Digital Technology Enablers of Tele-Neurorehabilitation in Pre- and Post-COVID-19 Pandemic Era - A Scoping Review.

Neurorehabilitation (NR), a major component of neurosciences, is the process of restoring a patient's damaged/disorganized neurological function, through training, therapy, and education, while focusing on patient's independence and well-being. Since the advent of the COVID-19 pandemic, various applications of telecare and telehealth services surged drastically and became an integral part of current clinical practices. Tele-Neurorehabilitation (TNR) is one of such applications. When rehabilitation services were disrupted globally due to lockdown and travel restrictions, the importance of TNR was recognized, especially in developed, low, and middle-income countries. With exponential deployment of telehealth interventions in neurosciences, TNR has become a distinct stand-alone sub-specialty of neurosciences and telehealth. Digital technologies, such as wearables, robotics, and Virtual Reality (VR) have enabled TNR to improve the quality of patients' lives. Providing NR remotely using digital technologies and customized digital devices is now a reality, and likely to be the new norm soon. This article provides an overview of the needs, utilization, and deployment of TNR, and focuses on digital technology enablers of TNR in pre- and post-COVID-19 pandemic era.

The Legal Void Outside Brain Death in India: The Legislative Need of 'DNR' in Brain Death.

Objective: The legal definitions of brain death are tantamount for legal dogmas and sometimes criminal intimidation of the treating doctors. The tests for brain death are only applicable to patients planned for organ transplantation. We intend to discuss the necessity of the "Do Not Resuscitate (DNR)" legislature in cases of brain death patients and applicability of tests for brain death irrespective of the intention for organ donation. Methods: A comprehensive review of the literature was performed till May 31, 2020 from the MEDLINE (1966 to July 2019) and Web of Science (1900 to July 2019). Search criteria included all publications with the MESH terms: "Brain Death/legislation and jurisprudence"[Mesh] OR "Brain Death/organization and administration"[Mesh] AND "India" [Mesh]. We also discuss the different opinions and implications of brain death versus brain stem death in India with the senior author (KG) who was responsible for South Asia's first multi-organ transplant after certifying brain death. Additionally, a hypothetical scenario of a DNR case is discussed in the current legal paradigm of India. Results: The systematic search yielded only five articles reporting a series of brain stem death cases with an acceptance rate of organ transplant among brain stem deaths being 34.8%. The most common solid organs transplanted were the kidney (73%) and liver (21%). A hypothetical scenario of a DNR and possible legal implications of the same under the current 'Transplantation of Human Organs Act (THOA)' of India remains unclear. A comparison of brain death laws in most Asian countries shows a similar pattern regarding the declaration of brain death and the lack of knowledge or legislature regarding DNR cases. Conclusion: After the determination of brain death, discontinuation of organ support requires the consent of the family. The lack of education and the lack of awareness have been major impediments in this medico-legal battle. There is also an urgent need to make laws for cases that do not qualify for brain death. This would help in not only realistic realization but also better triage of the health care resources while legally safeguarding the medical fraternity.

Telemedicine to Expand Access to Critical Care Around the World.

This multiauthored communication gives a state-of-the-art global perspective on the increasing adoption of tele-critical care. Exponentially increasing sophistication in the deployment of Computers, Information, and Communication Technology has ensured extending the reach of limited intensivists virtually and reaching the unreached. Natural disasters, COVID-19 pandemic, and wars have made tele-intensive care a reality. Concerns and regulatory issues are being sorted out, cross-border cost-effective tele-critical care is steadily increasing Components to set up a tele-intensive care unit, and overcoming barriers is discussed. Importance of developing best practice guidelines and retraining is emphasized.

Disseminating medical literature and knowledge in India in the 1980s: the SMLRT story.

The informed netizen of today is in a state of information overload. With 785 million broadband subscribers and an urban and rural teledensity of 138% and 60%, respectively [1], India is already the second-largest online digital market. Today, in theory, medical journals and textbooks can be accessed by anyone, anytime, anywhere, and at affordable rates. Fifty odd years ago, when the authors entered medical school, the use of computers in medical education was unknown in India, as in other parts of the world. It was in this milieu, thirty-seven years ago, that eleven young Madras (Chennai)-based doctors decided to make medical literature easily accessible, particularly to clinicians in suburban and rural India. The aim was to make relevant, affordable reprints easily available to the practitioner at their place of work or study. Photocopying and using the postal service was the chosen, and indeed the only available, mode of operation. This article will outline the methodology used, trials and tribulations faced, and persistence displayed. At that time, the processes deployed appeared relevant and truly innovative. Over the ensuing years, developments in information technology made the services redundant. Extensive, even revolutionary, changes such as universal digitization and availability of a cost-effective Internet radically changed how medical literature could be accessed in India.

A model for sustainable, partnership-based telehealth services in rural India: An early process evaluation from Tuver village, Gujarat.

BACKGROUND: Telehealth can improve access to high-quality healthcare for rural populations in India. However, rural communities often have other needs, such as sanitation or employment, to benefit fully from telehealth offerings, highlighting a need for systems-level solutions. A Business of Humanity approach argues that innovative solutions to wicked problems like these require strategic decision-making that attends to a) humaneness, e.g., equity and safety and b) humankind, or the needs and potential of large and growing markets comprised of marginalized and low-income individuals. The approach is expected to improve economic performance and long-term value creation for partners, thus supporting sustainability. METHODS: A demonstration project was conducted in Tuver, a rural and tribal village in Gujarat, India. The project included seven components: a partnership that emphasized power-sharing and complementary contributions; telehealth services; health promotion; digital services; power infrastructure; water and sanitation; and agribusiness. Core partners included the academic partner, local village leadership, a local development foundation, a telehealth provider, and a design-build contractor. This early process evaluation relies on administrative data, field notes, and project documentation and was analyzed using a case study approach. RESULTS: Findings highlight the importance of taking a systems perspective and engaging inter-sectoral partners through alignment of values and goals. Additionally, the creation of a synergistic, health-promoting ecosystem offers potential to support telehealth services in the long-term. At the same time, engaging rural, tribal communities in the use of technological advances posed a challenge, though local staff and intermediaries were effective in bridging disconnects. CONCLUSION: Overall, this early process evaluation highlights the promise and challenges of using a Business of Humanity approach for coordinated, sustainable community-level action to improve the health and well-being of marginalized communities.

Combined Warden and Mustard procedure for late presenting transposition with anomalous pulmonary venous connections and regressed left ventricle.

The presence of systemic and pulmonary venous anomalies in late presenting transposition of great arteries (TGA) may make standard atrial switch procedures difficult, necessitating modification in the surgical procedure. We present a case report of a 13-year-old boy with a partial anomalous connection of right superior pulmonary vein with TGA and regressed left ventricle, where a combination of Warden procedure and Mustard procedure was used.

Arterial switch for double-outlet left ventricle - Diagnostic and surgical considerations.

Double-outlet left ventricle (DOLV) is a rare congenital cardiac anomaly in which both the aorta and pulmonary artery arise completely or predominantly from the left ventricle. DOLV is a spectrum and can be classified depending on the position of the ventricular septal defect (VSD) relative to the great vessels, the relationship of the great vessels, and the presence or absence of pulmonary or aortic outflow obstruction. In the absence of tricuspid atresia or hypoplastic right ventricle, two ventricle repair is the preferred surgical treatment. We report a 31-day-old, 2.1 kg neonate with DOLV, subaortic VSD who underwent a successful arterial switch with VSD closure.

Good Death in Neurological Practice.

BACKGROUND: Clinicians in neurological practice, particularly surgeons, encounter more deaths than most other specialists. OBJECTIVE: This communication reviews the literature on "good death" and extrapolates the observations and inferences to neurological practice. Changes in approaches to "good death" in the COVID-19 era (coronavirus disease 2019) are also discussed. MATERIALS AND METHODS: The author, over a 40-year period, has come across 2,500 deaths in a government, trust, and corporate hospital in Chennai, India. Retrospectively, the author questions if, in spite of his conservatism and obsession with quality of life, he should have taken proactive measures to also ensure a good quality of death. RESULTS AND CONCLUSION: In the background of the lessons learned in a metro, across various socioeconomic groups and with varied access to technology, the author concludes that ensuring "good death" should also fall within the domain of neurologic practice.

eNeuroIntensive Care in India: The Need of the Hour.

BACKGROUND: As ICU consultants in smaller hospitals may not be familiar with neurocritical care and with current travel restrictions due to the COVID-19 pandemic, one needs to relook at how neurocritical care can be provided. OBJECTIVE: This article reviews the authors' experience of providing remote neurointensive care, from a non-specialist ICU over a 16-month period. MATERIAL AND METHODS: 61 neuro consultations were provided for 56 patients admitted in remote ICU's, including five repeat consultations. Most teleconsultations were from three rural hospitals. The central command center has monitored remote patients with neurological conditions, in 23 ICUs. RESULTS AND CONCLUSIONS: Providing real-time virtual neuro intensive advice to ICU's in smaller cities even without dedicated neuro-intensive units is feasible in India. eNeuroIntensive care is particularly necessary in the current "New Normal" era.

Digital Health Care in Public Private Partnership Mode.

Background: Health care is provided in developing countries, in a milieu of acute shortages of health care infrastructure and personnel. Governments are realizing that digital health through public private partnerships (PPPs) could address this issue. Literature review did not reveal reports on primary use of telemedicine or Technology-enabled Remote Health care (TeRH) in a PPP mode. Materials and Methods: The authors report using digital health in a mega PPP project in nine districts in Andhra Pradesh, a state in South India, where millions are benefiting from TeRH. Strategies deployed to address operational, technical, and clinical challenges in virtually reaching the unreached deploying technology are described. A detailed analysis was made of services provided in 183 Urban Primary Health Centres (UPHCs) over 47 months. Results: 2,648,322 unique patients had quality digital health care. Of 11,055,936 consultations, 1,013,996 were specialist teleconsultations, including cardiology, endocrinology, general medicine, orthopedics and OB/Gynecology. 7,408,283 laboratory tests were done. Costs for laboratory tests was 28.84% of that in private laboratories. Cost per specialist teleconsultation was [Formula: see text]165 (Rupees). Quality control of laboratories was ensured through remote monitoring. Discussion: Implementing digital health in PPP projects requires expertise across clinical, technology, contract management, financing, data standards, information security, project planning, and cost-effective implementation. Conclusions: This successful mega project has confirmed that given a dedicated cooperative team e-health in a PPP mode in a developing country is eminently doable. Digital health care records were introduced and maintained for 100% of the beneficiaries (2.6 million in this study). TeRH can now bridge the health care divide.

Clinical profiles and risk factors for early and medium-term mortality following heart transplantation in a pediatric population: A single-center experience.

AIMS AND OBJECTIVES: There is a paucity of data regarding the outcomes of Heart transplantation in children from the Indian subcontinent. The data of patients under the age of 18 undergoing an isolated heart transplantation was analyzed for patient clinical profiles and risk factors for early and medium-term mortality. Hospital mortality was defined as death within 90 days of transplantation and medium-term survival as follow up of up to 6 years. MATERIALS AND METHODS: A total of 97 patients operated between March 2014 and October 2019 were included in this study. Data was collected about their INTERMACS status, pulmonary vascular resistance, donor heart ischemic times, donor age, donor to recipient weight ratio and creatinine levels. RESULTS: The age range was from 1 to 18 with a mean of 10.6 ± 4.6 years. 67 % patients were in INTERMACS category 3 or less.12 children were on mechanical circulatory support at the time of transplant. The 90 day survival was 89 %. The risk factors for hospital mortality was lower INTERMACS category (odd's ratio 0.2143, P = 0.026), elevated creatinine (odd's ratio 5.42, P = 0.076) and elevated right atrial pressure (odd's ratio 1.19, P = 0.015). Ischemic time, pulmonary vascular resistance (PVR) and PVR index (PVRI) had no effect on 90 day survival. Kaplan Meier estimates for 5 year survival was 73 %. The medium term survival was affected by INTERMACS category (Hazard ratio 0.7, P = .078), donor age > 25 (Hazard ratio 1.6, P = 0.26) and raised serum creatinine values.(Hazard ratio 2.7, P = 0.012). All the survivors are in good functional class. CONCLUSIONS: Excellent outcomes are possible after heart transplantation in a pediatric population even in a resource constrained environment of a developing economy. More efforts are needed to promote pediatric organ donation and patients need to be referred in better INTERMACS category for optimal outcomes.

Science and Art of Reviewing Papers to Maintain Standards in Academia.

This review article highlights the necessity and importance of peer review of articles submitted to journals. Publication in a peer reviewed, good impact indexed journal is an indirect endorsement of the article contents. The editor and the readership depend on the integrity and total involvement of reviewers. What is expected of the reviewer and the authors is discussed. Reviewers need to be sensitive to authors' reactions. Authors should also respond, not react or be hypersensitive.

Telemedicine and Neurological Practice in the COVID-19 Era.

BACKGROUND: The COVID-19 pandemic has within months turned the world upside down. With personal distancing and shortage of personal protective equipment, face-to-face health care encounters are increasingly becoming problematic. Neurological manifestations are also being observed in clinical presentations. OBJECTIVE: Worldwide most countries, the World Health Organization (WHO) and Centre for Disease Control (USA) have recommended use of Telemedicine during the current pandemic.With acute shortage of neurologists and neurosurgeons and their lopsided distribution, it becomes more difficult to provide neurological care to those who need it the most, particularly with travel restrictions. The author has since 2002 been advocating use of Telemedicine in Neurosciences. MATERIALS AND METHODS: This article reviews the increasing deployment of Telemedicine in neurological practice in the last few years, particularly the radical exponential use in the last few months due to COVID-19. CONCLUSIONS: With possible reduction in face-to-face consultations, remote evaluation may become mainstream. Webinars will play an increasing role. CME's and resident training will become more and more digital. The world will never be the same again. It is imperative that we accept and start deploying the "New Normal".

Telemedicine in Camp Mode While Screening for Noncommunicable Diseases: A Preliminary Report from India.

Introduction: Noncommunicable diseases (NCDs) are a major cause of disease burden. NCDs are a global epidemic and India is no exception. Risk factors contributing to NCDs can be detected before symptoms occur. Screening is an effective tool. Real-time teleconsultation during screening is a value-added service. This preliminary report documents the process and observations during teleconsultations provided in NCD screening camps, across multiple locations in India. That real-time teleconsultations in camp mode make a difference and are relevant in India is discussed. Materials and Methods: To provide awareness about risk factors of common NCDs such as diabetes, cardiovascular diseases, and anemia, screening camps were conducted. A 22-member field team organizes internet-enabled camps using point-of-care diagnostics. Software was developed to capture participant details and provide decision support to the field team. This resulted in identification of participants eligible for teleconsultations. Participants with risk factors of the targeted NCDs (hyperglycemia and dyslipidemia) were offered teleconsultations during screening. Currently, the program is active across six locations (Bengaluru, Coimbatore, Delhi National Capital Region, Kolkata, Pune, and Vijayawada) in India. Results: Since program inception from August 27, 2015 to October 31, 2018, a total of 757,325 participants have been screened. Twenty-seven thousand three hundred fifty-three participants were eligible for teleconsultations. Thirteen thousand six hundred fifteen availed onsite teleconsultations; 99.8% of the 1409 teleconsultation beneficiaries surveyed were "extremely satisfied and very happy." Conclusion: Providing real-time teleconsultations to 13,615 individuals "at risk" of specific NCDs from six centers across India is doable and well received by beneficiaries.

Human health during space travel: An overview.

This article reviews current challenges to health in space and has a secondary intention to set the tone for this special supplement on 'Extra-Terrestrial Neurosciences'. The effects of microgravity, radiation, isolation, disturbance in circadian rhythms and the hostile environment on the cardiovascular, neurological, immunological and various biological human systems are discussed here. Alterations in physiology, environmental hazards, and mitigative safety measures are briefly discussed along with challenges encountered in providing remote diagnoses and health care during space missions.