Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update on organizational stroke management.

AIM: Stroke is characterised by high morbidity, mortality and disability, which seriously affects the health and safety of the people. Stroke has become a serious public health problem in China. Organisational stroke management can significantly reduce the mortality and disability rates of patients with stroke. We provide this evidence-based guideline to present current and comprehensive recommendations for organisational stroke management. METHODS: A formal literature search of MEDLINE (1 January 1997 through 30 September 2019) was performed. Data were synthesised with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The Chinese Stroke Association's Levels of Evidence grading algorithm was used to grade each recommendation. RESULTS: Evidence-based guidelines are presented for the organisational management of patients presenting with stroke. The focus of the guideline was subdivided into prehospital first aid system of stroke, rapid diagnosis and treatment of emergency in stroke centre, organisational management of stroke unit and stroke clinic, construction of regional collaborative network among stroke centres and evaluation and continuous improvement of stroke medical quality. CONCLUSIONS: The guidelines offer an organisational stroke management model for patients with stroke which might help dramatically.

Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table.

Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke.

COVID-19 and Teleneurology in Sub-Saharan Africa: Leveraging the Current Exigency.

Africa has over 1.3 billion inhabitants, with over 60% of this population residing in rural areas that have poor access to medical experts. Despite having a ridiculously huge, underserved population, very few African countries currently have any form of sustained and organized telemedicine practice, and even fewer have dedicated tele-neurology services. The ongoing COVID-19 pandemic has proved to be one of the most significant disruptors of vital sectors of human endeavor in modern times. In the healthcare sector, there is an increasing advocacy to deliver non-urgent care via telemedicine. This paper examined the current state of tele-neurology practice and infrastructural preparedness in sub-Saharan Africa. Currently, there is over 70% mobile phone penetration in most of the countries and virtually all of them have mobile internet services of different technologies and generations. Although the needed infrastructure is increasingly available, it should be improved upon. We have proposed the access, costs, ethics, and support (ACES) model as a bespoke, holistic strategy for the successful implementation and advancement of tele-neurology in sub-Saharan Africa.

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.

Treatment of progressive multiple sclerosis: Challenges and promising perspectives.

Management of progressive multiple sclerosis (MS) is one of the main challenges of the new century. Based on our knowledge of pathophysiology, three therapeutic strategies are proposed: anti-inflammatory (ocrelizumab, siponimod…); remyelinating (opicinumab); and neuroprotective (high-dose biotin, ibudilast, simvastatin…). Nevertheless, despite recent promising positive clinical trials, new methodological approaches for therapeutic protocols with adaptable outcomes to assess progression are still needed.

Practice guideline: Cervical and ocular vestibular evoked myogenic potential testing: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.

OBJECTIVE: To systematically review the evidence and make recommendations with regard to diagnostic utility of cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP, respectively). Four questions were asked: Does cVEMP accurately identify superior canal dehiscence syndrome (SCDS)? Does oVEMP accurately identify SCDS? For suspected vestibular symptoms, does cVEMP/oVEMP accurately identify vestibular dysfunction related to the saccule/utricle? For vestibular symptoms, does cVEMP/oVEMP accurately and substantively aid diagnosis of any specific vestibular disorder besides SCDS? METHODS: The guideline panel identified and classified relevant published studies (January 1980-December 2016) according to the 2004 American Academy of Neurology process. RESULTS AND RECOMMENDATIONS: Level C positive: Clinicians may use cVEMP stimulus threshold values to distinguish SCDS from controls (2 Class III studies) (sensitivity 86%-91%, specificity 90%-96%). Corrected cVEMP amplitude may be used to distinguish SCDS from controls (2 Class III studies) (sensitivity 100%, specificity 93%). Clinicians may use oVEMP amplitude to distinguish SCDS from normal controls (3 Class III studies) (sensitivity 77%-100%, specificity 98%-100%). oVEMP threshold may be used to aid in distinguishing SCDS from controls (3 Class III studies) (sensitivity 70%-100%, specificity 77%-100%). Level U: Evidence is insufficient to determine whether cVEMP and oVEMP can accurately identify vestibular function specifically related to the saccule/utricle, or whether cVEMP or oVEMP is useful in diagnosing vestibular neuritis or Ménière disease. Level C negative: It has not been demonstrated that cVEMP substantively aids in diagnosing benign paroxysmal positional vertigo, or that cVEMP or oVEMP aids in diagnosing/managing vestibular migraine.

Frenkel: ¿un precursor de la neurorrehabilitación? / Frenkel: one of the forerunners of neurorehabilitation?

El término ‘neurorrehabilitación’ es entendido como el proceso destinado a reducir la deficiencia, la limitación de la actividad y la restricción de la participación que padecen las personas como consecuencia de una enfermedad neurológica, y en el que los profesionales involucrados en dicho ámbito tendrán como objetivo la reducción del grado de afectación funcional del paciente. Debido al desconocimiento que existió en relación con la capacidad plástica que presenta el sistema nervioso humano, los orígenes científicos de la rehabilitación neurológica son relativamente recientes, y se sitúan alrededor de la Segunda Guerra Mundial. Sin embargo, existen indicios de que el neurólogo Heinrich Sebastian Frenkel (1860-1931) pudo establecer las bases de la neurorrehabilitación antes de esa época. En relación con los trabajos realizados y publicados por Frenkel, existen referentes históricos que apoyarían la hipótesis de que, considerando sus metodologías de tratamiento empleadas y documentadas, lo que denominó Übungstherapie (gimnasia neurológica) podría considerarse la base de la neurorrehabilitación moderna. Estos conocimientos pudieron haberse tenido en cuenta por multitud de autores que introdujeron dichas experiencias y aprendizajes en los diversos métodos terapéuticos que surgieron con posterioridad, incluso los más novedosos y tecnológicos, si bien las raíces de la neurorrehabilitación aplicada podrían encontrarse a finales del siglo XIX (AU)

Neurorehabilitation is understood as the process intended to reduce the deficiency, limitation of activity and restriction of participation experienced by people as a result of a neurological diseases, and where the professionals involved in this field will aim to reduce the functional involvement degree of the patient. Due to the ignorance existed about the plastic capacity in the nervous system in humans, the scientific origins of neurological rehabilitation is relatively recent, which are located around the Second World War. However, there are signs that the neurologist Heinrich Sebastian Frenkel (1860-1931) was able to establish the basis of neurorehabilitation before that time. There are historical concerning regarding the work conducted and published by Frenkel that would support the hypothesis, based on the characteristics of their treatment employed and documented methodologies, that what he called ‘Übungstherapie’ (neurological gymnastic), it could be considered as the basis of what we consider today as modern neurorehabilitation. This knowledge could have been used by many authors who introduced those experiences and lessons learned to the multiple therapeutic methods that emerged after, even the most innovative and technological, while the roots of neurorehabilitation could be found at the end of the 19th century (AU)

Summary of evidence-based guideline: complementary and alternative medicine in multiple sclerosis: report of the guideline development subcommittee of the American Academy of Neurology.

OBJECTIVE: To develop evidence-based recommendations for complementary and alternative medicine (CAM) in multiple sclerosis (MS). METHODS: We searched the literature (1970-March 2011; March 2011-September 2013 MEDLINE search), classified articles, and linked recommendations to evidence. RESULTS AND RECOMMENDATIONS: Clinicians might offer oral cannabis extract for spasticity symptoms and pain (excluding central neuropathic pain) (Level A). Clinicians might offer tetrahydrocannabinol for spasticity symptoms and pain (excluding central neuropathic pain) (Level B). Clinicians should counsel patients that these agents are probably ineffective for objective spasticity (short-term)/tremor (Level B) and possibly effective for spasticity and pain (long-term) (Level C). Clinicians might offer Sativex oromucosal cannabinoid spray (nabiximols) for spasticity symptoms, pain, and urinary frequency (Level B). Clinicians should counsel patients that these agents are probably ineffective for objective spasticity/urinary incontinence (Level B). Clinicians might choose not to offer these agents for tremor (Level C). Clinicians might counsel patients that magnetic therapy is probably effective for fatigue and probably ineffective for depression (Level B); fish oil is probably ineffective for relapses, disability, fatigue, MRI lesions, and quality of life (QOL) (Level B); ginkgo biloba is ineffective for cognition (Level A) and possibly effective for fatigue (Level C); reflexology is possibly effective for paresthesia (Level C); Cari Loder regimen is possibly ineffective for disability, symptoms, depression, and fatigue (Level C); and bee sting therapy is possibly ineffective for relapses, disability, fatigue, lesion burden/volume, and health-related QOL (Level C). Cannabinoids may cause adverse effects. Clinicians should exercise caution regarding standardized vs nonstandardized cannabis extracts and overall CAM quality control/nonregulation. Safety/efficacy of other CAM/CAM interaction with MS disease-modifying therapies is unknown.

Person-oriented perspectives in neurology.

Person-oriented medicine is characterized by a holistic approach in patient ma- nagement that embraces physical, psychological, social and spiritual aspects of health and dise- ase. It responds to the needs of patients and health care workers to form an effective therapeutic relationship based on trust, empathy, compassion and responsiveness to the individual needs of a patient. Person-oriented perspectives in neurology include active collaborative partnership between a physician and a patient, and intuitive perception, which has a neurobiological correlate in the hu- man mirror neuron system, thus expressing a considerable impact on the quality of the physician's diagnostic and therapeutic activities. On the other hand, personalized approach in medicine implies integration of clinical information and personal genotyping. Personalized neurology provides gene- based preclinical prediction of disease with improved risk assessment, early detection of disease and targeted intervention. The combination of personalized approach and clinical information accelera- tes the translation of genetic discoveries into clinical practice, which ultimately results in improved health care system. Person-oriented perspectives contribute significantly to the growing pluralism of medical science and provide a greater humanization of medicine, individualized treatment and autonomy during therapeutic processes.

[Regional and national stroke units in Germany: amended certification criteria]. / Regionale und überregionale Stroke-Units in Deutschland : Aktualisierte Zertifizierungskriterien.

Stroke units (SU) have been certified for many years by the German Stroke Society (DSG) and the German Stroke Aid Foundation (SDSH). Since 2009 this is now undertaken in the third generation by the LGA InterCert of the Technical Surveillance Society of Rhineland (TÜV Rheinland). This article presents the amended certification criteria which came into effect in 2012. Many criteria and definitions could be further defined and specified and residual grey areas and fields of conflict could be reduced. For the first time a distinction has been made between the minimum requirements relevant for certification and additional recommendations by the SU Commission of the DSG. In this manner the authors are aiming to motivate SU operators not just to align quality assurance measures to the minimum requirements but to deliberately go beyond them. There is a great deal of evidence to indicate that this will not only serve to increase the motivation of personnel and the quality of treatment but simultaneously the economic situation can also be improved.

Evaluation and management of bone health in children with epilepsy on long-term antiepileptic drugs: United Kingdom survey of paediatric neurologists.

BACKGROUND AND OBJECTIVE: Current evidence indicates long-term use of antiepileptic drugs (AEDs) is associated with impaired childhood bone health. The objective of this study was to ascertain the current clinical practice of paediatric neurologists managing children with epilepsy on long-term (>2 years) AED therapy, particularly against the UK Medicines and Healthcare products Regulatory Agency (MHRA) current recommendation of vitamin D supplementation in patients on long-term AEDs at-risk of impaired bone health. METHODS: An internet-based survey of UK paediatric neurologists who routinely see children with epilepsy (n = 95) covered clinicians' epilepsy case-load and reflection on their current clinical practice with estimation of the frequency with which they considered various bone health issues. Responses were graded as 'frequent'(≥50%), 'sometimes'(25%-50%) and 'infrequent'(<25%). RESULTS: Overall response rate was 72/95 (76%). 3% frequently recommend prophylactic calcium and vitamin D supplementation, 6% frequently perform bone screening investigations, 7% frequently give bone health advice and 10% frequently enquire about skeletal risk factors. Clinical practices were not associated with epilepsy caseload (p-values 0.44-1). 84% infrequently performed bone health screening investigations. 54% of respondents indicated that, if performed, 100% would undertake bone profile, 64% 25(OH) Vitamin D, 18% PTH, 49% dual energy X-ray absorptiometry (DEXA) scan and 13% bone X-ray. CONCLUSIONS: The majority of paediatric neurologists do not routinely consider bone health related issues in children on long-term AEDs. Greater emphasis should be placed on vitamin D supplementation in these children.

[Quality improvement of multiple choice examinations: in psychiatry, psychosomatic medicine, psychotherapy, and neurology]. / Qualitätsverbesserung von Multiple-Choice-Prüfungen: In Psychiatrie, Psychosomatik, Psychotherapie und Neurologie.

We describe a continuous improvement process in planning, performance, and evaluation of multiple choice examination questions in psychiatry, neurology, psychosomatic medicine, and psychotherapy. We analyzed 640 multiple choice questions of 1,419 students during a period of 4 years. Crucial changes concerned the abolishment of problematic question types, implementation of validated new question formats, extension of case-based questions, elongation of question stems, quantitative evaluation of item difficulty, discriminatory value, and the introduction of a peer review system. Consequences of these improvements were greater item difficulty (average 18%) and discriminatory value (average 67%) and reduced post hoc analysis times. Introduction of peer reviews resulted in longer preparation time, which was however appreciated by the peers due to a clear improvement in item quality.

Epilepsy surgery and vagal nerve stimulation: what all neurologists should know.

Epilepsy surgery treatment should be considered as standard of care for all patients with medically intractable partial-onset epilepsy who are found to be good surgical candidates based on their presurgical evaluation. Delaying surgical treatment continues to be a problem among neurologists. The early recognition of pharmacoresistance and patients' referral for presurgical evaluation can shorten the time to identify potential surgical candidates. A successful early surgery can be expected to significantly improve these patients' quality of life, not only because of a seizure-free state but also by improving psychiatric comorbidities. Vagal nerve stimulation (VNS) is currently the only FDA-approved neurostimulation treatment strategy for patients who are not considered candidates for epilepsy surgery. VNS has been shown to decrease seizure frequency by approximately 50% in 30 to 40% of implanted patients. The future of epilepsy surgery and neurostimulation for those individuals with medically intractable partial-onset epilepsy shows great promise.