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Cho C, Park S, Ma S, Lee HJ, Lim EC, Hong SK. Feasibility of video-based real-time nystagmus tracking: a lightweight deep learning model approach using ocular object segmentation. Front Neurol 2024; 15:1342108. [PMID: 38450068 PMCID: PMC10915048 DOI: 10.3389/fneur.2024.1342108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/30/2024] [Indexed: 03/08/2024] Open
Abstract
Background Eye movement tests remain significantly underutilized in emergency departments and primary healthcare units, despite their superior diagnostic sensitivity compared to neuroimaging modalities for the differential diagnosis of acute vertigo. This underutilization may be attributed to a potential lack of awareness regarding these tests and the absence of appropriate tools for detecting nystagmus. This study aimed to develop a nystagmus measurement algorithm using a lightweight deep-learning model that recognizes the ocular regions. Method The deep learning model was used to segment the eye regions, detect blinking, and determine the pupil center. The model was trained using images extracted from video clips of a clinical battery of eye movement tests and synthesized images reproducing real eye movement scenarios using virtual reality. Each eye image was annotated with segmentation masks of the sclera, iris, and pupil, with gaze vectors of the pupil center for eye tracking. We conducted a comprehensive evaluation of model performance and its execution speeds in comparison to various alternative models using metrics that are suitable for the tasks. Results The mean Intersection over Union values of the segmentation model ranged from 0.90 to 0.97 for different classes (sclera, iris, and pupil) across types of images (synthetic vs. real-world images). Additionally, the mean absolute error for eye tracking was 0.595 for real-world data and the F1 score for blink detection was ≥ 0.95, which indicates our model is performing at a very high level of accuracy. Execution speed was also the most rapid for ocular object segmentation under the same hardware condition as compared to alternative models. The prediction for horizontal and vertical nystagmus in real eye movement video revealed high accuracy with a strong correlation between the observed and predicted values (r = 0.9949 for horizontal and r = 0.9950 for vertical; both p < 0.05). Conclusion The potential of our model, which can automatically segment ocular regions and track nystagmus in real time from eye movement videos, holds significant promise for emergency settings or remote intervention within the field of neurotology.
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Affiliation(s)
- Changje Cho
- Hallym University Medical Center, DIDIM Research Institute, Chuncheon, Republic of Korea
| | - Sejik Park
- Hallym University Medical Center, DIDIM Research Institute, Chuncheon, Republic of Korea
| | - Sunmi Ma
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Hyo-Jeong Lee
- Hallym University Medical Center, DIDIM Research Institute, Chuncheon, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Eun-Cheon Lim
- Hallym University Medical Center, DIDIM Research Institute, Chuncheon, Republic of Korea
| | - Sung Kwang Hong
- Hallym University Medical Center, DIDIM Research Institute, Chuncheon, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
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Noda M, Kuroda T, Nomura A, Ito M, Yoshizaki T, Fushiki H. Smartphone-Assisted Medical Care for Vestibular Dysfunction as a Telehealth Strategy for Digital Therapy Beyond COVID-19: Scoping Review. JMIR Mhealth Uhealth 2023; 11:e48638. [PMID: 37695671 PMCID: PMC10496931 DOI: 10.2196/48638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Dizziness and vertigo can be caused by various factors, such as peripheral vestibular and central disorders. Although consultations with specialists are advisable when necessary, patients with severe vertigo symptoms may have limited mobility, which may interfere with hospital visits. The spread of COVID-19 has further limited the number of hospital visits for patients with dizziness; therefore, a method of medical care that enables more accurate treatment under time and geographical constraints is needed. Telemedicine has become widespread, owing to the popularity of smartphone and tablet devices in recent years, and the use of devices and systems has made it possible to provide efficient medical care. However, no previous scoping review has mapped existing studies on telemedicine for vertigo and dizziness, and no recommendations have been made regarding which devices and systems should be used for specific diseases. OBJECTIVE The aim of this review was to map and assess previous studies on the use of information communications technology, smartphones, and apps for treating patients with vertigo and discuss the added value of introducing telemedicine to improve the quality of medical care and create an environment that builds security and trust among patients. METHODS A scoping review was conducted with the methodological framework of Arksey and O'Malley and in accordance with the of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines. The PubMed, MEDLINE, and Cochrane Library databases were searched to retrieve previous reports on smartphone-assisted telemedicine treatment for vertigo published between January 2000 and May 2023. Two authors independently assessed eligibility and extracted data. RESULTS This review included 20 papers that reported devices or systems for telemedicine for vestibular dysfunction. Among studies that reported the use of a device or app, 2 were related to anamnesis and subjective symptoms, 12 were related to objective examination, 7 were related to remote diagnosis, and 7 were related to treatment and rehabilitation. CONCLUSIONS With the advancement of technology, the use of telemedicine in patients with dizziness may be feasible. In the future, it will be necessary to consider how telemedicine can be used in dizziness treatment and develop an effective treatment system combining in-person medical care and the effective use of devices for the management of severe vertigo and related diseases. The smooth introduction of telemedicine in vertigo treatment is expected to improve the quality of treatment, increase opportunities for patients to receive medical care, and reduce time and travel costs, leading to a sense of security and trust among patients.
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Affiliation(s)
- Masao Noda
- Department of Otolaryngology, Jichi Medical University, Shimotsuke, Japan
- Mejiro University Ear Institute Clinic, Saitama, Japan
| | - Tatsuaki Kuroda
- Mejiro University Ear Institute Clinic, Saitama, Japan
- Kuroda Ear, Nose and Throat Clinic, Kumamoto, Japan
| | - Akihiro Nomura
- College of Transdisciplinary Sciences for Innovation, Kanazawa University, Kanazawa, Japan
| | - Makoto Ito
- Department of Otolaryngology, Jichi Medical University, Shimotsuke, Japan
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Getz DR, Mangalampalli A, Klopfenstein J, Tsung AJ, Kattah JC. Role of bedside video-oculography in selecting neuroimaging in patients with acute vertigo and ataxia posterior fossa mass lesions. J Neurol Sci 2023; 444:120513. [PMID: 36502577 DOI: 10.1016/j.jns.2022.120513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/06/2022] [Accepted: 11/26/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Daniel R Getz
- Department of Neurology, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Anusha Mangalampalli
- Department of Neurology, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Jeffrey Klopfenstein
- Department of Neurosurgery, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Andrew J Tsung
- Department of Neurosurgery, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America; Department of Neurosurgery, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America.
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Korda A, Wimmer W, Wyss T, Michailidou E, Zamaro E, Wagner F, Caversaccio MD, Mantokoudis G. Artificial intelligence for early stroke diagnosis in acute vestibular syndrome. Front Neurol 2022; 13:919777. [PMID: 36158956 PMCID: PMC9492879 DOI: 10.3389/fneur.2022.919777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Measuring the Vestibular-Ocular-Reflex (VOR) gains with the video head impulse test (vHIT) allows for accurate discrimination between peripheral and central causes of acute vestibular syndrome (AVS). In this study, we sought to investigate whether the accuracy of artificial intelligence (AI) based vestibular stroke classification applied in unprocessed vHIT data is comparable to VOR gain classification. Methods We performed a prospective study from July 2015 until April 2020 on all patients presenting at the emergency department (ED) with signs of an AVS. The patients underwent vHIT followed by a delayed MRI, which served as a gold standard for stroke confirmation. The MRI ground truth labels were then applied to train a recurrent neural network (long short-term memory architecture) that used eye- and head velocity time series extracted from the vHIT examinations. Results We assessed 57 AVS patients, 39 acute unilateral vestibulopathy patients (AUVP) and 18 stroke patients. The overall sensitivity, specificity and accuracy for detecting stroke with a VOR gain cut-off of 0.57 was 88.8, 92.3, and 91.2%, respectively. The trained neural network was able to classify strokes with a sensitivity of 87.7%, a specificity of 88.4%, and an accuracy of 87.9% based on the unprocessed vHIT data. The accuracy of these two methods was not significantly different (p = 0.09). Conclusion AI can accurately diagnose a vestibular stroke by using unprocessed vHIT time series. The quantification of eye- and head movements with the use of machine learning and AI can serve in the future for an automated diagnosis in ED patients with acute dizziness. The application of different neural network architectures can potentially further improve performance and enable direct inference from raw video recordings.
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Affiliation(s)
- Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Hearing Research Laboratory, ARTORG Center, University of Bern, Bern, Switzerland
| | - Thomas Wyss
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Efterpi Michailidou
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D. Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- *Correspondence: Georgios Mantokoudis
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Korda A, Wimmer W, Zamaro E, Wagner F, Sauter TC, Caversaccio MD, Mantokoudis G. Videooculography “HINTS” in Acute Vestibular Syndrome: A Prospective Study. Front Neurol 2022; 13:920357. [PMID: 35903121 PMCID: PMC9314570 DOI: 10.3389/fneur.2022.920357] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/02/2022] [Indexed: 11/23/2022] Open
Abstract
Objective A three-step bedside test (“HINTS”: Head Impulse-Nystagmus-Test of Skew), is a well-established way to differentiate peripheral from central causes in patients with acute vestibular syndrome (AVS). Nowadays, the use of videooculography gives physicians the possibility to quantify all eye movements. The goal of this study is to compare the accuracy of VOG “HINTS” (vHINTS) to an expert evaluation. Methods We performed a prospective study from July 2015 to April 2020 on all patients presenting at the emergency department with signs of AVS. All the patients underwent clinical HINTS (cHINTS) and vHINTS followed by delayed MRI, which served as a gold standard for stroke confirmation. Results We assessed 46 patients with AVS, 35 patients with acute unilateral vestibulopathy, and 11 patients with stroke. The overall accuracy of vHINTS in detecting a central pathology was 94.2% with 100% sensitivity and 88.9% specificity. Experts, however, assessed cHINTS with a lower accuracy of 88.3%, 90.9% sensitivity, and 85.7% specificity. The agreement between clinical and video head impulse tests was good, whereas for nystagmus direction was fair. Conclusions vHINTS proved to be very accurate in detecting strokes in patients AVS, with 9% points better sensitivity than the expert. The evaluation of nystagmus direction was the most difficult part of HINTS.
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Affiliation(s)
- Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Hearing Research Laboratory, ARTORG Center, University of Bern, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D. Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- *Correspondence: Georgios Mantokoudis
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Swan AA, Akin FW, Amuan ME, Riska KM, Hall CD, Kalvesmaki A, Padilla S, Crowsey E, Pugh MJ. Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury. J Head Trauma Rehabil 2022; 37:199-212. [PMID: 34320551 DOI: 10.1097/htr.0000000000000714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. SETTING Administrative medical record data from the Department of Veterans Affairs (VA). PARTICIPANTS Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. DESIGN A cross-sectional, retrospective, observational study. MAIN MEASURES International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. RESULTS Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. CONCLUSIONS Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.
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Affiliation(s)
- Alicia A Swan
- Department of Psychology, The University of Texas at San Antonio, San Antonio (Dr Swan and Ms Crowsey); South Texas Veterans Health Care System, San Antonio (Dr Swan); James H Quillen VA Medical Center, Mountain Home, Tennessee (Drs Akin and Hall); Departments of Audiology and Speech Language Pathology (Dr Akin) and Rehabilitative Sciences (Dr Hall), East Tennessee State University, Johnson City; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, Utah (Mss Amuan and Padilla and Drs Kalvesmaki and Pugh); Department of Internal Medicine, University of Utah, Salt Lake City (Mss Amuan and Padilla and Drs Kalvesmaki and Pugh); Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, North Carolina (Dr Riska); and Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina (Dr Riska)
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Liu J, He J, Zhang C. Clinical Significance and Value of Serum Homocysteine and Urine 11 Dehydrothromboxane B2 Combined with Transferrin-Specific Peptide in the Diagnosis of Cerebral Apoplexy. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6130413. [PMID: 35620205 PMCID: PMC9129925 DOI: 10.1155/2022/6130413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/25/2022]
Abstract
Objective To explore the clinical significance and value of serum homocysteine (Hcy) and urine 11 dehydrothromboxane B2 (urine 11-DH-TXB2) combined with transferrin-specific peptide (TF-UP) in the diagnosis of stroke. Methods One hundred stroke patients treated from January 2019 to June 2021 were enrolled in our hospital as the study group. All the patients in the study group met the diagnostic criteria of stroke. The focus of stroke was confirmed by CT or MRI, and the first onset was less than 48 hours. One hundred healthy persons who went through physical examination in our hospital were enrolled as the control group. The comparison was taken to explore the clinical significance and value of Hcy and urine 11-DH-TXB2 combined with TF-UP in the diagnosis of stroke. Results There exhibited no significant difference in the history of smoking, drinking, and atrial fibrillation (P > 0.05). There were significant differences in systolic blood pressure, diastolic blood pressure, eGFR, history of hypertension, diabetes, and coronary heart disease (P < 0.05). In terms of the levels of Hcy, urine 11-DH-TXB2, and TF-UP, the levels of Hcy and urine 11-DH-TXB2 in the study group were higher compared to the control group, while the level of TF-UP in the study group was lower compared to the control group (P < 0.05). The results of logistic regression analysis indicated that there was a significant correlation between Hcy, urine 11-DH-TXB2, TF-UP, and stroke, and Hcy and urine 11-DH-TXB2 indicated positive correlation with stroke disease, while TF-UP level was negatively correlated with stroke disease (P < 0.05). The levels of Hcy, urine 11-DH-TXB2, and TF-UP were adopted as evaluation indexes to draw ROC curve. The results show that the area under the curve (AUC) of Hcy is 0.760 (95% CI 0.670~0.850). The best critical point was 3342.5 pg/mg Ucr, the sensitivity was 65.6%, and the specificity was 77.1%. The AUC of urine 11-DH-TXB2 was 0.773 (95% CI 0.685~0.861). The best critical point was 3354.44 pg/mg Ucr, the sensitivity was 71.2%, and the specificity was 78.3%. The AUC of TF-UP was 0.735 (95% CI 0.641~0.829). The best critical point was 3365.43 pg/mg Ucr, the sensitivity was 68.4%, and the specificity was 80.5%. If Hcy was detected in combination with other indexes, AUC increased to 0.749 when combined with urine 11-DH-TXB2, and AUC increased to 0.797 when combined with TF-UP. When the three are combined, the AUC can reach 0.836, the sensitivity is 79.1%, and the specificity is 80%. It shows that the combined detection of Hcy, urine 11-DH-TXB2, and TF-UP is of higher diagnostic value. The difference of data exhibited statistically significant (P < 0.05). Conclusion There is imbalance between Hcy, urine 11-DH-TXB2, and TF-UP in patients with acute stroke. High Hcy, urine 11-DH-TXB2, and low TF-UP are closely related to the occurrence of cerebral infarction. Hcy, urine 11-DH-TXB2, and TF-UP may be the risk factors of stroke and positively correlated with the degree of neurological impairment. Effective monitoring of Hcy and urine 11-DH-TXB2 combined with TF-UP levels and positive intervention measures may effectively prevent the occurrence and development of cerebral infarction, reduce Hcy and urine 11-DH-TXB2, or increase the level of TF-UP, which may provide new ideas for the treatment of cerebrovascular diseases.
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Affiliation(s)
- Junli Liu
- Laboratory Department, Union Jiangbei Hospital, 430100, China
| | - Juan He
- Laboratory Department, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430079, China
| | - Chang Zhang
- Hubei No. 3 People's Hospital of Jianghan University, Clinical Laboratory, 430033, China
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Müller-Barna P, Leinweber C, Pfaffenrath J, Schütt-Becker N, von Martial R, Greck S, Hubert N, Rambold H, Haberl R, Hubert GJ. Identification of Stroke and TIA in Patients With Acute Dizziness, Vertigo or Imbalance in Emergency Departments of Primary Care Hospitals: Early Experiences With a Network-Based Telemedical Approach. Front Neurol 2022; 13:766685. [PMID: 35309564 PMCID: PMC8924543 DOI: 10.3389/fneur.2022.766685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAcute dizziness, vertigo, and imbalance are frequent and difficult to interpret symptoms in the emergency department (ED). Primary care hospitals often lack the expertise to identify stroke or TIA as underlying causes. A telemedical approach based on telestroke networks may offer adequate diagnostics and treatment.AimThe aim of this study is to evaluate the accuracy of a novel ED algorithm in differentiating between peripheral and central vestibular causes.MethodsWithin the Telemedical Project for Integrative Stroke Care (TEMPiS), a telemedical application including a videooculography (VOG) system was introduced in 2018 in 19 primary care spoke hospitals. An ED triage algorithm was established for all patients with acute dizziness, vertigo, or imbalance of unknown cause (ADVIUC) as a leading complaint. In three predefined months, all ADVIUC cases were prospectively registered and discharge letters analyzed. Accuracy of the ED triage algorithm in differentiation between central and peripheral vestibular cases was analyzed by comparison of ED diagnoses to final discharge diagnoses. The rate of missed strokes was calculated in relation to all cases with a suitable brain imaging. Acceptance of teleconsultants and physicians in spoke hospitals was assessed by surveys.ResultsA total number of 388 ADVIUC cases were collected, with a median of 12 cases per months and hospital (IQR 8–14.5). The most frequent hospital discharge diagnoses are vestibular neuritis (22%), stroke/TIA (18%), benign paroxysmal positioning vertigo (18%), and dizziness due to internal medicine causes (15%). Detection of a central vestibular cause by the ED triage algorithm has a high sensitivity (98.6%), albeit poor specificity (45.9%). One stroke out of 32 verified by brain scan was missed (3.1%). User satisfaction, helpfulness of the project, improvement of care, personal competence, and satisfaction about handling of the VOG systems were rated consistently positive.DiscussionThe concept shows good acceptance for a telemedical and network-based approach to manage ADVIUC cases in the ED of primary care hospitals. Identification of stroke cases is accurate, while specificity needs further improvement. The concept could be a major step toward a broadly available state of the art diagnostics and therapy for patients with ADVIUC in primary care hospitals.
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Affiliation(s)
- Peter Müller-Barna
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
- *Correspondence: Peter Müller-Barna
| | - Christina Leinweber
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Julia Pfaffenrath
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nina Schütt-Becker
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Rascha von Martial
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Susanne Greck
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nikolai Hubert
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Holger Rambold
- Department of Neurology, InnKlinikum Altötting, Altötting, Germany
- Department of Neurology, University of Regensburg, Regensburg, Germany
- MVZ Kliniken Mühldorf, Mühldorf am Inn, Germany
| | - Roman Haberl
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
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von Martial R, Leinweber C, Hubert N, Rambold H, Haberl RL, Hubert GJ, Müller-Barna P. Feasibility of Telemedical HINTS (Head Impulse-Nystagmus-Test of Skew) Evaluation in Patients With Acute Dizziness or Vertigo in the Emergency Department of Primary Care Hospitals. Front Neurol 2022; 12:768460. [PMID: 35222226 PMCID: PMC8873087 DOI: 10.3389/fneur.2021.768460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background Acute dizziness, vertigo and imbalance are common symptoms in emergency departments. Stroke needs to be distinguished from vestibular diseases. A battery of three clinical bedside tests (HINTS: Head Impulse Test, Nystagmus, Test of Skew) has been shown to detect stroke as underlying cause with high reliability, but implementation is challenging in primary care hospitals. Aim of this study is to prove the feasibility of a telemedical HINTS examination via a remotely controlled videooculography (VOG) system. Methods The existing video system of our telestroke network TEMPiS (Telemedic Project for Integrative Stroke Care) was expanded through a VOG system. This feature enables the remote teleneurologist to assess a telemedical HINTS examination based on inspection of eye movements and quantitative video head impulse test (vHIT) evaluation. ED doctors in 11 spoke hospitals were trained in performing vHIT, nystagmus detection and alternating cover test. Patients with first time acute dizziness, vertigo or imbalance, whether ongoing or resolved, presented to the teleneurologist were included in the analysis, as long as no focal neurological deficit according to the standard teleneurological examination or obvious internal medicine cause was present and a fully trained team was available. Primary outcome was defined as the feasibility of the telemedical HINTS examination. Results From 01.06.2019 to 31.03.2020, 81 consecutive patients were included. In 72 (88.9%) cases the telemedical HINTS examination was performed. The complete telemedical HINTS examination was feasible in 46 cases (63.9%), nystagmus detection in all cases (100%) and alternating covert test in 70 cases (97.2%). The vHIT was recorded and interpretable in 47 cases (65.3%). Results of the examination with the VOG system yielded clear results in 21 cases (45.7%) with 14 central and 7 peripheral lesions. The main reason for incomplete examination was the insufficient generation of head impulses. Conclusion In our analysis the telemedical HINTS examination within a telestroke network was feasible in two thirds of the patients. This offers the opportunity to improve specific diagnostics and therapy for patients with acute dizziness and vertigo even in primary care hospitals. Improved training for spoke hospital staff is needed to further increase the feasibility of vHIT.
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Affiliation(s)
- Rascha von Martial
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Christina Leinweber
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Nikolai Hubert
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Holger Rambold
- Department of Neurology, InnKlinikum gKU Altötting und Mühldorf, InnKlinikum Altötting, Altötting, Germany
- Department of Neurology, University of Regensburg, Regensburg, Germany
- Department of Neurology, MVZ Kliniken Mühldorf, Mühldorf am Inn, Germany
| | - Roman Ludwig Haberl
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Peter Müller-Barna
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
- *Correspondence: Peter Müller-Barna
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10
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Schoo DP, Ward BK. New Frontiers in Managing the Dizzy Patient. Otolaryngol Clin North Am 2021; 54:1069-1080. [PMID: 34294438 DOI: 10.1016/j.otc.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Despite progress in vestibular research in the last 20 years, much remains poorly understood about vestibular pathophysiology and its management. A shared language is a critical first step in understanding vestibular disorders and is under development. Telehealth will continue for patients with dizziness, and ambulatory monitoring of nystagmus will become a diagnostic tool. In the next 2 decades, it is anticipated that vestibular perceptual threshold testing will become common in tertiary centers, imaging with improved spatial resolution will yield better understanding of vestibular pathophysiology, and that vestibular implants will become a part of clinical practice.
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Affiliation(s)
- Desi P Schoo
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Bryan K Ward
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA.
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11
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Hoyer C, Szabo K. Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting. Front Neurol 2021; 12:682827. [PMID: 34335448 PMCID: PMC8317999 DOI: 10.3389/fneur.2021.682827] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
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12
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Bergrath S, Brokmann JC, Beckers S, Felzen M, Czaplik M, Rossaint R. Implementation of a full-scale prehospital telemedicine system: evaluation of the process and systemic effects in a pre-post intervention study. BMJ Open 2021; 11:e041942. [PMID: 33762230 PMCID: PMC7993199 DOI: 10.1136/bmjopen-2020-041942] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To review the implementation strategy from a research project towards routine care of a comprehensive mobile physician-staffed prehospital telemedicine system. The objective is to evaluate the implementation process and systemic influences on emergency medical service (EMS) resource utilisation. DESIGN Retrospective pre-post implementation study. SETTING Two interdisciplinary projects and the EMS of a German urban region. INTERVENTIONS Implementation of a full-scale prehospital telemedicine system. ENDPOINTS Descriptive evaluation of the implementation strategy. Primary endpoint: ground-based and helicopter-based physician staffed emergency missions before and after implementation. RESULTS The first research project revealed positive effects on guideline adherence and patient safety in two simulation studies, with feasibility demonstrated in a clinical study. After technical optimisation, safety and positive effects were demonstrated in a multicentre trial. Routine care in the city of Aachen, Germany was conducted stepwise from April 2014 to March 2015, including modified dispatch criteria. Systemic parameters of all EMS assignments between pre-implementation (April 2013 to March 2014) and post implementation (April 2015 to March 2016): on-scene EMS physician operations decreased from 7882/25 187 missions (31.3%) to 6360/26 462 (24.0%), p<0.0001. The need for neighbouring physician-staffed units dropped from 234/25 187 (0.93%) to 119/26 462 (0.45%), p<0.0001, and the need for helicopter EMS from 198/25 187 (0.79%) to 100/26 462 (0.38%), p<0.0001. In the post implementation period 2347 telemedical interventions were conducted, with 26 462 emergency missions (8.87%). CONCLUSION A stepwise implementation strategy allowed transfer from the project phase to routine care. We detected a reduced need for conventional on-scene physician care by ground-based and helicopter-based EMS, but cannot exclude unrecognised confounders, including modified dispatch criteria and possible learning effects. This creates the potential for increased availability of EMS physicians for life-threatening emergencies by shifting physician interventions from conventional to telemedical care. TRIAL REGISTRATION NUMBER NCT04127565.
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Affiliation(s)
- Sebastian Bergrath
- Department of Anaesthesiology, RWTH Aachen University, Medical Faculty, Aachen, Nordrhein-Westfalen, Germany
- Emergency Department, Kliniken Maria Hilf GmbH, Monchengladbach, Nordrhein-Westfalen, Germany
| | | | - Stefan Beckers
- Department of Anaesthesiology, RWTH Aachen University, Medical Faculty, Aachen, Nordrhein-Westfalen, Germany
| | - Marc Felzen
- Department of Anaesthesiology, RWTH Aachen University, Medical Faculty, Aachen, Nordrhein-Westfalen, Germany
| | - Michael Czaplik
- Department of Anaesthesiology, RWTH Aachen University, Medical Faculty, Aachen, Nordrhein-Westfalen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, RWTH Aachen University, Medical Faculty, Aachen, Nordrhein-Westfalen, Germany
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13
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Kühne Escolà J, Nagel S, Verez Sola C, Doroszewski E, Jaschonek H, Gutschalk A, Gumbinger C, Purrucker JC. Diagnostic Accuracy in Teleneurological Stroke Consultations. J Clin Med 2021; 10:jcm10061170. [PMID: 33799590 PMCID: PMC7998723 DOI: 10.3390/jcm10061170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The accuracy of diagnosing acute cerebrovascular disease via a teleneurology service and the characteristics of misdiagnosed patients are insufficiently known. Methods: A random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017 was screened. Teleneurological diagnosis and hospital discharge diagnosis were compared. Diagnoses were then grouped into two main categories: cerebrovascular disease (CVD) and noncerebrovascular disease. Test characteristics were calculated. Results: Out of 1078 consultations, 52% (n = 561) had a final diagnosis of CVD. Patients with CVD could be accurately identified via teleneurological consultation (sensitivity 95.2%, 95% CI 93.2–96.8), but we observed a tendency towards false-positive diagnosis (specificity 77.4%, 95% CI 73.6–80.8). Characteristics of patients with a false-negative CVD diagnosis were similar to those of patients with a true-positive diagnosis, but patients with a false-negative CVD diagnosis had ischemic heart disease less frequently. In retrospect, one patient would have been considered a candidate for intravenous thrombolysis (0.2%). Conclusions: Teleneurological consultations are accurate for identifying patients with CVD, and there is a very low rate of missed candidates for thrombolysis. Apart from a lower prevalence of ischemic heart disease, characteristics of “stroke chameleons” were similar to those of correctly identified CVD patients.
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14
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Parker TM, Farrell N, Otero-Millan J, Kheradmand A, McClenney A, Newman-Toker DE. Proof of Concept for an "eyePhone" App to Measure Video Head Impulses. Digit Biomark 2020; 5:1-8. [PMID: 33615116 DOI: 10.1159/000511287] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/01/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Differentiating benign from dangerous causes of dizziness or vertigo presents a major diagnostic challenge for many clinicians. Bedside presentations of peripheral vestibular disorders and posterior fossa strokes are often indistinguishable other than by a few subtle vestibular eye movements. The most challenging of these to interpret is the head impulse test (HIT) of vestibulo-ocular reflex (VOR) function. There have been major advances in portable video-oculography (VOG) quantification of the video HIT (vHIT), but these specialized devices are not routinely available in most clinical settings. As a first step towards smartphone-based diagnosis of strokes in patients presenting vestibular symptoms, we sought proof of concept that we could use a smartphone application ("app") to accurately record the vHIT. Methods This was a cross-sectional agreement study comparing a novel index test (smartphone-based vHIT app) to an accepted reference standard test (VOG-based vHIT) for measuring VOR function. We recorded passive (examiner-performed) vHIT sequentially with both methods in a convenience sample of patients visiting an otoneurology clinic. We quantitatively correlated VOR gains (ratio of eye to head movements during the HIT) from each side/ear and experts qualitatively assessed the physiologic traces by the two methods. Results We recruited 11 patients; 1 patient's vHIT could not be reliably quantified with either device. The novel and reference test VOR gain measurements for each ear (n = 20) were highly correlated (Pearson's r = 0.9, p = 0.0000001) and, qualitatively, clinically equivalent. Conclusions This preliminary study provides proof of concept that an "eyePhone" app could be used to measure vHIT and eventually developed to diagnose vestibular strokes by smartphone.
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Affiliation(s)
- T Maxwell Parker
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nathan Farrell
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jorge Otero-Millan
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Optometry and Vision Science, University of California, Berkeley, Berkeley, California, USA
| | - Amir Kheradmand
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ayodele McClenney
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
| | - David E Newman-Toker
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
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15
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Domingues RB, Mantese CE, Aquino EDS, Fantini FGMM, Prado GFD, Nitrini R. Telemedicine in neurology: current evidence. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:818-826. [PMID: 33295422 DOI: 10.1590/0004-282x20200131] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Telemedicine was first introduced in Neurology as a tool to facilitate access to acute stroke treatment. More recently, evidence has emerged of the use of telemedicine in several other areas of Neurology. With the advent of the COVID-19 pandemic and the need for social isolation, Brazilian authorities have expanded the regulation of the use of telemedicine, thus allowing the treatment of many patients with neurological diseases to be conducted with less risk of SARS-CoV-2 contamination. OBJECTIVE This study aimed to critically review the current evidence of the use, efficacy, safety, and usefulness of telemedicine in Neurology. METHODS A review of PubMed indexed articles was carried out by searching for the terms "telemedicine AND": "headache", "multiple sclerosis", "vestibular disorders", "cerebrovascular diseases", "epilepsy", "neuromuscular diseases", "dementia", and "movement disorders". The more relevant studies in each of these areas were critically analyzed. RESULTS Several articles were found and analyzed in each of these areas of Neurology. The main described contributions of telemedicine in the diagnosis and treatment of such neurological conditions were presented, indicating a great potential of use of this type of assistance in all these fields. CONCLUSION Current evidence supports that teleneurology can be a tool to increase care for patients suffering from neurological diseases.
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Affiliation(s)
- Renan Barros Domingues
- Comissão Aberta de Telemedicina, Academia Brasileira de Neurologia, São Paulo SP, Brazil.,Santa Casa de Misericórdia de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
| | - Carlos Eduardo Mantese
- Comissão Aberta de Telemedicina, Academia Brasileira de Neurologia, São Paulo SP, Brazil.,Hospital Sírio Libanês, Telemedicina, São Paulo SP, Brazil.,Hospital Mãe de Deus, Porto Alegre RS, Brazil
| | - Emanuelle da Silva Aquino
- Comissão Aberta de Telemedicina, Academia Brasileira de Neurologia, São Paulo SP, Brazil.,Hospital Sírio Libanês, Telemedicina, São Paulo SP, Brazil.,Universidade de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Gilmar Fernandes do Prado
- Diretoria Executiva, Academia Brasileira de Neurologia, São Paulo SP, Brazil.,Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
| | - Ricardo Nitrini
- Universidade de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.,Diretoria Científica, Academia Brasileira de Neurologia, São Paulo SP, Brazil
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16
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Chari DA, Wu MJ, Crowson MG, Kozin ED, Rauch SD. Telemedicine Algorithm for the Management of Dizzy Patients. Otolaryngol Head Neck Surg 2020; 163:857-859. [PMID: 32600170 DOI: 10.1177/0194599820935859] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As a result of the COVID-19 pandemic, telemedicine has been thrust to the forefront of health care. Despite its inherent limitations, telemedicine offers many advantages to both patient and physician as an alternative to in-person evaluation of select patients. In the near term, telemedicine allows nonpandemic care to proceed while observing appropriate public health concerns to minimize the spread of pandemic pathogens. Thus, it behooves practitioners to use telemedicine consultations for common otolaryngology complaints. Assessment of the dizzy patient is well-suited to an algorithmic approach that can be adapted to a telemedicine setting. As best practices for telemedicine have yet to be defined, we present herein a practical approach to the history and limited physical examination of the dizzy patient in the telemedicine setting for the general otolaryngologist. Indeed, once the acute crisis has abated, we suspect that this approach will continue to be an effective way to manage dizzy patients.
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Affiliation(s)
- Divya A Chari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew J Wu
- Department of Otolaryngology-Head and Neck, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Matthew G Crowson
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Elliott D Kozin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven D Rauch
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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17
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Grossman SN, Calix R, Tow S, Odel JG, Sun LD, Balcer LJ, Galetta SL, Rucker JC. Neuro-ophthalmology in the Era of COVID-19: Future Implications of a Public Health Crisis. Ophthalmology 2020; 127:e72-e74. [PMID: 32387481 PMCID: PMC7204645 DOI: 10.1016/j.ophtha.2020.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 11/17/2022] Open
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