Critically ill neurologic patients during the COVID-19 pandemic: A short communication.

PURPOSE: We aimed to evaluate utilization of inpatient hospital and critical care services among critically ill neurologic patients during the COVID-19 pandemic. We hypothesized, based on prior observations among ischemic stroke patients, that there would be significant decline in critically ill neurologic patients presenting to hospitals during the pandemic which may impact outcomes. METHODS: We used TriNetX, a large research network, collecting real-time electronic medical records data. We extracted data on utilization of critical care and hospital inpatient services among cohorts of patients with common neurocritical conditions between January-June 2020 and compared it to data from similar time-frames in previous years. We also compared clinical outcomes, comprising need for intubation and 30-day mortality, among these cohorts. RESULTS: We found a 28.1% reduction in intensive care unit (ICU) admissions with critical neurologic illnesses in 2020 when compared to 2019 (8568 vs. 11,917 patients, p â€‹< â€‹0.0001) and a 34.4% reduction compared to 2018 (8568 vs. 13,064 patients, p â€‹< â€‹0.0001). However, there was no statistically significant difference in mortality (2020: 12.2 vs. 2019: 12.4%; p â€‹= â€‹0.7; vs. 2018: 12.6%; p â€‹= â€‹0.62) or intubation rates across the years among patients using critical care services. There was 1% increase in mortality among non-ICU patients with similar diagnoses in 2020 compared to previous years (2020: 3.9% vs. 2019: 2.9% vs. 2018: 3.1%; p â€‹< â€‹0.0001, p â€‹= â€‹0.0001), but no difference in intubation rates. CONCLUSION: There was a significant reduction in hospital and ICU admissions among patients with acute neurologic emergencies in 2020, after onset of COVID-19 pandemic, compared to previous years. While we did not find a significant difference in mortality among patients admitted to the ICU, there was slightly higher mortality among non-ICU patients with same diagnoses in 2020 compared to previous years. Prospective evaluation and further investigation into the reasons for these trends is needed.

Immunosuppression in chronic autoimmune neurological disorders during the COVID-19 pandemic.

OBJECTIVE: To study the risk of acquiring Corona Virus Disease 2019 (COVID-19) and its outcomes in patients on immunosuppressive therapy (IST) for chronic autoimmune neuromuscular disorders (aNMD) and multiple sclerosis (MS). METHODS: We used TriNetX, a global health collaborative clinical research platform collecting real-time electronic medical records data, which has one of the largest known global COVID-19 database. We included patients with chronic autoimmune neuromuscular disorders (aNMD) [myasthenia gravis (MG), inflammatory myositis, and chronic inflammatory neuropathies (CIN)] and MS, based on the International Classification of Disease-10 (ICD-10) coding for one year before January 20th, 2020. We examined the use of IST, rate of COVID- 19, hospitalization, intubation, and mortality among the patients with aNMD and MS. RESULTS: A total of 33,451 patients with aNMD and 42,899 patients with MS were included. Among them, 111 (0.33%) patients with aNMD and 115 patients (0.27%) with MS had COVID-19. About one third of them required hospitalization. IST did not appear to have a significant impact on overall infection risk in either group; however, risk of hospitalization for immunosuppressed patients with aNMD was higher (Odds ratio 2.86, p-value 0.011). CONCLUSIONS: IST use does not appear to make patients with aNMD and MS more vulnerable to COVID-19. IST may be continued during the pandemic, as previously suggested by expert opinion guidelines. However, it is important to consider individualizing immunotherapy regimens in some cases. Additional physician reported registry-based data is needed to further confirm these findings.

Stroke transfers for thrombectomy in the era of extended time.

BACKGROUND AND PURPOSE: The Dawn and Extend Intra-Arterial (IA) acute stroke intervention trials have proven the benefit of thrombectomy in a select group of patients up to 24 h since their last known well time (LKWT) or time of symptom onset. Following the issuance of new treatment guidelines for large vessel occlusion strokes, we reviewed the paradigm shift effect on transfers for possible thrombectomy in a rural state. HYPOTHESIS: Extended time window for thrombectomy increases the need for better identification of potential transfers for thrombectomy in rural states with few hospitals capable of 24/7 interventional thrombectomy. METHODS: We analyzed all transfers to a comprehensive stroke center (CSC) from January to December 2018 which were specifically transferred for possible further intervention. This time period was selected in accordance with the change in American Heart Association (AHA) guidelines for extended time windows in mechanical thrombectomy (MT) care. RESULTS: A total of 132 patients were transferred for possible thrombectomy and advanced imaging. Thirty-four % patients underwent diagnostic angiogram with 33% patients having successful MT. Of the excluded patients 19% had large core infarcts by the time they arrived at hub hospital, 1.5% had hemorrhagic conversion, 32% had stroke without treatable occlusion not amenable for thrombectomy or cortical strokes on follow-up imaging, and 13.5% did not have stroke or LVO on follow-up imaging. CONCLUSION: Since the AHA's change in time window guidelines for mechanical thrombectomies, there has been an increased effort in identifying good candidates with computerized tomography angiography (CTA). To avoid undue burden on stroke systems of care, CTA identification of these patients at the spoke hospitals is key along with timely transport to appropriate thrombectomy capable sites. Given the rural nature of this state along with limited resources, selection of patients is a practical issue, especially for avoiding futile transfers, which might be true for large areas of the USA.

A neuromuscular-based analysis of the open payments program.

INTRODUCTION: In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. METHOD: Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. RESULTS: The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. DISCUSSION: A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Prevalence of Chronic Obstructive Pulmonary Disease in Patients Diagnosed with Cerebrovascular Accidents and Its Effect on Health Care Utilization: A Cross-sectional Study.

BACKGROUND: To assess prevalence and to determine the impact of chronic obstructive pulmonary disease (COPD) on health care utilization in patients with cerebrovascular accident (CVA). METHODS: We performed retrospective analysis of data from 12,102 patients who had diagnosis of CVA from 2014 to 2019 at tertiary medical center. We calculated the prevalence of COPD among patients with diagnosis of CVA. We performed unadjusted, covariate adjusted, and propensity-matched analysis to evaluate differences in health care utilization in patients with CVA and COPD compared to patients with CVA without COPD. RESULTS: 12,102 patients were diagnosed with CVA episodes. The prevalence of COPD among CVA patients was 7.65 % (95%CI: 7.18-8.13). The unadjusted and covariate adjusted analysis demonstrated that the average number of hospitalizations among CVA patients with a diagnosis of COPD was significantly higher than CVA patients without COPD. After adjusting for modifiable and nonmodifiable confounders, CVA patients diagnosed with COPD have on average 1 more hospitalization (1.21; 95%CI: 1.12-1.30) than those who are not diagnosed with COPD. Subsequent analysis based on propensity-matched data suggests that CVA patients diagnosed with COPD have on average approximately 1 more hospitalization (1.44; 95% CI: 1.31-1.58) than CVA patients without COPD. CONCLUSIONS: Our study suggests significant prevalence of COPD among CVA patients. The presence of COPD as a comorbidity resulted in patients with COPD and CVA having increased number of hospitalizations compared to CVA patients without COPD.