To investigate the impact of a 3-week neurology curriculum on house staff in a teaching hospital in Tamale, Ghana.

Background and Objectives: To better understand patients' and neurologists' assessments of their experiences regarding effectiveness of teleneurology encounters. Methods: Following an audio-video telehealth visit, neurologists asked patients to participate in a survey-based research study about the encounter, and then, the neurologists also recorded their own evaluations. Data were analyzed using standard quantitative and qualitative techniques for dichotomous and ordered-category survey responses in this cross-sectional analysis. Results: The study included unique encounters between 187 patients and 11 general neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of the patients (66.8%, 125/187) were female. One third (33.2%; 62) were patients new to the NYU Langone Health neurology practices. The most common patient chief 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%). Most patients (94.7%, 177/187) reported that the teleneurology encounter satisfied their needs. Patients and their neurologists agreed that the experience was effective in 91% (162/178) of encounters, regardless of whether the visit was for a new or established patient visit. Discussion: More than 90% of new and established patients and their neurologists agreed that teleneurology encounters were effective despite some limitations of the examination, the occasional need for patient assistance, and technical difficulties. Our results provide further evidence to justify and to expand the clinical use of teleneurology.

Background:Prior to the COVID-19 pandemic, about half of patients from populations that sought care in neurology tried complementary and integrative therapies (CITs). With the increased utilization of telehealth services, we sought to determine whether patients also increased their use of virtual CITs.Methods:We examined datasets from two separate cross-sectional surveys that included cohorts of patients with neurological disorders. One was a dataset from a study that examined patient and provider experiences with teleneurology visits; the other was a study that assessed patients with a history of COVID-19 infection who presented for neurologic evaluation. We assessed and reported the use of virtual (and non-virtual) CITs using descriptive statistics, and determined whether there were clinical characteristics that predicted the use of CITs using logistic regression analyses.Findings:Patients who postponed medical treatment for non-COVID-19-related problems during the pandemic were more likely to seek CITs. Virtual exercise, virtual psychotherapy, and relaxation/meditation smartphone applications were the most frequent types of virtual CITs chosen by patients. In both studies, age was a key demographic factor associated with mobile/virtual CIT usage.Interpretations:Our investigation demonstrates that virtual CIT-related technologies were utilized in the treatment of neurologic conditions during the pandemic, particularly by those patients who deferred non-COVID-related care.

Given the reductions in in-person visits and the increases in teleneurology visits, we sought to determine whether patients increased their use of virtual complementary and integrative therapies.

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.

To determine the patient and physician perspective of the same teleneurology visit

Emerging data suggest the central nervous system (CNS) complications of coronavirus disease (COVID-19) occur with greater frequency than related coronaviruses, severe acute respiratory syndrome coronavirus (SARS-CoV-1) and Middle East respiratory syndrome (1). A large, retrospective report from Wuhan described neurological symptoms in 36.5% of patients (2). We previously reported 2 cases of cranial nerve–related complications of COVID-19 (3). During the peak of COVID-19–related hospitalizations and fatalities in New York City, 2 additional cases of isolated sixth nerve palsy presented in an outpatient and inpatient setting. CASE 1 A 43-year-old right-handed woman with a history of migraines and well-controlled systemic hypertension presented to the emergency department (ED) with acute onset of painless diplopia. She had a fever for 3 days with a maximum temperature of 102°F, cough, fatigue, and lightheadedness. The morning of admission she awoke with binocular, horizontal diplopia, worse in far gaze and on left lateral gaze. Her neurologic examination was consistent with an isolated left sixth nerve palsy (Fig. 1). She was admitted for fever and respiratory symptoms, and a nasal swab for SARS-CoV-2 polymerase chain reaction was positive. Additional inflammatory and infectious serologic studies were negative, including Lyme western blot, antinuclear antibody, and angiotensin-converting enzyme. A contrast-enhanced MRI of the brain and orbits was unrevealing. The patient declined inpatient lumbar puncture and was discharged home after being afebrile for 72 hours.FIG. 1.: Motility examination of Patient 1 on Day 10 after the onset of diplopia revealed mild residual limitation of left eye abduction (right panel).CASE 2 A 52-year-old man with a history of well-controlled systemic hypertension presented with acute onset diplopia for about 1 week amidst a viral illness. On Day 1 of illness, he developed a fever of 103°F, anosmia, and ageusia. On Day 2, he developed an acute sense of imbalance with "a parallel view of everything" when looking in the distance. He described horizontal binocular diplopia, worse in the distance and left gaze. He denied facial weakness or changes in sensation. Fevers persisted and he developed myalgias and fatigue. On Days 3–5, he endorsed severe headache but no meningismus. As EDs were overwhelmed at the peak of the COVID-19 pandemic in New York City, symptomatic individuals without respiratory or other distress were not encouraged to visit the ED. Furthermore, outpatient in-person visits were limited to urgent and emergent cases alone, and evaluation of febrile individuals within the clinic was highly discouraged to mitigate viral exposure and spread. The patient was therefore evaluated by a telehealth visit on Day 8; during which he was noted to have an abduction deficit of the left eye as well as decreased saccadic velocity and an esotropia on an alternate cover test self-performed by the patient (Fig. 2). An isolated sixth nerve palsy was diagnosed. The patient declined neuroimaging for his fear of exposing others. At follow-up 6 days later (Day 14 of symptoms onset), he noted fever, myalgias, fatigue, and double vision had resolved. His anosmia and ageusia persisted.FIG. 2.: Motility examination of Patient 2 revealed limitation of left eye abduction (right panel).DISCUSSION Over the course of the COVID-19 pandemic the spectrum of clinical symptoms related to the virus has evolved and expanded. The symptoms initially reported in Wuhan, China, (4) were limited to hospitalized patients, which likely biased the outcomes. Other common presenting symptoms emerged, such as sore throat, diarrhea, ageusia, and anosmia (5,6). More serious complications have also been encountered, including those affecting the CNS (7–9). The pathophysiology of COVID-19's neurotropism is not entirely understood, but based on our knowledge of other respiratory viruses, several hypotheses have been proposed. Hematogenous spread is believed to occur by direct invasion of endothelial cells by the virus, leading to breakdown of the blood–brain barrier. Alternatively, it may also occur secondary to infected leukocytes inciting proinflammatory mediators and subsequent blood–brain barrier permeability (10). On the other hand, COVID-19 may access the CNS by direct invasion of the virus through peripheral nerves (11,12). Investigations of akin coronaviruses and influenza A in animal models suggest the CNS entry may occur through retrograde, transsynaptic invasion of the virus through the olfactory bulb or through the mechanoreceptors and chemoreceptors sending afferent fibers to the medulla (11,13–17). In Case 1, the patient's neuroimaging was unremarkable, without abnormal enhancement involving the sixth nerve along its course. Similarly, in the case of COVID-19–related isolated sixth nerve palsy previously described by our group, there were no radiologic findings related to the sixth nerve (3). However, the presence of optic nerve sheath enhancement suggested possible viral leptomeningeal invasion. Although other respiratory viruses are known to gain access to the CNS hematogenously (18), pathologic studies have failed to demonstrate presence of SARS-CoV-2 particles in adjacent nonneuronal cells of infected areas (11), suggesting an alternative mode of viral transmission. This may explain why enhancement of the sixth nerve did not occur in these cases because there was no immediate breakdown of the blood–brain barrier. Other considerations would include a hypertensive episode in the state of acute viral illness (19,20). The 2 patients described here, as well as the isolated sixth nerve palsy case previously described (3), all suffered from comorbid hypertension. Such observation leads one to speculate the possibility of hypertension as a risk factor for COVID-19–related sixth nerve palsy. Although some neurologists and neuro-ophthalmologists may not pursue imaging in the case of an isolated sixth nerve palsy in a patient with vascular risk factors, our clinical experience during this pandemic emphasizes the value of MRI brain and orbits with gadolinium. This additional clinical data may improve our understanding of disease pathogenesis and neurotropic mechanisms of COVID-19. In addition, managing patients with COVID-19 early in the height of the pandemic in New York City created an opportunity to trial telemedicine as an effective mode of delivering care. Telemedicine allowed us to provide safe and effective care by allowing patients to remain isolated while still acquiring sufficient clinical data to make an assessment and plan. Evaluation of the efferent system by video is feasible and may include a motility examination and alternate cover testing (21). Without distancing restrictions, patient education and counseling could also be addressed more satisfactorily. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: C. Greer, J. Bhatt, and M. Dinkin; b. Acquisition of data: C. Greer, J. Bhatt, and Marc Dinkin; c. Analysis and interpretation of data: C. Greer, J. Bhatt, C. Oliveira, and M. Dinkin. Category 2: a. Drafting the manuscript: C. Greer; b. Revising it for intellectual content: C. Greer, J. Bhatt, C. Oliveira, and M. Dinkin. Category 3: a. Final approval of the completed manuscript: C. Greer, J. Bhatt, C. Oliveira, and M. Dinkin.

Guillain-Barré Syndrome is a popular eponym that comes from a 1916 paper by Drs. Guillain, Barré, and Strohl. These physicians described two soldiers in the French Sixth Army during World War I who developed acute progressive motor weakness. Although Drs. Guillain and Barré have continued to be included in the syndrome's eponym, Dr. Strohl has been forgotten despite having strongly contributed to the original paper. The reasons previously mentioned for Dr. Strohl's absence appear trivial in contemporary practice and thus, his name deserves to be reintroduced to Guillain-Barré-Strohl Syndrome.

Tuberculous meningitis (TBM) is the most lethal manifestation of tuberculosis and requires rapid diagnosis and initiation of treatment to prevent death and serious neurological disability.….

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Neuromuscular disorders as a group are linked by anatomy with significant differences in pathogenetic mechanisms, clinical expression, and time course of disease. Each neuromuscular disease is relatively uncommon, yet causes a significant burden of disease socioeconomically. Epidemiologic studies in different global regions have demonstrated certain neuromuscular diseases have increased incidence and prevalence rates over time. Understanding differences in global epidemiologic trends will aid clinical research and policies focused on prevention of disease. There is a critical need to understand the global impact of neuromuscular diseases using metrics currently established for communicable and noncommunicable diseases.