Insomnia: A Current Review.

Insomnia is a prevalent sleep disorder with pervasive effects on quality of life. The deleterious effects of insomnia are largely preventable with appropriate therapeutic interventions. Pharmacotherapy should be initiated in patients with inadequate response to CBT-I and tailored to comorbidities. Referral to a sleep medicine specialist should be considered in patients with a suboptimal response.

Antisense-induced downregulation of major circadian genes modulates the expression of histone deacetylase-2 (HDAC-2) and CREB-binding protein (CBP) in the medial shell region of nucleus accumbens of mice exposed to chronic excessive alcohol consumption.

Circadian genes in the medial accumbal shell (mNAcSh) region regulate binge alcohol consumption. Here, we investigated if antisense-induced knockdown of major circadian genes (Per1, Per2, and NPAS2) in the mNAcSh of mice exposed to intermittent access two-bottle choice (IA2BC) paradigm modulates the expression of histone deacetylase-2 (HDAC-2) and CREB-binding protein (CBP), key epigenetic modifiers associated with withdrawal-associated behaviors such as anxiety. Adult male C57BL/6J mice (N = 28), surgically implanted with bilateral guide cannulas above the mNAcSh, were chronically (4 weeks) exposed to alcohol (20% v/v) or saccharin (0.03%) via IA2BC paradigm. In the fourth week, a mixture of antisense (AS-ODNs; N = 14/group) or nonsense (NS-ODNs; N = 14/group) oligodeoxynucleotides against circadian genes were bilaterally infused into the mNAcSh. Subsequently, alcohol/saccharin consumption and preference were measured followed by euthanization of animals and verification of microinjection sites by visual inspection and the expression of HDAC-2 and CBP by using RT-PCR along with the verification of antisense-induced downregulation of circadian genes in the mNAcSh. As compared with NS-ODNs, AS-ODNs infusion significantly attenuated the alcohol-induced increase in HDAC-2 and reduction in CBP expression in the mNAcSh along with a significant reduction in alcohol consumption and preference. No significant effect was observed on either saccharin consumption or preference. Our results suggest that circadian genes in the mNAcSh may have a causal to play in mediating epigenetic changes observed after chronic alcohol consumption.

Activation of dopamine D2 receptors in the medial shell region of the nucleus accumbens increases Per1 expression to enhance alcohol consumption.

Circadian genes, including Per1, in the medial shell region of nucleus accumbens (mNAcSh), regulate binge alcohol consumption. However, the upstream mechanism regulating circadian genes-induced alcohol consumption is not known. Since activation of dopamine D2 receptors (D2R) increases Per1 gene expression, we hypothesised that local infusion of quinpirole, a D2R agonist, by increasing Per1 gene expression in the mNAcSh, will increase binge alcohol consumption in mice. We performed two experiments on male C57BL/6J mice, instrumented with bilateral guide cannulas above the mNAcSh, and exposed to a 4-day drinking-in-dark (DID) paradigm. The first experiment determined the effects of bilateral infusion of quinpirole (100 ng/300 nl/site) or DMSO (Vehicle group) in the mNAcSh on Per1 gene expression and alcohol consumption. The second experiment determined the effect of antisense-induced downregulation of Per1 in the mNAcSh on the quinpirole-induced increase in alcohol consumption. Control experiments were performed by exposing the animals to sucrose (10% w/v). After the experiment, animals were euthanised, brains removed and processed for localisation of injection sites and analysis of Per1 gene expression in the mNAcSh. As compared with the DMSO, local bilateral infusion of quinpirole significantly increased the expression of Per1 in the mNAcSh along with an increase in the amount of alcohol consumed in mice exposed to DID paradigm. In addition, local antisense-induced downregulation of Per1 significantly attenuated the effects of intro-accumbal infusion of quinpirole on alcohol consumption. Our results suggest that Per1 in the mNAcSh mediates D2R activation-induced increase in alcohol consumption.

Antisense-induced knockdown of cAMP response element-binding protein downregulates Per1 gene expression in the shell region of nucleus accumbens resulting in reduced alcohol consumption in mice.

INTRODUCTION: We recently showed that circadian genes expressed in the shell region of nucleus accumbens (NAcSh) play a key role in alcohol consumption, though, the molecular mechanism of those effects is unclear. Because CREB-binding protein (CBP) promotes Per1 gene expression, we hypothesized that alcohol consumption would increase CBP expression in the NAcSh and antisense-induced knockdown of CBP would reduce Per1 expression and result in a reduction in alcohol consumption. METHODS: To test our hypothesis, we performed two experiments. The Drinking-in-the-dark (DID) paradigm was used to evaluate alcohol consumption in male C57BL/6J mice. In Experiment 1 we examined the effects of alcohol consumption on CBP gene expression in the NAcSh. Control animals were exposed to, sucrose [10% (w/v) taste and calorie] and water (consummatory behavior). In Experiment 2 examined the effects of CBP gene silencing on the expression of the Per1 gene in the NAcSh and alcohol consumption in mice exposed to alcohol using the DID paradigm. CBP gene silencing was achieved by local infusion of two doses of either CBP antisense oligodeoxynucleotides (AS-ODNs; Antisense group) or nonsense ODNs (NS-ODNs; Nonsense group) bilaterally microinjected into the NAcSh within 24 h before alcohol consumption on Day 4 of the DID paradigm. The microinfusion sites were verified by cresyl violet staining. RESULTS: Compared to sucrose, alcohol consumption, under the DID paradigm, significantly increased the expression of CBP in the NAcSh. Compared to Controls, bilateral infusion of CBP AS-ODNs significantly reduced the expression of Per1 in the NAcSh and alcohol consumption without affecting the amount of sucrose consumed. CONCLUSIONS: Our results suggest that CBP is an upstream regulator of Per1 expression in the NAcSh and may act via Per1 to modulate alcohol consumption.

Antisense-Induced Downregulation of Clock Genes in the Shell Region of the Nucleus Accumbens Reduces Binge Drinking in Mice.

INTRODUCTIONS: Binge drinking is a deadly pattern of alcohol consumption. Evidence suggests that genetic variation in clock genes is strongly associated with alcohol misuse; however, the neuroanatomical basis for such a relationship is unknown. The shell region of the nucleus accumbens (NAcSh) is well known to play a role in binge drinking. Hence, we examined whether clock genes in the NAcSh regulate binge drinking. METHODS: To address this question, 2 experiments were performed on male C57BL/6J mice. In the first experiment, mice exposed to alcohol or sucrose under the 4-day drinking-in-the-dark (DID) paradigm were euthanized at 2 different time points on day 4 [7 hours after light (pre-binge drinking) or dark (post-binge drinking) onset]. The brains were processed for RT-PCR to examine the expression of circadian clock genes (Clock, Per1, and Per2) in the NAcSh and suprachiasmatic nucleus (SCN). In the second experiment, mice were exposed to alcohol, sucrose, or water as described above. On day 4, 1 hour prior to the onset of alcohol exposure, mice were bilaterally infused with either a mixture of circadian clock gene antisense oligodeoxynucleotides (AS-ODNs; antisense group) or nonsense/random ODNs (R-ODNs; control group) through surgically implanted cannulas above the NAcSh. Alcohol/sucrose/water consumption was measured for 4 hours. Blood alcohol concentration was measured to confirm binge drinking. Microinfusion sites were histologically verified using cresyl violet staining. RESULTS: As compared to sucrose, mice euthanized post-binge drinking (not pre-binge drinking) on day 4 displayed a greater expression of circadian genes in the NAcSh but not in the SCN. Knockdown of clock genes in the NAcSh caused a significantly lower volume of alcohol to be consumed on day 4 than in the control treatment. No differences were found in sucrose or water consumption. CONCLUSIONS: Our results suggest that clock genes in the NAcSh play a crucial role in binge drinking.

Insomnia treatment effects among young adult drinkers: Secondary outcomes of a randomized pilot trial.

BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) has moderate-to-large effects on insomnia among young adult drinkers, with preliminary data indicating that improvements in insomnia may have downstream effects on alcohol-related consequences. However, the mechanism(s) by which insomnia treatment may facilitate reductions in alcohol-related problems is unclear. Secondary outcome data from a randomized pilot trial were used to examine CBT-I effects on four proposed mediators of the insomnia/alcohol link: alcohol craving, delay discounting, negative affect, and difficulties with emotion regulation. METHODS: Young adults (ages 18 to 30 years) with insomnia who reported 1+ binge drinking episode (4/5+ drinks for women/men) in the past month were randomized to receive CBT-I (n = 28) or to a sleep hygiene control (n = 28). Outcomes were assessed at baseline, after 5 weeks of treatment, and at 1-month posttreatment. RESULTS: Relative to those in sleep hygiene, CBT-I participants reported greater decreases in alcohol craving (d = 0.33) at the end of treatment and greater 1-month posttreatment decreases in delay discounting of large rewards (d = 0.42). CBT-I did not have a significant effect on delay discounting of smaller rewards or momentary negative affect. There was also no significant treatment effect on difficulties with emotion regulation, although findings were confounded by a significant group difference at baseline in difficulties with emotion regulation. CONCLUSIONS: Treatment of insomnia may lead to improvements in alcohol craving and delay discounting of large rewards among young adult drinkers with insomnia. Additional research examining whether improvement in insomnia is a mechanism for improvement in addiction domains is warranted.

Sleep Fragmentation and Atherosclerosis: is There a Relationship?

Sleep fragmentation refers to the disruption of sleep architecture with poor quality of sleep despite optimal duration of sleep. Sleep fragmentation has been shown to have multiple effects on different body systems. This article reviews the effect of sleep fragmentation on the rate of atherosclerosis which has been linked to comorbidities like myocardial infarction, stroke, and coronary artery disease with an aim to educate patients regarding the importance of sleep hygiene and to incorporate a good amount and quality of sleep as life style modification along with diet and exercise.

A single episode of binge alcohol drinking causes sleep disturbance, disrupts sleep homeostasis, and down-regulates equilibrative nucleoside transporter 1.

Binge alcohol drinking, a risky pattern of alcohol consumption, has severe consequences toward health and well-being of an individual, his family, and society. Although, binge drinking has detrimental effects on sleep, underlying mechanisms are unknown. We used adult male C57BL/6J mice and exposed them to a single, 4-h session of binge alcohol self-administration, in stress-free environment, to examine neuronal mechanisms affecting sleep. We first verified binge pattern of alcohol consumption. When allowed to self-administer alcohol in a non-stressful environment, mice consumed alcohol in a binge pattern. Next, effect of binge drinking on sleep-wakefulness was monitored. While sleep-wakefulness remained unchanged during drinking session, significant increase in non-rapid eye movement (NREM) sleep was observed during 4 h of active period post-binge, followed by increased wakefulness, reduced sleep during subsequent sleep (light) period; although the timing of sleep onset (at lights-on) remained unaffected. Next, electrophysiological and biochemical indicators of sleep homeostasis were examined using sleep deprivation-recovery sleep paradigm. Mice exposed to binge drinking did not show an increase in cortical theta power and basal forebrain adenosine levels during sleep deprivation; NREM sleep and NREM delta power did not increase during recovery sleep suggesting that mice exposed to binge alcohol do not develop sleep pressure. Our final experiment examined expression of genes regulating sleep homeostasis following binge drinking. While binge drinking did not affect adenosine kinase and A1 receptor, expression of equilibrative nucleoside transporter 1 (ENT1) was significantly reduced. These results suggest that binge alcohol consumption-induced down-regulation of ENT1 expression may disrupt sleep homeostasis and cause sleep disturbances. Open Data: Materials are available on https://cos.io/our-services/open-science-badges/ https://osf.io/93n6m/.

Melatonin promotes sleep in mice by inhibiting orexin neurons in the perifornical lateral hypothalamus.

Melatonin promotes sleep. However, the underlying mechanisms are unknown. Orexin neurons in the perifornical lateral hypothalamus (PFH) are pivotal for wake promotion. Does melatonin promote sleep by inhibiting orexin neurons? We used C57BL/6J mice and designed 4 experiments to address this question. Experiment 1 used double-labeled immunofluorescence and examined the presence of melatonin receptors on orexin neurons. Second, mice, implanted with bilateral guides targeted toward PFH and sleep-recording electrodes, were infused with melatonin (500 pmole/50 nL/side) at dark onset (onset of active period), and spontaneous bouts of sleep-wakefulness were examined. Third, mice, implanted with bilateral guides into the PFH, were infused with melatonin (500 pmole/50 nL/side) at dark onset and euthanized 2 hours later, to examine the activation of orexin neurons using c-Fos expression in orexin neurons. Fourth, mice, implanted with PFH bilateral guides and sleep-recording electrodes, were infused with melatonin receptor antagonist, luzindole (10 pmol/50 nL/side), at light onset (onset of sleep period), and spontaneous bouts of sleep-wakefulness were examined. Our results suggest that orexin neurons express MT1, but not MT2 receptors. Melatonin infusion into the PFH, at dark onset, site-specifically and significantly increased NREM sleep (43.7%, P = .003) and reduced wakefulness (12.3%, P = .013). Local melatonin infusion at dark onset inhibited orexin neurons as evident by a significant reduction (66%, P = .0004) in the number of orexin neurons expressing c-Fos. Finally, luzindole infusion-induced blockade of melatonin receptors in PFH at sleep onset significantly increased wakefulness (44.1%, P = .015). Based on these results, we suggest that melatonin may act via the MT1 receptors to inhibit orexin neurons and promote sleep.

Sleep Medicine: Stroke and Sleep.

Cerebrovascular disease encompassing both ischemic and hemorrhagic strokes are among the leading causes of disability and mortality globally. The current evidence strongly suggests that identifying and addressing sleep disorders should be a part of both primary and secondary stroke prevention. Stroke and sleep are 'bedfellows' since sleep disorders, including sleep-disordered breathing, parasomnias, sleep-related movement disorders, insomnia, and hypersomnia are intimately intertwined with co-morbid cardiovascular conditions and increase stroke risk. Post-stroke sleep disorders also impact stroke rehabilitation, quality of life, and if left untreated can contribute to stroke recurrence.

Hypersomnia.

Adequate alertness is necessary for proper daytime functioning. Impairment of alertness or increase in sleepiness results in suboptimal performance and adversely affects the quality of life. While some causes of somnolence are intrinsic to the brain circuitry and neurochemical architecture, others are due to maladaptive behaviors and disorders affecting the normal sleep homeostasis. Identification of the problem and understanding the underlying etiology is the key to timely treatment and better outcomes.

Sleep Medicine: Parasomnias.

Parasomnias are abnormal and undesirable behaviors during sleep and are thought to be due to the sleep state instability. Some of them are benign, while some of them point to a possible underlying neurodegenerative process. This article briefly discusses the clinical characteristics, demographics, and pathophysiology of major parasomnias and associated disorders. The classification outlined in this article conforms to the current version of International Classification of Sleep disorders.

Lesion of the basal forebrain cholinergic neurons attenuates sleepiness and adenosine after alcohol consumption.

Alcohol has a profound effect on sleep. However, neuronal substrates mediating sleep-promoting effects of alcohol are unknown. Since the basal forebrain (BF) cholinergic neurons are implicated in the homeostatic regulation of sleep, we hypothesized that the BF cholinergic neurons may have an important role in sleepiness observed after alcohol consumption. 192-IgG-saporin (bilateral BF infusions) was used to selectively lesion BF cholinergic neurons in adult male Sprague-Dawley rats. Standard surgical procedures were used to implant sleep recording electrodes or microdialysis guide cannulas. The first experiment used between-group design [lesion and sham (controls)] and examined effects of BF cholinergic neuronal lesions on alcohol (3 g/Kg; ig) induced sleep promotion. The second experiment used within-group design [lesion (ipsilateral BF) and sham (controls; contralateral BF) in same animal] and local reverse microdialysis infusion of alcohol (300 mM) to examine the effects of cholinergic neuronal lesions on extracellular adenosine in the BF. Alcohol had a robust sleep promoting effect in controls as evidenced by a significant reduction in sleep onset latency and wakefulness; non-rapid eye movement sleep was significantly increased. No such alcohol-induced sleep promotion was observed in lesioned rats with significantly fewer BF cholinergic neurons. Rapid eye movement sleep was minimally affected. Adenosine release was significantly reduced following local infusion of alcohol on the lesion side, with significantly fewer cholinergic neurons as compared with the control side. Based on these results, we suggest that alcohol promotes sleep by increasing extracellular adenosine via its action on cholinergic neurons of the BF. Read the Editorial Highlight for this article on page 620.

Sleep and Parkinson Disease.

Sleep disorders are prevalent in Parkinson disease (PD), a disease with well recognized motor dysfunction. Sleep related problems received little attention until the last three decades. Sleep disorders seen in PD patients include insomnia, excessive sleepiness, restless legs syndrome, REM sleep behavior disorder. Some of these can have significant impact and lower the quality of life in these patients. An understanding of sleep issues in PD can help identify them early and result in optimal management.

Nicotine administration in the wake-promoting basal forebrain attenuates sleep-promoting effects of alcohol.

Nicotine and alcohol co-abuse is highly prevalent, although the underlying causes are unclear. It has been suggested that nicotine enhances pleasurable effects of alcohol while reducing aversive effects. Recently, we reported that nicotine acts via the basal forebrain (BF) to activate nucleus accumbens and increase alcohol consumption. Does nicotine suppress alcohol-induced aversive effects via the BF? We hypothesized that nicotine may act via the BF to suppress sleep-promoting effects of alcohol. To test this hypothesis, adult male Sprague-Dawley rats were implanted with sleep-recording electrodes and bilateral guides targeted toward the BF. Nicotine (75 pmol/500 nL/side) or artificial cerebrospinal fluid (ACSF; 500 nL/side) was microinjected into the BF followed by intragastric alcohol (ACSF + EtOH and NiC + EtOH groups; 3 g/kg) or water (NiC + W and ACSF + W groups; 10 mL/kg) administration. On completion, rats were killed and processed to localize injection sites in the BF. The statistical analysis revealed a significant effect of treatment on sleep-wakefulness. While rats exposed to alcohol (ACSF + EtOH) displayed strong sleep promotion, nicotine pre-treatment in the BF (NiC + EtOH) attenuated alcohol-induced sleep and normalized sleep-wakefulness. These results suggest that nicotine acts via the BF to suppress the aversive, sleep-promoting effects of alcohol, further supporting the role of BF in alcohol-nicotine co-use.

Acute binge alcohol administration reverses sleep-wake cycle in Sprague Dawley rats.

BACKGROUND: Binge alcohol drinking is among the most common pattern of alcohol consumption in our society. Binge alcohol consumption has serious negative consequence on mental and physical health. Although alcohol consumption is known to have profound impact on sleep, it is yet unknown as to how binge alcohol affects/alters sleep-wakefulness. The objective of this study was to examine the effect of acute binge alcohol administration on sleep-wakefulness. METHODS: Male Sprague Dawley rats were used in the study. Under standard aseptic surgical conditions, rats (N = 7) were implanted with sleep-recording electrodes. After postoperative recovery and habituation, baseline sleep-wakefulness was recorded. Subsequently, rats were exposed to binge alcohol treatment as follows: One hour before light onset, a priming dose of 5 g/kg of alcohol was administered followed by 2 subsequent doses (adjusted based on the intoxication level of the rat) approximately 8 hours apart. Sleep-wakefulness was continuously recorded for 3 days post-binge. RESULTS: Acute binge alcohol administration had no significant effect on sleep-wakefulness on post-binge Day 1. However, on post-binge Day 2, after blood alcohol concentration (BAC) was 0, sleep disruptions were observed manifested by a reversal of sleep-wakefulness as evident from insomnia-like symptoms (significant increase in wakefulness; significant reduction in nonrapid eye movement [NREM] sleep) during the normal sleep (light) period and excessive sleep (significant increase in NREM sleep) during the normal active (dark) period similar to excessive daytime sleepiness in humans. All sleep-wakefulness changes were normalized on Day 3 post-binge. CONCLUSIONS: Alcohol hangover is defined as the presence of unpleasant symptoms that peak when BAC is 0. Our results suggest that the reversal of sleep-wakefulness accompanies alcohol hangover after binge alcohol administration.

Nicotine administration in the cholinergic basal forebrain increases alcohol consumption in C57BL/6J mice.

BACKGROUND: Alcohol and nicotine are the most commonly abused drugs. The frequent co-morbidity of alcohol and nicotine addiction has led to the hypothesis that they may act via a common substrate: the nicotinic acetylcholine receptors (nAChRs) especially α4ß2 and α7 subtypes, the most prevalent nAChRs in the brain. Compelling evidence suggests that alcohol enhances the function of α4ß2 subtype. The FDA approved smoking cessation drug, varenicline ("Chantix"), a partial agonist of α4ß2 nAChR subtype, reduces alcohol self-administration and alcohol craving in humans and rodents. The cholinergic basal forebrain (BF) controls various functions including arousal, attention, and cognition, and there is a predominance of α4ß2 and α7 subtypes. We have shown that the BF has an important role in mediating the effects of alcohol and local infusion of nicotine in the BF activates nucleus accumbens. Does BF have any role in mediating the effect of nicotine on alcohol consumption? This study was designed to address this question. METHODS: Under standard surgical procedure, C57BL/6J mice were stereotaxically implanted with bilateral stainless steel guide cannula above the BF. Following post operative recovery and habituation, the animals were exposed to the "drinking-in-the-dark" paradigm whereby alcohol (20%) was presented for 2 hours daily for 3 days. On the fourth day, nicotine or artificial cerebrospinal fluid (ACSF) was microinjected bilaterally in the BF. After 1 hour, mice were exposed to alcohol and allowed to self-administer for 4 hours. The effect of BF nicotine infusion on sucrose consumption was also examined. On completion, mice were euthanized, brain removed and processed to localize the BF injection sites. RESULTS: As compared with the ACSF, bilateral nicotine injections into the BF significantly (p < 0.05; n = 5/group) increased alcohol consumption. Sucrose consumption remained unaffected. CONCLUSIONS: Based on our results, we believe that the BF may have an important role in nicotine-alcohol co-use.

Nicotine infusion in the wake-promoting basal forebrain enhances alcohol-induced activation of nucleus accumbens.

BACKGROUND: Nicotine and alcohol co-abuse is highly prevalent. Recently, we have shown that nicotine infusion in the basal forebrain (BF) increases alcohol consumption. As nucleus accumbens (NAc) is the terminal brain region associated with drug addiction, we hypothesize that nicotine infusion in the BF may enhance alcohol-induced activation of NAc. METHODS: Adult male Sprague-Dawley rats were surgically implanted with bilateral guide cannulas in the BF. Following postoperative recovery, rats were divided into 4 groups: (i) ACSF + W group received artificial cerebrospinal fluid (ACSF; 500 nl/side) in the BF and systemic water (intragastric [ig]; 10 ml/kg; N = 5), (ii) ethanol (EtOH) group received ACSF in the BF (500 nl/side) and systemic alcohol (ig; 3 g/kg; N = 5), (iii) NiC group received nicotine in the BF (75 pmole/500 nl/side) and systemic water (ig; 10 ml/kg; N = 5), and (iv) NiC + EtOH group received nicotine in the BF (75 pmole/500 nl/side) and systemic alcohol (ig; 3 g/kg; N = 5). Rats were euthanized 2 hours after treatment to examine c-Fos expression in the NAc by immunohistochemistry. RESULTS: All injections sites were localized in the BF. Two-way analysis of variance (ig vs. infusion) revealed significant main effects of both treatments (ig and infusion, p < 0.001) on c-Fos expression in the NAc shell, but not in the core. Subsequent post hoc test (Bonferroni's) revealed that as compared to ACSF + W group, c-Fos expression was significantly increased in the shell of NAc of rats in all 3 (EtOH, NiC, and NiC + EtOH) groups with maximal increase observed in NiC + EtOH group. CONCLUSIONS: The results suggest the following: (i) BF nicotine infusion induced c-Fos in both core and the shell region of NAc at levels comparable to those observed after systemic alcohol administration; (ii) BF nicotine infusion with systemic alcohol induced a significant additive increase in c-Fos expression only in the NAc shell region. These findings implicate the BF in alcohol and nicotine co-use.

Isolated hypersomnia due to bilateral thalamic infarcts.

We describe a unique patient who developed hypersomnia as the sole presenting symptom of bilateral thalamic infarcts.

Setting Up a Teleneurology Clinic during COVID-19 Pandemic: Experience from an Academic Practice.

The declaration of the COVID-19 pandemic necessitated rapid implementation of telehealth across all neurological subspecialties. Transitioning to telehealth technology can be challenging for physicians and health care facilities with no prior experience. Here, we describe our experience at the Neurology and Sleep Disorders Clinic at the University of Missouri-Columbia of successful transition of all in-person clinic visits to telehealth visits within a span of 2 weeks with a collaborative effort of clinic staff and the leadership. Within a month of launch, 18 clinic providers with no prior telehealth experience conducted 1451 telehealth visits, which was the 2nd highest number of telehealth visits conducted by any department at the University of Missouri-Columbia Health Care system. Lack of connectivity, poor video/audio quality, and unavailability of smart devices among rural populations were the important shortcomings identified during our telehealth experience. Our study highlighted the need for expansion of high-speed internet access across rural Missouri. We hope our experience will help other health care facilities to learn and incorporate telehealth technology at their facilities, overcome the associated challenges, and serve patient needs while limiting the spread of the COVID-19.