Academic Neurology and the COVID-19 Pandemic: Resilience, Hope, and Solutions.

The SARS-CoV-2 (COVID-19) viral pandemic dramatically affected human health, health care delivery, health care workers, and health care research worldwide. The field of academic neurology was no exception. In this 2022 Presidential Plenary, we discuss the challenges faced by neurologists and neuroscientists professionally and personally. We review the threats posed by the pandemic to neuroscience research activities, materials, productivity, and funding. We then discuss the impact of the pandemic on clinical trials for neurologic diseases. Restrictions to patient enrolment due to limited in-person access to laboratory testing, imaging, and study visits led to delay in both clinical trial enrolment and study completion but also to innovative new means to engage clinical trial participants remotely and to strategies to critically appraise the frequency and design of trial-related patient evaluations. Clinical care was also challenged by initial pandemic prioritization of urgent visit and inpatient care and the rapid pivot to telehealth for most other neurology care encounters. Front-line neurology care teams faced their fears of infection, with the first few months of the pandemic being characterized by uncertainty, inconsistent national health care strategies, limited personal protective equipment, and an alarming rate of human illness and death caused by COVID-19. The personal and societal toll of the pandemic is incalculable. Across research and clinical neurology providers, women and particularly those with young families juggled the impossible balance of career and family care as schools closed and children required home-based education. Shining through this dark time are lessons that should shape a brighter future for our field. We are resilient, and the advances in neuroscience and neurology care continue to advance improved neurologic outcomes. The National Institutes of Health devised multiple support strategies for researchers to help bridge the pandemic. Telehealth, clinical trial designs that are more participant-centric with remote monitoring, and flexible work schedules are strategies to rebalance overworked lives and improve our engagement with our patients. As we re-emerge, we have the chance to reframe our field.

Diseño de un protocolo con validez ecológica para la detección temprana de riesgo neurológico en población pediátrica de la primera infancia / Design of a protocol with ecological validity for the early detection of neurological risk in the pediatric population of early childhood

Introducción. El desarrollo del ser humano está determinado por factores biológicos, ambientales y contextuales que determinan la adquisición de habilidades neurológicas, y que bajo situaciones patológicas aumentan el riesgo de alteraciones en el neurodesarrollo desde etapas tempranas. Objetivo. Diseñar un protocolo con validez ecológica para la detección temprana de riesgo neurológico en la primera infancia por parte de equipos interdisciplinarios de rehabilitación. Métodos. Se realizó un estudio mixto, retrospectivo, transversal y descriptivo con un diseño exploratorio secuencial (DESPLOX). En la fase cualitativa se conformaron dos grupos focales: uno con padres (n=8) y otro con profesionales (n=6), de los cuales se obtuvieron las categorías del protocolo. En la fase cuantitativa se revisaron sistemáticamente artículos científicos (n=30) para la construcción de las orientaciones de acción. Finalmente, el protocolo se validó mediante un panel de expertos empleando el coeficiente de V de Aiken. Resultados. En la fase cualitativa emergieron cuatro categorías: 1) detección temprana, 2) contextos del desarrollo, 3) plan de intervención y 4) calidad y humanización en la atención. En la fase cuantitativa se seleccionaron las orientaciones de acción ubicadas en los Q2 y Q3. Posteriormente se evidenció una validación del protocolo igual a X ̅ =0,98. Conclusiones. Un protocolo de neurorrehabilitación válido ecológicamente se caracteriza por reconocer las percepciones, vivencias y experiencias de familiares y profesionales; recoger evidencia científica confiable; aportar orientaciones y recomendaciones sistémicas para la atención de niñas y niños, y contener criterios de validación de contenido.

Introduction. The human being's development is determined by biological, environmental, and contextual factors that determine the acquisition of neurological skills and that, under pathological situations, increase the risk of alterations in neurodevelopment from early stages. Objective. Design a protocol with ecological validity for the early detection of neurological risk in early childhood by interdisciplinary rehabilitation teams. Methods. A mixed, retrospective, cross-sectional, and descriptive study was performed with Exploratory Sequential Designs (DEXPLOS). In the qualitative phase, two focus groups were formed: one with parents (n=8) and another with professionals (n=6), from which the protocol categories were obtained. In the quantitative phase, scientific articles (n=30) were systematically reviewed to construct the action guidelines. Finally, the protocol was validated by a panel of experts using Aiken's V coefficient. Results. In the qualitative phase, four categories emerged: 1) early detection, 2) development contexts, 3) intervention plan, and 4) quality and humanization of care. In the quantitative phase, the action orientations located in Q2 and Q2 were selected. Subsequently, a validation of the protocol equal to X ̅=0.98 was evidenced. Conclusions. An ecologically valid neuro-rehabilitation protocol is characterized by recognizing the perceptions, expe-riences, and experiences of relatives and professionals; collecting reliable scientific evidence; providing systemic guide-lines and recommendations for the care of girls and boys, and containing content validation criteria.

Pharmacogenetic testing in psychiatry and neurology: an overview of reviews.

Pharmacogenetic testing is available to healthcare professionals to guide drug selection and prevent adverse events. However, its implementation in the clinical practice of psychiatry/neurology still has barriers, mainly due to a lack of evidence. We conducted a literature search on Cochrane Library, Embase and Pubmed, from their inception to 18 June 2020. We included 16 published systematic reviews. The most studied drug categories were anticonvulsants and selective serotonin reuptake inhibitors associated with human leukocyte antigen and cytochrome P450 genes (HLA-A, HLA-B, CYP2C9, CYP2D6, CYP2C19), classified as critically low quality/low quality. There is a need for more robust studies with adequate design to assess the potential benefits of adopting pharmacogenetics in health systems and services.

Consensus recommendations on the management of multiple sclerosis patients in Argentina.

INTRODUCTION: During the last 20 years, multiple sclerosis (MS) disease has seen major changes with new diagnostic criteria, a better identification of disease phenotypes, individualization of disease prognosis and the appearance of new therapeutic options in relapsing remitting as well as progressive MS. As a result, the management of MS patients has become more complex and challenging. The objective of these consensus recommendations was to review how the disease should be managed in Argentina to improve long-term outcomes in MS patients. METHODS: A panel of 36 experts in neurology from Argentina, dedicated to the diagnosis and care of MS patients, gathered both virtually and in person during 2018 and 2019 to carry out a consensus recommendation on the management of MS patients in Argentina. To achieve consensus, the methodology of "formal consensus-RAND/UCLA method" was used. RESULTS: Recommendations focused on diagnosis, disease prognosis, tailored treatment, treatment failure identification and pharmacovigilance process. CONCLUSIONS: The recommendations of these consensus guidelines attempt to optimize the health care and management of patients with MS in Argentina.

Proposal for a new diagnosis for U.S. diplomats in Havana, Cuba, experiencing vestibular and neurological symptoms.

Between 2016 and 2017, several U.S. Diplomats in Havana, Cuba, experienced perplexing vestibular and neurological symptoms attributed to an unknown source. They presented with significant vestibular and headache symptoms similar to individuals who experience vestibular migraine (VM). As such, we hypothesize that VM may be a possible explanation for the Havana cohort's presenting symptoms. To evaluate this hypothesis, we compared symptoms reported by the affected individuals in Havana, Cuba, to symptoms reported by corresponding patients from a tertiary academic neurotology clinic with a chief complaint of vertigo or disequilibrium, who met the International Classification of Headache Disorders criteria for VM. The prevalence of the Havana subjects experiencing various symptomatic domains was compared with the VM cohort, leading to 26 unique domains and statistical comparisons between the cohorts. Of the 26 domains compared between the two cohorts, 18 were not significantly different. This included the two most important components of meeting criteria for VM, namely the co-existence of headache and vestibular symptoms. On regression analysis, the only feature which kept its significant difference between the two cohorts was acute intense head pressure (P = 0.007). The domains with similar occurrence ratios included dizziness, headache, light sensitivity, hearing reduction, and tinnitus. In other words, multiple headache and vestibular symptoms, consistent with VM criteria, were similar between the two cohorts. The considerable similarities across various domains between VM patients and Havana subjects could be due to migraine as a possible common etiology for both groups. We propose VM as a potential etiology for the symptomatology in the U.S. diplomats in Cuba.

Comparison of Physician Therapeutic Inertia for Management of Patients With Multiple Sclerosis in Canada, Argentina, Chile, and Spain.

Importance: There is growing interest in understanding and addressing factors that govern the decision-making process in multiple sclerosis (MS) care. Therapeutic inertia (TI) is the failure to escalate therapy when goals are unmet. Limited data are available on the prevalence of TI and factors affecting therapeutic decisions in the management of patients with MS worldwide. Objectives: To compare TI across 4 countries (Canada, Argentina, Chile, and Spain) and to identify factors contributing to TI. Design, Setting, and Participants: Prospective cohort study conducted between July 10, 2017, and May 4, 2018. Participants were exposed to behavioral experiments in which instruments were used to assess their risk preferences (eg, aversion to ambiguity) and therapeutic decisions in 10 simulated MS case scenarios. Mixed-effects linear and logistic regression analyses were performed to determine the association between the participants' baseline characteristics and TI. The association of unmeasured confounders was assessed by the E-value and a bootstrapping analysis. This multicenter study included neurologists practicing at academic and community centers in Canada, Argentina, Chile, and Spain who make therapeutic decisions for patients with MS. Main Outcomes and Measures: The primary outcome was the prevalence of TI. The TI score was calculated by dividing the number of case scenarios in which participants showed TI by the number of case scenarios that measured TI. Higher TI scores indicated greater degrees of TI. The secondary outcome was the identification of factors that contributed to TI. Results: Of 300 neurologists with expertise in MS care who were invited to be part of the study, 226 (75.3%) agreed to participate. Among those who initially showed interest in participating, 195 physicians (86.3%) completed the study, while 31 did not. The mean (SD) age of participants was 43.3 (11.2) years; 52.3% were male. Therapeutic inertia was present in 72.8% (142 of 195) of participants, leading to suboptimal decisions in 20.4% (318 of 1560) of case scenarios. The prevalence of TI among the Canadian group was the lowest compared with the other 3 countries (60.0% [33 of 55] vs 77.9% [109 of 140]; P = .01). For the primary outcome, the TI score in the Canadian group (mean [SD], 0.98 [1.15]) was significantly lower compared with groups from other countries (mean [SD], 1.70 [1.43] for Argentina, 2.24 [1.54] for Chile, and 2.56 [1.64] for Spain) (P = .001). The mixed-effects linear models revealed that participants from Argentina, Chile, and Spain (combined) had higher TI scores compared with their Canadian counterparts (ß coefficient, 0.90; 95% CI, 0.52-1.28; P < .001). A higher number of patients with MS per week (OR, 0.44; 95% CI, 0.22-0.88), years of practice (OR, 0.93; 95% CI, 0.86-0.99), and participation from Canada (OR, 0.47; 95% CI, 0.23-0.96) were associated with a lower likelihood of TI. Aversion to ambiguity was associated with a 2-fold higher likelihood of TI (OR, 2.25; 95% CI, 1.02-5.00). All 95% CIs of the ß coefficients of covariates were lower than the E-value of 2.35, making it unlikely for the results to be due to the association of unmeasured confounders. Conclusions and Relevance: This study showed that Canadian participants had the lowest prevalence and magnitude of TI. Higher TI scores were associated with a lower expertise in MS care and with a greater tendency for aversion to ambiguity.

Seizure Rescue Medication Use among US Pediatric Epilepsy Providers: A Survey of the Pediatric Epilepsy Research Consortium.

OBJECTIVE: To assess how pediatric neurologists prescribe home seizure rescue medications to treat acute prolonged seizures and clusters of seizures in children. STUDY DESIGN: A brief, email survey was sent to the members of the Pediatric Epilepsy Research Consortium assessing seizure rescue medication prescribing practices for patients of different age groups, cognitive abilities, and seizure type. Survey responses were anonymous. RESULTS: Thirty-six respondents (of 76 surveyed; 47% response rate) completed the survey. Rectal diazepam was the most commonly chosen rescue medication for a prolonged convulsive seizure in a severely developmentally delayed 16-year-old (44%) and typical and delayed 7-year-old (44% and 61%, respectively), 3-year-old (78% and 86%, respectively), and 9-month-old (83%) patients. Most responders (69%) indicated that developmentally typical 16-year-olds would be prescribed intranasal midazolam. For clusters of seizures, clonazepam orally disintegrating tablets were the most frequent first-line option in all age groups, except developmentally delayed 3-year-old and 9-month-old children, for whom rectal diazepam was chosen more commonly. Medication dosing generally followed standard dosing guidelines with very few exceptions. CONCLUSIONS: Rectal diazepam remains the most frequently used rescue medication for prolonged seizures for nearly all age groups, except in developmentally typical teenagers, for whom intranasal midazolam is used more often. Clonazepam orally disintegrating tablets are the most frequently used medication for treatment of clusters of seizures, except in younger patients. Further work is necessary to establish best practices for type and administration route of seizure rescue medications.

Fibromyalgia and small fiber neuropathy: the plot thickens!

Several groups of investigators have described the presence of small fiber neuropathy in fibromyalgia patients. This writing discusses how this new finding could renovate fibromyalgia concept, diagnosis, and treatment. Predominant rheumatology thinking proposes fibromyalgia as a "centralized pain syndrome." An alternative hypothesis views fibromyalgia as a stress-related dysautonomia with neuropathic pain features. Dorsal root ganglia may be the key autonomic-nociceptive short-circuit sites. The recent recognition of small fiber neuropathy in a large subgroup of fibromyalgia patients reinforces the dysautonomia-neuropathic hypothesis and validates fibromyalgia pain. These new findings support fibromyalgia as a primarily neurological entity, nevertheless, rheumatologist will likely remain the best equipped specialist to diagnose fibromyalgia and differentiate it from other multi-symptomatic rheumatic syndromes. Skin biopsy and corneal confocal microscopy will probably become useful fibromyalgia diagnostic tests. Dorsal root ganglia sodium channel blockers are potential fibromyalgia analgesic medications. Subgroups of young girls with "autoimmune neuropathic fibromyalgia" may respond to immunoglobulin therapy. Multimodal intervention directed to regain autonomic nervous system resilience will likely remain the cornerstone for fibromyalgia therapy.

Opinion and Special Articles: Amateur fundus photography with various new devices: Our experience as neurology residents.

Times are changing in the way we secure and share patient fundus photographs to enhance our diagnostic skills in neurology. At the recent American Academy of Neurology meeting, the use of a fundus camera and smartphones to secure good-quality fundus photographs of patients presenting with headache to the emergency department (ED) was presented. We were enthusiastic to replicate the success of the Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study in our neurology department, but encountered problems in terms of cost, setup, feasibility, and portability of the device. As neurology residents, we came up with 3 easier options. We present these 3 options as our personal experience, and hope to reignite enthusiasm among neurology trainees to find their own means of performing ophthalmoscopy routinely in the hospital, as it appears that the Internet market is now thriving with many other devices to make this examination easier and more rewarding. Of the options explored above, the Handheld Fundus Camera was a clear favorite among the residents, and we have placed one in our call room for routine use. It travels to the clinic, floor, intensive care unit, and ED when needed. It has enhanced the way we approach the fundus examination and been a fun skill to acquire. We look forward to further advances that will make it possible to carry such a device in a physician's pocket.

Telestroke Imaging: A Review.

The use of telecommunications technology to provide the healthcare services, telemedicine, has been in use since the 1860s. The use of technology has ranged from providing medical care to far-off places during wartimes to monitoring physiological measurements of astronauts in space. Since the 1990s, reports have been published on diagnoses of neurological diseases with the use of video links. Studies confirm that the neurological examinations, including the National Institutes of Health Stroke Scale, performed during teleneurology are dependable. The transfer of stroke patients in rural hospitals to bigger medical centers delays treatment while there exists current and projected shortage of neurologists. Telestroke provides the solution. Patients suspected of acute stroke need a noncontrast computerized tomography (CT) scan for tissue plasminogen activator administration. Vascular imaging such as CT angiography, magnetic resonance angiography, and digital subtraction angiography can help show large-vessel occlusion or critical stenosis responsive to endovascular therapy. A standard protocol can be followed to decide a vascular modality of choice, considering advantages and disadvantages of each imaging modality. Telestroke solves the problems of distance and of shortage of neurologists. Neuroimaging plays a vital role in the delivery of telestroke, and the telestroke doctor should be comfortable with making a decision on selecting an appropriate vascular imaging modality.

Remote care of a patient with stroke in rural Trinidad: use of telemedicine to optimise global neurological care.

We report a patient driven home care system that successfully assisted 24/7 with the management of a 68-year-old woman after a stroke-a global illness. The patient's caregiver and physician used computer devices, smartphones and internet access for information exchange. Patient, caregiver, family and physician satisfaction, coupled with outcome and cost were indictors of quality of care. The novelty of this basic model of teleneurology is characterised by implementing a patient/caregiver driven system designed to improve access to cost-efficient neurological care, which has potential for use in primary, secondary and tertiary levels of healthcare in rural and underserved regions of the world. We suggest involvement of healthcare stakeholders in teleneurology to address this global problem of limited access to neurological care. This model can facilitate the management of neurological diseases, impact on outcome, reduce frequency of consultations and hospitalisations, facilitate teaching of healthcare workers and promote research.

Physical Maturity and Concussion Symptom Duration among Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between physical maturity and risk of prolonged concussion symptoms in adolescent ice hockey players. STUDY DESIGN: Prospective cohort study of 145 patients ages 13-18 years with concussion referred to 3 hospital-affiliated sports medicine clinics between September 1, 2012 and March 31, 2015. Concussion evaluations included Post Concussive Symptom Score, neurologic examination, and postinjury computerized neurocognitive testing. Pubertal development at initial visit was assessed by the Pubertal Developmental Scale. Duration of concussion symptoms (days) was the main outcome. Statistical comparisons were conducted using Student t test, Wilcoxon rank sum, and logistic regression. RESULTS: Mean symptom duration was 44.5 ± 48.7 days. Nearly one-half (48.3%) of all players enrolled had prolonged concussion symptoms (≥ 28 days); most (86.9%) had symptom resolution by 90 days. Among males, less physically mature adolescents took longer to recover than more physically mature players (54.5 days vs 33.4 days; P = .004). "Early" Pubertal Category Score was the strongest predictor of prolonged symptoms (OR = 4.29, 95% CI 1.24-14.85; P = .021) among males. Among females, heavier weight increased the odds of experiencing prolonged symptoms (OR 1.07, 95% CI 1.00-1.14; P = .039). CONCLUSIONS: Among adolescent ice hockey players, early-pubertal stage is independently associated with longer recovery from concussion in males, and heavier weight is associated with longer concussion recovery in females. Until further studies determine valid physical maturity indicators, peripubertal collision sport athletes should compete in leagues grouped by relative age and be discouraged from "playing up" on varsity teams.

Acupuntura na Medicina Felina

As práticas de medicina veterinária complementar(MVC) oferecem uma abordagem integral do paciente, buscando a manutenção da saúde do indivíduo em equilíbrio como meio do qual é parte1. São técnicas terapêuticas conservativas e pouco invasivas, pois estimulamo organismo a ativar mecanismos intrínsecos para alcançar a homeostase.As MVCs oferecem abordagem integral do paciente primordialmente curativa, cujo foco terapêutico é o controle das causas de base do processo de doença 2,3.

Acupuntura na Medicina Felina

As práticas de medicina veterinária complementar(MVC) oferecem uma abordagem integral do paciente, buscando a manutenção da saúde do indivíduo em equilíbrio como meio do qual é parte1. São técnicas terapêuticas conservativas e pouco invasivas, pois estimulamo organismo a ativar mecanismos intrínsecos para alcançar a homeostase.As MVCs oferecem abordagem integral do paciente primordialmente curativa, cujo foco terapêutico é o controle das causas de base do processo de doença 2,3.

An approach to improve the performance of subject-independent BCIs-based on motor imagery allocating subjects by gender.

BACKGROUND: One of the difficulties for the implementation of Brain-Computer Interface (BCI) systems for motor impaired patients is the time consumed in the system design process, since patients do not have the adequate physical nor psychological conditions to complete the process. For this reason most of BCIs are designed in a subject-dependent approach using data of healthy subjects. The developing of subject-independent systems is an option to decrease the required training sessions to design a BCI with patient functionality. This paper presents a proof-of-concept study to evaluate subject-independent system based on hand motor imagery taking gender into account. METHODS: Subject-Independent BCIs are proposed using Common Spatial Patterns and log variance features of two groups of healthy subjects; one of the groups was composed by people of male gender and the other one by people of female gender. The performance of the developed gender-specific BCI designs was evaluated with respect to a subject-independent BCI designed without taking gender into account, and afterwards its performance was evaluated with data of two healthy subjects that were not included in the initial sample. As an additional test to probe the potential use for subcortical stroke patients we applied the methodology to two patients with right hand weakness. T-test was employed to determine the significance of the difference between traditional approach and the proposed gender-specific approach. RESULTS: For most of the tested conditions, the gender-specific BCIs have a statistically significant better performance than those that did not take gender into account. It was also observed that with a BCI designed with log-variance features in the alpha and beta band of healthy subjects' data, it was possible to classify hand motor imagery of subcortical stroke patients above the practical level of chance. CONCLUSIONS: A larger subjects' sample test may be necessary to improve the performances of the gender-specific BCIs and to further test this methodology on different patients. The reduction of complexity in the implementation of BCI systems could bring these systems closer to applications such as controlling devices for the motor rehabilitation of stroke patients, and therefore, contribute to a more effective neurological rehabilitation.

Assessment of gait deviation on the Babinski-Weill test in healthy Brazilians.

OBJECTIVE: The aim of this study was to validate a simple and reproducible method for assessing gait deviation on the Babinski-Weill test in a representative sample of healthy Brazilians. METHODS: Gait deviations were measured in 75 individuals (median=30 years, 41 women) for forward, backwards, and Babinski-Weill steps. The test entailed blindfolded individuals walking 10 paces at a frequency of 1 Hz with deviations subsequently measured by a protractor. RESULTS: Mean gait deviation forward was 0.53° with standard deviation (SD)=4.22 and backwards was 2.14° with SD=4.29. No significant difference in deviation was detected between genders (t test p=0.40 forward and p=0.77 backwards) or for age (ANOVA, p=0.33 forward and p=0.63 backwards). On the Babinski-Weill test, mean gait deviation was 5.26°; SD=16.32 in women and -3.11°; SD=12.41 in men, with no significant difference between genders (t test, p=0.056). DISCUSSION: Defining normative gait patterns helps distinguish pathological states.