Provider Impressions of Inpatient Teleneurology Consultation.

Background and Objectives: Teleneurology usage has increased during the severe acute respiratory syndrome coronavirus 2 pandemic. However, studies evaluating physician impressions of inpatient teleneurology are limited. We implemented a quality improvement initiative to evaluate neurologists' impression following individual inpatient teleneurology consultation at a satellite hospital of a large academic center with no in-person neurology coverage. Methods: A REDCap survey link was embedded within templates used by neurologists for documentation of inpatient consultations to be completed immediately after encounters. All teleneurology encounters with completed surveys at a single satellite hospital of the University of Pennsylvania Health System Neurology Department between May 10, 2021, and August 14, 2022, were included. Individual patient-level and encounter-level data were extracted from the medical record. Results: A total of 374 surveys (response rate of 54.05%) were completed by 19 neurologists; 341 questionnaires were included in the analysis. Seven neurologists who specialized as neurohospitalists completed 231 surveys (67.74% of total surveys completed), while 12 non-neurohospitalists completed 110 (32.36%). The history obtained was rated as worse (14%) or the same (86%) as an in-person consult; none reported the history as better than nonteleneurology encounters. The physician-patient relationship was poor or fair in 25% of the encounters and good or excellent in 75% of visits. The overall experience was judged to be worse than in-person consultation in 32% of encounters, the same in 66%, and better in 2%. Fifty-one percent of providers responded that there were elements of the neurologic examination that might have changed their assessment and plan of care if performed in-person. Encounters with peripheral or neuromuscular-related chief complaints had the most inadequate examinations and worse overall experiences, while the most positive impressions of these clinical experiences were observed among seizure-related chief complaints. Discussion: Determining best practices for inpatient teleneurology should consider the patient chief complaint to use teleneurology in scenarios with the highest likelihood of a positive experience. Further efforts should be made to the patient experience and to improve the remote examination to enhance the applicability of teleneurology to the full spectrum of inpatient neurologic consultations.

Dosing and transition characteristics in people with narcolepsy transitioning from sodium oxybate to low-sodium oxybate: Data from the real-world TENOR study.

OBJECTIVE: The Transition Experience of persons with Narcolepsy taking Oxybate in the Real-world (TENOR) study assessed the real-world experience of people with narcolepsy switching from sodium oxybate (SXB) to low-sodium oxybate (LXB; 92 % less sodium than SXB). METHODS: TENOR is a patient-centric, prospective, observational, virtual-format study. Eligible participants included US adults with narcolepsy transitioning from SXB to LXB (±7 days from LXB initiation). Longitudinal data were collected from baseline (taking SXB) through 21 weeks post-transition. RESULTS: TENOR included 85 participants with narcolepsy (type 1, n = 45; type 2, n = 40). Mean (SD) age was 40.3 (13.0) years; the majority (73 %) were female and White (87 %). At study completion, wake-promoting agents were the most common concomitant medications (47 %). Mean (SD) SXB treatment duration was 57.8 (52.1) months; 96 % took SXB twice nightly. After transitioning, 97 % continued on twice-nightly regimens. Mean (SD) dose of both total nightly SXB (n = 85) and baseline LXB (n = 84) was 7.7 (1.5) g; SXB-LXB dose conversions at baseline were gram-for-gram in 87 % of participants. The mean final total nightly dose of LXB was 7.9 g. The most common participant-reported reasons for transitioning included lower sodium content for improved long-term health (93 %), physician recommendation (47 %), to avoid cardiovascular issues (39 %), to avoid side effects (31 %), and to improve control of narcolepsy symptoms (18 %). CONCLUSION: Most participants transitioned from SXB to LXB using a gram-for-gram strategy. The most commonly cited reason for transition was long-term health benefits due to lower sodium.

Individualized Treatment Patterns for Patients with Narcolepsy Treated with Oxybate: A Clinical Practice Perspective.

Purpose: Real-world data regarding divided nightly dosing of oxybate and individualized prescribing in patients with narcolepsy are limited. Study objectives were to understand oxybate prescribing practices, including optimizing dose regimens and adjusting dosing per occasional changes in patients' routines, and physician recommendations for representative patient scenarios. Patients and Methods: A cross-sectional, web- and audio-based survey of physicians treating ≥2 patients with narcolepsy, prescribed nightly oxybate (sodium oxybate) dosing for ≥6 months, was conducted. Physicians were surveyed on patients' usual oxybate dosing regimens, frequency of and reasons for oxybate dosing-related discussions, and preferred methods for and perceptions of adjusting oxybate dosing. Physicians provided dosing-related guidance for 4 representative scenarios. Results: Participating physicians (N=25) were neurologists (52%), psychiatrists (44%), and neuropsychiatrists (4%). Individualized oxybate prescribing practices were reflected by the variability of physicians' reporting of the percentage of their patients being prescribed once-nightly, twice-nightly, and thrice-nightly dosing regimens. Most physicians (68%) reported discussing adjusting individualized treatment to accommodate occasional changes to patients' routines; the most common reasons were consuming contraindicated beverages (alcohol; 65%) and travel (59%). Adjusting total nightly dose (68%) and dose timing (68%) were preferred adjustment methods. Most physicians (88%) felt the ability to individualize oxybate dosing was important and had a positive impact on ability to provide care. For each representative scenario, physicians provided several dose-adjustment recommendations, and physician responses encouraged patient participation in treatment decision-making. Conclusion: Physicians provided guidance supportive of oxybate dose adjustments to accommodate occasional changes in patients' routines, and perceived individualized dosing as important in providing care.

Smart sleep: what to consider when adopting AI-enabled solutions in clinical practice of sleep medicine.

Since the publication of its 2020 position statement on artificial intelligence (AI) in sleep medicine by the American Academy of Sleep Medicine, there has been a tremendous expansion of AI-related software and hardware options for sleep clinicians. To help clinicians understand the current state of AI and sleep medicine, and to further enable these solutions to be adopted into clinical practice, a discussion panel was conducted on June 7, 2022, at the Associated Professional Sleep Societies Sleep Conference in Charlotte, North Carolina. The article is a summary of key discussion points from this session, including aspects of considerations for the clinician in evaluating AI-enabled solutions including but not limited to what steps might be taken both by the Food and Drug Administration and clinicians to protect patients, logistical issues, technical challenges, billing and compliance considerations, education and training considerations, and other unique challenges specific to AI-enabled solutions. Our summary of this session is meant to support clinicians in efforts to assist in the clinical care of patients with sleep disorders utilizing AI-enabled solutions. CITATION: Bandyopadhyay A, Bae C, Cheng H, et al. Smart sleep: what to consider when adopting AI-enabled solutions in clinical practice of sleep medicine. J Clin Sleep Med. 2023;19(10):1823-1833.

Effectiveness and tolerability in people with narcolepsy transitioning from sodium oxybate to low-sodium oxybate: Data from the real-world TENOR study.

OBJECTIVES: The Transition Experience of persons with Narcolepsy taking Oxybate in the Real-world (TENOR) study was conducted to provide real-world insight into the experience of people with narcolepsy switching from sodium oxybate (SXB) to low-sodium oxybate (LXB; 92% less sodium than SXB). METHODS: TENOR is a patient-centric, prospective, observational, virtual-format study. Participants were adults with narcolepsy (type 1 or 2) who were transitioning from SXB to LXB treatment (±7 days from LXB initiation). Effectiveness and tolerability data were collected online from baseline (taking SXB) through 21 weeks (taking LXB) via daily and weekly diaries and questionnaires, including the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire, short version (FOSQ-10), and the British Columbia Cognitive Complaints Inventory (BC-CCI). RESULTS: TENOR participants (N = 85) were 73% female with a mean (SD) age of 40.3 (13.0) years. Mean (SD) ESS scores decreased numerically throughout the transition from SXB to LXB (baseline: 9.9 [5.2]; week 21: 7.5 [4.7]), with 59.5% and 75.0% of participants having scores in the normal range (≤10) at baseline and week 21, respectively. Mean (SD) FOSQ-10 scores (baseline: 14.4 [3.4]; week 21: 15.2 [3.2]) and BC-CCI scores (baseline: 6.1 [4.4]; week 21: 5.0 [4.3]) also remained stable. The most common symptoms related to tolerability reported by participants at baseline were sleep inertia, hyperhidrosis, and dizziness (45.2%, 40.5%, and 27.4%, respectively), which decreased in prevalence by week 21 (33.8%, 13.2%, and 8.8%, respectively). CONCLUSIONS: Findings from TENOR confirm maintenance of effectiveness and tolerability when transitioning from SXB to LXB treatment.

Cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure use.

OBJECTIVES: To evaluate the cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure (PAP) use in obstructive sleep apnea (OSA). STUDY DESIGN: A post hoc cost-effectiveness analysis (from US payers' perspective) of data from a 3-month tele-OSA trial, augmented with 33 months of epidemiologic follow-up. METHODS: Cost-effectiveness was compared among 3 groups of participants with an apnea-hypopnea index of at least 15 events/hour: (1) no messaging (n = 172), (2) messaging for 3 months (n = 124), and (3) messaging for 3 years (n = 46). We report the incremental cost (2020 US$) per incremental hour of PAP use and the fraction probability of acceptability based on a willingness-to-pay threshold of $1825 per year ($5/day). RESULTS: The use of 3 years of messaging had similar mean annual costs ($5825) compared with no messaging ($5889; P = .89) but lower mean cost compared with 3 months of messaging ($7376; P = .02). Those who received messaging for 3 years had the highest mean PAP use (4.11 hours/night), followed by no messaging (3.03 hours/night) and 3 months of messaging (2.84 hours/night) (all P < .05). The incremental cost-effectiveness ratios indicated that 3 years of messaging showed lower costs and greater hours of PAP use compared with both no messaging and 3 months of messaging. Based on a willingness-to-pay threshold of $1825, there is a greater than 97.5% chance (ie, 95% confidence) that 3 years of messaging is acceptable compared with the other 2 interventions. CONCLUSIONS: Long-term tele-messaging is highly likely to be cost-effective compared with both no and short-term messaging, with an acceptable willingness-to-pay threshold. Future long-term cost-effectiveness studies in a randomized controlled trial setting are warranted.

Association Between Positive Airway Pressure Adherence and Health Care Costs Among Individuals With OSA.

BACKGROUND: The impact of positive airway pressure (PAP) therapy for OSA on health care costs is uncertain. RESEARCH QUESTION: Are 3-year health care costs associated with PAP adherence in participants from the Tele-OSA clinical trial? STUDY DESIGN AND METHODS: Participants with OSA and prescribed PAP in the Tele-OSA study were stratified into three PAP adherence groups based on usage patterns over 3 years: (1) high (consistently ≥ 4 h/night), (2) moderate (2-3.9 h/night or inconsistently ≥ 4 h/night), and (3) low (< 2 h/night). Using data from 3 months of the Tele-OSA trial and 33 months of posttrial follow up, average health care costs (2020 US dollars) in 6-month intervals were derived from electronic health records and analyzed using multivariable generalized linear models. RESULTS: Of 543 participants, 25% were categorized as having high adherence, 22% were categorized as having moderate adherence, and 52% were categorized as having low adherence to PAP therapy. Average PAP use mean ± SD was 6.5 ± 1.0 h, 3.7 ± 1.2 h, and 0.5 ± 0.5 h for the high, moderate, and low adherence groups, respectively. The high adherence group had the lowest average covariate-adjusted 6-month health care costs ± SE ($3,207 ± $251) compared with the moderate ($3,638 ± $363) and low ($4,040 ± $304) adherence groups. Significant cost differences were observed between the high and low adherence groups ($832; 95% CI, $127 to $1,538); differences between moderate and low adherence were nonsignificant ($401; 95% CI, -$441 to $1,243). INTERPRETATION: In participants with OSA, better PAP adherence was associated with significantly lower health care costs over 3 years. Findings support the importance of strategies to enhance long-term PAP adherence.

Excessive Daytime Sleepiness in Obstructive Sleep Apnea. Mechanisms and Clinical Management.

Many patients with obstructive sleep apnea (OSA) experience excessive daytime sleepiness (EDS), which can negatively affect daily functioning, cognition, mood, and other aspects of well-being. Although EDS can be reduced with primary OSA treatment, such as continuous positive airway pressure (CPAP) therapy, a significant proportion of patients continue to experience EDS despite receiving optimized therapy for OSA. This article reviews the pathophysiology and clinical evaluation and management of EDS in patients with OSA. The mechanisms underlying EDS in CPAP-treated patients remain unclear. Experimental risk factors include chronic intermittent hypoxia and sleep fragmentation, which lead to oxidative injury and changes in neurons and brain circuit connectedness involving noradrenergic and dopaminergic neurotransmission in wake-promoting regions of the brain. In addition, neuroimaging studies have shown alterations in the brain's white matter and gray matter in patients with OSA and EDS. Clinical management of EDS begins with ruling out other potential causes of EDS and evaluating its severity. Tools to evaluate EDS include objective and self-reported assessments of sleepiness, as well as cognitive assessments. Patients who experience residual EDS despite primary OSA therapy may benefit from wake-promoting pharmacotherapy. Agents that inhibit reuptake of dopamine or of dopamine and norepinephrine (modafinil/armodafinil and solriamfetol, respectively) have demonstrated efficacy in reducing EDS and improving quality of life in patients with OSA. Additional research is needed on the effects of wake-promoting treatments on cognition in these patients and to identify individual or disorder-specific responses.

The use of telemedicine for the diagnosis and treatment of sleep disorders: an American Academy of Sleep Medicine update.

NONE: The COVID-19 pandemic led to widespread use of telemedicine and highlighted its importance in improving access to sleep care and advocating for sleep health. This update incorporates the lessons learned from such widespread utilization of telehealth to build on the American Academy of Sleep Medicine's 2015 position paper on the use of telemedicine for diagnosing and treating sleep disorders. Important key factors in this update include an emphasis on quality and value, privacy and safety, health advocacy through sleep telemedicine, and future directions.

A case series of PD-1 inhibitor-associated paraneoplastic neurologic syndromes.

Immune checkpoint inhibitors (ICIs) are highly efficacious for treating many solid tumor types. Because of their immune-activating mechanism of action, ICIs can trigger various immune-mediated toxicities. We present three cases: i) a woman with anti-Ri brainstem encephalitis; ii) a man with anti-Hu sensory neuronopathy; and iii) a woman with suspected combined anti-Hu and anti-NMDA paraneoplastic syndromes associated with the initiation of the ICIs pembrolizumab and nivolumab. These cases suggest that ICIs can induce both humoral and cell-mediated paraneoplastic neurologic syndromes. Identifying biomarkers that predict risk of developing ICI-associated paraneoplastic syndromes and the development of efficacious treatment strategies for neurologic ICI-toxicities are critical unmet needs.

The Challenges of Data Quality Evaluation in a Joint Data Warehouse.

INTRODUCTION: The use of clinically derived data from electronic health records (EHRs) and other electronic clinical systems can greatly facilitate clinical research as well as operational and quality initiatives. One approach for making these data available is to incorporate data from different sources into a joint data warehouse. When using such a data warehouse, it is important to understand the quality of the data. The primary objective of this study was to determine the completeness and concordance of common types of clinical data available in the Knowledge Program (KP) joint data warehouse, which contains feeds from several electronic systems including the EHR. METHODS: A manual review was performed of specific data elements for 250 patients from an EHR, and these were compared with corresponding elements in the KP data warehouse. Completeness and concordance were calculated for five categories of data including demographics, vital signs, laboratory results, diagnoses, and medications. RESULTS: In general, data elements for demographics, vital signs, diagnoses, and laboratory results were present in more cases in the source EHR compared to the KP. When data elements were available in both sources, there was a high concordance. In contrast, the KP data warehouse documented a higher prevalence of deaths and medications compared to the EHR. DISCUSSION: Several factors contributed to the discrepancies between data in the KP and the EHR-including the start date and frequency of data feeds updates into the KP, inability to transfer data located in nonstructured formats (e.g., free text or scanned documents), as well as incomplete and missing data variables in the source EHR. CONCLUSION: When evaluating the quality of a data warehouse with multiple data sources, assessing completeness and concordance between data set and source data may be better than designating one to be a gold standard. This will allow the user to optimize the method and timing of data transfer in order to capture data with better accuracy.

Referral Patterns and Positive Airway Pressure Adherence upon Diagnosis of Obstructive Sleep Apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) is a serious medical condition that adds to patient morbidity and mortality. Treatment with positive airway pressure (PAP) is the standard of care, but many patients refuse or do not tolerate PAP. Little is known about the subsequent management of these patients. We sought to understand what types of treatment, if any, adult patients with OSA receive who either fail or refuse PAP therapy within our institution. STUDY DESIGN: Retrospective chart review. SETTING: Academic hospital. SUBJECTS: All adult patients undergoing polysomnogram during the months of March and April 2010 (n = 1174) who were diagnosed with OSA. METHODS: The electronic medical record was reviewed to determine the subsequent management of patients with a diagnosis of OSA, including tolerance or failure of PAP and referral to specialists upon intolerance. RESULTS: Of 1174 patients, 616 met inclusion criteria. Ultimately, 260 (42%) had documented adherence to PAP. Of 241 untreated patients, 84 patients (35%) were referred for further attempts at management of diagnosed OSA. Nearly half of patients with diagnosed OSA did not have continued treatment or referral. CONCLUSION: To our knowledge, this is the first study to define the subsequent management of patients who have failed or refused PAP. Despite the known sequelae of OSA, clinicians are not treating a significant percentage of patients with diagnosed OSA. Those who fail to tolerate PAP therapy are unlikely to be referred for additional treatment. Therapies other than PAP may be warranted in this population.

The Knowledge Program: an innovative, comprehensive electronic data capture system and warehouse.

Data contained in the electronic health record (EHR) present a tremendous opportunity to improve quality-of-care and enhance research capabilities. However, the EHR is not structured to provide data for such purposes: most clinical information is entered as free text and content varies substantially between providers. Discrete information on patients' functional status is typically not collected. Data extraction tools are often unavailable. We have developed the Knowledge Program (KP), a comprehensive initiative to improve the collection of discrete clinical information into the EHR and the retrievability of data for use in research, quality, and patient care. A distinct feature of the KP is the systematic collection of patient-reported outcomes, which is captured discretely, allowing more refined analyses of care outcomes. The KP capitalizes on features of the Epic EHR and utilizes an external IT infrastructure distinct from Epic for enhanced functionality. Here, we describe the development and implementation of the KP.

The use of sleep studies in neurologic practice.

Sleep medicine is a multidisciplinary specialty that is rapidly advancing with exciting new discoveries. Some sleep disorders are diagnosed by clinical history alone, but others such as sleep apnea, narcolepsy, periodic limb movement disorder, parasomnias, and nocturnal seizures (conditions that will be addressed by other articles in this issue) usually require evaluation in the sleep laboratory. Sleep studies are used for diagnostic purposes, to assess disease severity, and to evaluate treatment efficacy. Routine sleep testing can be tailored to answer the specific clinical question at hand. In this article, the authors review the most commonly performed sleep tests in the sleep laboratory and their indications, interpretation, and limitations. These include the polysomnogram (PSG), the Multiple Sleep Latency Test (MSLT), the Maintenance of Wakefulness Test (MWT), and actigraphy. The accurate interpretation of these studies requires a comprehensive sleep and medical history.

Challenges in cardiac risk assessment in bariatric surgery patients.

Bariatric surgery has serious associated medical comorbidity and procedure-related risks and is thus considered an intermediate- to high-risk noncardiac surgery. Most patients referred for bariatric surgery have a low or very low functional capacity, making cardiac risk assessment imperative. Stress echocardiography has a high negative predictive value and can avoid some of the table weight and torso diameter problems associated with myocardial perfusion imaging. Echocardiograph contrast agents improve the ability to identify endocardial borders and assess ventricular wall motion and may be used with stress and nonstress imaging protocols. Single photon emission computer tomography (SPECT) imaging with attenuation correction, combined supine and prone imaging, use of technetium isotope, and positron emission tomography (PET) imaging may all provide some advantage for myocardial perfusion imaging for the obese patient.

Challenges in pulmonary risk assessment and perioperative management in bariatric surgery patients.

Bariatric surgery has serious associated medical comorbidity and procedure-related risks and is, thus, considered an intermediate-to-high-risk non-cardiac surgery. Altered respiratory mechanics, obstructive sleep apnea (OSA), and less often, pulmonary hypertension and postoperative pulmonary embolism are the major contributors to poor pulmonary outcomes in obese patients. Attention to posture and positioning is critical in patients with OSA. Suspected OSA patients requiring intravenous narcotics should be kept in a monitored setting with frequent assessments and naloxone kept at the bedside. Use of reverse Tredelenburg position, preinduction, maintenance of positive end-expiratory pressure, and use of continuous positive airway pressure can help improve oxygenation in the perioperative period.

The assessment, diagnosis, and treatment of excessive sleepiness: practical considerations for the psychiatrist.

Excessive sleepiness occurs frequently in the general population and is a common feature of many psychiatric conditions. The reductions in quality of life associated with excessive sleepiness may be substantial, involving compromised cognitive performance and work productivity as well as possible harm to the individual and the public. Excessive sleepiness may be the result of a number of extrinsic and intrinsic causes. Although it is an established symptom of certain psychiatric illnesses, abnormal excessive sleepiness in psychiatric patients may be the result of a comorbid disorder of sleep or wakefulness. Underdiagnosis and undertreatment of sleep disorders are common in community psychiatric practices because clinicians may not be aware of the different causes and consequences of excessive sleepiness. It is essential to recognize and treat the underlying cause of this disorder. In cases where sleep disorders are suspected, a comprehensive treatment program might include nonpharmacologic approaches, pharmacologic approaches, or both may need to be initiated to encompass the complexity of sleep disorder treatments. Careful monitoring and follow-up of patients with excessive daytime sleepiness, including counseling and long-term support, are essential to ensure treatment compliance and to maintain improvements over time.

Fever is associated with third ventricular shift after intracerebral hemorrhage: pathophysiologic implications.

BACKGROUND: Studies have shown the detrimental effect of increased temperature on brain injury. Fever is common after intracerebral hemorrhage (ICH). The term 'central fever' is often used when no cause is identified. AIM: The aim of the study was to determine the correlation of fever with third ventricular shift in 61 patients with ICH and hypothesize about the mechanism of fever. SETTING: Neurointensive Care Unit. DESIGN: Prospective observational study. MATERIALS AND METHODS: From August 1999 to April 2000, data from 61 patients with ICH were prospectively collected including maximum temperature (Tmax) and fever (T> 37.5 degrees C) at 24, 48, 72 and 96 hours, ICH volume, and third ventricular shift. Outcome measures included discharge mortality, 3-month National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel Index (BI). STATISTICAL ANALYSIS: Spearman correlation coefficient, Mann-Whitney test, and logistic regression were used to assess relationships. RESULTS: Fifty-six per cent of patients had fever in the first 24 hours and 53% for at least two consecutive days. There was a correlation between ICH volume and Tmax at 24 hours (P =0.04) and 72 hours (P =0.03) and fever at 24 hours (P =0.039) and 72 hours (P =0.036). Tmax at 72 hours correlated with third ventricular shift (P =0.01). Those with shift were more likely to have fever within the first 72 hours (P =0.049) and worse outcome. Fever at 72 hours was associated with a higher discharge mortality (P =0.046) and trend of a worse 3-month NIHSS score (P =0.06). CONCLUSION: Fever is common after ICH and correlates with ICH volume and third ventricular shift suggesting a role of hypothalamic compression in "central fever." There was a trend towards a worse outcome with fever.