Implementation and Patient Experience of Outpatient Teleneurology.

Background: Teleneurology has been well described for acute stroke, but outpatient use has been limited. At home, virtual visits have the potential to improve access to neurological care. Introduction: This study reports on the use of a personal device videoconferencing platform for outpatient neurologic follow-up visits. Materials and Methods: This is a cross-sectional study that identified all virtual neurologic follow-up visits completed by patients ≥18 years at a single institution over 4 years. Virtual visits were conducted by personal smartphone or computer via videoconferencing with a provider. Patients were asked to rate their overall experience with the visit and provider (five-point scale). Travel distance from the institution was calculated using patient's home addresses. Results: Three thousand nine hundred thirteen patients completed 5,581 virtual visits during the study (mean age 49.4 ± 17.0 years, 58.7% female). Number of virtual visits increased from 30 in year 1 to 4,468 in year 4. Virtual visits were completed in all outpatient neurologic subspecialties. A total of 30.1% of patients were local (<50 miles), 25.9% were near regional (50-150 miles), 21.7% were far regional (151-270 miles), and 22.2% were remote (>270 miles). A distance of 1,327,128 miles of travel was prevented across the 5,581 visits. On average, patients rated their overall virtual visit experience 4.7/5 ± 0.89 and rated their provider 4.9/5 ± 0.48. Discussion: Virtual visits prevented a substantial amount of travel and resulted in high patient satisfaction. The sizable proportion of local patients may indicate that teleneurology provides important access for reasons beyond travel distance. Conclusion: This study demonstrates the feasibility of implementing outpatient teleneurology services.

Bridging the gap in epilepsy care: A single-center experience of 3700 outpatient tele-epilepsy visits.

We describe the largest-to-date single-center implementation of tele-epilepsy. Beginning in 2017, all patients at a single tertiary care academic epilepsy center were offered the option to complete outpatient follow-up visits via video-conferencing using personal devices. A retrospective review of all patients who self-selected virtual visits over nearly 3 years showed 2140 patients completed 3698 tele-epilepsy visits, with 41% completing more than one visit during the study period. Based on the distance from the center to the home address, 26.7% of patients were local (≤50 miles), 30.5% were near regional (51-150 miles), 20.1% were far regional (151-270 miles), and 22.7% were remote (>270 miles), from 43 different states. An estimated 928 696 miles of travel was prevented, with a median travel distance saved of 124.5 miles (interquartile range = 45.0-253.0). The mean visit time was 15.7 (±10.4) minutes. More than 90% of patients gave the visit and provider experience the maximum rating, with a nearly 60% response rate on the post-visit survey. Virtual outpatient follow-up care provides a convenient way to connect with epilepsy specialists and reduce the burden of care by cutting travel time. Our experience demonstrates that outpatient tele-epilepsy is feasible, sustainable, and scalable.

Investigation of a novel approach for aquaculture site selection.

This study investigated the potential use of two "species distribution models" (SDMs), Mahalanobis Typicality and Maxent, for aquaculture site selection. SDMs are used in ecological studies to predict the spatial distribution of species based on analysis of conditions at locations of known presence or absence. Here the input points are aquaculture sites, rather than species occurrence, thus the models evaluate the parameters at the sites and identify similar areas across the rest of the study area. This is a novel approach that avoids the need for data reclassification and weighting which can be a source of conflict and uncertainty within the commonly used multi-criteria evaluation (MCE) technique. Using pangasius culture in the Mekong Delta, Vietnam, as a case study, Mahalanobis Typicality and Maxent SDMs were evaluated against two models developed using the MCE approach. Mahalanobis Typicality and Maxent assess suitability based on similarity to existing farms, while the MCE approach assesses suitability using optimal values for culture. Mahalanobis Typicality considers the variables to have equal importance whereas Maxent analyses the variables to determine those which influence the distribution of the input data. All of the models indicate there are suitable areas for culture along the two main channels of the Mekong River which are currently used to farm pangasius and also inland in the north and east of the study area. The results show the Mahalanobis Typicality model had more high scoring areas and greater overall similarity than Maxent to the MCE outputs, suggesting, for this case study, it was the most appropriate SDM for aquaculture site selection. With suitable input data, a combined SDM and MCE model would overcome limitations of the individual approaches, allowing more robust planning and management decisions for aquaculture, other stakeholders and the environment.

Priority setting: women's health topics in multiple sclerosis.

Background: A scoping review found that most studies on women's health in multiple sclerosis (MS) focused on pregnancy, fetal/neonatal outcomes and sexual dysfunction. Few studies addressed menopause, contraception, gynecologic cancers/cancer screening. However, the perceived relative importance of these knowledge gaps to people living with MS and other partners is unknown. We engaged a range of partners, including people living with MS, health care providers, researchers, and patient advocacy groups, to set priorities for future research in women's health in MS. Methods: We employed a three-step global engagement process. First, we identified which broad research topics relevant to women's health in MS were of highest priority using two surveys. Second, we developed specific research questions within these topics using focus groups. Finally, we prioritized the research questions with a third survey. Results: Overall, 5,266 individuals responded to the initial surveys [n = 1,430 global survey, mean (SD) age 50.0 (12.6), all continents; n = 3,836 North American Research Committee on Multiple Sclerosis survey, mean (SD) age 64.8 (9.6), United States]. Menopause, sexual dysfunction, pregnancy, gynecologic cancer/cancer screening, hormones and parenthood were identified as the most important topics. Focus groups generated 80 potential research questions related to these topics. In the final survey 712 individuals prioritized these questions. The highest priority questions in each research topic were: (i) How do perimenopause and menopause affect disease activity, course, response to disease-modifying treatment and quality of life in MS; (ii) What are the most effective strategies for managing issues around sexual intimacy, including related to low sexual desire, changes in physical function, and MS symptoms; (iii) Are there long-term effects of disease-modifying therapies on the children of persons with MS; (iv) What are the short and long-term effects of disease-modifying drugs on gynecologic cancer risk, particularly for high efficacy disease-modifying drugs and hematopoietic stem cell transplantation; (v) Are there hormone related treatments that can stabilize fluctuations in MS symptoms; and (vi) How does MS fatigue impact parenting strategies. Conclusion: Priorities for research relating to women's health issues for persons with MS have been delineated using a collaborative process with key partners. Alignment of future research with these priorities should be monitored.

Progressive Encephalomyelopathy in an Older Man: A Case Report From the National Multiple Sclerosis Society Case Conference Proceedings.

We present a case of subacute onset progressive encephalomyelopathy in a 77-year-old man with symmetric lateral column signal abnormalities on spinal MRI. We discuss the differential and presumptive final diagnosis along with a review of the postulated disease immunopathogenesis.

Gender Representation Among Physician Authors of Practice Guidelines Developed, Endorsed, or Affirmed by the American Academy of Neurology.

BACKGROUND AND OBJECTIVES: To assess American Academy of Neurology (AAN)-recommended Practice Guidelines (PGs) for equity in gender representation among physician authors. METHODS: This cross-sectional study included AAN-recommended PG publications from January 1, 2015, to December 31, 2020. Author degrees and gender were identified by 2 reviewers using the publication and/or online searches. Gender was determined from pronouns or photographs. Gender representation was compared with Association of American Medical Colleges (AAMC) data on academic neurologists. Data were analyzed using Z tests of 2 proportions and descriptive statistics. RESULTS: AAMC benchmarks report academic women neurologists represented 35% of the specialty in 2015, 38% in 2018, and 39% in 2020. We identified 68 unique PG publications with 709 physician authors, 31% (223) women, 68% (484) men, and 0.3% (2) gender could not be identified. Representation of women physicians was low among PG authors across all benchmarks, significantly so for 2018 and 2020 (p < 0.01). Among physician first authors, women were significantly underrepresented across all benchmarks (18% [12/65], p < 0.01). Representation of women physicians was lower when men physicians were first authors vs women physicians (31% [161/524] vs 43% [50/118], p = 0.02). Among subspecialties with 10+ PGs, women physician authorship was highest in child neurology (48% [57/120]) and lowest in stroke and vascular neurology (16% [18/113]). DISCUSSION: We found that women physicians were underrepresented as authors of AAN-recommended PGs. This suggests a missed opportunity for neurology because PGs that include expertise from women physicians may improve care and translation into practice. In addition, women physicians lose out on professional development from authorship. Further research is needed to understand causality and address gaps.

Women's Health in Multiple Sclerosis: A Scoping Review.

BACKGROUND: Women with multiple sclerosis (MS) may face challenges related to managing reproduction, pregnancy, and menopause while simultaneously managing their disease. The purpose of this scoping review was to map the literature broadly related to topics relevant to women's health in MS to inform the clinical and research communities about the existing types and sources of evidence and knowledge gaps. Apart from coverage of topics within the field of women's health, we were interested in potential gaps related to geographic and racial and ethnic diversity. We also aimed to understand the degree of inclusion of women with progressive MS in this research. METHODS: We searched the EMBASE and Ovid Medline databases from 1980 until November 23, 2020. We included case-control and cohort studies, clinical trials and case series published in any language, conducted in women with MS, clinically isolated syndrome, or radiologically isolated syndrome, that addressed women's health. Two reviewers independently screened abstracts and full-text reports for study inclusion, and completed data extraction. RESULTS: Of 112,106 citations screened, 1,041 underwent full-text review and 353 met the inclusion criteria. The number of studies regarding women's health has increased exponentially over time. Almost half of the studies were conducted (at least in part) in Europe, while 21.7% were conducted in North America; only one study was conducted in Africa. Most studies did not report the race or ethnicity of their participants (n = 308, 87.2%). Among the 353 studies, 509 topics were reported as some studies addressed more than one topic. Over one-third of these focused on pregnancy (n = 201, 37.2%), followed by fetal/neonatal outcomes (14.4%) and sexual dysfunction (10%). Among the 201 studies that focused on pregnancy, only 51 (25.4%) included participants with progressive MS. CONCLUSIONS: This review identifies important knowledge gaps related to women's health in MS and particularly the need for future studies to include participants with a broader range of races and ethnicities, with progressive MS, and living in Asia-Pacific and African regions.

Story Arcs in Serious Illness: Natural Language Processing features of Palliative Care Conversations.

OBJECTIVE: Serious illness conversations are complex clinical narratives that remain poorly understood. Natural Language Processing (NLP) offers new approaches for identifying hidden patterns within the lexicon of stories that may reveal insights about the taxonomy of serious illness conversations. METHODS: We analyzed verbatim transcripts from 354 consultations involving 231 patients and 45 palliative care clinicians from the Palliative Care Communication Research Initiative. We stratified each conversation into deciles of "narrative time" based on word counts. We used standard NLP analyses to examine the frequency and distribution of words and phrases indicating temporal reference, illness terminology, sentiment and modal verbs (indicating possibility/desirability). RESULTS: Temporal references shifted steadily from talking about the past to talking about the future over deciles of narrative time. Conversations progressed incrementally from "sadder" to "happier" lexicon; reduction in illness terminology accounted substantially for this pattern. We observed the following sequence in peak frequency over narrative time: symptom terms, treatment terms, prognosis terms and modal verbs indicating possibility. CONCLUSIONS: NLP methods can identify narrative arcs in serious illness conversations. PRACTICE IMPLICATIONS: Fully automating NLP methods will allow for efficient, large scale and real time measurement of serious illness conversations for research, education and system re-design.

Identifying Connectional Silence in Palliative Care Consultations: A Tandem Machine-Learning and Human Coding Method.

Background: Systematic measurement of conversational features in the natural clinical setting is essential to better understand, disseminate, and incentivize high quality serious illness communication. Advances in machine-learning (ML) classification of human speech offer exceptional opportunity to complement human coding (HC) methods for measurement in large scale studies. Objectives: To test the reliability, efficiency, and sensitivity of a tandem ML-HC method for identifying one feature of clinical importance in serious illness conversations: Connectional Silence. Design: This was a cross-sectional analysis of 354 audio-recorded inpatient palliative care consultations from the Palliative Care Communication Research Initiative multisite cohort study. Setting/Subjects: Hospitalized people with advanced cancer. Measurements: We created 1000 brief audio "clips" of randomly selected moments predicted by a screening ML algorithm to be two-second or longer pauses in conversation. Each clip included 10 seconds of speaking before and 5 seconds after each pause. Two HCs independently evaluated each clip for Connectional Silence as operationalized from conceptual taxonomies of silence in serious illness conversations. HCs also evaluated 100 minutes from 10 additional conversations having unique speakers to identify how frequently the ML screening algorithm missed episodes of Connectional Silence. Results:Connectional Silences were rare (5.5%) among all two-second or longer pauses in palliative care conversations. Tandem ML-HC demonstrated strong reliability (kappa 0.62; 95% confidence interval: 0.47-0.76). HC alone required 61% more time than the Tandem ML-HC method. No Connectional Silences were missed by the ML screening algorithm. Conclusions: Tandem ML-HC methods are reliable, efficient, and sensitive for identifying Connectional Silence in serious illness conversations.

Modelling the nitrogen loadings from large yellow croaker (Larimichthys crocea) cage aquaculture.

Large yellow croaker (LYC) cage farming is a rapidly developing industry in the coastal areas of the East China Sea. However, little is known about the environmental nutrient loadings resulting from the current aquaculture practices for this species. In this study, a nitrogenous waste model was developed for LYC based on thermal growth and bioenergetic theories. The growth model produced a good fit with the measured data of the growth trajectory of the fish. The total, dissolved and particulate nitrogen outputs were estimated to be 133, 51 and 82 kg N tonne(-1) of fish production, respectively, with daily dissolved and particulate nitrogen outputs varying from 69 to 104 and 106 to 181 mg N fish(-1), respectively, during the 2012 operational cycle. Greater than 80 % of the nitrogen input from feed was predicted to be lost to the environment, resulting in low nitrogen retention (<20 %) in the fish tissues. Ammonia contributed the greatest proportion (>85 %) of the dissolved nitrogen generated from cage farming. This nitrogen loading assessment model is the first to address nitrogenous output from LYC farming and could be a valuable tool to examine the effects of management and feeding practices on waste from cage farming. The application of this model could help improve the scientific understanding of offshore fish farming systems. Furthermore, the model predicts that a 63 % reduction in nitrogenous waste production could be achieved by switching from the use of trash fish for feed to the use of pelleted feed.

Canadian Rural/Remote Primary Care Physicians Perspectives on Child/Adolescent Mental Health Care Service Delivery.

INTRODUCTION: Primary Care Physicians (PCP) play a key role in the recognition and management of child/adolescent mental health struggles. In rural and under-serviced areas of Canada, there is a gap between child/adolescent mental health needs and service provision. METHODS: From a Canadian national needs assessment survey, PCPs' narrative comments were examined using quantitative and qualitative approaches. Using the phenomenological method, individual comments were drawn upon to illustrate the themes that emerged. These themes were further analyzed using chi-square to identify significant differences in the frequency in which they were reported. RESULTS: Out of 909 PCPs completing the survey, 39.38% (n = 358) wrote comments. Major themes that emerged were: 1) psychiatrist access, including issues such as long waiting lists, no child/adolescent psychiatrists available, no direct access to child/adolescent psychiatrists; 2) poor communication/continuity, need for more systemized/transparent referral processes, and need to rely on adult psychiatrists; and, 3) referral of patients to other mental health professionals such as paediatricians, psychologists, and social workers. CONCLUSIONS: Concerns that emerged across sites primarily revolved around lack of access to care and systems issues that interfere with effective service delivery. These concerns suggest potential opportunities for future improvement of service delivery. IMPLICATIONS: Although the survey only had one comment box located at the end, PCPs wrote their comments throughout the survey. Further research focusing on PCPs' expressed written concerns may give further insight into child/adolescent mental health care service delivery systems. A comparative study targeting urban versus rural regions in Canada may provide further valuable insights.

INTRODUCTION: Les médecins de soins de première ligne (MSPL) jouent un rôle essentiel dans la reconnaissance et la prise en charge des problèmes de santé mentale des enfants/adolescents. Dans les régions rurales et sous-desservies du Canada, il y a un écart entre les besoins de santé mentale des enfants/adolescents et la prestation de services. MÉTHODES: Tirés d'un sondage canadien national évaluant les besoins, les commentaires narratifs des MSPL ont été examinés à l'aide d'approches quantitatives et qualitatives. Au moyen de la méthode phénoménologique, les commentaires individuels ont servi à illustrer les thèmes dégagés. Ces thèmes ont ensuite été analysés avec le chi-carré afin d'identifier les différences significatives de la fréquence à laquelle ils étaient mentionnés. RÉSULTATS: Sur les 909 MSPL qui ont répondu au sondage, 39,38% (n = 358) ont écrit des commentaires. Les thèmes majeurs qui se sont dégagés étaient: 1) l'accès aux psychiatres, notamment des questions comme les longues listes d'attente, pas de pédopsychiatres disponibles, pas d'accès direct aux pédopsychiatres; 2) mauvaise communication/continuité, besoin de processus plus nombreux d'aiguillage systémique/transparent, et besoin de consulter des psychiatres pour adultes; 3) adresser les patients à d'autres professionnels de la santé comme les pédiatres, les psychologues et les travailleurs sociaux. CONCLUSIONS: Les préoccupations soulevées dans les divers centres s'articulaient autour de l'accès aux soins et des problèmes des systèmes qui empiètent sur la prestation efficace de services. Ces préoccupations suggèrent des possibilités pour l'amélioration future de la prestation de services. Implications: Bien que le sondage n'ait offert qu'un espace pour les commentaires à la fin, les MSPL ont écrit leurs commentaires sur tout le sondage. D'autres recherches portant sur les commentaires écrits des MSPL peuvent offrir d'autres idées sur les systèmes de prestation de services de santé mentale aux enfants/adolescents Une étude comparative ciblant les régions urbaines par rapport aux régions rurales du Canada peut fournir un apport valable.

Population recovery following decline in an endangered stream-breeding frog (Mixophyes fleayi) from subtropical Australia.

Amphibians have undergone dramatic declines and extinctions worldwide. Prominent among these have been the stream-breeding frogs in the rainforests of eastern Australia. The amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) has been postulated as the primary cause of these declines. We conducted a capture-mark-recapture study over a 7-year period on the endangered Fleay's barred frog (Mixophyes fleayi) at two independent streams (30 km apart) in order to assess the stability of these populations. This species had undergone a severe decline across its narrow geographic range. Mark-recapture modelling showed that the number of individuals increased 3-10 fold along stream transects over this period. Frog detection probabilities were frequently above 50% but declined as the populations increased. Adult survival was important to overall population persistence in light of low recruitment events, suggesting that longevity may be a key factor in this recovery. One male and female were present in the capture record for >6 years. This study provides an unambiguous example of population recovery in the presence of Bd.

Referral Patterns and Training Needs in Psychiatry among Primary Care Physicians in Canadian Rural/Remote Areas.

OBJECTIVES: This study examined the referral patterns of rural/remote primary care physicians (PCPs) as well as their needs and interests for further training in child/adolescent mental health. METHODS: Surveys were mailed to Canadian rural/remote PCPs requesting participants' demographic information, training and qualifications, referral patterns, and identification of needs and interests for continuing medical education (CME). RESULTS: PCPs were most likely to refer to mental health programs, and excessive wait times are the most common deterrent. Major reasons for referral were to obtain recommendations regarding medications and assessing non-responsive patients. While PCPs expressed higher levels of confidence in making appropriate referrals, they were much less confident in their knowledge and skills in managing mental health problems. Professional development in child/adolescent psychiatry is a moderate or highly perceived CME need. Overall, attention deficit/hyperactivity disorder (ADHD) was the most commonly chosen topic of interest and CME in the community was preferred, but some regional differences emerged. CONCLUSIONS: PCPs viewed limited community resources and self-identified gaps in skills as barriers to service provision. Professional development in child and adolescent mental health for PCPs by preferred modes appears desired.

Spatial modeling of environmental vulnerability of marine finfish aquaculture using GIS-based neuro-fuzzy techniques.

Combining GIS with neuro-fuzzy modeling has the advantage that expert scientific knowledge in coastal aquaculture activities can be incorporated into a geospatial model to classify areas particularly vulnerable to pollutants. Data on the physical environment and its suitability for aquaculture in an Irish fjard, which is host to a number of different aquaculture activities, were derived from a three-dimensional hydrodynamic and GIS models. Subsequent incorporation into environmental vulnerability models, based on neuro-fuzzy techniques, highlighted localities particularly vulnerable to aquaculture development. The models produced an overall classification accuracy of 85.71%, with a Kappa coefficient of agreement of 81%, and were sensitive to different input parameters. A statistical comparison between vulnerability scores and nitrogen concentrations in sediment associated with salmon cages showed good correlation. Neuro-fuzzy techniques within GIS modeling classify vulnerability of coastal regions appropriately and have a role in policy decisions for aquaculture site selection.

Aquaculture: global status and trends.

Aquaculture contributed 43 per cent of aquatic animal food for human consumption in 2007 (e.g. fish, crustaceans and molluscs, but excluding mammals, reptiles and aquatic plants) and is expected to grow further to meet the future demand. It is very diverse and, contrary to many perceptions, dominated by shellfish and herbivorous and omnivorous pond fish either entirely or partly utilizing natural productivity. The rapid growth in the production of carnivorous species such as salmon, shrimp and catfish has been driven by globalizing trade and favourable economics of larger scale intensive farming. Most aquaculture systems rely on low/uncosted environmental goods and services, so a critical issue for the future is whether these are brought into company accounts and the consequent effects this would have on production economics. Failing that, increased competition for natural resources will force governments to allocate strategically or leave the market to determine their use depending on activities that can extract the highest value. Further uncertainties include the impact of climate change, future fisheries supplies (for competition and feed supply), practical limits in terms of scale and in the economics of integration and the development and acceptability of new bio-engineering technologies. In the medium term, increased output is likely to require expansion in new environments, further intensification and efficiency gains for more sustainable and cost-effective production. The trend towards enhanced intensive systems with key monocultures remains strong and, at least for the foreseeable future, will be a significant contributor to future supplies. Dependence on external feeds (including fish), water and energy are key issues. Some new species will enter production and policies that support the reduction of resource footprints and improve integration could lead to new developments as well as reversing decline in some more traditional systems.