The Italian technical/administrative recommendations for telemedicine in clinical neurophysiology

Telemedicine in nutritional management of children with severe neurological impairment: implication for quality of life

Children with severe neurological impairment (SNI) frequently present feeding problems requiring a close monitoring of their nutritional status. In addition to constant clinical monitoring of body composition and nutritional indexes in these patients, frequent reports of dietary intake and weight gain variations are useful to ensure proper nutritional management. Furthermore, non-oral feeding is often needed to avoid malnutrition or aspiration pneumonia, constantly necessitating medical assistance. Despite their necessity for frequent hospital accesses, these patients' disabilities represent an important obstacle to accessing care, generating anxiety and concern in children and their families. Telemedicine has proven to be a promising instrument for improving pediatric patients' healthcare in several fields. By breaking down geographical and temporal barriers, telehealth may represent a valuable tool to implement in clinical practice, in order to improve patients' outcomes and quality of life. The aim of this narrative review is to provide an overview of the main nutritional issues in children with SNI, the potential implications of telemedicine in their management and the available evidence regarding the effects and benefits of telehealth.

Application of tele-neuropsychology and tele-mental health before and during COVID-19 era: a bibliometric analysis

Background

Telehealth use was previously limited by strict regulations and financial constraints. However, the pandemic prompted some countries to ease their telehealth laws. Thus, we conducted a bibliometric analysis and network visualization to gauge changes in tele-neuropsychology (Tele-NP) and tele-mental Health (Tele-MH) trends with the onset of the COVID-19 pandemic.

Materials and methods

The authors conducted a literature search on SCOPUS and included relevant articles pertaining to Tele-NP and Tele-MH, which were published before the COVID-19 pandemic (2017-2019) and during the COVID-19 pandemic (2020-2022). The authors presented publication patterns on psychiatric disorders, mode of administration, journals, active countries, authors, affiliations, funding sponsors, keywords, publication, and citation output.

Results

Three hundred forty-one articles were included in our study with 80 articles before the pandemic and 261 during the pandemic. Our analysis revealed the greatest increase in publications and citations output was from the year 2020 to 2021. A greater number of journals published tele-NP and tele-MH-related research, with higher frequency, during the COVID-19 pandemic with Telemedicine and E-health leading the way. WHO regional analysis revealed that the Region of the Americas (AMRO) was the leading contributor in terms of publications. Harvard Medical Center remained the number one contributor both before and during the COVID-19- pandemic. Publications by funding sponsors, particularly by those that were US-based, increased twice as much during the pandemic.

Conclusion

The increase in research output following the COVID-19 outbreak reflects the growing interest and relevance of telemedicine for the delivery of mental health services.

Models of care and relevance of territorial management in assisting persons with epilepsy

Epilepsy is a widespread social disease that affects people of all ages and often involves both diagnostic and therapeutic difficulties. Beyond seizure control, it is necessary to ensure people with epilepsy a good quality of life and respect for human rights, seeking to increase self-management capacity and break down stigma. People with epilepsy should have privileged access to specialized epilepsy centers, where multidisciplinary care is possible. These centers, organized by different levels of complexity, should be uniformly distributed throughout the country and networked together. The scientific community and health care organizations must therefore design all necessary strategies so that knowledge about epilepsy improves among the general population and the most effective pathways of care are effectively implemented.

Telemedicine and YouTube™: Video quality analysis before and after COVID-19 pandemic

OBJECTIVE

To assess the quality content of YouTube™ videos on telemedicine during COVID-19 pandemic.

MATERIALS AND METHODS

First, the frequency of worldwide YouTube™ and Google™ searches for telemedicine was analyzed. Second, we queried YouTube™ with telemedicine-related terms. Third, the Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT A/V), the Global Quality Score (GQS), and the Misinformation tool were used for the quality assessment.

RESULTS

According to selection criteria, 129 videos were collected for the analysis. From January 2018 to January 2022, the peak relative interest on YouTube™ and Google™ occurred in March 2020. Of all, 27.1 and 72.9% were uploaded before (Jan 2018-Feb 2020) and after (Mar 2020-Mar 2022) the COVID-19 outbreak, respectively. According to the PEMAT A/V, the overall median understandability and actionability was 50.0% (33.3 [IQR 0-66.7] vs 50.0 [27.1-75], p = 0.2) and 66.7% (63.6 [IQR 50.0-75.7] vs 67.9 [50.0-79.2],p = 0.6), respectively. According to GQS, 3.9%, 17.8%, 24.0%, 26.4% and 27.9% were classified as excellent, good, medium, generally poor, and poor-quality videos, respectively. The highest rate of poor-quality videos was recorded in videos uploaded before COVID-19 pandemic (37.1 vs 24.5%). According to overall misinformation score, a higher score was recorded for the videos uploaded after COVID-19 pandemic (1.8 [IQR 1.4-2.3] vs 2.2 [1.8-2.8], p = 0.01).

CONCLUSIONS

The interest in telemedicine showed a significant peak when the COVID-19 pandemic was declared. However, the contents provided on YouTubeTM were not informative enough. In the future, official medical institutions should standardize telemedicine regulation and online content to reduce the widespread of misleading information.

Unmet needs and perspectives in management of drug resistant focal epilepsy: An Italian study

This study aimed to evaluate the consensus level between a representative group of Italian neurologists and people with Drug-Resistant Epilepsy (DRE) regarding a series of statements about different aspects involved in the management of epilepsy to identify the unmet needs of the People with Epilepsy (PwE) and the future perspectives for the management of this disease. This observational study was conducted using a classic Delphi technique. A 19-statement questionnaire was administered anonymously through an online platform to a panel of expert clinicians and a panel of PwE, analyzing three main topics of interest: drug resistance, access to care, and PwE's experience. The consensus was achieved on 8 of the 19 statements administered to the panel of medical experts and on 4 of the 14 submitted to the panel of PwE, particularly on the definition of DRE and its consequences on treatment, Quality of Life (QoL), and autonomy of PwE. Most of the items, however, did not reach a consensus and highlighted the lack of a shared univocal view on some topics, such as accessibility to care throughout the country and the role of emerging tools such as telemedicine, narrative medicine, and digital devices. In many cases, the two panels expressed different views on the statements. The results outlined many fields of possible intervention, such as the need for educational initiatives targeted at physicians and PwE - for example, regarding telemedicine, digital devices, and narrative medicine - as well as the spread of better knowledge about epilepsy among the general population, in order to reduce epilepsy stigma. Institutions, moreover, could take a cue from this survey to develop facilities aimed at enhancing PwE's autonomy and promoting more equal access to care throughout the country.

Telemedicine applied to neuromuscular disorders: focus on the COVID-19 pandemic era

Neuromuscular diseases are rare and usually chronic progressive disorders that require a multidisciplinary clinical evaluation and functional monitoring. The patient-physician relationship and therapies are also key elements to be provided. The COVID-19 pandemic dramatically changed the way patients' health was managed and national health care services underwent a radical reorganization. Telemedicine, with the use of Information and Communication Technology (ICT) by health professionals, became the main strategy to ensure the continuation of care. However, the experience regarding the use of Telemedicine in neuromuscular disorders is very limited and the scientific literature is extremely scarce. From the first experiences in the '50s, the development of Telemedicine has been supplemented and supported by the implementation of ICT to guarantee the secure and effective transmission of medical data. Italian national guidelines (2010-2020) describe the technical and professional guarantees necessary to provide Telemedicine services. Nevertheless, at the time the pandemic appeared, no guidelines for clinical evaluation or for the administration of functional scales remotely were available for neuromuscular diseases. This has been a critical point when clinical evaluations were mandatory also for the renewal of drug prescriptions. However, the common opinion that telemedicine basic services were important to overcome the change in medical practice due to COVID-19 in neuromuscular diseases, even in pediatric age, emerged. Moreover, alternative digital modalities to evaluate patients at home in a kind of virtual clinic were considered as a field of future development.

A nationwide survey on clinical neurophysiology education in Italian schools of specialization in neurology

Introduction

Clinical neurophysiology deals with nervous system functions assessed with electrophysiological and ultrasound-based imaging techniques. Even though the need for highly specialized neurophysiologists has increased, residency training rarely takes today’s requirements into account. This study aimed to snapshot the neurophysiological training provided by Italian specialization schools in neurology.

Methods

A single-page web-based survey comprising 13 multiple-choice categorical and interval scale questions was sent via e-mail to neurology specialization school directors. The survey addressed the programs’ structural neurophysiology organization, time dedicated to each clinical neurophysiology subspecialty, and descriptors assessing the discipline’s importance (e.g., residents who attempted residential courses, gained certifications, or awards gained).

Results

The most studied neurophysiological techniques were electroencephalography (EEG) and electromyography (EMG). Most specialization schools devoted less than 3 months each to multimodal evoked potentials (EPs), ultrasound sonography (US), and intra-operative monitoring. Of the 35 specialization schools surveyed, 77.1% reported that four students, or fewer, participated in the Italian Society of Clinical Neurophysiology Examination in Neurophysiology. Of the 35 specialization centers surveyed, 11.4% declared that the final evaluation required students to discuss a neurophysiological test.

Discussion

Our survey underlined the poorly standardized technical requirements in postgraduate neurology specialization schools, wide variability among training programs, and limited training on multi-modal evoked potentials, intraoperative monitoring, and sonography. These findings underline the need to reappraise and improve educational and training standards for clinical neurophysiology during postgraduate specialization schools in neurology with an international perspective.

Ethical and Legal Challenges of Telemedicine in the Era of the COVID-19 Pandemic

Background and objective: Telemedicine or telehealth services has been increasingly practiced in the recent years. During the COVID-19 pandemic, telemedicine turned into and indispensable service in order to avoid contagion between healthcare professionals and patients, involving a growing number of medical disciplines. Nevertheless, at present, several ethical and legal issues related to the practice of these services still remain unsolved and need adequate regulation. This narrative review will give a synthesis of the main ethical and legal issues of telemedicine practice during the COVID-19 pandemic. Material and Methods: A literature search was performed on PubMed using MeSH terms: Telemedicine (which includes Mobile Health or Health, Mobile, mHealth, Telehealth, and eHealth), Ethics, Legislation/Jurisprudence, and COVID-19. These terms were combined into a search string to better identify relevant articles published in the English language from March 2019 to September 2021. Results: Overall, 24 out of the initial 85 articles were considered eligible for this review. Legal and ethical issues concerned important aspects such as: informed consent (information about the risks and benefits of remote therapy) and autonomy (87%), patient privacy (78%) and confidentiality (57%), data protection and security (74%), malpractice and professional liability/integrity (70%), equity of access (30%), quality of care (30%), the professional-patient relationship (22%), and the principle of beneficence or being disposed to act for the benefit of others (13%). Conclusions: The ethical and legal issues related to the practice of telehealth or telemedicine services still need standard and specific rules of application in order to guarantee equitable access, quality of care, sustainable costs, professional liability, respect of patient privacy, data protection, and confidentiality. At present, telemedicine services could be only used as complementary or supplementary tools to the traditional healthcare services. Some indications for medical providers are suggested.

Telemedicine for healthcare: Capabilities, features, barriers, and applications

Regular hospital visits can be expensive, particularly in rural areas, due to travel costs. In the era of the Covid-19 Pandemic, where physical interaction becomes risky, people prefer telemedicine. Fortunately, medical visits can be reduced when telemedicine services are used through video conferencing or other virtual technologies. Thus, telemedicine saves both the patient's and the health care provider time and the cost of the treatment. Furthermore, due to its fast and advantageous characteristics, it can streamline the workflow of hospitals and clinics. This disruptive technology would make it easier to monitor discharged patients and manage their recovery. As a result, it is sufficient to state that telemedicine can create a win-win situation. This paper aims to explore the significant capabilities, features with treatment workflow, and barriers to the adoption of telemedicine in Healthcare. The paper identifies seventeen significant applications of telemedicine in Healthcare. Telemedicine is described as a medical practitioner to diagnose and treat patients in a remote area. Using health apps for scheduled follow-up visits makes doctors and patients more effective and improves the probability of follow-up, reducing missing appointments and optimising patient outcomes. Patients should have an accurate medical history and show the doctor any prominent rashes, bruises, or other signs that need attention through the excellent quality audio-video system. Further, practitioners need file management and a payment gateway system. Telemedicine technologies allow patients and doctors both to review the treatment process. However, this technology supplements physical consultation and is in no way a substitute for a physical consultation. Today this technology is a safe choice for patients who cannot go to the doctor or sit at home, especially during a pandemic.

Telerehabilitation and Wellbeing Experience in Children with Special Needs during the COVID-19 Pandemic

Social distancing due to the COVID-19 pandemic represented a golden opportunity to implement telerehabilitation for clinical groups of children. The present study aims to show the impact that telerehabilitation had on the experience of well-being of children with special needs being treated at the Foundation IRCCS Neurological Institute ‘C. Besta’ in Milan (Specific Learning Disorders and Cerebral Palsy diagnosis); it aims to do so by comparing it with experiences of those who did not undertake telerehabilitation despite the diagnosis during the pandemic, and with typically developing children. Results show that the three groups differed in the Support, Respect and Learning dimensions of well-being experience. Post hoc comparisons revealed that children with Specific Learning Disorders and Cerebral Palsy scored higher than normotypical children in Support and in Respect scales. Furthermore, children who experienced telerehabilitation showed the highest scores on the Learning scale in comparison with the other two groups. These results support the importance of reorganizing care and assistance by integrating telemedicine, which seems to have fostered a positive experience of well-being in people with special needs, particularly in the perception of a supportive environment that respects psychological needs.

The reliability and validity of the Turkish version of the Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ) and Telemedicine Patient Questionnaire (TPQ) in individuals with multiple sclerosis

Objective

The study was aimed to translate and adapt the Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ) and Telemedicine Patient Questionnaire (TPQ) into Turkish, thereafter to analyze the psychometric properties of both questionnaires.

Methods

A total of 149 multiple sclerosis (MS) patients were recruited in the study. For 4 years, all patients were supervised by a department clinician using telemedicine. Cronbach’s alpha coefficient was used to assess internal consistency. By evaluating the scores of 41 retested patients 1 week later, the test-retest reliability was determined using the intraclass correlation coefficient (ICC). Pearson’s correlation coefficient was used to assess the construct validity (r).

Results

A total of 149 patients (103 women, 46 men) with a mean age of 40.9±10.9 years were included in the study. MS duration of the patients was 9.15±6.24 years. Internal consistency of all items and the total score of the TSUQ were excellent (>0.80; ranged 0.971–0.974). On the other hand, the internal consistency of all items and total score of the TPQ was excellent, either (>0.80; ranged 0.878–0.890). The ICC of the TSUQ’s and TPQ’s total score was excellent (>0.80). The correlation between TSUQ and TPQ was strong (r=0.734, p<0.01). In addition, there was moderate relationship between the TSUQ and the Beck Depression Scale (BDS) (r=−0.363, p<0.01). On the other hand, there was low correlation between TPQ and BDS (r=−0.217, p<0.05).

Conclusion

The Turkish version of the TSUQ and the TPQ is valid and reliable in individuals with MS.

Neuro-telehealth for fragile patients in a tertiary referral neurological institute during the COVID-19 pandemic in Milan, Lombardy

Background

Lombardy was severely hit by the COVID-19 pandemic since February 2020 and the Health System underwent rapid reorganization. Outpatient clinics were stopped for non-urgent patients: it became a priority to manage hundreds of fragile neurological patients who suddenly had less reference points. In Italy, before the pandemic, Televisits were neither recognized nor priced.

Methods

At the Fondazione IRCCS Istituto Neurologico C. Besta, we reorganized outpatient clinics to deliver Neuro-telemedicine services, including Televisits and Teleneurorehabilitation, since March 2020. A dedicated Working Group prepared the procedure, tested the system, and designed satisfaction questionnaires for adults and children.

Results

After a pilot phase, we prepared a procedure for Telemedicine outpatient clinics which was approved by hospital directions. It included prescription, booking, consenting, privacy and data protection, secure connection with patients (Teams Microsoft 365), electronic report preparation and delivery, reporting, and accountability of the services. During the March–September 2020 period, we delivered 3167 Telemedicine services, including 1618 Televisits, to 1694 patients (972 adults, 722 children) with a wide range of chronic neurological disorders. We successfully administered different clinical assessment and scales. Satisfaction among patients and caregivers was very high.

Conclusions

During the dramatic emergency, we were able to take care of more than 1600 patients by organizing Neuro-telehealth in a few weeks, lessening the impact of the pandemic on fragile patients with chronic neurological disorders; this strategy is now stably embedded in our care pathways. In Italy, Telehealth is at present recognized and priced and is becoming a stable pillar of the health system.

Telemedicine and Virtual Reality at Time of COVID-19 Pandemic: An Overview for Future Perspectives in Neurorehabilitation

In catastrophic situations such as pandemics, patients' healthcare including admissions to hospitals and emergency services are challenged by the risk of infection and by limitations of healthcare resources. In such a setting, the use of telemedicine interventions has become extremely important. New technologies have proved helpful in pandemics as a solution to improve the quality of life in vulnerable patients such as persons with neurological diseases. Moreover, telemedicine interventions provide at-home solutions allowing clinicians to telemonitor and assess patients remotely, thus minimizing risk of infection. After a review of different studies using telemedicine in neurological patients, we propose a telemedicine process flow for healthcare of subjects with chronic neurological disease to respond to the new challenges for delivering quality healthcare during the transformation of public and private healthcare organizations around the world forced by COVID-19 pandemic contingency. This telemedicine process flow represents a replacement for in-person treatment and thereby the provision equitable access to the care of vulnerable people. It is conceptualized as comprehensive service including (1) teleassistance with patient counseling and medical treatment, (2) telemonitoring of patients' health conditions and any changes over time, as well as (3) telerehabilitation, i.e., interventions to assess and promote body functions, activities, and consecutively participation. The hereby proposed telemedicine process flow could be adopted on a large scale to improve the public health response during healthcare crises like the COVID-19 pandemic but could equally promote equitable health care independent of people's mobility or location with respect to the specialized health care center.

Cognitive Telerehabilitation for Older Adults With Neurodegenerative Diseases in the COVID-19 Era: A Perspective Study

The COVID-19 pandemic is a global health problem that is radically transforming public and private healthcare organizations around the world, negatively affecting the rehabilitative treatments of non-COVID pathologies as well. In this situation, it becomes crucial to be able to guarantee the continuity of care also to all those patients with neurodegenerative diseases unable to reach healthcare services. Remote communication technologies are gaining momentum as potentially effective options to support health care interventions-including cognitive rehabilitation-while patients can stay safely at home. In this context, we are implementing HomeCoRe (i.e., Home Cognitive Rehabilitation software) in order to offer an innovative approach and a valid support for home-based cognitive rehabilitation in neurodegenerative diseases, such as mild cognitive impairment and early dementia. HomeCoRe has been developed within a research project between engineers and clinicians in order to obtain a usable and safe cognitive rehabilitation tool. This software has multiple advantages for patients and therapists over traditional approaches, as shown in its use in hospital settings. HomeCoRe could then represent an opportunity for accessing cognitive rehabilitation in all those situations where patients and therapists are not in the same location due to particular restrictions, such as COVID-19 pandemic.

The Impact of the COVID-19 Pandemic on People With Epilepsy. An Italian Survey and a Global Perspective

Objectives: We explored the impact of the coronavirus disease-19 (COVID-19) emergency on the health of people with epilepsy (PwE). We also investigated their attitude toward telemedicine.

Methods: The PubMed database up to September 10, 2020 was searched for questionnaire-based studies conducted in PwE during the COVID-19 emergency, and the literature retrieved was reviewed. In addition, all patients who had a telephone consultation with our center between May 7 and July 31, 2020 were invited to fill in a 57-item online questionnaire focusing on epilepsy and comorbidities, any changes in lifestyle or clinical conditions and any emergency-related problems arising during the COVID-19 emergency, and their views on telemedicine. Associations between variables were detected through X² test and Fisher's exact test. Univariate and multivariate logistic regression models were used to evaluate the effects of different factors on clinical conditions.

Results: Twelve studies met the literature search criteria. They showed that the rate of seizure worsening during the emergency ranged from 4 to 35% and was mainly correlated with epilepsy severity, sleep disturbances and COVID-19-related issues. Our questionnaire was filled in by 222 PwE or caregivers. One hundred (76.6%) reported unchanged clinical conditions, 25 (11.3%) an improvement, and 27 (12%) a deterioration. Reported clinical worsening was associated with a psychiatric condition and/or medication (OR = 12.59, p < 0.001), sleep disorders (OR = 8.41, p = 0.001), limited access to healthcare (OR = 4.71, p = 0.016), and experiencing seizures during the emergency (OR = 4.51, p = 0.007). Telemedicine was considered acceptable by 116 subjects (52.3%).

Conclusions: Most PwE did not experience a significant change in their clinical conditions during the COVID-19 emergency. However, severity of epilepsy, concomitant disability, comorbid psychiatric conditions, sleep disorders and limited access to healthcare may affect their health.