Telehealth describes the provision of medical services remotely through technology, and may enhance patient access to specialty care services. Although teleneurology has expanded widely since the introduction of telestroke in 1999, telehealth services for outpatients with neuromuscular or musculoskeletal disorders are less widespread. In this narrative review, we will describe the current technology, applications, outcomes, and limitations of this dynamically growing field. Evidence for telehealth applications related to neuromuscular diseases, palliative care, specialized multidisciplinary services, and musculoskeletal care are reviewed. With growing demand for specialized services and finite resources, telehealth provides a promising avenue to promote access to high-quality care, decrease the cost and burden of travel for patients, and with the expansion of software to personal computing and mobile devices, offer flexible, low-overhead practice opportunities for clinicians. Providers embarking on careers in telehealth should be aware of current legal restrictions impacting care to minimize risk and avoid liability. Muscle Nerve 58: 475-485, 2018.

The design, synthesis, and evaluation of 3alpha-(diphenylmethoxy)tropane (benztropine) analogues have provided potent and selective probes for the dopamine transporter. Structure-activity relationships (SARs) have been developed that contrast with those described for cocaine, despite significant structural similarity. Furthermore, behavioral evaluation of many of the benztropine analogues in animal models of cocaine abuse has suggested that these two classes of tropane-based dopamine uptake inhibitors have distinct pharmacological profiles. In general, the benztropine analogues do not demonstrate efficacious locomotor stimulation in mice, do not fully substitute for a cocaine discriminative stimulus, and are not appreciably self-administered in rhesus monkeys. These compounds are generally more potent than cocaine as dopamine uptake inhibitors in vitro, although their actions in vivo are not consistent with this action. These observations suggest that differing binding profiles at the serotonin and norepinephrine transporters as well as at muscarinic receptors might have significant impact on the pharmacological actions of these compounds. In addition, by varying the structures of the parent compounds and thereby modifying their physical properties, pharmacokinetics as well as pharmacodynamics will be directly affected. Therefore, in an attempt to systematically evaluate the impact of chemical modification on these actions, a series of N-substituted (H, CH3, allyl, benzyl, propylphenyl, and butylphenyl) analogues of 3'-chloro-, 4'-chloro-, and 4,4''-dichloro-3alpha-(diphenylmethoxy)tropanes were synthesized. These compounds were evaluated for displacement, in rat tissue, of [3H]WIN 35,428 from the dopamine transporter, [3H]citalopram from the serotonin transporter, [3H]nisoxetine from the norepinephrine transporter, and [3H]pirenzepine from muscarinic m1 receptors. SARs were developed and compared to a series of N-substituted-3alpha-(bis-4'-fluorophenyl)methoxytropanes. The present SARs followed previously reported studies with the single exception of the N-butylphenyl substituent, which did not provide the high affinity binding in any of these three sets of analogues, as it did in the 4',4''-difluoro series. X-ray crystallographic analyses of the three parent ligands (1a, 2a, and 3a) were compared to that of 3alpha-(bis-4'-fluorophenyl)methoxytropane which provided supportive evidence toward the proposal that the combination of steric bulk in both the 3-position and the N-substituent, in this class of compounds, is not optimal for binding at the dopamine transporter. These studies provide binding profile data that can now be used to correlate with future behavioral analyses of these compounds and may provide insight into the kind of binding profile that might be targeted as a potential treatment for cocaine abuse.

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Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment.To this end, the definition of spasticity has expanded over time to more accurately

Approximately 16,000 persons in the United States are affected by amyotrophic lateral sclerosis (ALS). 1 Persons with ALS (PALS) have distinctive pathophysiological risks and health determinants that may increase their vulnerability for infection with severe-acute-respiratory-syndrome-associated-coronavirus (SARS-CoV-2) and severe Coronavirus-2019 (COVID-19) outcome. 2,3 Data on the prevalence and impact of COVID-19 in this population is scarce. 4 The Veteran Administration Informatics and Computing Infrastructure (VINCI) Resource Center and the Veteran Health Administration (VHA) Spinal Cord Injury/Disorders (SCI/D) Registry are operational tools which extract data from the Corporate Data Warehouse (a relational database which merges multiple VA data sources). VINCI utilizes data so that aggregate statistics can be accessed. In adjunct, the VHA-SCI/D Registry has specific inclusion criteria (i.e.: Veterans must be followed at an SCI/D Center) and the data extracted is validated.Both VINCI and VHA-SCI/D Registry have added the functionality for the identification of COVID-19-positive patients. Within this letter, the authors will describe the COVID-19 prevalence and case fatality rate (CFR), as reported by aggregate summaries from VINCI, as well as the characteristics and outcomes, as reported by the VHA-SCI/D Registry, for COVID-19-positive veterans with ALS.From January 1st, 2020 to January 31st, 2021, VINCI identified 192,690 (3.6%) COVID-19-positive cases (excluding active, defined as patients tested or treated at a VA facility for known or probable COVID-19 who have neither died nor reached convalescent status) from a total of 5,295,285 Veterans. Of these positive cases, 8838 (4.6%; CI: 4.5%-4.7%) COVID-related deaths were recorded (within 30 days of diagnosis). Considering the 4086 PALS within VINCI, 138 COVID-19-positive cases were identified. Of these, 19 (13.8%; CI 8.5%-20.7%) died. Compared to the overall veteran population, veterans with ALS were 3.0 times more likely to die within 30 days of COVID-19 diagnosis (CI: 1.9-4.9, p < .001).The VHA-SCI/D Registry includes 1910 of the 4086 (47%) Veterans with ALS. Of these, 699 (37%) were laboratory tested for COVID-19, and a total of 68 (10%) were found to be COVID-positive.Excluding three active cases, 48% had an uncomplicated course, 18%

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Background: Cannabis is increasingly used by persons at end of life to ameliorate symptoms such as pain, spasticity, anorexia, or anxiety. Cannabis hyperemesis is a distressing adverse effect of chronic use and may cause significant morbidity. Unfortunately, the clinical presentation of this syndrome may be subtle in a person with complex medical issues or disability. Providers must remain vigilant for possible variations in presentation in these populations. Aim: To assess literature on cannabis hyperemesis and present unique considerations for clinical assessment and treatment for patients at end of life. Design: Initial literature scoping yielded limited evidence on the subject in the setting of chronic disease and disability. A case of cannabis hyperemesis in a person with advanced amyotrophic lateral sclerosis is presented to illustrate challenges in diagnosis and management in this setting. A narrative synthesis of current literature on assessment and management and special considerations for evaluation and treatment for patients under palliative care was performed. Results: Several unique considerations for the diagnosis and management of cannabis hyperemesis in palliative care patients are highlighted in the case presented, including: (1) Symptoms may possibly be abolished through decrease rather than complete abstinence from cannabis, (2) Frequent hot baths may not be present in patients with physical impairments in activities of daily living, and (3) Management of primary symptoms (pain, spasticity, nausea, and anxiety) in the end-of-life care patient must be considered to maximize comfort. Conclusion: The presentation of cannabis hyperemesis may be atypical in palliative care patients due to disability. More work is needed to improve risk stratification for patients using cannabis for palliative care.