The Past, Present, and Future of Tele-EEG.

Tele-electroencephalogram (EEG) has become more pervasive over the last 20 years due to advances in technology, both independent of and driven by personnel shortages. The professionalization of EEG services has both limited growth and controlled the quality of tele-EEG. Growing data on the conditions that benefit from brain monitoring have informed increased critical care EEG and ambulatory EEG utilization. Guidelines that marshal responsible use of still-limited resources and changes in broadband and billing practices have also shaped the tele-EEG landscape. It is helpful to characterize the drivers of tele-EEG to navigate barriers to sustainable growth and to build dynamic systems that anticipate challenges in any of the domains that expand access and enhance quality of these diagnostic services. We explore the historical factors and current trends in tele-EEG in the United States in this review.

SNPs previously associated with Dupuytren's disease replicated in a North American cohort.

OBJECTIVE: Dupuytren's disease is a progressive fibrosis of the hand that often results in debilitating flexion contractures. Its etiology is not completely understood but likely involves both genetic and environmental factors. A recent study performed in Europe identified DNA variants that associate with Dupuytren's disease. Given the likelihood for genetic variation among populations, we planned to validate the genetic variants identified by this study in a North American population. METHODS: In the Marshfield Clinic's Personalized Medicine Research Project, 296 cases with Dupuytren's disease were identified and matched 3-to-1 to controls without Dupuytren's disease. Clinical data were abstracted from the electronic medical record. The top 12 single nucleotide polymorphisms (SNPs) from the European study were selected and tested in a multiplex assay using the MassArray Analyzer 4 (Sequenom, Inc., San Diego, CA). Differences in allele frequency were determined, and variants with a P value of <0.004 were considered significant. RESULTS: We replicated 5 of the 12 SNPs previously reported to be associated with Dupuytren's disease. CONCLUSION: Our findings support a role for the Wnt signaling pathway in the development of Dupuytren's disease, and suggest that further study of this pathway may result in early diagnosis and non-surgical treatments for Dupuytren's disease.

Remote assessment of stroke using the iPhone 4.

Therapy with recombinant tissue plasminogen activator is underused in the treatment of ischemic stroke in rural hospitals, due to a lack of local stroke expertise. Telemedicine solutions for stroke are a level I, class A recommendation when a vascular neurologist is absent. However, current solutions require exorbitant startup costs, which are prohibitive for the rural hospitals in which they are needed most. This study demonstrates the efficacy of using the relatively inexpensive iPhone 4 in telestroke management. Twenty patients with stroke were assessed at the bedside using an iPhone 4, and each examination was directed remotely on another iPhone 4. Both the physician performing the bedside exam and the remote physician calculated a National Institutes of Health Stroke Scale (NIHSS) score for each patient. Each physician was blinded to the other's NIHSS score. In the 20 patients assessed, NIHSS scores ranged from 0 to 22. Interrater reliability assessed using the κ statistic demonstrated excellent agreement in 10 items (level of consciousness, month and age, visual fields, right motor arm, left motor arm, right motor leg, left motor leg, sensation, language, and neglect), moderate agreement in 3 items (gaze, facial palsy, and dysarthria), and poor agreement in 1 item (ataxia). Total NIHSS scores obtained remotely and at bedside showed an excellent level of agreement (intraclass correlation coefficient, 0.98). Our findings indicate that the iPhone 4 is an economical mobile solution that can be used to assess stroke patients remotely with high fidelity and can be readily incorporated into a telestroke network.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Biomarkers in Axial Spondyloarthritis: Observational Studies From the Program to Understand the Longterm Outcomes in Spondyloarthritis Registry.

OBJECTIVES: This study was conducted to assess the utility of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting radiographic sacroiliitis and active disease in axial spondyloarthritis (SpA) and to explore the association between use of a tumor necrosis factor inhibitor (TNFi) and these laboratory values compared with traditional inflammatory markers. METHODS: Observational data from the Program to Understand the Longterm Outcomes in Spondyloarthritis (PULSAR) registry were analyzed. We generated receiver operating characteristic curves to calculate laboratory cutoff values; we used these values in multivariable logistic regression models to identify associations with radiographically confirmed sacroiliitis and active disease. We also used logistic regression to determine the likelihood of elevated laboratory values after initiation of TNFi. RESULTS: Most study participants (n = 354) were White, male, and HLA-B27 positive. NLR (odds ratio [OR] 1.459, P = 0.034), PLR (OR 4.842, P < 0.001), erythrocyte sedimentation rate (OR 4.397, P < 0.001), and C-reactive protein (CRP) level (OR 2.911, P = 0.001) were independent predictors of radiographic sacroiliitis. Models that included PLR with traditional biomarkers performed better than those with traditional biomarkers alone. NLR (OR 6.931, P = 0.002) and CRP (OR 2.678, P = 0.004) were predictors of active disease, but the model that included both NLR and CRP performed better than CRP alone. TNFi use reduced the odds of elevated NLR (OR 0.172, P < 0.001), PLR (OR 0.073, P < 0.001), erythrocyte sedimentation rate (OR 0.319, P < 0.001), and CRP (OR 0.407, P < 0.001), but models that included NLR or PLR and traditional biomarkers performed best. CONCLUSIONS: These findings demonstrate an association between NLR and PLR and sacroiliitis and disease activity, with NLR and PLR showing response after TNFi treatment and adding useful clinical information to established biomarkers, thus perhaps assisting in management of axial SpA.

Evaluation of a mitochondrial DNA mutation in maternally inherited and sporadic cases of Dupuytren disease.

OBJECTIVE: The purpose was to test the hypothesis that Dupuytren disease (DD) is associated with a previously reported mutation in mitochondrial DNA at position 2839. METHODS: Two hundred sixty-nine cases of DD and an equal number of matched controls were identified in Marshfield Clinic's Personalized Medicine Research Project (PMRP). Clinical data used to describe the cohort were abstracted from the electronic medical records of the population. Genetic analysis of all the cases and controls was done using a custom synthesis TaqMan assay, while genetic analysis of sixteen of the above cases with a familial history of DD was performed by mitochondrial DNA sequencing at position C2839A. RESULTS: Cases and controls were evenly distributed with 167 (62%) men and 102 (38%) women. The majority, 264 (98%) of the cases and controls were white non-Hispanic. Of the 269 cases, 16 were found to have a familial history of DD. Two cases had a maternal history, eight a paternal history, five an affected sibling, and one a paternal grandfather. All cases and controls were found to have only the C allele at the site of the reported mitochondrial C2839A polymorphism. CONCLUSIONS: The previously reported mitochondrial mutation was not present in our small, maternally inherited cohort or in the total population of 538 cases and controls. This finding does not support the reported incidence of this polymorphism in 90% of the affected population with a maternal inheritance, and calls into question the role of the C2839A mitochondrial DNA polymorphism in familial or sporadic cases of DD.

Nanoparticle-driven assembly of block copolymers: a simple route to ordered hybrid materials.

The addition of nanoparticles that selectively hydrogen bond with one of the segments of a block copolymer is shown to induce order in otherwise disordered systems. This enables the fabrication of well-ordered hybrid materials with spherical, cylindrical, or lamellar domains at particle loadings of more than 40%, as evidenced by TEM and SAXS. The approach described is simple and applicable to a wide range of nanoparticles and block copolymers, and it lays the groundwork for the design of cooperatively assembled functional devices.

Repair of the motor branch of the ulnar nerve using a dorsal approach: case report.

We present the case of a young woman who sustained a stab injury to the left palm with a kitchen knife that entered the thenar eminence and exited dorsally between the index and middle metacarpals. We repaired the injured motor branch of the ulnar nerve using a dorsal approach and a proximal osteotomy of the index metacarpal.

American Academy of Neurology Telehealth Position Statement.

Telehealth services complement in-person neurologic care. The American Academy of Neurology supports patient access to telehealth services regardless of location, coverage for telehealth services by all subscriber benefits and insurance, equitable provider reimbursement, simplified state licensing requirements easing access to virtual care, and expanding telehealth research and quality initiatives. The roles and responsibilities of providers should be clearly delineated in telehealth service models.

Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update.

PURPOSE: While there is strong evidence supporting the importance of telemedicine in stroke, its role in other areas of neurology is not as clear. The goal of this review is to provide an overview of evidence-based data on the role of teleneurology in the care of patients with neurologic disorders other than stroke. RECENT FINDINGS: Studies across multiple specialties report noninferiority of evaluations by telemedicine compared with traditional, in-person evaluations in terms of patient and caregiver satisfaction. Evidence reports benefits in expediting care, increasing access, reducing cost, and improving diagnostic accuracy and health outcomes. However, many studies are limited, and gaps in knowledge remain. SUMMARY: Telemedicine use is expanding across the vast array of neurologic disorders. More studies are needed to validate and support its use.

The State of Remote Sensing Capabilities of Cascading Hazards over High Mountain Asia.

Cascading hazard processes refer to a primary trigger such as heavy rainfall, seismic activity, or snow melt, followed by a chain or web of consequences that can cause subsequent hazards influenced by a complex array of preconditions and vulnerabilities. These interact in multiple ways and can have tremendous impacts on populations proximate to or downstream of these initial triggers. High Mountain Asia (HMA) is extremely vulnerable to cascading hazard processes given the tectonic, geomorphologic, and climatic setting of the region, particularly as it relates to glacial lakes. Given the limitations of in situ surveys in steep and often inaccessible terrain, remote sensing data are a valuable resource for better understanding and quantifying these processes. The present work provides a survey of cascading hazard processes impacting HMA and how these can be characterized using remote sensing sources. We discuss how remote sensing products can be used to address these process chains, citing several examples of cascading hazard scenarios across HMA. This work also provides a perspective on the current gaps and challenges, community needs, and view forward towards improved characterization of evolving hazards and risk across HMA.

CSF proteomic fingerprints for HIV-associated cognitive impairment.

Cognitive impairment remains a major complication of advanced human immunodeficiency virus (HIV) infection despite the widespread use of anti-retroviral therapy. Diagnosis is made by exclusion making biomarkers of great potential use. Thus, we used an integrated proteomics platform to assess cerebrospinal fluid protein profiles from 50 HIV-1 seropositive Hispanic women. Nine of 38 proteins identified were unique in those patients with cognitive impairment (CI). These proteins were linked to cell signaling, structural function, and antioxidant activities. This work highlights, in a preliminary manner, the utility of proteomic profiling for biomarker discovery for HIV-1 associated cognitive dysfunction.

Developing an outline for teleneurology curriculum: AAN Telemedicine Work Group recommendations.

The emerging field of teleneurology is delivering quality care to neurologic patients in increasingly numerous technologies and configurations. Teleneurology is well-positioned to address many of the logistical issues neurologists and their patients encounter today. However, formalized medical training has not caught up with this developing field, and there is a lack of formal education concentrating on the specific opportunities and challenges of teleneurology. Considering this, the American Academy of Neurology Telemedicine Work Group identified equivalencies with which any practitioner of teleneurology should be familiar. The purpose of this curriculum is not to define teleneurology or mandate where its use is appropriate, but rather to provide guidance on basic equivalencies that students, residents, and practitioners should know while practicing teleneurology. Comprehensive training in clinical bedside neurology is necessary to safely practice teleneurology and the components of this curriculum are an extension of that training. In this article, we offer a detailed discussion on the rationale for the contents of this curriculum and conclude by providing a model curriculum and an outline for evaluating residents in teleneurology.

Memantine protects hippocampal neuronal function in murine human immunodeficiency virus type 1 encephalitis.

Memantine, a low-to-moderate-affinity NMDA receptor antagonist, can be used to treat cognitive impairment associated with Alzheimer's disease. However, its potential neuroprotective effects for human immunodeficiency virus type 1-associated (HIV-1-associated) dementia are less well appreciated. To this end we studied hippocampal synaptic function in a severe combined immunodeficient (SCID) mouse model of HIV-1 encephalitis (HIVE). Human monocyte-derived macrophages (MDMs) infected with HIV-1(ADA) were injected stereotactically into the caudate and putamen of SCID mice, generating HIVE. These brain subregions are among those most affected in humans. Impaired synaptic transmission and long-term potentiation (LTP) were detected in the CA1 region of hippocampal brain slices of HIVE mice. Memantine-treated HIVE mice showed significant improvements in synaptic function during frequency facilitation tests and LTP induced by high-frequency stimulation when compared with untreated animals. Immunocytochemical measures of neuronal antigens mirrored the neuronal physiological tests. These results demonstrate that memantine attenuates hippocampal synaptic impairment in murine HIVE and provide a rationale for its use in infected humans who experience cognitive decline.

Hippocampal volume, memory, and cortisol status in major depressive disorder: effects of treatment.

BACKGROUND: Depression has been linked to stress, memory deficits, and hypercortisolemia. However, the relationships between depression, hippocampal structure and function, and cortisol levels are unclear and the effects of antidepressant treatment on the measures are not well studied. METHODS: Whole hippocampal volume, performance on verbal and visual declarative memory function and cortisol status was evaluated in 38 subjects with major depressive disorder (MDD) and 33 healthy subjects. All measures were repeated in a subgroup (n = 22) of depressed patients after successful selective serotonin reuptake inhibitor (SSRI) treatment. RESULTS: Hippocampal volume was not significantly different between patients with untreated MMD and healthy subjects, after controlling for whole brain volume, age and gender. However, depressed subjects had significantly greater deficits in delayed memory and percent retention on the verbal portion of the Wechsler Memory Scale-Revised (WMS-R) compared with healthy subjects, without significant differences in visual memory, attention, vigilance, or distractibility. Baseline plasma or urinary free cortisol (UFC) was not related to either hippocampal volume or memory deficits. Successful treatment with antidepressants did not change hippocampal volume but did result in a significant improvement in memory function and a reduction in UFC excretion. CONCLUSIONS: Medication-free nonelderly depressed outpatients without alcohol dependence or adverse experiences in childhood had normal hippocampal volume. Focal declarative memory deficits in depression supported localized hippocampal dysfunction in depressed patients. Treatment with antidepressants significantly improved memory and depression but did not alter hippocampal volume, suggesting that antidepressants may improve hippocampal function in the absence of detectable structural changes.

Inferring the mental processes of other minds.

In 4 experiments, the authors examined how several variables influence the quality and quantity of information that people use to make judgments about other people. The results showed that when possible, participants consistently responded appropriately to variables that influenced information that they used to make inferences about other minds. The results also suggested that under circumstances with no opportunity to contrast behavior in different situations, people might not be sensitive to the quality and quantity of information present. The authors interpreted results to mean that under most circumstances, people make inferences in a way that efficiently uses information about the causes of behavior.

Additive-driven assembly of block copolymer-nanoparticle hybrid materials for solution processable floating gate memory.

Floating gate memory devices were fabricated using well-ordered gold nanoparticle/block copolymer hybrid films as the charge trapping layers, SiO(2) as the dielectric layer, and poly(3-hexylthiophene) as the semiconductor layer. The charge trapping layer was prepared via self-assembly. The addition of Au nanoparticles that selectively hydrogen bond with pyridine in a poly(styrene-b-2-vinyl pyridine) block copolymer yields well-ordered hybrid materials at Au nanoparticle loadings up to 40 wt %. The characteristics of the memory window were tuned by simple control of the Au nanoparticle concentration. This approach enables the fabrication of well-ordered charge storage layers by solution processing, which is extendable for the fabrications of large area and high density devices via roll-to-roll processing.