7-year outcomes of the first successful pediatric bilateral hand transplantation

Introduction: The purpose of this case report is to describe the 7-year functional outcomes and health-related quality of life (HRQOL) of the first successful pediatric bilateral hand transplantation. The report focuses on activity and participation. The authors suggest assessment methods that can be applied to future cases. Method(s): The child underwent quadrimembral amputation at age two years and received bilateral hand allografts at age eight. Rehabilitation included biomechanical, neurorehabilitation, and occupational approaches in acute and outpatient settings. Therapist observed outcomes assessments, patientreported and parent-reported outcome questionnaires were repeated over a 7-year period. Result(s): At 7-years post transplantation, the adolescent and his mother reported a high level of satisfaction with the outcomes. Therapist observed assessments showed the adolescent achieved functional gross motor dexterity with each upper extremity. Although left gross and fine dexterity was superior to the right at all timepoints observed, the adolescent used his right upper extremity as dominant and incorporated both extremities as appropriate for bimanual tasks. The adolescent achieved modified independence to full independence with self-care activities. The adolescent participated in diverse activities with a high level of enjoyment. Participation was more diverse, social, and communitybased prior to and after the initial COVID-19 pandemic restrictions. At 7-years post transplantation when the adolescent was 15-years of age, the parent rated more instrumental activities of daily living as somewhat difficult. Discussion and Conclusion(s): Therapist observed outcomes assessments, patient-reported and parent-reported outcome questionnaires, showed the child had incorporated his hands into various activities, was completing daily activities independently, and HRQOL outcomes in social, emotional, cognitive, and physical domains were favorable. Most results were stable over time. The decrease in right hand dexterity scores might reflect small kinesiological changes in the right hand. Difficulty with some instrumental activities of daily living were likely due to new activities typical of child development for this now 15-year-old patient.

Complications Of A Severe Case Of Multisystem Inflammatory Syndrome In Children

Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion(s): COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.

Neurologic and Neuromuscular Sequelae of COVID-19.

It is known that there can be neurologic complications related to acute infection with SARS-CoV-2, the virus that causes COVID-19. Currently, there is a growing body of evidence that postacute sequelae of SARS-CoV-2 infection can manifest as neurologic sequelae as a result of direct neuroinvasion, autoimmunity, and possibly lead to chronic neurodegenerative processes. Certain complications can be associated with worse prognosis, lower functional outcome, and higher mortality. This article provides an overview of the known pathophysiology, symptoms presentation, complications and treatment approaches of the post-acute neurologic and neuromuscular sequelae of SARS-CoV-2 infection.

A Smart and Home-based Telerehabilitation Tool for Patients with Neuromuscular Disorder

Over fourteen million people suffer from neuromuscular diseases in the UK such as strokes, spinal cord injuries, and Parkinson's disease etc. That means at least one in six people in the UK are living with one or more neurological conditions. In order for patients to return to normal life sooner, a rigorous rehabilitation process is needed. In hospitals, physiotherapists and neurological experts prescribe specific neurorehabilitation exercises. In most cases, patients need to schedule an appointment to receive treatment in a hospital or to have physiotherapists visit them at home. The number of neuromuscular patients has increased, resulting in longer hospital waiting times. In particular, during COVID-19, patients were not allowed to visit hospitals or have physiotherapists visit them due to government restrictions. Online guides for personalised and custom rehabilitation therapy for joint spasticity and stiffness are also not available. This paper reports the development of an IoT-based prototype system that monitors and records joint movements using sensory footwear (consisting of FSR and IMU sensors) and Kinect sensors. In addition, a prototype web portal is also being developed to record performance data during exercises at home and interact with clinicians remotely. A pilot study has been conducted with six healthy individuals and test results show that there is a strong correlation between Kinect data and FSR data in terms of coordination between joint movements. © 2022 IEEE.

Feasibility and opportunities of digital offers in the care of chronic neurological diseases using the example of a telemedicine-supported day clinic for Parkinson's disease and movement disorders.

Chronic diseases are steadily increasing as a result of demographic change and medical progress. Non-drug therapies and the provision of remedies are highly relevant in this context, but face an insufficient quantitative and qualitative supply situation. The digitalization of the healthcare industry is currently experiencing an upswing, driven by the Hospital Future Act [4] as well as by the relaxation of the ban on remote treatment by the 2018 Physicians' Congress [24],and most recently by the COVID-19 pandemic. Digitalization enables a redesign of treatment and care processes through telemedicine, digital health applications (DiGAS), the electronic prescription, tele-monitoring and patient portals. The present paper aims to work out opportunities, challenges of digital offers as well as necessities for the supporting use from the previous experiences of a telemedicine-supported day clinic for Parkinson's disease and movement disorders. These experiences and conceptual approaches give rise to new future-oriented treatment concepts that have enormous potential for complementing conventional therapy with digital offers in an interdisciplinary, cross-sectoral and patient-centered way individually and symptom-specifically.Copyright © Hippocampus Verlag 2023.

Physiotherapy results of a patient with critical illness polyneuropathy due to COVID-19: A case report

The aim of this study is to examine the results of physiotherapy in a patient with critical illness polyneuropathy (CIP) due to coronavirus disease 2019 (CO-VID-19). The 48-year-old male patient with CIP due to COVID-19 was enrolled in a physiotherapy program for 3 months with 5 sessions/week. Pain intensity, motor skills, daily living activities, fatigue level, cognitive status, and decubitus ulcer were evaluated with a visual analogue scale, the Medical Research Coun-cil-Sum Score, the Functional Independence Scale, the Fatigue Severity Scale, the Standardized Mini-Mental Test, and pressure wound staging, respectively. Positive improvements were achieved in functional level, fatigue, pain, and pressure sores with the physiotherapy program for this patient with CIP due to COVID-19. This report provides an idea about the effects of physiotherapy programs for COVID-19-related CIP to academics and clinicians working in this field.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Using DTI tractography to guide tDCS interventions in a complex acquired brain Injury neurorehabilitation protocol - a case report

51-year-old man (C.P.) had a diffuse-axonal-injury after falling from a 5-meter height, followed by a 22-minute anoxia due to a cardiac arrest. In the ICU, he tested positive to COVID-19, and needed intubation. After coronavirus infection, C.P. presented Guillain-Barre syndrome. 2months after discharge, he was admitted to rehabilitation. DTI tractography for evaluation of the structural integrity of white matter tracts revealed: i) Lesions in the basal ganglia;ii) Sequelary lesions in the right frontal, cortical, subcortical, temporal, parieto-occipital and cerebellar hemispheres;iii) Asymmetry of the corticospinal tracts - less fibers on the left;iv) Poor definition of the fibers of the right arcuate fasciculus;v)Asymmetrical thinning of the cortico-ponto-cerebellar tracts, worse on the left, and more discreetly in the spinocerebellar tracts. Based on this, C.P. underwent 4 different 30-session tDCS protocols consisting of twice-daily 20min 2mA sessions (10min interval), 5days/week (120sessions total), combined with physiotherapy, cognitive, swallowing and speech therapy. Montages: Pr1 (anode: Cz - 5x10cm;cathode: 10th Thoracic Vertebra - 5x7cm);Pr2 (1 - anode:C3;cathode:Fp2 / 2 - anode: Cerebellum;cathode:Fp2);Pr3 (anode:F3;cathode:Fp2) and Pr4 (anode:Cp5;cathode:Fp2). Except for Pr1, electrode size for all protocols were 5x7cm. We used the Coma Recovery Scale (CRS-R) and Rancho Los Amigos Scale (RLAS) for clinical assessments at the baseline and after every 10 sessions until the end of the intervention. At the baseline, C.P. presented a minimal responsive state of consciousness (CRS-R: 3;RLAS: Level 1) and tolerated well the tDCS interventions. CRS-R scores gradually improved in various domains during the treatment. At the end, RLAS score was level 5 and CRS-R, 19. Our preliminary results suggest DTI tractography may be a potential biomarker to guide more personalized tDCS interventions for complex cases of patients with acquired brain injuries. A second DTI tractography will be made in the future for comparison purposes. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: Acquired Brain Injury, Traumatic Brain Injury, COVID-19, Guillain Barre SyndromeCopyright © 2023

The impact of a 12 month Music Therapy pilot on patients and staff within a NHS, in-patient, neurorehabilitation unit during the Covid-19 pandemic

Introduction: The UK Stroke pathway has been well developed since the introduction of the National Stroke Strategy in 2007 (Department of Health, 2007). Music Therapy (MT) is an AHP that has less presence within the current stroke pathway. In line with the national guidelines for Stroke rehabilitation (NICE, 2013), music therapy targets specific patient rehabilitation goals integrating a multi-disciplinary approach to therapy. Chiltern Music Therapy funded a 12-month, 1 day a week pilot MT service at Buckinghamshire Neuro Rehab Unit between 2020-2021. Method(s): The MT service comprised of a mixture of individual and group sessions. 27 patients were seen. Demographics, techniques, outcomes and feedback data was collected by the therapist, aiming to identify the benefits of MT for patients during the pandemic and how the pilot service enhanced standard therapies. Result(s): Patients accessed 86.5 hours of face-to-face (FtF) MT during the Covid-19 pandemic. 72% of SMART goals were fully or partially achieved. Data suggests MT reduces stress and anxiety, improves mood, and helps patients feel hopeful about the future;MT enhances patient engagement with therapy interventions;MT input increases patient's positive development in the areas of communication, cognition, motor skills, emotional expression, sense of self and behaviour. Staff and patient feedback was overwhelmingly positive. Conclusion(s): Introducing a MT service into existing therapy provision for stroke patients provided opportunities for FtF interaction during the Covid-19 pandemic. MT meets multiple national standards and guidelines for stroke. MT enhances patient engagement with therapy interventions, assists achieving rehab goals whilst reducing stress and anxiety and improving mood.

Tele-rehab aftercare.

Telerehabilitation applications are increasingly used in neurorehabilitation, especially since the SARS-CoV-2 pandemic. Their acceptance by care providers, patients and payers has increased. In the field of multiple sclerosis (MS), stroke and Parkinson's disease therapy, positive effects of telerehabilitation on various disease parameters have been demonstrated in smaller studies in recent years. The "non-inferiority"to outpatient rehabilitation measures has been shown convincingly in some rehabilitation patient collectives. In Germany, the Federation of German Pension Insurance Institutions (DRV Bund) has created an opportunity for the dissemination of telerehabilitative procedures by establishing tele-rehab aftercare.Copyright © Hippocampus Verlag 2023.

Patient experiences receiving rehabilitation care via telehealth: Identifying opportunities for remote care.

Use of telehealth has grown substantially in recent times due to the COVID-19 pandemic. Remote care services may greatly benefit patients with disabilities; chronic conditions; and neurological, musculoskeletal, and pain disorders, thereby allowing continuity of rehabilitation care, reducing barriers such as transportation, and minimizing COVID-19 exposure. In March 2020, our rehabilitation hospital, Shirley Ryan AbilityLab, launched a HIPAA-compliant telemedicine program for outpatient and day rehabilitation clinics and telerehabilitation therapy programs. The objective of this study was to examine patients' experiences and satisfaction with telemedicine in the rehabilitation physician practice, including novel virtual multidisciplinary evaluations. The present study examines survey data collected from 157 patients receiving telemedicine services at Shirley Ryan AbilityLab from December 2020-August 2021. Respondents were 61.8% female, predominantly White (82.2%) with ages ranging across the lifespan (69.4% over age 50 years). Diagnostic categories of the respondents included: musculoskeletal conditions 28%, chronic pain 22.3%, localized pain 10.2%, neurological conditions 26.8%, and Parkinson's and movement disorders 12.7%. Survey responses indicate that the telemedicine experiences were positive and well received. The majority of participants found these services easy to use, effective, and safe, and were overall satisfied with the attention and care they received from the providers-even for those who had not previously used telehealth. Respondents identified a variety of benefits, including alleviating financial and travel-related burdens. There were no significant differences in telehealth experiences or satisfaction across the different clinical diagnostic groups. Respondents viewed the integrated physician and rehabilitation therapist telehealth multidisciplinary model favorably, citing positive feedback regarding receiving multiple perspectives and recommendations, feeling like an integrated member of their healthcare team, and having a comprehensive, holistic team approach along with effective communication. These findings support that telemedicine can provide an effective care model in physiatry (physical medicine and rehabilitation) clinics, across different neurological, musculoskeletal, and pain conditions and in multidisciplinary team care settings. The insights provided by the present study expand our understanding of patient experiences with remote care frameworks for rehabilitation care, while controlling for institutional variation, and ultimately will help provide guidance regarding longer term integration of telemedicine in physiatry and multidisciplinary care models.

Feasibility, Safety, and Effectiveness of Telerehabilitation in Mild-to-Moderate Parkinson's Disease.

Introduction: Parkinson's disease (PD) patients frequently engage in rehabilitation to ameliorate symptoms. During the Coronavirus disease 2019 (COVID-19) pandemic, access to rehabilitation programs has been markedly limited, consequently, telerehabilitation gained popularity. In this prospective, open-label, and pilot study, we aimed to investigate feasibility, safety, and efficacy of telerehabilitation in mild-to-moderate PD patients. Materials and Methods: Twenty-three PD patients, with Hoehn and Yahr stage <3, without gait disturbances or dementia and capable of using the televisit platform, were recruited for a 5-week telerehabilitation program, consisting of 1 remote visit with a therapist and a minimum of two sessions of >30-min of self-conducted exercises per week. Patients received video tutorials of exercises and were asked to keep a diary of sessions. At baseline (T0), at the end of the intervention (T1), and 1 month after the end of treatment (T2), patients were remotely assessed with MDS-UPDRS part I-III, PDQ-39, Functional Independence Measure (FIM), and Frontal Assessment Battery scales, respectively. Acceptable compliance to the program was defined as >60% matching of frequency and duration of sessions, whereas optimal compliance was set at >80% matching. Results: The dropout rate was 0%. Over 85% of patients reached acceptable adherence cut-off and around 70% reached optimal one. No adverse events were reported during sessions. The repeated measure analysis of variance (rANOVA) showed a significant effect of factor "time" for MDS-UPDRS-III (p < 0.0001) with a mean reduction of 4.217 points between T0 and T1 and return to baseline at T2. No significant effect was found for other outcome measures. Conclusion: Our findings demonstrate that telerehabilitation is safe, feasible, and effective on motor symptoms in mild-to-moderate PD patients.

Overcoming adversity: Building a remote interdisciplinary neurorehabilitation service during the COVID-19 pandemic.

Background: The COVID-19 pandemic necessitated rapid change in neurorehabilitation delivery at the Defence Medical Rehabilitation Centre (DMRC), with a reduction in inpatient capacity. Aims and method: An interdisciplinary remote working group developed a novel neurorehabilitation telerehabilitation (TR) model. The plan, do, study, act (PDSA) model was used to develop and monitor activity in the changing pandemic context and to identify clinical outputs, key themes and learning points. Results: Eight PDSA cycles were performed, including video outpatient clinics, multidisciplinary team meetings, virtual ward rounds and TR for patients at home. Ten patients and 21 staff members provided feedback. Qualitative themes emerged including information technology, consultation environment, access to clinical notes and record keeping, clinical considerations, consent, patient and staff feedback, and feasibility. Conclusion: COVID-19 accelerated the implementation of TR at DMRC, allowing maintenance of service during lockdown. TR was acceptable to patients but placed a significant burden on staff. Practical suggestions for establishing a TR service are provided alongside challenges and limitations.

Cognitive Deficits among Individuals Admitted to a Post-Acute Pneumological Rehabilitation Unit in Southern Italy after COVID-19 Infection.

(1) Background: We investigated the differences in the neuropsychological profile as well as the pneumological and motor functions in two groups of patients admitted to rehabilitation who received different respiratory support during their COVID-19 infection. (2) Methods: Group-1 (n = 18; 15 male, median age 67.5) consisted of patients who received non-invasive mechanical ventilation; Group-2 (n = 19; 16 male, median age 63) consisted of patients who received invasive mechanical ventilation. All patients underwent a neuropsychological assessment including Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and the Repeatable Battery for the Assessment of Neuropsychological Status (R-BANS) to evaluate the patients' cognition. Depression and anxiety were also measured at admission and discharge to rehabilitation. (3) Results: At admission, patients impaired at MMSE were 44% in Group-1 and 5% in Group-2, while patients impaired at FAB were 88% in Group-1 and 26% in Group-2. Wilcoxon's effect size revealed meaningful differences between groups for FAB, R-BANS global score, immediate and delayed memory, and attention-coding task, with Group-2 performing better than Group-1 across all measures. At discharge, 52% of the 25 patients re-assessed still had mild to moderate cognitive deficits, while 19% had depression and 35% had anxiety. (4) Conclusions: Patients who received oxygen therapy experienced higher levels of acute and chronic stress compared to those who benefitted from invasive mechanical ventilation. Despite patients showing a meaningful improvement at discharge, cognitive impairment persisted in a great number of patients; therefore, long-term neuropsychological follow-up and treatment for COVID-19 patients are recommended.

Unexplained hypoxia requiring prone ventilation in a patient with acute disseminated encephalomyelitis

Introduction: Acute Disseminated Encephalomyelitis (ADEM) is a rare, immune-mediated, demyelinating disorder of the central nervous system characterized by acute encephalopathy with neurologic deficits and MRI findings consistent with multifocal demyelination requiring immunosuppression for therapy.1,2 Patients seldom develop hypoxia during the course of the illness, requiring prone ventilation to improve oxygenation which is the first line of therapy and a proven standard of care in patients with ARDS.3,4We would like to present a case of ADEM where a patient developed unexplained hypoxia requiring prone ventilation. Case description: A 35-year-old male with no significant past medical history presented to our neuro-specialist centre with one day history of severe lower back pain associated with lower limb weakness and numbness. His symptoms, which commenced 10 days post his Covid vaccination, rapidly progressed over 2 days of hospital admission to involve right upper limb & facial weakness. MRI scan of brain and spine showed features of ADEM and pulse Methylprednisolone was initiated. CT thorax and abdomen on admission was unremarkable. He was transferred to the critical care unit in view of progressive ascending paralysis and was intubated on his 5th inpatient day due to involvement of respiratory muscles. Following 4 cycles of plasma exchange with albumin (day 6,7,9 and 10 of hospital admission), he developed unexplained hypoxic episodes which eventually resulted in sustained hypoxia, requiring 100% oxygen. Airway pressures and lung compliance were within normal range. Bedside ultrasound demonstrated good lung sliding in all lung fields and good left ventricular contractility with no evidence of right ventricular dilatation. There was no evidence of pericardial/pleural effusion. CT thorax repeated on day 9 showed no features of acute thromboembolic disease and there were no signs of lung parenchymal involvement. Formal echocardiography with bubble test showed normal heart with no evidence of patent foramen ovale. Multi-disciplinary discussions involving cardiology, respiratory, neurology teams and regional ECMO centre could not explain the enigma of impaired oxygenation. The patient responded well to 16 hours of prone ventilation on day 10 with decreasing oxygen requirements. In the subsequent 3 months of his inpatient stay, he was weaned off oxygen and was tracheostomised in view of his neurological illness. He continues to receive physiotherapy and neuro rehabilitation which had led to clinical improvement. Conclusion: The possible reason for hypoxia could be impaired tissue oxygenation post plasma exchange. However, it could be a coincidental finding and there is not much literature to explain this phenomenon and warrants further research.5.

BENIGN PARTIAL ROLANDIC EPILEPSY FOLLOWING SARS-COV-2 INFECTION AND NEUROCOVID-19 EXPERIENCE: A CASE STUDY

Background Early evidence described by a number of scholars worldwide suggests that neu-roCOVID-19 has both mild [e.g. loss of smell (anosmia), loss of taste (ageusia), neurological tics (heterophilia), visual disturbances, headaches, dizziness, disorien-tation] and more severe sequelae (e.g. cognitive impairment, seizures, delirium, psychosis, strokes). Long-term neurological problems or neurological deficits may also occur. The aim of this study was to describe the examination and neurother-apy of a boy following SARS-CoV-2 infection and NeuroCOVID-19 in whom neurological tics and motor automatisms as well as cognitive impairment, particularly attention deficit disorder, developed as a consequence. Case study: We present a boy K.S., 7 years old, without any neurodevelopmental disorders, following a SARS-CoV-2 infection in May 2021 and the contraction of neuro-COVID-19 confirmed by a genetic test for the quantitative detection of neutralising antibodies (responsible for immunity) in the IgG class against SARS-CoV-2. The boy had relatively mild pseudomonal symptoms of the illness: temperature 38.5, runny nose, cough, muscle aches, headaches and general weakness. He was treated symptomatically and recovered after 2 weeks. Two months later, at the beginning of July 2021, neurological tics consisting of an upward turning of the eyeballs to the left appeared. These tics intensified in August 2021 and were accompanied by motor automatisms consisting of the left hand stiffening in salute-like position, while at the same time there was an inclination of the head to the left. In September 2021, after exertion in the swimming pool, an epileptic seizure occurred which caused the boy to start drowning. In the days that fol-lowed the above described tics and motor automatisms increased. He also developed sleep disorders, which consisted of him waking up several times during the night, during which time neurological tics and motor automatisms also ap-peared. Gradually, cognitive dysfunctions, especially attention deficits and behavioural changes, joined in, making it impossible for the boy to function independently at school and in many situations of daily life. Neurophysiological examination: qEEG, ERPs and sLORETA tomography performed on 11.09.2021 using automatic seizure activity detection software showed the pres-ence of the neuromarker benign partial rolandic epilepsy (BPERS) and neurocog-nitive disturbances resembling the symptoms of attention deficit hyperactivity disorder (ADHD), compared with the neuromarkers of children with this condition (n=100) from the normative database of the Human Brain Index (HBI) in Switzer-land. Detection of the neuromarkerBPERS was helpful in selecting an individu-alised neurostimulation protocol. The patient participated in 20 neurofeedback sessions using (1) SMR reinforcement, theta inhibition;(2) theta inhibition, B1 reinforcement (15-18 Hz);(3) qEEG-guided neurofeedback. Neurostimulation with neurofeedback was conducted twice a week, for 15-20 minutes gradually increasing to 30-40 minutes per session. The patient also received individual goal-directed psychotherapy After successive sessions of neurofeedback, a gradual reduction neurological symptoms was observed. By the end of neu-rotherapy, neurological tics, motor automatisms, neurocognitive disorders and behavioural disturbances had completely disappeared. The patient functions well in school and achieves very good results. Conclusions: HBI methodology was helpful in finding functional neuromarkers of benign partial Rolandic epilepsy and disturbed cognitive control. Therefore, it was possible to offer more effective neurorehabilitation of the disorders, which contribute to a better quality of life for the patient.

Audit and feedback in cardio- and cerebrovascular setting: Toward a path of high reliability in Italian healthcare.

Adopting audit and feedback (A&F) strategies could be a suitable healthcare intervention to fulfill the challenge of monitoring and improving clinical guidelines in evidence-based medicine. Indeed, A&F is used to encourage professionals to better adhere to standard guidelines to improve healthcare performance. Briefly, an audit is an inspection of professional practice in comparison to professional standards or targets whose results are subsequently communicated to professionals in a structured manner. Although A&F strategies have been adopted in several time-dependent settings, such as for acute myocardial infarction (AMI) and stroke, interest of audits in rehabilitation care is also emerging. Recently, the Italian Ministry of Health has funded a national network project called EASY-NET, whose main objective is to evaluate the effectiveness of A&F strategies to improve healthcare practice and equity in various clinical and organizational settings in seven Italian regions. Last but not the least of these regions is the Sicily, represented within the project by the IRCCS Centro Neurolesi Bonino-Pulejo of Messina as the work package 7 (WP7). The EASY-NET WP7 is focused on the effectiveness of A&F strategies in both AMI and ischemic stroke setting, from acute to rehabilitation process of care. In this study, we described the study protocol, including the study design and methodology, providing a detailed description of the new model of A&F based on telemedicine, and discussing the possible challenges of this project.

Changes in neurorehabilitation management during the COVID-19 pandemic: A scoping review.

BACKGROUND: The SARS-CoV-2 infection (COVID-19) has generated a threat to global health, determining the need for healthcare for large numbers of people in an extremely short timeOBJECTIVE:To investigate the management changes in the neurorehabilitation services during the COVID-19 pandemic. METHODS: An electronic search was conducted in September 2021 by 2 independent reviewers in the following databases: MEDLINE (PubMed), the Physiotherapy Evidence Database, and the Cochrane Database of Systematic Reviews. All studies on organizational and welfare changes resulting from the COVID-19 pandemic in neurorehabilitation services were included. Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. RESULTS: The summary of results was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.Electronic searches after the screening of title and abstract identified 80 studies, 13 studies met the inclusion criteria. A narrative summary of results of all included studies were reported in a tabular format. CONCLUSIONS: Different organizational models were adopted in neurorehabilitation during the COVID-19 pandemic impacting the therapies time frame, the physical and mental health of healthcare professionals and the caregiver's workload. There is still uncertainty about the effectiveness of these new therapeutic strategies on the management of neurorehabilitation services and future studies should explore the effect on the patients' needs.

ENHANCEMENT OF STROKE REHABILITATION WITH LEVODOPA (ESTRELSTUDY) - DESIGN AND PROGRESS OF THE ONGOING MULTICENTER PLACEBOCONTROLLED RANDOMIZED TRIAL

Background: In this multicenter, randomized, placebo-controlled trial we study whether Levodopa given in addition to usual rehabilitative therapies is associated with a patient-relevant enhancement of motor recovery after acute stroke. Methods: ESTREL (Enhancement of Stroke REhabilitation with Levodopa) is a multicenter, placebo-controlled randomized superiority trial. Patients with an acute ischemic or hemorrhagic stroke ≤7 days leading to a clinically meaningful hemiparesis in need of in-hospital rehabilitation are enrolled in stroke units and later transferred to experienced neurorehabilitation centers. Participants receive Levodopa 100mg/Carbidopa 25mg three times daily or matching placebo for 5 weeks in addition to standardized rehabilitative therapy. The primary outcome is the Fugl-Meyer- Motor Assessment score 3 months after randomization. We present the characteristics of the first 200 of 610 patients to be enrolled. Results: 13 certified stroke units and 13 neurorehabilitation centers are involved (“stroke-pathway-trial”). The first 200 participants had a median age of 73 [IQR 64-82] years and 43.5 % were female. 169 patients (84.5%) had ischemic stroke. At baseline, the median NIH-Stroke scale score was 8 [5-10]. Successful 3-month assessment was performed in 183 patients (91.5%);11 (5%) died, 5 (2.5%) withdrew from the study and 1 patient missed the clinical 3 months-visit due to the COVID-19 pandemic. Conclusions: The ESTREL study will provide evidence whether the additional use of Levodopa in the rehabilitation process of stroke patients is safe and effective. The ESTREL-study started successfully due to the good cooperation between acute stroke units and rehabilitation centers, as well as the high acceptance rate among patients.

Case Report: Functional Outcome of COVID-19 Subjects With Myasthenia Gravis and Critical Illness Polyneuropathy.

Background: The COVID-19 disease can affect subjects suffering from myasthenia gravis (MG) and worsen its clinical course, leading to intensive care unit (ICU) admission. Critically ill subjects can develop a neuromuscular complication called ICU-acquired weakness (ICUAW). This disorder has also been detected in ICU subjects with COVID-19, but the association between MG and ICUAW has never been described in critically ill patients. We describe the case and functional outcome of a COVID-19 patient suffering from MG who developed critical illness polyneuropathy (CIP). Case Presentation: A 66-year-old man with a history of hypertension and ocular MG had COVID-19 and required ICU admission. The patient underwent mechanical ventilation and tracheotomy and was treated with remdesivir and corticosteroids. Fifteen days after admission, he complained of tetraparesis without the ocular involvement that remained unchanged despite the increase in anticholinesterase therapy. The length of stay (LOS) in ICU was 35 days. On day 2 of admission, the patient underwent a frontal muscle jitter study that confirmed the MG, and electroneurography (ENG) and electromyography (EMG) that showed overlapping ICUAW with electrophysiological signs characteristic of CIP. The cerebrospinal fluid (CSF) showed normal pressure, cell count, and protein levels (<45 mg/dl) without albumin-cytologic disassociation. The CSF/serum glucose ratio was normal. The CSF culture for possible organisms, laboratory tests for autoimmune disorders, the panel of antiganglioside antibodies, and the paraneoplastic syndrome were negative. Strength and functional outcomes were tested with the MRC scale, the DRS, Barthel scale, and the Functional Independence Measure (FIM) at admission, discharge, and follow-up. Muscular strength improved progressively, and the MRC scale sum-score was 50 at discharge. Anticholinesterase therapy with pyridostigmine at a dosage of 30 mg 3 times daily, which the patient was taking before COVID-19, was resumed. His motor abilities recovered, and functional evaluations showed full recovery at follow-up. Conclusion: In the described subject, the coexistence of both neuromuscular disorders did not affect the clinical course and recovery, but the question remains about generalization to all patients with MG. The rehabilitation interventions might have facilitated the outcome.

Exploring challenges and opportunities posed by COVID-19 on team working and the delivery of residential neurorehabilitation to children and young people with acquired brain injury

Introduction: COVID-19 has placed major demands on healthcare services and practitioners (HCP's). Research has highlighted resilience, new skills and new ways of working. However, little attention has been paid as to whether challenges faced may have demonstrated or influenced effective change in working practices of individuals and teams delivering neurorehabilitation services to children and young people following an acquired brain injury. Patients and Methods: Exploratory qualitative study. Fourteen HCP's (10 female, 4 male) across 6 occupational disciplines participated in semi-structured interviews (February-May 2021). Transcriptions analysed using thematic content analysis managed in NVivo. Five broad topic areas explored (1) professional roles, role identity and professional autonomy, (2) role boundaries, (3) team working, (4) collective identity in relation to organisational challenges, (5) working practices. Results: A wealth of data was retrieved, analysis of findings from three of the key theme categories presented: Individual Professionalism, Working as Team and, Delivery of Rehabilitation services. Although there was much uncertainty, rapidly changing information and constraints imposed by the pandemic, the professionalism of the team was evident as HCP's regrouped and reviewed how service provision could continue. Personal and professional growth saw teams collectively flourish. Creative solutions led to teams working differently and more cohesively. A greater appreciation of team roles and goals within the specialist environment of paediatric rehabilitation emerged. Conclusions: Changes in structure, processes and provision of services necessitated greater interdisciplinary team integration and sharing of skills and expertise. As confidence and competencies of HCP's grew the potential for a more 24/7 approach to rehabilitation gained wide staff acceptance.