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Thawani SP, Minen MT, Stainman RS, Friedman S, Bhatt JM, Foo FYA, Torres DM, Weinberg HJ, Kim NH, Levitan V, Cardiel MI, Zakin E, Conway JM, Kurzweil AM, Hasanaj L, Galetta SL, Balcer LJ, Busis NA. Neurologists' Evaluations of Experience and Effectiveness of Teleneurology Encounters. Telemed J E Health 2023; 29:442-453. [PMID: 35834603 DOI: 10.1089/tmj.2021.0551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives: To better understand neurologists' assessments of the experiences and effectiveness of teleneurology encounters. Methods: After completing an audio-video telehealth visit with verbally consenting patients, neurologists recorded their evaluations of the encounter. Data were analyzed using standard quantitative and qualitative techniques. Results: The study included unique encounters between 187 patients and 11 neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of patients (66.8%, 125/187) were female. One third of patients (33.2%; 62) were new patients. The most common patient complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Neurologists reported that they completed a virtual examination that provided enough information for medical decision-making in 94.9% of encounters (169/178, 9 missing responses). Fourteen of 25 examination elements important for medical decision-making could be performed sufficiently during virtual encounters. Examination assistance was needed for 16.4% (30/183) of patients, who were, on average, 17.3 years older than those who did not require assistance (62.9 years vs. 45.6 years, p = 0.0002). In 19.1% (34/178) of encounters, neurologists learned clinically relevant information from seeing patients in their homes. Neurologists' assessments of the effectiveness of encounters were not related to the presence (97.2%, 35/36 effective) or absence (95%, 134/141 effective) of technical difficulties (p = 0.5729) in 177 encounters (10 missing responses). Discussion: Neurologists reported that nearly 95% of teleneurology encounters were effective despite limitations of the virtual examination, occasional need for patient assistance, and technical difficulties.
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Affiliation(s)
- Sujata P Thawani
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Mia T Minen
- Department of Neurology and NYU Langone Health, New York, New York, USA.,Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Rebecca S Stainman
- Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Steven Friedman
- Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Jaydeep M Bhatt
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Farng-Yang A Foo
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Daniel M Torres
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Harold J Weinberg
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Nina H Kim
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Valeriya Levitan
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Myrna I Cardiel
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Elina Zakin
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Jenna M Conway
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | | | - Lisena Hasanaj
- Department of Neurology and NYU Langone Health, New York, New York, USA
| | - Steven L Galetta
- Department of Neurology and NYU Langone Health, New York, New York, USA.,Department of Ophthalmology, NYU Langone Health, New York, New York, USA
| | - Laura J Balcer
- Department of Neurology and NYU Langone Health, New York, New York, USA.,Department of Population Health, NYU Langone Health, New York, New York, USA.,Department of Ophthalmology, NYU Langone Health, New York, New York, USA
| | - Neil A Busis
- Department of Neurology and NYU Langone Health, New York, New York, USA
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Kasturiarachi BM, Krishnaiah B. Recognizing Aphemia and How to Differentiate From Aphasia in the Era of Telemedicine. Neurohospitalist 2021; 11:348-350. [PMID: 34567396 DOI: 10.1177/1941874421990546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Aphemia, or pure motor mutism, is a phenomenon that has been reported previously in the literature and typically is associated with small infarcts in the inferior dominant precentral gyrus, pars opercularis, or inferior perirolandic gyrus. Clinically, it is important to distinguish aphemia from aphasia syndromes. Telemedicine is becoming more prevalent and involving neurologists across the country. This is an important consideration when addressing aphemic patients as many mistakes can be made during a virtual exam clouding a patient's clinical picture. Case Presentation Our patient is a 61-year-old female with a past medical history of hypertension, diabetes, and an old right frontoparietal stroke without any residual deficits. She presented after her family stated that she "quit speaking" for about seven hours. Initial neurological evaluation was done via telemedicine due to the COVID-19 pandemic and was pertinent for decreased consciousness, inability to answer either orientation question, a right facial droop, and aphasia. Later it was found that the patient exhibited a pure motor mutism rather than aphasia and had an MRI lesion in the left inferior precentral gyrus. Conclusion Differentiating aphemia from aphasia is an important clinical skill for a neurologist to foster especially in the era of telemedicine. An intimate knowledge of the parts of a speech exam are vital in directing emergency staff during stroke evaluation. Additionally, distinguishing these clinical syndromes has implications with respect to prognosis and long-term rehabilitation.
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Affiliation(s)
| | - Balaji Krishnaiah
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA
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Alam M, Haq AU. Wrist drop and focal seizures in a 60-year-old man. Postgrad Med J 2018; 94:729. [PMID: 30341228 DOI: 10.1136/postgradmedj-2018-136115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 10/07/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Mehtab Alam
- Department of Neurology, Lady Reading Hospital, Peshawar, Pakistan
| | - Ayaz Ul Haq
- Department of Neurology, Lady Reading Hospital, Peshawar, Pakistan
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van Zijl JC, Beudel M, Elting JWJ, de Jong BM, van der Naalt J, van den Bergh WM, Rossetti AO, Tijssen MAJ, Horn J. The Inter-rater Variability of Clinical Assessment in Post-anoxic Myoclonus. Tremor Other Hyperkinet Mov (N Y) 2017; 7:470. [PMID: 28966876 PMCID: PMC5618111 DOI: 10.7916/d81r6xbv] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 06/01/2017] [Indexed: 12/01/2022]
Abstract
Background Acute post-anoxic myoclonus (PAM) can be divided into an unfavorable (generalized/subcortical) and more favorable ((multi)focal/cortical) outcome group that could support prognostication in post-anoxic encephalopathy; however, the inter-rater variability of clinically assessing these PAM subtypes is unknown. Methods We prospectively examined PAM patients using a standardized video protocol. Videos were rated by three neurologists who classified PAM phenotype (generalized/(multi)focal), stimulus sensitivity, localization (proximal/distal/both), and severity (Clinical Global Impression-Severity Scale (CGI-S) and Unified Myoclonus Rating Scale (UMRS)). Results Poor inter-rater agreement was found for phenotype and stimulus sensitivity (κ=−0.05), moderate agreement for localization (κ=0.46). Substantial agreement was obtained for the CGI-S (intraclass correlation coefficient (ICC)=0.64) and almost perfect agreement for the UMRS (ICC=0.82). Discussion Clinical assessment of PAM is not reproducible between physicians, and should therefore not be used for prognostication. PAM severity measured by the UMRS appears to be reliable; however, the relation between PAM severity and outcome is unknown.
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Affiliation(s)
- Jonathan C van Zijl
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Martijn Beudel
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Jan-Willem J Elting
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands.,Department of Clinical Neurophysiology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Bauke M de Jong
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Intensive Care Medicine, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, The Netherlands
| | - Janneke Horn
- Intensive Care Medicine, Amsterdam Medical Center (AMC), University of Amsterdam, Amsterdam, The Netherlands
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Abstract
BACKGROUND Telemedicine is used for specialist consultation, patient evaluation, and remote monitoring. We propose that telemedicine has a valuable role in medical education through facilitating faculty supervision of trainees. MATERIALS AND METHODS We surveyed resident physician trainees and faculty at a single institution who provided service for acute neurologic consultations over 29 months. The survey compared experiences using the supervisory methods of telephone, robotic telepresence (RTP), and in-person interaction. Participants answered 10 questions addressing their experience relevant to faculty-trainee interaction quality and clinical supervision, achieved with the three supervisory methods under study. RESULTS Surveys were received from 20 of 36 trainees (56%) and 8 of 10 faculty members (80%). More than 90% of trainees and faculty strongly agreed that in-person communication was satisfactory for patient data review, problem synthesis, and refinement of the trainees' impressions, with RTP ranking a close second. Moreover, 38% of faculty and 70% of trainees reported the telephone method as unsatisfactory for reacquisition of patient history, data synthesis, and direct observation of trainees' clinical skills. RTP provided more than 90% of trainees with sufficient staff support and facilitated trainee autonomy. CONCLUSIONS Overall, 85% of both trainees and faculty preferred in-person supervision most, with RTP ranked second and telephone being least favored. Although in-person faculty supervision of trainees' management of neurologic emergencies is always preferred, it is not always practical. This survey highlights the valuable role of RTP in graduate medical education and RTP as preferred over telephone as an adjunctive supervision tool in residency.
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Affiliation(s)
- Neha M Kramer
- 1 Department of Neurology, Mayo Clinic , Rochester, Minnesota
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Feil K, Boettcher N, Lezius F, Habs M, Hoegen T, Huettemann K, Muth C, Eren O, Schoeberl F, Zwergal A, Bayer O, Strupp M. Clinical evaluation of the bed cycling test. Brain Behav 2016; 6:e00445. [PMID: 27096103 PMCID: PMC4829574 DOI: 10.1002/brb3.445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Additionally to the forearm rolling test to detect mild unilateral upper limb dysfunction, the bed cycling test (BCT) for detection of mild to moderate lower limb dysfunction was developed, evaluated and compared to the leg holding test. METHODS In a prospective observer-blinded study, 60 patients with MRI/CT-proven focal cerebral hemisphere lesions and a mild to moderate unilateral paresis of the lower limb (graduated MRC 3-4/5), and 60 control persons with normal imaging were examined and filmed. Nine observers blinded to the diagnosis evaluated these videos. The sensitivity, specificity and the positive and negative predictive values of the clinical tests were analyzed. RESULTS The observers gave a correct evaluation of BCT in 35.5% of all patients with focal cerebral lesions compared to 26.0% for the leg holding test. On the other hand, observers had false negative results in 29.1% of cases with BCT and 44.7% with leg holding test. In 36.7% of patients, only BCT was pathological while leg holding test was unremarkable. The sensitivity of the combination of both tests was 0.68 (95% CI 0.61-0.75). The BCT is more sensitive (64.3%) than leg holding test (46.2%) while the specificity of leg holding test (85.6%) is higher than of BCT (70.1%) to detect a cerebral lesion affecting the lower limb. The inter-rater variability is high with no differences comparing different types of clinical experience. CONCLUSIONS The BCT is a useful additional clinical bedside test to detect subtle unilateral cerebral lesions. The BCT is easy to perform and can be added to the routine neurological examination.
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Affiliation(s)
- Katharina Feil
- Department of Neurology University Hospital Munich Germany; German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Nicolina Boettcher
- German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Franziska Lezius
- Department of Anesthesiology and Operative Intensive Care Medicine Charité University Berlin Germany
| | - Maximilian Habs
- Department of Neurology University Hospital Munich Germany; German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Tobias Hoegen
- Department of Neurology University Hospital Munich Germany
| | | | - Carolin Muth
- German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Ozan Eren
- German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Florian Schoeberl
- Department of Neurology University Hospital Munich Germany; German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Andreas Zwergal
- Department of Neurology University Hospital Munich Germany; German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Otmar Bayer
- German Center for Vertigo and Balance Disorders University Hospital Munich Germany
| | - Michael Strupp
- Department of Neurology University Hospital Munich Germany; German Center for Vertigo and Balance Disorders University Hospital Munich Germany
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Abstract
Tinnitus is the usually unwanted perception of sound, in most cases there is no genuine physical source of sound. Less than 10% of tinnitus patients suffer from pulsatile tinnitus. Objective Pulsatile tinnitus can also be the first indication of dural arteriovenous fistula, so examination for such vascular origin must be performed.
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Affiliation(s)
- Dario A Yacovino
- Neurology Department"Cesar Milstein" Hospital Buenos Aires Argentina; Memory and balance Clinic Buenos Aires Argentina
| | - Pablo Casas
- Memory and balance Clinic Buenos Aires Argentina
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Friedman LS, Farmer JM, Perlman S, Wilmot G, Gomez C, Bushara KO, Mathews KD, Subramony SH, Ashizawa T, Balcer LJ, Wilson RB, Lynch DR. Measuring the rate of progression in Friedreich ataxia: implications for clinical trial design. Mov Disord 2010; 25:426-32. [PMID: 20063431 PMCID: PMC2954653 DOI: 10.1002/mds.22912] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Friedreich ataxia is an autosomal recessive neurodegenerative disorder characterized by ataxia of all four limbs, dysarthria, and arreflexia. A variety of measures are currently used to quantify disease progression, including the Friedreich Ataxia Rating Scale, examiner-rated functional disability scales, self-reported activities of daily living and performance measures such as the timed 25-foot walk, 9-hole pegboard test, PATA speech test, and low-contrast letter acuity vision charts. This study examines the rate of disease progression over one and two years in a cohort of 236 Friedreich ataxia patients using these scales and performance measure composites. The Friedreich Ataxia Rating Scale and performance-measure composites captured disease progression, with a greater sensitivity to change over 2 years than over 1 year. The measures differed in their sensitivity to change and in possible bias. These results help to establish norms for progression in FRDA that can be useful in measuring the long-term success of therapeutic agents and defining sample-size calculations for double-blind clinical trials.
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Affiliation(s)
- Lisa S Friedman
- Department of Neurology, University of Pennsylvania School of Medicine, United States
- Department of Pediatrics, University of Pennsylvania School of Medicine, United States
- Children’s Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Jennifer M Farmer
- Department of Neurology, University of Pennsylvania School of Medicine, United States
- Department of Pediatrics, University of Pennsylvania School of Medicine, United States
- Children’s Hospital of Philadelphia, Philadelphia, PA, 19104, United States
| | - Susan Perlman
- University of California Los Angeles, Los Angeles, CA, United States
| | | | - Christopher Gomez
- University of Minnesota, Minneapolis, MN, United States
- University of Chicago, Chicago, IL, United States
| | | | | | - S. H Subramony
- University of Texas Medical Branch, Galveston, TX, United States
- University of Mississippi, Jackson, MS, United States
| | - Tetsuo Ashizawa
- University of Texas Medical Branch, Galveston, TX, United States
- University of Florida, Gainesville, FL, United States
| | - Laura J Balcer
- Department of Neurology, University of Pennsylvania School of Medicine, United States
| | - Robert B Wilson
- Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, United States
| | - David R Lynch
- Department of Neurology, University of Pennsylvania School of Medicine, United States
- Department of Pediatrics, University of Pennsylvania School of Medicine, United States
- Children’s Hospital of Philadelphia, Philadelphia, PA, 19104, United States
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