Predictors of No-Show in Neurology Clinics.

In this study, we aim to identify predictors of a no-show in neurology clinics at our institution. We conducted a retrospective review of neurology clinics from July 2013 through September 2018. We compared odds ratio of patients who missed appointments (no-show) to those who were present at appointments (show) in terms of age, lead-time, subspecialty, race, gender, quarter of the year, insurance type, and distance from hospital. There were 60,012 (84%) show and 11,166 (16%) no-show patients. With each day increase in lead time, odds of no-show increased by a factor of 1.0019 (p < 0.0001). Odds of no-show were higher in younger (p ≤ 0.0001, OR = 0.49) compared to older (age ≥ 60) patients and in women (p < 0.001, OR = 1.1352) compared to men. They were higher in Black/African American (p < 0.0001, OR = 1.4712) and lower in Asian (p = 0.03, OR = 0.6871) and American Indian/Alaskan Native (p = 0.055, OR = 0.6318) as compared to White/Caucasian. Patients with Medicare (p < 0.0001, OR = 1.5127) and Medicaid (p < 0.0001, OR = 1.3354) had higher odds of no-show compared to other insurance. Young age, female, Black/African American, long lead time to clinic appointments, Medicaid/Medicare insurance, and certain subspecialties (resident and stroke clinics) are associated with high odds of no show. Possible suggested interventions include better communication and flexible appointments for the high-risk groups as well as utilizing telemedicine.

Industry payments to hospitalist physicians: a 5-year analysis of the Open Payments programme from 2014 to 2018.

We analysed Open Payments programme data (https://openpaymentsdata.cms.gov) on industry-to-physician payments to hospitalists for the years 2014 to 2018. Payments to hospitalists increased by 106.5% from 2014 to 2018 with food and beverage (38.5%) and compensation for services other than consulting (24.3%) being the highest-paid categories. Industry payment to hospitalists was highly skewed with top 10 hospitalists receiving more than 30% of the total payments during the study period. The most common drugs associated with payments were anticoagulant medications (apixaban and rivaroxaban). Industry seems to be spending a significant amount of money to increase awareness of medications among hospitalists. Identification of these trends and potential motives of industry spending is critical to address any potential physician bias.

Incidence of Thrombotic Events and Outcomes in COVID-19 Patients Admitted to Intensive Care Units.

Introduction While coronavirus disease 2019 (COVID-19) mostly causes respiratory illnesses, emerging evidence has shown that patients with severe COVID-19 can develop complications like venous thromboembolism (VTE) and arterial thrombosis as well. The incidence of thrombosis among critically ill patients in the literature has been highly variable, ranging from 25 to 69%. Similarly, reported mortality among critically ill patients has been highly variable too, and it has ranged from 30 to 97%. In this study, we analyzed data from a large database to address the incidence, the risk factors leading to thrombotic complications, and mortality rates among COVID-19 patients. Material and methods Data were obtained from TriNetX (TriNetX, Inc., Cambridge, MA), a multinational clinical research platform that collects medical records from 42 healthcare organizations (HCOs). All nominal data were compared using the chi-squared test. Alpha of <0.05 was considered statistically significant. We used Benjamini-Hochberg correction with a false discovery rate of 0.1 to correct for multiple comparisons. Results We identified 18,652 COVID-19-positive patients, with a median age of 50.7 years [interquartile range (IQR): 31.8-69.6]; among them, 51.8% (9,672) were males and 48.2% (8,951) were females. Of these patients, 630 [3.37%; median age: 61 years (IQR: 44.9-77.1)] were critically ill, requiring intensive care unit (ICU) care within one month of their diagnosis. Men were over-represented among the ICU patients when compared to women (3.7% vs 3%, p=0.009, Χ2=6.66). African Americans were over-represented among the ICU patients when compared to Caucasians (8.5% vs 4%, p<0.0001, Χ2=76.65). Older patients, i.e., 65 years and older, were over-represented in the ICU compared to patients aged 18-64 years (6.8% vs 2.5%, p<0.0001, Χ2=121.43). The cumulative incidence of thrombotic events in the ICU population was 20.4% (129/630). Thrombotic events were significantly more common in patients who were 65 years and older when compared to patients in the age group of 18-64 years (24.6% vs 17.31%, p=0.02, Χ2=5.38). Mortality among ICU patients was higher in those who were 65 years and older when compared to the age group of 18-64 years (31.9% vs 17.3% p=0.0003, Χ2=18.41). The overall mortality in the study population was higher in patients who were 65 years and older when compared to patients aged 18-64 years (18.55% vs 1.4%, p<0.0001, Χ2=1915). Conclusions Among COVID-19 patients, men, African Americans, and people who are 65 years and older are more likely to have severe disease and require ICU level of care. Patients who are 65 years and older are more likely to have thrombotic events, myocardial infarction (MI), and stroke. Overall mortality and ICU mortality are higher among COVID-19 patients who are 65 years and older.

Locked-In with COVID-19.

Coronavirus Disease 2019 (COVID-19) can be associated with various neurological manifestations including acute strokes. Hyper acute diagnosis and treatment are key factors which decrease mortality and morbidity in stroke patients. The COVID-19 pandemic has introduced a great strain on the healthcare system, and as a result clinicians are facing several barriers in diagnosing and treating strokes. Delayed presentation of strokes is a problem as some in the general population defer the decision to seek immediate medical attention fearing contracting the virus. Also playing a role is the paucity of healthcare professionals available during a pandemic. Recent literature demonstrates the association of acute strokes in young patients with COVID-19. Lack of clear pathophysiology of the neurological manifestations from COVID-19 intensifies the problem. A thorough examination of the intensive care unit patient has always been a challenge owing to several factors including use of sedatives, sepsis, uremia, and encephalopathy secondary to medications. Locked-In Syndrome (LIS) secondary to stroke is much more challenging to diagnose as patients are unable to communicate or elicit any motor functions apart from certain ocular movements. We present the case of a 25 year old patient with no known history of coagulopathy, but had developed COVID-19 cytokine storm which culminated in LIS secondary to pontine strokes.

A Five-Year Analysis of Industry Payments to Sleep Neurologists From 2014 Through 2018.

Background and objectives  Sleep medicine has been one of the fastest-growing medical fields in recent years. The industry plays a big role in developing new medications and devices for both diagnosis and treatment of sleep-related problems. We analyzed payments made by industry to physicians from 2014 through 2018 based on the Open Payments Program data. Methods Centers for Medicare and Medicaid Services Open Payment Program and American Board of Psychiatry and Neurology databases were explored to elicit financial relationships between industry and sleep neurologists. Results Payments made by industry to sleep neurologists have been steadily increasing from 2014 through 2018. Approximately 16% to 22% of sleep certified neurologists received payments from industry during the study period. Interestingly, the payments made to the top 10% of the sleep physicians contributed approximately 85% to 96% of the total payments. The top two categories to which the highest payments were made were compensation for services and royalty and/or licensing fees. Silenor® (doxepin), Xyrem® (sodium oxybate), Aptiom® (eslicarbazepine acetate), Belsomra® (suvorexant), and Fycompa® (perampanel) were most of the drugs, which made the highest payments, that got approved by the Food and Drug Administration in the last decade. Conclusions  It seems that the industry is spending significant amounts of money in educating the physicians and in marketing the newer drugs. This analysis of the data on payments from industry is very useful in identifying any potential conflicts of interest from physicians. Further analyses are needed to study the trends of physician practice behavior and decision making.

Coronavirus Disease 2019 in Patients With Prior Ischemic Stroke.

BACKGROUND: It is uncertain if patients with prior ischemic stroke are vulnerable to coronavirus disease 2019 (COVID-19) and its complications. METHODS: We used TriNetX, a global health collaborative clinical research platform with a large global COVID-19 database. COVID-19 infection was identified with a positive lab value for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and related ribonucleic acid (RNA). FINDINGS: A total of 604,258 patients with history of ischemic stroke were identified, of which 891 patients (study cohort) were diagnosed with COVID-19. A control cohort with 32,136 patients diagnosed with COVID-19 after January 20th 2020 without a history of ischemic stroke were identified. A comparison between study cohort and control cohort showed patients with prior history of stroke (study cohort) were older (69.5 vs 47.8; p<0.0001) and had more comorbidities contributing to worse clinical outcomes. After propensity matching for demographic variables and comorbidities, only rate of hospitalization (287 vs 231; p=0.0035) and need for critical care services (85 vs 55; p=0.0082) remained statistically significant while intubation (51 vs 43; p=0.39) and death (119 vs 115; p=0.77) showed trends towards worse outcomes but were not statistically significant.  Interpretation: Patients with history of ischemic stroke tend to be significantly older with several comorbid conditions contributing to worse clinical outcomes after COVID-19, which makes them a vulnerable population.

Trends of Industry Payments in Neurology Subspecialties.

Background Open Payments is a national disclosure program to promote transparency by the public disclosure of financial relationships between the pharmaceutical and medical device industries and physicians. Objective To explore payments from the industry to physicians in various neurology subspecialties. Methods Open Payments Program (OPP) data (https://openpaymentsdata.cms.gov) on industry-to-physician payments for the years 2014-2018 were extracted for general neurology, neuromuscular, neurophysiology, and vascular neurology. The data were then analyzed to explore trends in payments for various subspecialties and to identify the possible factors underlying these trends. Results Overall, industry-to-physician payments for neurology subspecialties increased by 16% from 2014 to 2018. The introduction of newer drugs in a subspecialty was likely the driving factor for higher industry payments. Nearly half of the total industry-to-physician payments were for the subspecialty of multiple sclerosis (MS)/Neuroimmunology; this coincided with Aubagio and Copaxone being the top two medications associated with the highest industry payments in 2014, Aubagio, and Lemtrada in 2018. A significant increase in spending percentages for headache, neuromuscular disorders, and movement disorders was observed while a relative decrease in the payments for MS/neuroimmunology and epilepsy was identified; these trends coincide with the introduction of new drugs such as Aimovig, Neuplazid, Nusinersen, and Austedo for headache, neuromuscular and movement disorders. Conclusions From 2014 to 2018, the total industry-to-physician payments for neurology subspecialties increased while the distribution of industry-to-physician payments for various neurology subspecialties showed notable changes. The introduction of newer medications in a subspecialty coincided with higher industry payments. Identification of these trends and potential motives of the industry spending is critical to address any potential physician bias in prescribing medications.

Coronavirus Disease 2019-Induced Rhabdomyolysis.

Rhabdomyolysis is caused by necrosis of muscles and leakage of intracellular contents into blood circulation. It is most commonly caused by trauma, crush injuries, drugs, toxins, immobilization, compartment syndrome, prolonged surgical procedures, and less likely by infections. Infection-related rhabdomyolysis is rare, but not uncommon, and is seen in both viral and bacterial infections. Extrapulmonary manifestations of coronavirus disease 2019 (COVID-19) include thrombotic like pulmonary emboli, acute cerebrovascular accident, myocardial infarction, cardiac arrhythmias, liver injury, gangrene, diarrhea, acute renal failure, and so on. We here describe a case of COVID-19-induced rhabdomyolysis in a 19-year-old Hispanic male presenting with muscle aches, fatigue, fevers, and no pulmonary symptoms.

Spectrum of neuropsychiatric manifestations in COVID-19.

Corona Virus Disease 2019 (COVID-19) emerged in December 2019 from Wuhan, China. It typically presents with mild upper respiratory tract infection symptoms and may have life threatening complications, including acute respiratory distress syndrome, acute stroke, myocardial infarction, kidney failure, shock, and even death. Coronavirus infections are known to have neuroinvasive potential with consequent neuropsychiatric manifestations. We analyzed COVID-19 adult patients in the TriNetX database, which is a global health collaborative clinical research platform collecting real-time electronic medical records data from a network of health care organizations (HCOs) from January 20, 2020 to June 10th, 2020. 40,469 patients were diagnosed with COVID-19 among whom 9086 (22.5%) patients had neuropsychiatric manifestations. The most common neurologic manifestations included headache (3.7%) and sleep disorders (3.4%), Encephalopathy (2.3%), Stroke and transient ischemic attack (TIA) (1.0%) and 0.6% had seizures. Most common psychiatric manifestations included anxiety and other related disorders (4.6%), mood disorders (3.8%), while 0.2% patients had suicidal ideation. Early recognition and prompt management of neuropsychiatric manifestations in these patients have a potential to decrease overall morbidity and mortality.

Albuterol-Induced Type B Lactic Acidosis: Not an Uncommon Finding.

Lactic acidosis (LA) is usually a medical emergency diagnosed by laboratory evaluation in emergency rooms (ERs) and hospital settings in critically ill patients. LA is classified into two major types based on pathophysiology; type A results from tissue hypoxia and/or hypoperfusion and type B results from deranged metabolic activity in the cells in the absence of hypoxia/hypoperfusion. Prompt evaluation and treatment are essential to prevent morbidity and mortality, especially in patients with type A LA. Most cases of LA are due to type A (hypoperfusion/hypoxia). However, with increased testing of lactic acid levels in ERs and hospitals, we are encountering a few cases of type B LA as well. Diagnosing the exact type is crucial because of differences in management. We here describe a patient with albuterol-induced type B LA, which resolved after discontinuing the albuterol breathing treatments.

Staphylococcus warneri: Skin Commensal and a Rare Cause of Urinary Tract Infection.

Coagulase negative Staphylococci often grow in cultures and form one of the most abundant flora among skin microbiome. It is important and challenging to identify and treat clinically significant infections caused by these organisms. Prosthetic devices, catheters and conditions causing immunocompromised states are the risk factors for such infections. We describe a case of clinically significant and symptomatic urinary tract infection (UTI) in a 65-year-old man with liver cirrhosis caused by Staphylococcus warneri which forms <1% of Staphylococcal skin flora. He was treated successfully with fluoroquinolone antibiotic based on culture results. It is important to understand potential of this organism to cause serious infections which warrant culture-directed antibiotic therapy.

Gallbladder Neuroendocrine Carcinoma: A Rare Endocrine Tumor.

Gallbladder neuroendocrine neoplasms (GB-NEN) are very rare neuroendocrine tumors (NETs). GB-NEN can present as carcinoid or typical/atypical carcinoid or small cell carcinoma. Most of the GB-NENs present as gall bladder polyps or stones with right upper quadrant pain, nausea and non-specific symptoms which leads to clinical misdiagnosis. Considering the rare occurrence of GB-NENs, and lack of multi-center research data there is no unified standard for identification and treatment. We here present an 84-year-old male presenting with right upper quadrant and epigastric pain, and eventually diagnosed with mixed cell (more of small cells mixed with intermediate to large cells) neuroendocrine cancer of gall bladder.

Corona Virus Disease 2019 (COVID-19) Presenting as Acute ST Elevation Myocardial Infarction.

Patients with Covid-19 disease commonly present with symptoms related to respiratory illness, and less commonly they develop cardiovascular complications either on presentation or during the course of the disease. The mortality/morbidity is high in these patients with cardiovascular involvement. Acute ST-elevation myocardial infarction (STEMI) is a medical emergency which needs immediate coronary re-perfusion for better patient outcomes. Here we present a patient who presented to the emergency room with acute STEMI and later tested positive for COVID-19. She was successfully treated with coronary revascularization and stent placement, and remains on the ventilator to date as she quickly developed acute respiratory distress syndrome. We need more research in Covid-19 patients with cardiovascular involvement for early diagnosis, prevention of exposure to health care workers and effective treatment.

New Delhi Metallo-beta-lactamase-producing Enterobacter Cloacae - A Rare Multidrug Resistance Strain in a Caucasian Woman.

New Delhi metallo-beta-lactamase (NDM-1) is a novel metallo-beta-lactamase (MBL) gene carried by some Enterobacteriaceae that induces resistance to most of the antibiotics. First described in a Swedish patient hospitalized in India with an infection due to Klebsiella pneumoniae. NDM-1 makes bacteria resistant to a broad range of beta-lactam antibiotics. These include the antibiotics of the carbapenem family, which are a mainstay for the treatment of antibiotic-resistant bacterial infections. Most of these carbapenem resistant Enterobacteriaceae (CRE) are increasingly recognized in hospital settings and post-acute care settings like long-term acute care settings. Percentage of CRE infections is increasing in the United States of America, and invasive infections with CRE carry high mortality rates and limited treatment options. We here present a rare case of elderly Caucasian woman with CRE cellulitis of both legs with no travel history.

Euglycemic Diabetic Ketoacidosis in a Young Pregnant Woman Precipitated by Urinary Tract Infection.

Diabetic ketoacidosis (DKA) is a life-threatening diabetic complication and medical emergency. Euglycemic DKA (EKDA) is a variant of DKA with normal range glucose levels. The condition can be difficult to diagnose due to the misleading euglycemic levels. Pregnancy, infection, low-calorie intake, and use of insulin are some of the common etiologies of EDKA. We report a case of a young, pregnant female, with type I diabetes mellitus, in her third trimester admitted with EKDA. The EKDA was triggered by urinary tract infection (UTI), and the patient had other etiologies that have predisposed her to EKDA. Along with the case presentation, we discuss the common etiologies, pathophysiology, and management of EKDA. Euglycemic DKA is a life-threatening emergency that needs to be recognized early and treated aggressively, especially in pregnant patients, to avoid deleterious effects to maternal and fetal health.

Isolated Area Postrema Syndrome Presenting as Intractable Nausea and Vomiting.

Neuromyelitis optica (NMO) is a disease of central nervous system, characterized by demyelination and axonal damage mostly involving optic nerves and spinal cord. Usually these patients present with symptoms related to optic neuritis or myelitis with a typical relapsing course. Some patients present with less common symptoms involving brain stem like nausea and vomiting, especially those involving area postrema (AP) located in dorsal medulla. International panel for NMO diagnosis revised criteria in 2015 and came up with a unifying term NMO spectrum disorders (NMOSD) instead of NMO. Patients with NMO having AP involvement are grouped under area postrema syndrome (APS). Usually patients with AP symptoms also have neurological symptoms upon presentation. Here we present a rare case of an NMO who presented with isolated APS with no other neurological symptoms.

Dahl's Sign: An Indicator of Severe Chronic Obstructive Pulmonary Disease.

Dahl's sign, a clinical sign in which areas of thickened and darkened skin seen on the lower thighs and/or elbows, is seen in patients with severe chronic respiratory disorders such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, congestive heart failure (CHF), and chronic moderate to severe persistent asthma. The aim of our present report is to create awareness and encourage providers to lay emphasis on physical examination in every medical examination that can give clues to the severity of the underlying disorder.