Early Impact of the COVID-19 Pandemic on Outpatient Neurologic Care in Hawai'i.

In March 2020, Hawai'i instituted public health measures to prevent the spread of Coronavirus disease 2019 (COVID-19), including stay-at-home orders, closure of non-essential businesses and parks, use of facial coverings, social distancing, and a mandatory 14-day quarantine for travelers. In response to these measures, Hawai'i Pacific Neuroscience (HPN) modified practice processes to ensure continuity of neurological treatment. A survey of patients was performed to assess the impact of the COVID-19 pandemic and pandemic-related practice processes for quality improvement. Overall, 367 patients seen at HPN between April 22, 2020, and May 18, 2020, were surveyed via telephone. Almost half (49.6%) participated in a telemedicine appointment, with the majority finding it easy to use (87.4%) and as valuable as face-to-face appointments (68.7%). Many (44.5%) patients said they would have missed a health care appointment without the availability of telemedicine, and 47.3% indicated they might prefer to use telemedicine over in-person appointments in the future. Many reported new or worsening mental health problems, including depression (27.6%), anxiety (38.3%), or sleep disturbances (37.4%). A significant number reported worsening of their condition, with 33.1% of patients who experience migraines reporting increased symptom severity or frequency, 45.8% patients with Alzheimer's disease reporting worsened symptoms, 38.5% of patients with Parkinson's disease who had a recent fall, and 50.0% of patients with multiple sclerosis experiencing new or worsened symptoms. Insights from this survey applied to the practice's pandemic-related processes include emphasizing lifestyle modification, screening for changes in mental health, optimizing treatment plans, and continuing the option of telemedicine.

Early impact of the COVID-19 pandemic on outpatient migraine care in Hawaii: Results of a quality improvement survey.

OBJECTIVE: A survey was implemented for early assessment of pandemic-related practice processes and quality improvement (QI). BACKGROUND: In response to the public health measures in Hawaii to curtail the coronavirus 2019 pandemic, Hawaii Pacific Neuroscience (HPN) adapted their patient care to ensure continuity of neurological treatment. METHODS: The telephone survey was conducted on patients seen at HPN during the period of April 22, 2020-May 18, 2020 to address four areas related to patients' outpatient experience: delivery of care, general well-being, experience with telemedicine, and disease-specific questions. RESULTS: A total of 928 patients were contacted of which 429 (46.2%) patients responded and 367 (85.5%) agreed to participate. A total of 133 patients with migraine and 234 patients with other neurological conditions provided responses. Our migraine patients' survey responses suggest that their well-being was disproportionately negatively affected by the pandemic. Survey respondents with migraine were significantly more likely than their non-migraine peers to report worsening anxiety and sleep problems [62/132 (47.0%) vs. 78/234 (33.3%), χ2  = 6.64, p = 0.010, and 64/132 (48.5%) vs. 73/234 (31.2%), χ2  = 10.77, p = 0.001]; migraine patients also reported worsening of depression as a result of the pandemic more than patients with other diagnoses, though this was not statistically significant [44/132 (33.3%) vs. 57/234 (24.4%), χ2  = 3.40, p = 0.065]. In regard to access to healthcare, significantly more migraine patients reported running out of medications than those with other diagnoses [20/133 (15.0%) vs. 18/234 (7.7%), χ2  = 4.93, p = 0.026]. More avoided seeking medical help for new health problems because of the pandemic [30/133 (22.6%) vs. 30/234 (12.8%), χ2  = 5.88, p = 0.015]. Migraine patients were also significantly impacted economically by the pandemic; 43/132 (32.4%) of migraine patients reported losing their jobs as the result of the pandemic versus 34/234 (14.5%) of their peers (χ2  = 11.20, p < 0.001). An increase in headache severity or frequency was reported in 39/118 (33.1%) of respondents and 19/118 (16.1%) reported to using more abortive therapy than usual. Telemedicine was well received by almost all patients who took advantage of the option. Most of those patients found telemedicine to be easy to use and as valuable as an in-person visit. Migraine patients indicated with more frequency that without the telemedicine option, they would have missed their medical appointments [37/68 (54.4%) vs. 56/144 (38.6%), χ2  = 4.31, p = 0.038]; a majority would prefer or consider telemedicine for future appointments over in-person visits. CONCLUSIONS: Insights gained from this QI survey to the practice's new pandemic-related processes include stressing lifestyle modification, optimizing treatment plans, and continuing the option of telemedicine.

Delayed-Onset Muscle Soreness and Topical Analgesic Alter Corticospinal Excitability of the Biceps Brachii.

INTRODUCTION: The interactive effect of delayed-onset muscle soreness (DOMS) and a topical analgesic on corticospinal excitability was investigated. METHODS: Thirty-two participants completed Experiments A (no DOMS) and B (DOMS). For each experiment, participants were randomly assigned to two groups: 1) topical analgesic gel (topical analgesic, n = 8), or 2) placebo gel (placebo, n = 8) group. Before the application of gel (pregel), as well as 5, 15, 30, and 45 min postgel, motor-evoked potential (MEP) area, latency, and silent period, as well as cervicomedullary MEP and maximal compound motor unit action potential areas and latencies were measured. In addition, pressure-pain threshold (PPT) was measured pre-DOMS and at the same timepoints in experiment B. RESULTS: In experiment A, neither group showed a significant change for any outcome measure. In experiment B, both groups exhibited a significant decrease in PPT from pre-DOMS to pregel. After the application of topical analgesic, but not placebo, there was a significant increase in PPT at 45 min postgel, respectively, compared with pregel and a main effect of time for the silent period to increase compared with pregel. Participants with DOMS had reduced MEP and cervicomedullary MEP areas and increased corticospinal silent periods compared with those who did not have DOMS. CONCLUSIONS: These findings suggest that DOMS reduced corticospinal excitability and after the administration of menthol-based topical analgesic, there was a reduction in pain, which was accompanied by increased corticospinal inhibition.

Nerve injury after laparoscopic varicocelectomy.

PURPOSE: Laparoscopic varicocelectomy is a minimally invasive option for varicoceles in children. Occasional reports of nerve injury after inguinal laparoscopic procedures have been published. There is anatomical variation in the sensory innervation of the anterior thigh and variable branching patterns of the nerves involved. We report a retrospective analysis of our patients, focusing on the incidence of sensory changes on the ipsilateral anterior thigh after laparoscopic varicocelectomy. MATERIALS AND METHODS: The medical records of all patients who underwent laparoscopic varicocelectomy at 1 institution performed by 2 of us (YR and DV) from 1997 to 2002 were retrospectively reviewed. Demographics, outcomes and any postoperative sensory complications were obtained by chart review and telephone interview. RESULTS: A total of 58 patients underwent laparoscopic varicocelectomy during this 5-year analysis and 51 with a total of 62 varicoceles were available for review. Three patients (4.8%) experienced transient numbness of the ipsilateral anterior thigh, which resolved or improved in an average of 8.0 months (range 6 to 9). Symptoms were not always noticed immediately postoperatively (range 0 to 10 days). In affected patients the sensory distribution was usually consistent with injury to the genitofemoral nerve. CONCLUSIONS: Laparoscopic varicocelectomy is a minimally invasive procedure that still has the potential for complications. Cautery or harmonic dissection of the peritoneum overlying the spermatic cord and excessive traction on the tissues surrounding the cord should be avoided intraoperatively. Patients and surgeons should be aware of the possibility of nerve injury and the resultant sensory deficit.