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.

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.

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.

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.

A Stroke Care Model at an Academic, Comprehensive Stroke Center During the 2020 COVID-19 Pandemic.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes. METHODS: The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE. AIMS: The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management. CONCLUSIONS: The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis.

Reprint of : Transcatheter closure of patent foramen ovale to prevent stroke recurrence in patients with otherwise unexplained ischaemic stroke: Expert consensus of the French Neurovascular Society and the French Society of Cardiology.

BACKGROUND: Unlike previous randomized clinical trials (RCTs), recent trials and meta-analyses have shown that transcatheter closure of patent foramen ovale (PFO) reduces stroke recurrence risk in young and middle-aged adults with an otherwise unexplained PFO-associated ischaemic stroke. AIM: To produce an expert consensus on the role of transcatheter PFO closure and antithrombotic drugs for secondary stroke prevention in patients with PFO-associated ischaemic stroke. METHODS: Five neurologists and five cardiologists with extensive experience in the relevant field were nominated by the French Neurovascular Society and the French Society of Cardiology to make recommendations based on evidence from RCTs and meta-analyses. RESULTS: The experts recommend that any decision concerning treatment of patients with PFO-associated ischaemic stroke should be taken after neurological and cardiological evaluation, bringing together the necessary neurovascular, echocardiography and interventional cardiology expertise. Transcatheter PFO closure is recommended in patients fulfilling all the following criteria: age 16-60 years; recent (≤6 months) ischaemic stroke; PFO associated with atrial septal aneurysm (>10mm) or with a right-to-left shunt>20 microbubbles or with a diameter≥2mm; PFO felt to be the most likely cause of stroke after thorough aetiological evaluation by a stroke specialist. Long-term oral anticoagulation may be considered in the event of contraindication to or patient refusal of PFO closure, in the absence of a high bleeding risk. After PFO closure, dual anti-platelet therapy with aspirin (75mg/day) and clopidogrel (75mg/day) is recommended for 3 months, followed by monotherapy with aspirin or clopidogrel for≥5 years. CONCLUSIONS: Although a big step forward that will benefit many patients has been taken with recent trials, many questions remain unanswered. Pending results from further studies, decision-making regarding management of patients with PFO-associated ischaemic stroke should be based on a close coordination between neurologists/stroke specialists and cardiologists.

Neurology practice and stroke services across East China: a multi-site, county-level hospital-based survey.

BACKGROUND: Neurological disorders are an economic and public health burden which requires efficient and adequate medical resources. Currently, little is known about the status of the quality of neurological care services available in China. As neurological primary care is mostly provided at the county hospital level, investigation of this geographical level is required. The aim of this study is to evaluate currently available neurology care services in Yangtze River Delta Urban Agglomerations in east China. METHODS: A multi-site, county-level hospital-based observational survey was conducted in east China from January 2017 to December 2017. A questionnaire was made to assess hospital and the departmental patient care capabilities, human resources and technical capacity in neurology departments. RESULTS: Of 228 hospitals across the Yangtze River Delta Urban Agglomerations, 217 documents were returned. Of these, 22 were excluded due to invalid hospital information or duplicate submission. Overall, most hospitals have neurology departments (162, 83.1%) while less than half of the hospitals have a stroke center (80, 41.0%) and neurology emergency department (46, 23.6%). Among 162 hospitals with neurology department, 5 were excluded due to inadequate sharing, leaving 157 hospitals for analysis. About 84.1% of these neurology departments can administer intravenous thrombolysis while about one third of them has the ability to perform arterial thrombectomy (36.9%). In addition, 46.2% of hospitals can carry out computed tomography angiography (CTA) in emergency room. Tertiary care hospitals are much more equipped with modern medical resources compared to the secondary hospitals. In four administrative regions, the neurology services are better in more economically advanced regions. CONCLUSIONS: Neurological care services need to be enhanced at the county-level hospitals to improve health care delivery.

New-onset seizure survey of epilepsy centers in the United States.

OBJECTIVES: Children presenting with new-onset seizures have variable access to resources and may not receive timely and adequate treatment. Some may experience adverse consequences when not evaluated in a timely manner by appropriate medical providers. Consequences can be especially severe for children under the age of two and for children who have psychiatric, cognitive, and behavioral comorbidities. There are no published data on how children with new-onset seizure are evaluated and treated across the US. Our goal was to gain insight into how different epilepsy centers across the country evaluate and treat children with new-onset seizures. METHODS: We conducted a survey of Epilepsy Centers in the US that are part of the Pediatric Epilepsy Research Consortium (PERC) and focused on children presenting with new-onset seizures; PERC is a group of pediatric epilepsy providers and researchers who participate in collaborative multicenter research in pediatric epilepsy with the goal of improving outcomes in children with pediatric epilepsy. The questionnaire was developed by the authors of this study. It was designed to provide a descriptive assessment of the consistency and variability in how patients with new-onset seizure are evaluated and treated at epilepsy sites across the country. The questionnaire was designed to assure all points of interest were explored. The questions were aimed at describing access to care, how care is delivered, whether centers prioritize based on clinical presentation and/or age, and availability of resources. The survey was sent to 80 epileptologists at 42 different Epilepsy Centers that are part of PERC. RESULTS: Respondents included 29 pediatric epileptologists representing 24 unique centers. In the cases where there were multiple respondents from each center, response of the most senior epileptologist was used. It is possible that the senior epileptologist may have not known about the center as much as a junior epileptologist, but this was used to establish consistencies among centers with multiple respondents. Results showed that 30% of centers had a dedicated new-onset seizure clinic. The median time for children to be seen was two to four weeks, and 12% reported that it takes more than five weeks until the patient is seen. There was a trend toward centers with new-onset seizure clinic having less wait times. Most centers identified lack of adequate care based on insurance coverage, resources, long wait times, and long travel times. SIGNIFICANCE: Most centers (70%) do not have a dedicated new-onset seizure clinic. Children presenting with new-onset seizures often do not receive timely and comprehensive care because of limitations in resources and lack of established standard of care. Standardizing care for patients presenting with new-onset seizures has not yet occurred in the US. Many centers do not have a screening process and employ staff other than physicians or nurses for screening and triaging patients. This study shows that having a neurologist or epileptologist in charge of triaging does not reduce wait times. This survey revealed that there is substantial variability in how these patients are evaluated. Although this study shows a trend for epilepsy centers with new-onset seizure clinic having less wait times, even when there is a new-onset seizure clinic, wait times can be greater than five weeks. Overall, however, a new-onset seizure clinic may be an effective way to improve access to timely and efficient care for these patients.

The World Federation of Neurology and the challenges in Environment Neurology.

Since its establishment the World Federation of Neurology (WFN) has manifested a keen interest in the environment and its relation to neurological diseases. Thus, in 2007 the WFN renamed the "Neurotoxicological Research Group" to "Environmental Neurology Research Group". In this short article, we review some recent events which illustrate the WFN involvement in Environmental Neurology as well its concerns about global health matters involving environmental issues.

Teleneurology service provided via tablet technology: 3-year outcomes and physician satisfaction.

INTRODUCTION: This study aimed to demonstrate that teleneurology consultations conducted via tablet technology are an efficient and cost-effective means of managing acute neurologic emergencies at community-based hospitals and that utilizing such technology yields high community physician satisfaction. METHOD: During a 39-month period, Vanderbilt University Medical Center in Tennessee USA, provided teleneurology services to 10 community-based hospitals that lacked adequate neurology coverage. Hospitalists at one community-based hospital were not comfortable treating any patient with a neurologic symptom, resulting in 100% of those patients being transferred. This facility now retains more than 60% of neurology patients. For less than US$1200, these hospitals were able to meet the only capital expenditure required to launch this service: the purchase of handheld tablet computers. Real-time teleneurology consultations were conducted via tablet using two-way video conferencing, radiologic image sharing, and medical record documentation. Community physicians were regularly surveyed to assess satisfaction. RESULTS: From February 2014 to May 2017, 3626 teleneurology consultations were conducted. Community physicians, in partnership with neurologists, successfully managed 87% of patients at the community-based hospital. Only 13% of patients required transfer to another facility for a higher level of care. The most common diagnoses included stroke (34%), seizure (11%), and headache/migraine (6%). The average time for the neurologist to answer a request for consultation page and connect with the community physician was 10.6 minutes. Ninety-one percent of community physicians were satisfied or somewhat satisfied with the overall service. CONCLUSION: In the assessment of neurology patients, tablets are a more cost-effective alternative to traditional telehealth technologies. The devices promote efficiency in consultations through ease of use and low transfer rates, and survey results indicate community physician satisfaction.

Neuro-ICU patient disposition: optimal venue for acute needs.

PURPOSE OF REVIEW: This article revises the recent evidence on ICU admission criteria for acute neurological patients [traumatic brain injury (TBI) patients, postoperative neurosurgical procedures and stroke]. RECENT FINDINGS: The appropriate utilization of ICU beds is essential, but it is complex and a challenge to attain. To date there are no widely accepted international guidelines for managing these acute brain-injured patients (stroke, TBI, postneurosurgery) in the ICU. The criteria for ICU admission after neurological acute injury, high-dependency unit or a specialized neurosurgical ward vary from institution to institution depending on local structures and characteristics of the available resources. Better evidence to standardize the treatment and the degree of monitoring is needed during neurological acute injury. It is highly recommended to implement clinical vigilance in these patients regardless of their destination (ICU, stroke unit or ward). SUMMARY: Currently evidence do not allow to define standardized protocol to guide ICU admission for acute neurological patients (TBI patients, postoperative neurosurgical procedures and stroke).

Headache Interest in Academic Neurology Leadership: A Cross-Sectional Study.

BACKGROUND: Headache disorders are exceedingly common, debilitating neurological conditions, and there is a striking paucity of headache specialists nationally. However, headache education is underrepresented in the curriculum of neurology residency programs and few neurology residents elect to pursue headache medicine fellowships. We aimed to explore the possibility that a low degree of headache interest among neurology department chairs and residency program directors (PDs) underlies this mismatch. METHODS: We performed a cross-sectional analysis of chairs and PDs associated with ACGME neurology residency programs. Data sources included the ACGME program list, faculty profiles on institutional webpages, Doximity profiles, the American Headache Society (AHS) membership directory, and the roster of United Council for Neurologic Specialties (UCNS) headache diplomates. A headache interest was deemed to be present with the presence of a declared headache or concussion interest, completion of a headache fellowship, active AHS membership, or UCNS certification. RESULTS: Our review included 137 residency programs comprising 127 department chairs, 132 PDs, and 5 faculty who were both chairs and PDs. Of all faculty, 62 (23.5%) were women. Headache expertise was declared by 10 (7.6%) chairs and 13 (9.5%) PDs. Headache fellowship training was pursued by 1 (0.8%) chair and 5 (3.6%) PDs, and among all faculty was the 10th most common subspecialty fellowship pursued. Three (2.3%) chairs and 7 (5.1%) PDs were AHS members. Seven (5.3%) chairs and 10 (7.3%) PDs were UCNS headache certified. An overall headache interest was present in 29 (11.0%) faculty, including 14 (10.6%) chairs and 15 (10.9%) PDs. A graduate degree aside from an MD (eg, PhD, MPH) was more likely to be achieved in faculty without a headache interest (29.4%) than faculty with a headache interest (6.9%, P = .0076). Residency programs where either the chair or PD had a headache interest were just as likely to feature a UCNS headache fellowship program than programs without chair or PD headache interest (25.0 vs 23.0%, P = .83). CONCLUSIONS: Current neurology department chairs and residency PDs have low rates of headache interest, which may influence the emphasis of headache education in neurology training. Headache interest is associated with lower rates of other graduate degrees, and future analysis should examine if academic faculty interested in headache are less likely to be in leadership positions because of a lack of research funding, opportunities, or accomplishments.

Navigating complexity in team-based clinical settings.

CONTEXT: Educators must prepare learners to navigate the complexities of clinical care. Training programmes have, however, traditionally prioritised teaching around the biomedical and the technical, not the socio-relational or systems issues that create complexity. If we are to transform medical education to meet the demands of 21st century practice, we need to understand how clinicians perceive and respond to complex situations. METHODS: Constructivist grounded theory informed data collection and analysis; during semi-structured interviews, we used rich pictures to elicit team members' perspectives about clinical complexity in neurology and in the intensive care unit. We identified themes through constant comparative analysis. RESULTS: Routine care became complex when the prognosis was unknown, when treatment was either non-existent or had been exhausted or when being patient and family centred challenged a system's capabilities, or participants' training or professional scope of practice. When faced with complexity, participants reported that care shifted from relying on medical expertise to engaging in advocacy. Some physician participants, however, either did not recognise their care as advocacy or perceived it as outside their scope of practice. In turn, advocacy was often delegated to others. CONCLUSIONS: Our research illuminates how expert clinicians manoeuvre moments of complexity; specifically, navigating complexity may rely on mastering health advocacy. Our results suggest that advocacy is often negotiated or collectively enacted in team settings, often with input from patients and families. In order to prepare learners to navigate complexity, we suggest that programmes situate advocacy training in complex clinical encounters, encourage reflection and engage non-physician team members in advocacy training.

A Profile of Neuro-Ophthalmic Practice Around the World.

BACKGROUND: To compare contrast neuro-ophthalmic practice in various countries, an 18-question survey was sent to the international North American Neuro-Ophthalmology Society (NANOS) members in the spring of 2016. METHODS: At least 1 NANOS member was contacted for each non-US nation in the NANOS membership roster. If there were multiple NANOS members from 1 country, multiple were contacted. If responses were received from more than 1 person from a single country, the first response received was used as the source data. The survey (in English) was emailed to 47 NANOS members from 31 countries. Twenty responses were received representing members from 15 nations. RESULTS: In all 15 nations, at least half of the neuro-ophthalmologists were trained as ophthalmologists. In 60% of nations, at least half of the neuro-ophthalmologists were trained internally, whereas in 33% of countries, at least half were trained in the United States. The number of physicians who practiced a significant amount of neuro-ophthalmology ranged from low (0.08/million, India) to high (3.10/million, Israel). Countries having the highest percentage of neuro-ophthalmologists exclusively practicing neuro-ophthalmology also were those with better patient access to neuro-ophthalmic care. Requirement of approval to see a neuro-ophthalmologist or for imaging studies requested by neuro-ophthalmologists was not typical. In most nations, academic neuro-ophthalmologists were paid a straight salary. In no nation were neuro-ophthalmologists paid more than another ophthalmic subspecialty. CONCLUSIONS: Individual national health care system designs and compensation models have had a profound influence on the rewards and challenges that face neuro-ophthalmologists. There seems to have been a connection between recognition of the discipline, financial rewards of neuro-ophthalmic practice, conditions that permit full-time neuro-ophthalmic practice, and patient access to care. A higher percentage of gross national product for health care did not seem to insure an adequate supply of neuro-ophthalmologists.

Telemedicine for Parkinson's Disease: Limited Engagement Between Local Clinicians and Remote Specialists.

INTRODUCTION: The integration of remote specialists into local care teams has not been widely evaluated. METHODS: Therefore, we surveyed clinicians whose patients with Parkinson's disease had participated in a national randomized controlled trial of video visits to determine (1) whether clinicians received recommendations from remote specialists; (2) whether those recommendations were implemented; (3) what barriers to specialty care local clinicians perceived; and (4) whether they would recommend video visits. RESULTS: Of 183 clinicians surveyed, 89 (49%) responded. Less than half received the recommendations of remote specialists, but they implemented most of the recommendations they received and found them to be beneficial. CONCLUSION: The greatest perceived barrier among respondents was distance from patient to specialist, and 40% of local clinicians would recommend video visits. As telemedicine grows, improved communication between remote specialists and local clinicians is likely needed.

Teleneurology for Veterans in a Major Metropolitan Area.

BACKGROUND: The recent growth in telehealth has been facilitated by the need to deliver healthcare to patients living in remote or rural areas. In contrast, the role of telehealth in more urban settings is less clear. A teleneurology program was established in 2011 at the Tibor Rubin VA Medical Center (TRVAMC) in Long Beach, California. A review of teleneurology encounters was conducted to assess the feasibility of applying this telehealth modality to patients with chronic neurological disorders living in an urban setting. METHODS: Teleneurology encounters were conducted by clinical video telehealth (CVT) between a provider at the TRVAMC and patients at local community-based outpatient clinics from November 2011 to December 2014. In a random sampling of veterans, they were asked to complete a patient satisfaction survey. RESULTS: A total of 745 teleneurology encounters were performed including 570 unique patients. Veterans with a broad range of neurological disorders were seen, including Parkinson's disease, headaches, epilepsy, dementia, cerebrovascular disease, peripheral nervous system disorders, multiple sclerosis, and other problems such as dizziness and paresthesia. Compared with patients in face-to-face clinics, patients in teleneurology clinics consistently kept their appointments. Technical problems were rare and easily resolved. The majority of patients were satisfied with the care they received through teleneurology, and preferred CVT rather than a face-to-face encounter. CONCLUSIONS: This report demonstrates the successful application of telehealth to evaluate and manage a diverse group of neurological disorders in an urban setting. Despite the relatively short distances involved, the majority of patients preferred telehealth over face-to-face encounters.

Guidelines for the use of magnetic resonance imaging in diagnosing and monitoring the treatment of multiple sclerosis: recommendations of the Swedish Multiple Sclerosis Association and the Swedish Neuroradiological Society.

Multiple sclerosis (MS) is associated with inflammatory lesions in the brain and spinal cord. The detection of such inflammatory lesions using magnetic resonance imaging (MRI) is important in the consideration of the diagnosis and differential diagnoses of MS, as well as in the monitoring of disease activity and predicting treatment efficacy. Although there is strong evidence supporting the use of MRI for both the diagnosis and monitoring of disease activity, there is a lack of evidence regarding which MRI protocols to use, the frequency of examinations, and in what clinical situations to consider MRI examination. A national workshop to discuss these issues was held in Stockholm, Sweden, in August 2015, which resulted in a Swedish consensus statement regarding the use of MRI in the care of individuals with MS. The aim of this consensus statement is to provide practical advice for the use of MRI in this setting. The recommendations are based on a review of relevant literature and the clinical experience of workshop attendees. It is our hope that these recommendations will benefit individuals with MS and guide healthcare professionals responsible for their care.

[Mission (im)possible : Setting up a neurological center 12,000 km away with telemedicine]. / "Mission (im)possible" : Aufbau eines neurologischen Zentrums 12.000 km entfernt mittels Telemedizin.

BACKGROUND: Specialized neurological treatment decreases the mortality and morbidity of stroke patients. In many regions of the world an extensive coverage is not available. The cooperation between the Krankenhaus Nordwest (KHNW, Frankfurt, Germany) and the Government of Brunei Darussalam describes the set-up process of a specialized neurological center, including stroke unit, science and rehabilitation center. AIM: The aim of this project called to teach to treat - to treat to teach was to set up a center of excellence in neurology in Brunei Darussalam over a distance of 12,000 km. Treatment options were elucidated by teaching and taught by case examples. MATERIAL AND METHODS: The construction of the Brunei Neuroscience Stroke and Rehabilitation Center (BNSRC) began in July 2010. To overcome the large distance between the department of neurology and neuroradiology at the KHNW and the BNSRC, a telemedical network was established. We provided daily teleteaching for all professions involved in patient care as well as 24/7 availability of teleneurological services from Germany to support the local team on site. RESULTS: In the BNSRC unit over 1000 patients with ischemic and hemorrhagic stroke and all the various acute neurological conditions were treated from July 2010 until July 2016 as inpatients and over 5000 were treated as outpatients. Since 2010, a total of 52 patients with stroke were treated by thrombolysis within the thrombolytic window and 81 hemicraniectomies were performed. CONCLUSION: The project has shown that it is possible to convey specialized neurological knowledge over large distances to provide significant benefits for patients and caregivers.