ABSTRACT
Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory autoimmune disorder of the central nervous system, with optic neuritis and transverse myelitis as its most common presentations. Although immunomodulatory treatment options for NMOSD have expanded, preventing reactivation of latent infections in patients can be both a therapeutic challenge and a special consideration for the neurohospitalist in an inpatient setting. We present a challenging case of a NMOSD patient who presented to the emergency department with worsening weakness and numbness in the setting of an NMOSD pseudo-relapse, later found to have untreated latent tuberculosis (TB) and chronic hepatitis B (HBV). She was briefly treated with high-dose IV methylprednisolone, which was stopped after her symptoms and imaging became more consistent with a pseudo-relapse. After confirmation that neither HBV nor TB had reactivated, the patient was discharged on isoniazid and entecavir. A month later, the patient's symptoms were stable, and she was started on inebilizumab for relapse prevention of NMOSD. This case report is the first to highlight the therapeutic complexities of managing NMOSD that requires immunosuppression in the setting of preventing reactivation of both TB and HBV.
ABSTRACT
Background and Objectives: In response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to outpatient evaluation through video (VTM) and telephone (TPH) telemedicine (TM) visits around the world. We sought to evaluate the sociodemographic differences in outpatient TM use among stroke patients. Methods: We conducted a retrospective chart review of outpatients evaluated at 3 tertiary stroke centers in the early period of the pandemic, 3/16/2020 through 7/31/2020. We compared the use of TM by patient characteristics including age, sex, race/ethnicity, insurance status, stroke type, patient type, and site. The association between TM use and patient characteristics was measured using the relative risk (RR) from a modified Poisson regression, and site-specific effects were controlled using a multilevel analysis. Results: A total of 2,024 visits were included from UTHealth (n = 878), MedStar Health (n = 269), and Columbia (n = 877). The median age was 64 [IQR 52-74] years, and 53% were female. Approximately half of the patients had private insurance, 36% had Medicare, and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% of total visits, and the use of TM over office visits was primarily associated with site, not patient characteristics. TM utilization was associated with Asian and other/unknown race. Among TM users, older age, Black race, Hispanic ethnicity, and Medicaid insurance were associated with lower VTM use. Black (aRR 0.88, 95% CI 0.86-0.91, p < 0.001) and Hispanic patients (aRR 0.92, 95% CI 0.87-0.98, p = 0.005) had approximately 10% lower VTM use, while Asian patients (aRR 0.98, 95% CI 0.89-1.07, p = 0.59) had similar VTM use compared with White patients. Patients with Medicaid were less likely to use VTM compared with those with private insurance (aRR 0.86, 95% CI 0.81-0.91, p < 0.001). Discussion: In our diverse cohort across 3 centers, we found differences in TM visit type by race and insurance early during the COVID-19 pandemic. These findings suggest disparities in VTM access across different stroke populations. As VTM remains an integral part of outpatient neurology practice, steps to ensure equitable access are essential.
ABSTRACT
Background: There have been varying impacts of COVID-19 on racial, ethnic, and socioeconomic communities in the US. Recent literature suggests that Black Americans have the highest unadjusted and adjusted mortality rates from COVID-19, while White Americans have the lowest unadjusted and adjusted rates. However, the role of socioeconomic status and comorbidities in these disparities in health outcomes from COVID-19 are unclear. Thus, the purpose of this study is to evaluate how socioeconomic status and race impact COVID-19 outcomes in patients hospitalized with COVID-19 in a large health care system in the Mid-Atlantic region. Material and methods: We retrospectively analyzed the association of COVID-19 outcomes and race, ethnicity, and socioeconomic status using electronic medical records and the REDCap database from the time period of March 5, 2020 to June 3, 2020. The outcomes evaluated were intubation, ICU admission, and discharge destination. Multivariate logistic regression analysis was then performed to examine whether race and socioeconomic status were independent risk factors of mortality controlling for age, Charlson comorbidity index (CCI), and comorbidities. Results: Race was not found to be an independent predictor for COVID-19 inpatient mortality. Race was found to be an independent risk factor for ICU admission with odds of ICU admission for Black patients to be 1.5 times higher (odds ratio (OR) 1.4 1.07 to 2.04) compared to Non-Black/Non-White (72.4% identifying as Hispanic) but no difference between Black and White races. Race was found not to be an independent risk factor for intubation nor was race an independent risk factor for increased length of ICU LOS, hospital LOS or intubation days. Socioeconomic status was not an independent risk factor for inpatient mortality although high income groups were significantly less likely to be admitted to the ICU compared to middle income patients. Conclusion: Our cohort of patients in a large mid-Atlantic health system showed that there was no statistically significant difference between race or socioeconomic status and COVID-19 related inpatient mortality. However, Black patients and individuals in the lower to middle socioeconomic group had a higher rate of COVID-19 hospitalizations when accounting for age, sex, and comorbidities. With ongoing vaccination efforts, equitable administration of resources should focus on disproportionately affected populations.
ABSTRACT
BACKGROUND AND OBJECTIVE: The purpose of this article is to determine if outcomes in patients presenting with retinal tears with bridging vessels (BVs) differ from those without BVs. PATIENTS AND METHODS: A case control study of all patients presenting with retinal tears during a 3-year period was completed. Comparisons were made between patients with and without BVs. Variables included vitreous hemorrhage (VH) at presentation, delayed VH, initial and final visual acuity, need for surgery, and retinal detachment. RESULTS: There was a significant increase in the number of patients with a VH at presentation (75% vs 28%; P < .0001), delayed VH (31% vs 7.5%; P = .001), and incidence of pars plana vitrectomy (16% vs 1.3%; P = .002) in the BV cohort. There was no significant difference in time to VH (9.4 vs 38.8 days; P = .32) or final visual acuity (20/25 vs 20/25; P = .45) between the two groups. CONCLUSIONS: The presence of a BV is an important prognostic indicator for risk of delayed VH. Documenting the presence of a BV allows for appropriate patient counseling. [Ophthalmic Surg Lasers Imaging Retina 2022;53:502-505.].
