Faculty Bibliography

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.

Background/UNASSIGNED:Equestrian athletes (horse riders) are at high risk for head injury, including concussions. Materials & methods/UNASSIGNED:Adults riders were recruited via social media posting to complete a branching survey collecting data on demographics, riding experience, helmet use, injury history and concussion symptom knowledge. Results are reported as frequencies and percentages, with associations tested using chi-square with significance level p < 0.05. Results/UNASSIGNED:Of the 2598 subjects, about 75% reported always wearing a helmet. Of those who did not, the most common reasons were that helmets are unnecessary (57.4%) or do not fit well (48.6%). Many indicated improper storage conditions and/or did not follow manufacturer's replacement recommendations. Most (75.4%) reported a high level of comfort with recognizing concussion signs, with half experiencing a prior head injury. Conclusion/UNASSIGNED:This information suggests opportunities for intervention to improve helmet use through increased fit, while the responses indicate a need for further education on proper helmet use.

Nearly 380,000 U.S. service members between 2000 and 2017 were, and at least 300,000 athletes annually are, diagnosed with concussion. It is imperative to establish a gold-standard diagnostic test to quickly and accurately diagnose concussion. In this non-randomized, prospective study, we examined the reliability and validity of a novel neurocognitive assessment tool, the Defense Automated Neurobehavioral Assessment (DANA), designed to be a more sensitive, yet efficient, measure of concussion symptomatology. In this study, the DANA Brief version was compared to an established measure of concussion screening, the Military Acute Concussion Evaluation (MACE), in a group of non-concussed service members. DANA Brief subtests demonstrated low to moderate reliability, as measured by intra-class correlation coefficient (ICC; values range: 0.28-0.58), which is comparable to other computerized neurocognitive tests that are widely-implemented to diagnose concussion. Statistically significant associations were found between learning and memory components of the DANA Brief and the diagnostic MACE cognitive test score (DANA Brief subtests: CDD: R ² = 0.05, p = 0.023; CDS: R ² = 0.10, p = 0.010). However, a more robust relationship was found between DANA Brief components involving attention and working memory, including immediate memory, and the MACE cognitive test score (DANA Brief subtests: GNG: R ² = 0.08, p = 0.003; PRO: R ² = 0.08, p = 0.002). These results provide evidence that the DANA Rapid version, a 5-min assessment self-administered on a hand-held portable device, based on the DANA Brief version, may serve as a clinically useful and improved neurocognitive concussion screen to minimize the time between injury and diagnosis in settings where professional medical evaluation may be unavailable or delayed. The DANA's portability, durability, shorter test time and lack of need for a medical professional to diagnose concussion overcome these critical limitations of the MACE.

Mild traumatic brain injury (mTBI, also known as a concussion) as a consequence of battlefield blast exposure or blunt force trauma has been of increasing concern to militaries during recent conflicts. This concern is due to the frequency of exposure to improvised explosive devices for forces engaged in operations both in Iraq and Afghanistan coupled with the recognition that mTBI may go unreported or undetected. Blasts can lead to mTBI through a variety of mechanisms. Debate continues as to whether exposure to a primary blast wave alone is sufficient to create brain injury in humans, and if so, exactly how this occurs with an intact skull. Resources dedicated to research in this area have also varied substantially among contributing NATO countries. Most of the research has been conducted in the US, focused on addressing uncertainties in management practices. Development of objective diagnostic tests should be a top priority to facilitate both diagnosis and prognosis, thereby improving management. It is expected that blast exposure and blunt force trauma to the head will continue to be a potential source of injury during future conflicts. An improved understanding of the effects of blast exposure will better enable military medical providers to manage mTBI cases and develop optimal protective measures. Without the immediate pressures that come with a high operational tempo, the time is right to look back at lessons learned, make full use of available data, and modify mitigation strategies with both available evidence and new evidence as it comes to light. Toward that end, leveraging our cooperation with the civilian medical community is critical because the military experience over the past 10 years has led to a renewed interest in many similar issues pertaining to mTBI in the civilian world. Such cross-fertilization of knowledge will undoubtedly benefit all. This paper highlights similarities and differences in approach to mTBI patient care in NATO and partner countries and provides a summary of and lessons learned from a NATO lecture series on the topic of mTBI, demonstrating utility of having patients present their experiences to a medical audience, linking practical clinical care to policy approaches.

INTRODUCTION/BACKGROUND:Current management of ischemic priapism revolves around 3 principles: resolving the acute event, preserving erectile function, and reducing the risk of future recurrences. Although more conservative management options, such as aspiration, irrigation, and surgical shunts, are effective in many patients, those who are refractory to these interventions or have prolonged priapism may benefit from placement of a penile prosthesis (PP). AIM/OBJECTIVE:To provide a comprehensive overview of priapism management, highlight the current literature on the utility of penile implants for refractory priapism, and provide insight from a high-volume center on surgical decision making and technique. METHODS:A complete review of the current guidelines and associated literature was performed. Associated algorithms were evaluated, and our experience was overlaid on the data present in the literature. MAIN OUTCOME MEASURES/METHODS:The current management algorithm for priapism was evaluated. Subsequently, the data on acute and delayed PP placement were assessed. Rates of postoperative infection, erectile dysfunction, and patient satisfaction were also examined. RESULTS:Overall, both delayed and early PP implants are associated with higher rates of failure than routine PP implants. In patients with refractory or prolonged priapism, early implantation may be technically easier, with decreased loss of penile length and associated complications. CONCLUSION/CONCLUSIONS:Patients should be evaluated on an individual basis and counseled on the risks and benefits of PP implantation in early and delayed time frames. Although there is no definitive evidence at this time regarding the ideal device or timing of implantation, there are well-established pros and cons of malleable vs inflatable prostheses and of acute vs delayed implantation. Mishra K, Loeb A, Bukavina L, et al. Management of Priapism: A Contemporary Review. Sex Med Rev 2020;8:131-139.

OBJECTIVE/UNASSIGNED:Findings highlight concerns regarding the usefulness of the RCFT in TLE lateralization, regardless of scoring approach.

Biochirality is the subject of distinct branches of science, including biophysics, biochemistry, the stereochemistry of protein folding, neuroscience, brain functional laterality and bioinformatics. At the protein level, biochirality is closely associated with various post-translational modifications (PTMs) accompanied by the non-equilibrium phase transitions (PhTs ^NE). PTMs ^NE support the dynamic balance of the prevalent chirality of enzymes and their substrates. The stereoselective nature of most biochemical reactions is evident in the enzymatic (Enz) and spontaneous (Sp) PTMs (PTMs ^Enz and PTMs ^Sp) of proteins. Protein chirality, which embraces biophysics and biochemistry, is a subject of this review. In this broad field, we focus attention to the amyloid-beta (Aβ) peptide, known for its essential cellular functions and associations with neuropathology. The widely discussed amyloid cascade hypothesis (ACH) of Alzheimer's disease (AD) states that disease pathogenesis is initiated by the oligomerization and subsequent aggregation of the Aβ peptide into plaques. The racemization-induced aggregation of protein and RNA have been extensively studied in the search for the contribution of spontaneous stochastic stereo-specific mechanisms that are common for both kinds of biomolecules. The failure of numerous Aβ drug-targeting therapies requires the reconsolidation of the ACH with the concept of PTMs ^Sp. The progress in methods of chiral discrimination can help overcome previous limitations in the understanding of AD pathogenesis. The primary target of attention becomes the network of stereospecific PTMs that affect the aggregation of many pathogenic agents, including Aβ. Extensive recent experimental results describe the truncated, isomerized and racemized forms of Aβ and the interplay between enzymatic and PTMs ^Sp. Currently, accumulated data suggest that non-enzymatic PTMs ^Sp occur in parallel to an existing metabolic network of enzymatic pathways, meaning that the presence and activity of enzymes does not prevent non-enzymatic reactions from occurring. PTMs ^Sp impact the functions of many proteins and peptides, including Aβ. This is in logical agreement with the silently accepted racemization hypothesis of protein aggregation (RHPA). Therefore, the ACH of AD should be complemented by the concept of PTMs ^Sp and RHPA.