clostridium botulinum of black tar heroin occurs along the distribution line. The heating of heroin powder to solubilize it for subcutaneous injection ("skin popping") does not kill the spores. The spores germinate in an anaerobic tissue environment and release botulinum toxin type A or B. Unless skin abscesses are found in the patient, the clinical diagnosis is often challenging. Facilitation of the compound muscle action potential by repetitive nerve stimulation at 20 to 50 Hz is an important and rapid diagnostic test. Definite diagnosis is made by detection of botulinum toxin in serum or isolation of C botulinum from the abscess. Early treatment with equine ABE botulinum antitoxin obtained from the Centers for Disease Control and Prevention often shortens the time on a ventilator.

The effects of potassium and muscle homogenate on proprioceptive responses in crayfish and crab.

Proprioception of limbs and joints is a basic sensory function throughout most of the animal kingdom. It is important to understand how proprioceptive organs and the associated sensory neurons function with altered environments such as increased potassium ion concentrations ([K+]) from diseased states, ionic imbalances, and damaged tissues. These factors can drastically alter neuronal activity. To assess this matter, we used the chordotonal organ in a walking leg of a blue crab (Callinectes sapidus) and the muscle receptor organ of the crayfish (Procambarus clarkii). These organs serve as tractable models for the analysis of proprioception. The preparations can help serve as translational models for these effects, which may be observed in other invertebrate species as well as mammalian species (including humans). When extracellular potassium concentration ([K+]o) is increased to 20 mM in both preparations, mixed results are observed with activity increasing in some preparations and decreasing in others after mechanical displacement. However, when [K+]o is increased to 40 mM, activity drastically decreases in all preparations. Additionally, proprioceptor sensory activity declines upon exposure to a diluted muscle homogenate, which contains a host of intracellular constituents. The robust effects of altered [K+] on proprioception in these models illuminate the potential detriments on neuronal function in cases of severe tissue damage as well as altered [K+]o.

The role of gender in scholarly authorship.

Gender disparities appear to be decreasing in academia according to a number of metrics, such as grant funding, hiring, acceptance at scholarly journals, and productivity, and it might be tempting to think that gender inequity will soon be a problem of the past. However, a large-scale analysis based on over eight million papers across the natural sciences, social sciences, and humanities reveals a number of understated and persistent ways in which gender inequities remain. For instance, even where raw publication counts seem to be equal between genders, close inspection reveals that, in certain fields, men predominate in the prestigious first and last author positions. Moreover, women are significantly underrepresented as authors of single-authored papers. Academics should be aware of the subtle ways that gender disparities can occur in scholarly authorship.

Evaluating Medical Student Communication/Professionalism Skills from a Patient's Perspective.

OBJECTIVE: Evaluate medical students' communication and professionalism skills from the perspective of the ambulatory patient and later compare these skills in their first year of residency. METHODS: Students in third year neurology clerkship clinics see patients alone followed by a revisit with an attending neurologist. The patient is then asked to complete a voluntary, anonymous, Likert scale questionnaire rating the student on friendliness, listening to the patient, respecting the patient, using understandable language, and grooming. For students who had completed 1 year of residency these professionalism ratings were compared with those from their residency director. RESULTS: Seven hundred forty-two questionnaires for 165 clerkship students from 2007 to 2009 were analyzed. Eighty-three percent of forms were returned with an average of 5 per student. In 64% of questionnaires, patients rated students very good in all five categories; in 35% patients selected either very good or good ratings; and <1% rated any student fair. No students were rated poor or very poor. Sixty-two percent of patients wrote complimentary comments about the students. From the Class of 2008, 52% of students received "better than their peers" professionalism ratings from their PGY1 residency directors and only one student was rated "below their peers." CONCLUSION: This questionnaire allowed patient perceptions of their students' communication/professionalism skills to be evaluated in a systematic manner. Residency director ratings of professionalism of the same students at the end of their first year of residency confirms continued professional behavior.

Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers.

This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

Education research: Assessment of neurology resident clinical competencies in the neurology clinic.

BACKGROUND: Objective evaluation of neurology resident clinical skills is required by the American Board of Psychiatry and Neurology and is important to insure improvement in clinical competency throughout their residency. METHODS: In this study, neurology residents from all 3 years of training and neurology faculty independently completed a form on new clinic patients documenting their decisions on anatomic localization, diagnosis, diagnostic tests, and management. RESULTS: Compared to the attending patient evaluation, we found significant improvement in identical scoring by year of residency training. All resident years outperformed medical students in the neurology clerkship. CONCLUSION: Our clinical assessment form adds one more tool to the list of currently used assessment methods to evaluate resident clinical competency.

Assessment of medical student clinical competencies in the neurology clinic.

Objective evaluation of medical student clinical skills is difficult. In this study, medical students and neurology faculty independently completed a form on new clinic patients documenting anatomic localization, diagnosis, diagnostic tests, and management. We found students and faculty agreed significantly more often in anatomic lesion location and diagnosis than in ordering diagnostic tests or planning optimal treatment. This form improved student clinical competency assessment and enhanced teaching in clinics.

West Nile virus neuroinvasive disease.

Since 1999, there have been nearly 20,000 cases of confirmed symptomatic West Nile virus (WNV) infection in the United States, and it is likely that more than 1 million people have been infected by the virus. WNV is now the most common cause of epidemic viral encephalitis in the United States, and it will likely remain an important cause of neurological disease for the foreseeable future. Clinical syndromes produced by WNV infection include asymptomatic infection, West Nile Fever, and West Nile neuroinvasive disease (WNND). WNND includes syndromes of meningitis, encephalitis, and acute flaccid paralysis/poliomyelitis. The clinical, laboratory, and diagnostic features of these syndromes are reviewed here. Many patients with WNND have normal neuroimaging studies, but abnormalities may be present in areas including the basal ganglia, thalamus, cerebellum, and brainstem. Cerebrospinal fluid invariably shows a pleocytosis, with a predominance of neutrophils in up to half the patients. Diagnosis of WNND depends predominantly on demonstration of WNV-specific IgM antibodies in cerebrospinal fluid. Recent studies suggest that some WNV-infected patients have persistent WNV IgM serum and/or cerebrospinal fluid antibody responses, and this may require revision of current serodiagnostic criteria. Although there is no proven therapy for WNND, several vaccines and antiviral therapy with antibodies, antisense oligonucleotides, and interferon preparations are currently undergoing human clinical trials. Recovery from neurological sequelae of WNV infection including cognitive deficits and weakness may be prolonged and incomplete.

Magnetic resonance imaging and computed tomography of skeletal muscles in oculopharyngeal muscular dystrophy.

OBJECTIVE: : To determine the spectrum of skeletal muscle involvement by neuroimaging in patients with oculopharyngeal muscular dystrophy (OPMD). METHODS: : A neuroradiologist, blinded to severity of patients' dystrophy, retrospectively read 22 magnetic resonance or computed tomography images of the head, neck, chest, abdomen, pelvis, and proximal leg from 13 patients with OPMD. Imaged muscles were evaluated for degree of fatty infiltration and bulk in a semiquantitative fashion using similar images from age-matched patients lacking neuromuscular disease. Neurologic examinations were performed without knowledge of imaging results. RESULTS: : We found abnormal tongue fatty infiltration in all patients and widespread infiltration in many other muscles. Over 50% of masseter, posterior neck, shoulder girdle, lumbar paraspinous, and gluteus muscles had abnormal fat. CONCLUSION: : Although patients with OPMD have dysphagia with weak lids and proximal limbs, they have neuroimaging evidence of widespread fatty infiltration of many muscles. Excessive fatty infiltration of the tongue may help identify atypical patients with OPMD.

Shingles (Herpes Zoster) and Post-herpetic Neuralgia.

During childhood chickenpox, varicella-zoster virus becomes latent in neurons of the dorsal root or trigeminal ganglia. Shingles results years to decades later from a breakdown of viral latency within a ganglion and subsequent virus spread to the skin producing a unilateral dermatomal vesicular rash accompanied by segmental pain. Treatment with famciclovir, valacyclovir, and high dose acyclovir is beneficial if started within the first 3 days of the rash. All three drugs can be given orally, are equally effective, shorten the duration of viral shedding and time to healing of the rash by 1 to 2 days, and lessen the intensity and duration of the acute neuritic pain. Famciclovir and valacyclovir have more convenient dosing schedules (three times daily) compared to acyclovir (five times daily). Mild cases of shingles in younger healthy individuals often do not require any antiviral treatment. Pain in shingles may have burning, lancinating, or allodynic qualities, ranges in intensity from mild to unbearable, and lasts 2 to 8 weeks. Pain treatment varies on the type and intensity of pain experienced. In a few patients, post-herpetic neuralgia develops and the dermatomal pain persists for months to years. Effective treatment of post-herpetic pain is often difficult.