Movement Disorders Virtual Fellowship Training in Times of Coronavirus Disease 2019: A Single-Center Experience.

Objective: To describe the impact a global pandemic has had on a teaching movement disorders program, as well as its subsequent transition to telemedicine. Methods: In the midst of the coronavirus disease 2019 (COVID-19) pandemic, we transitioned our movement disorders fellowship program virtually over the course of a few days. Here we describe the parameters used for the telemedicine fellow supervised clinic visit over the course of 2 months. Fellow's input was obtained from a brief survey at the end of the experience. Faculty's experience was collected upon independent faculty discussions. We also summarize the challenges and advantages of this teaching experience and its downsides. Results: A total of 130 patients (102 follow-up and 28 new patients) were seen over 22 clinic days with any of our 3 fellows being supervised by 1 of the 6 attending physicians. The main challenges were related to technical difficulties and lack of portions of the examination such as tone, reflexes, and sensory testing. The main advantages were related to increased patient access and a decrease in scheduling barriers. The overall satisfaction with the experience of the fellows was positive (69%). Conclusions: This sample shows the feasibility (despite lack of prior experience) of virtual clinical supervision of movement disorders fellows for follow-up and new complex patient encounters. This novel method for movement disorders training has implications for training locally, nationally, and internationally. Limitations and possible future directions such as the inclusion of nonsynchronous recordings and devices for tone and balance testing are also discussed.

Two-step tuberculin skin testing in school-going adolescents with initial 0-4 millimeter responses in a high tuberculosis prevalence setting in South India.

BACKGROUND: The utility of two-step tuberculin skin testing among adolescents in high tuberculosis prevalence settings is not well established. OBJECTIVES: To determine the proportion and determinants of a 0-4 mm response to an initial standard tuberculin skin test (TST) and evaluating 'boosting' with repeat testing. METHODS: Adolescents between 11 and 18 years attending schools/colleges underwent a TST; those with a response of between 0-4 mm had a repeat TST 1-4 weeks later. RESULTS: Initial TST was done for 6608/6643 participants; 1257 (19%) developed a 0-4 mm response to the initial TST. Younger age and under-nutrition were more likely to be associated with a 0-4 mm response, while the presence of BCG (Bacillus Calmette Guerin) scar and higher socio-economic class were less likely to be associated with a 0-4 mm response. On repeat testing boosting was seen in 13.2% (145/1098; ≥ 6 mm over the initial test) while 4.3% showed boosting using a more conservative cutoff of a repeat TST ≥ 10 mm with an increment of at least 6 mm (47/1098). History of exposure to a tuberculosis (TB) case was associated with enhanced response. CONCLUSION: The proportion of adolescents who demonstrated boosting on two-step TST testing in our study was relatively low. As a result repeat testing did not greatly alter the prevalence of TST positivity. However, the two-step TST helps identify individuals who can potentially boost their immune response to a second test, and thus, prevents them from being misclassified as those with newly acquired infection, or tuberculin converters. While two-step tuberculin skin testing may have a limited role in population- level TST surveys, it may be useful where serial tuberculin testing needs to be performed to distinguish those who show an enhanced response or boosters from those who indeed have a new infection, or converters.