Simulation-Based Teaching of Telemedicine for Future Users of Teleconsultation and Tele-Expertise: Feasibility Study.

BACKGROUND: Health care professionals worldwide are increasingly using telemedicine in their daily clinical practice. However, there is still a lack of dedicated education and training even though it is needed to improve the quality of the diverse range of telemedicine activities. Simulation-based training may be a useful tool in telemedicine education and training delivery. OBJECTIVE: This study aims to assess the feasibility and acceptability of simulation-based telemedicine training. METHODS: We assessed five telemedicine training sessions conducted in a simulation laboratory. The training was focused on video teleconsultations between a patient and a health care professional. The assessment included the participants' satisfaction and attitudes toward the training. RESULTS: We included 29 participants in total. Participant satisfaction was high (mean score 4.9 of 5), and those that took part stated the high applicability of the simulation-based training to their telemedicine practices (mean score 4.6 of 5). They also stated that they intended to use telemedicine in the future (mean score 4.5 of 5). CONCLUSIONS: Simulation-based training of telemedicine dedicated to video teleconsultation was feasible and showed high satisfaction from participants. However, it remains difficult to scale for a high number of health care professionals.

Does Intravenous Thrombolysis Influence the Time of Recanalization and Success of Mechanical Thrombectomy during the Acute Phase of Cerebral Infarction?

OBJECTIVES: Mechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke (AIS) caused by large vessel occlusion. Recanalization time is a key factor in the treatment of AIS. It has previously been suggested that intravenous thrombolysis (IVT) may be associated with a shorter recanalization time. The aim of our study was to investigate whether IVT or other factors could be associated with shorter or longer MT procedure times. METHODS: We performed a retrospective analysis of a local cohort of patients treated by MT. We collected procedure time (puncture to recanalization and clot visualization to recanalization), demographic data, localization of the thrombus, antithrombotic treatment at arrival, IVT infusion, and stroke subtype at discharge according to the TOAST classification. We planned to analyze the full cohort and the successful revascularization subgroup. RESULTS: There was no difference in procedure times between patients who received IVT and those who did not. In the successful revascularization subgroup, patients presenting with cardioembolic stroke had a significantly shorter time between clot visualizations and revascularization than the other patients (41 vs. 56 min, p = 0.024), but this was not the case in the full cohort. Also in the successful revascularization subgroup, the revascularization time was 76 vs. 61 min (p = 0.075) in patients presenting with tandem occlusion vs. the others, but there was no difference between these groups in the full cohort. CONCLUSIONS: There was no difference in terms of procedure times in patients treated by IVT and MT vs. patients treated by MT alone either in the full cohort or in the successful revascularization subgroup. The data from the successful revascularization subgroup may be useful for studying revascularization times, provided that data from procedures that were stopped prematurely by the operator due to the length of time since symptom onset is removed.

Evaluation of a French Regional Telemedicine Network Dedicated to Neurological Emergencies: A 14-Year Study.

BACKGROUND: Equality in healthcare between urban and rural areas is problematic in France. Telemedicine networks are expected to improve equality in expertise assessment. We aimed to evaluate the use and impact of a regional rural French telemedicine network, dedicated to medical and surgical neurological emergencies, on interhospital patient transfers. METHODS: Eight community hospital emergency departments were remotely connected to the only university hospital in Franche-Comté, France. We prospectively obtained data from all patients consecutively admitted to emergency care departments in the region and who received medical or neurosurgical expertise by telemedicine from January 2002 to December 2015. The reasons for requesting expertise, number of requested neurological opinions, and interhospital patient transfers were analyzed. Economic savings were determined by estimating the cost of avoided transfers. RESULTS: A total of 23,710 patients had telemedicine consultations in the region. The network was used by every community hospital (independently of the existence of local neurological teams). These consultations were overwhelmingly for cases of stroke (30%) and head or spinal injuries (36%). Cerebral tumors represented 9% of teleconsultations. In 2015, 75% of patients admitted to the remote hospitals that did not have onsite neurological expertise nevertheless received neurovascular tele-expertise. The rate of thrombolyzed patients dramatically increased within 13 years regionally (9.9%) and 33.5% of thrombolyses were performed by telemedicine. The number of patients examined by telemedicine and admitted for head or spinal injuries also increased over the 13-year period (12% vs. 21%). Secondary interhospital transfers were halved for both pathologies. The estimated saving is ∼€3.5 million. CONCLUSION: Telemedicine networks facilitate acute-phase neurological assessment and prevent unnecessary secondary interhospital transfers.

Proportion of single-chain recombinant tissue plasminogen activator and outcome after stroke.

OBJECTIVE: To determine whether the ratio single chain (sc)/(sc + 2 chain [tc]) recombinant tissue plasminogen activator (rtPA) influences outcomes in patients with cerebral ischemia. METHODS: We prospectively included consecutive patients treated with IV rtPA for cerebral ischemia in 13 stroke centers and determined the sc/(sc + tc) ratio in the treatment administered to each patient. We evaluated the outcome with the modified Rankin Scale (mRS) at 3 months (prespecified analysis) and occurrence of epileptic seizures (post hoc analysis). We registered Outcome of Patients Treated by IV Rt-PA for Cerebral Ischaemia According to the Ratio Sc-tPA/Tc-tPA (OPHELIE) under ClinicalTrials.gov identifier no. NCT01614080. RESULTS: We recruited 1,004 patients (515 men, median age 75 years, median onset-to-needle time 170 minutes, median NIH Stroke Scale score 10). We found no statistical association between sc/(sc + tc) ratios and handicap (mRS > 1), dependency (mRS > 2), or death at 3 months. Patients with symptomatic intracerebral hemorrhages had lower ratios (median 69% vs 72%, adjusted p = 0.003). The sc/(sc + tc) rtPA ratio did not differ between patients with and without seizures, but patients with early seizures were more likely to have received a sc/(sc + tc) rtPA ratio >80.5% (odds ratio 3.61; 95% confidence interval 1.26-10.34). CONCLUSIONS: The sc/(sc + tc) rtPA ratio does not influence outcomes in patients with cerebral ischemia. The capacity of rtPA to modulate NMDA receptor signaling might be associated with early seizures, but we observed this effect only in patients with a ratio of sc/(sc + tc) rtPA >80.5% in a post hoc analysis.

Primary Leptomeningeal Gliomatosis in Children and Adults: A Morphological and Molecular Comparative Study With Literature Review.

BACKGROUND: Primary leptomeningeal gliomatosis (PLG) is a poorly recognized tumor of the central nervous system. OBJECTIVE: To describe the histopathological, immunohistochemical, and molecular features of PLG. METHODS: Results of our multicentric retrospective study of 6 PLG cases (3 pediatric and 3 adult) were compared with literature data. RESULTS: The mean age was 54.7 years for adults and 8.7 years for children, with 3 males and 3 females. Clinical symptoms were nonspecific. Cerebrospinal fluid analyses showed a high protein level often associated with pleocytosis but without neoplastic cells. On neuroimaging, diffuse leptomeningeal enhancement and hydrocephalus were observed, except in 1 case. PLG was mostly misinterpreted as infectious or tumoral meningitis. The first biopsy was negative in 50% of cases. Histopathologically, PLG cases corresponded to 1 oligodendroglioma without 1p19q codeletion and 5 astrocytomas without expression of p53. No immunostaining for IDH1R132H and no mutations of IDH1/2 and H3F3A genes were found. Overall survival was highly variable (2-82 months) but seems to be increased in children treated with chemotherapy. CONCLUSION: This study shows the difficulties of PLG diagnosis. The challenge is to achieve an early biopsy to establish a diagnosis and to begin a treatment, but the prognosis remains poor. PLG seems to have a different molecular and immunohistochemical pattern compared with intraparenchymal malignant gliomas.

The role of the amygdala in the perception of positive emotions: an "intensity detector".

The specific role of the amygdala remains controversial even though the development of functional imaging techniques has established its implication in the emotional process. The aim of this study was to highlight the sensitivity of the amygdala to emotional intensity (arousal). We conducted an analysis of the modulation of amygdala activation according to variation in emotional intensity via an fMRI event-related protocol. Monitoring of electrodermal activity, a marker of psychophysiological emotional perception and a reflection of the activation of the autonomic nervous system, was carried out concurrently. Eighteen subjects (10 men; aged from 22 to 29 years) looked at emotionally positive photographs. We demonstrated that the left and right amygdalae were sensitive to changes in emotional intensity, activating more in response to stimuli with higher intensity. Furthermore, electrodermal responses were more frequent for the most intense stimuli, demonstrating the concomitant activation of the autonomic nervous system. These results highlight the sensitivity of the amygdala to the intensity of positively valenced visual stimuli, and in conjunction with results in the literature on negative emotions, reinforce the role of the amygdala in the perception of intensity.

Angelman syndrome: a case series assessing neurological issues in adulthood.

BACKGROUND: This study aimed to evaluate the clinical symptoms of Angelman syndrome (AS) in adults and to identify the neurological pathways affected in this disease. AS is a neurogenetic disorder resulting due to the deletion or inactivation of the ubiquitin-protein-ligase E3A gene on maternal chromosome 15. SUMMARY: A retrospective analysis of data from six adults patients with clinical, electroencephalographic and genetic confirmation of AS was performed. Movement disorders of the hands and mouth, laughing spells, severe expressive speech disorders, a happy nature, hyposomnia and anxiety are the major neurological characteristics of AS in adulthood. Cerebellar ataxia, muscle hypotonia and tremor, though constant in childhood, tend to be attenuated in adulthood. Epilepsy, one of the most frequent symptoms in childhood and in adulthood, is characterised by specific electroencephalographic patterns. Key Messages: These clinical characteristics are important to improve the clinical awareness and genetic diagnosis of AS. Clinicians must be better informed concerning the adult phenotype as it is not well described in the literature. We stress the importance of AS as one of the main causes of intractable epilepsy. The authors suggest frontal and cerebellar dysfunction. Further functional cerebral imaging studies are necessary.

Clinical manifestations of hysteria: an epistemological perspective or how historical dynamics illuminate current practice.

Hysteria has generated the most heated debates among physicians, from antiquity to the present day. It has been long confused with neuroses and neurological pathologies such as Parkinson's disease and epilepsy, principally associated with women and sexual disorders. The clinical manifestations must first be seen in their historical context, as interpretation varies according to the time period. Recently, the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association marked a break in the consensus that previously seemed to apply to the concept of hysteria and approach to the clinical manifestations. The clinical manifestations of hysteria are numerous and multifaceted, comprising 3 main classifications: paroxysms, attacks, and acute manifestations; long-lasting functional syndromes, and visceral events. Each main classification can be subdivided into several subgroups. The first main group of paroxysms, attacks, and acute manifestations includes major hysterical attacks, such as prodrome, trance and epileptic states, minor hysterical attacks such as syncope and tetany, twilight states, paroxysmal amnesia, and cataleptic attacks. The second group includes focal hysterical symptoms, paralyses, contractures and spasms, anesthesia, and sensory disorders. Visceral manifestations can be subdivided into spasms, pain, and general and trophic disorders. The diversity of the symptoms of hysteria and its changing clinical presentation calls into question the same hysterical attacks and the same symptoms, which have had only a few differences for over 2,000 years. A new definition of hysteria should be proposed, in that it is a phenomenon that is not pathological, but physiological and expressional.

[Telemedicine: application in the neurological emergencies]. / Télémédecine : application aux urgences neurologiques.

Telemedicine covers different fields going from teleconsultation to tele expertise. Thanks to different national and international studies, telemedicine applied to stroke (telestroke) should be considered as reliable, sure and efficient. Securized specific networks and standardised procedures are required. Telestroke can be used at each stage of stroke and every kind of stroke can benefit this technic. The main limitation is the lack of specific financial retribution.

Predicting acute ischaemic stroke outcome using clinical and temporal thresholds.

Background. Few studies have analysed the natural course of cerebral ischaemia for predicting outcome. We aimed to determine the early clinical findings and the thresholds for deficit severity and symptom duration that make it possible to stratify outcome. Methods. We included 154 patients with transient ischaemic attack or ischaemic stroke. Stroke profiles and neurological status were assessed from onset to 24 hrs, on admission, at 48 hrs, and at discharge. Outcomes were evaluated using the modified Rankin Scale. Positive and negative predictive values were calculated for the different thresholds. The model was subsequently evaluated on a new prospective cohort of 157 patients. Results. Initial National Institute of Health Stroke Scale (NIHSS) score <5 and symptoms regressing within 135 min were predictive of good outcome. Initial NIHSS score >22 and symptom stability after 1,230 min were predictive of physical dependency or death. Conclusions. Low and high NIHSS cut-off points are effective positive predictive values for good and poor outcomes. Thresholds for symptom duration are less conclusive.