Preparing a neurology department for SARS-CoV-2 (COVID-19): Early experiences at Columbia University Irving Medical Center and the New York Presbyterian Hospital in New York City

Probable Neuropsychological and Cognitive Complications Due to Cytokine Storm in Patients With COVID-19

Introduction

COVID-19 (coronavirus disease 2019) was first identified in China in December 2019 and is rapidly spreading worldwide as a pandemic. Since COVID-19 causes mild to severe acute respiratory syndrome, most studies in this context have focused on pathogenesis primarily in the respiratory system. However, evidence shows that the central nervous system (CNS) may also be affected by COVID-19. Since COVID-19 is spreading, it is necessary to study its possible cognitive effects on COVID-19 patients and their recovery.

Methods

The articles used in this study were searched by keywords, such as cytokine storm and COVID-19, COVID-19 and executive dysfunction, cognitive disorder, and COVID-19, central nervous system (CNS) and COVID-19, coronavirus, neuroinvasion in Science Direct, Scopus, PubMed, Embase, and Web of Science databases based on preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist. The study evaluates all observational studies published between December 2019 and April 2021 in peer-reviewed journals, including cross-sectional, cohort, case-control studies, case reports, and case series. The search result was 106 articles, of which 73 articles related to COVID-19, the stages of infection by this virus, its effect on the nervous system and neurological symptoms, the cytokine storm caused by this infection, and the possible cognitive consequences caused by this virus in patients, has been reviewed. Other articles were not checked due to their limited relevance to the topic under discussion.

Results

Studies showed that neurons may be directly affected by severe acute respiratory syndrome coronavirus (SARS-CoV)-1 and SARS-CoV-2. Furthermore, various studies indicated that systemic inflammation (so-called "cytokine storm") is also responsible for brain damage induced by infection with SARS-CoV-1 and SARS-CoV-2. In such a way that these patients showed elevated levels of interleukin (IL-), 6, 8, and 10 and of tumor necrosis factor-alpha (TNF-α) in their blood.

Conclusion

Various cognitive defects have been observed following an increased level of cytokines, such as tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-6, 8. Therefore, due to the increased level of these pro-inflammatory factors in the brains of these patients, cognitive deficits can be expected, which need further investigation.

Impact of the COVID-19 Pandemic on Continuous EEG Utilization

PURPOSE

The coronavirus disease 2019 (COVID-19) has significantly impacted healthcare delivery and utilization. The aim of this article was to assess the impact of the COVID-19 pandemic on in-hospital continuous electroencephalography (cEEG) utilization and identify areas for process improvement.

METHODS

A 38-question web-based survey was distributed to site principal investigators of the Critical Care EEG Monitoring Research Consortium, and institutional contacts for the Neurodiagnostic Credentialing and Accreditation Board. The survey addressed the following aspects of cEEG utilization: (1) general center characteristics, (2) cEEG utilization and review, (3) staffing and workflow, and (4) health impact on EEG technologists.

RESULTS

The survey was open from June 12, 2020 to June 30, 2020 and distributed to 174 centers with 79 responses (45.4%). Forty centers were located in COVID-19 hotspots. Fifty-seven centers (72.1%) reported cEEG volume reduction. Centers in the Northeast were most likely to report cEEG volume reduction (odds ratio [OR] 7.19 [1.53-33.83]; P = 0.012). Additionally, centers reporting decrease in outside hospital transfers reported cEEG volume reduction; OR 21.67 [4.57-102.81]; P ≤ 0.0001. Twenty-six centers (32.91%) reported reduction in EEG technologist coverage. Eighteen centers had personal protective equipment shortages for EEG technologists. Technologists at these centers were more likely to quarantine for suspected or confirmed COVID-19; OR 3.14 [1.01-9.63]; P = 0.058.

CONCLUSIONS

There has been a widespread reduction in cEEG volume during the pandemic. Given the anticipated duration of the pandemic and the importance of cEEG in managing hospitalized patients, methods to optimize use need to be prioritized to provide optimal care. Because the survey provides a cross-sectional assessment, follow-up studies can determine the long-term impact of the pandemic on cEEG utilization.

Setting Up a Teleneurology Clinic during COVID-19 Pandemic: Experience from an Academic Practice

The declaration of the COVID-19 pandemic necessitated rapid implementation of telehealth across all neurological subspecialties. Transitioning to telehealth technology can be challenging for physicians and health care facilities with no prior experience. Here, we describe our experience at the Neurology and Sleep Disorders Clinic at the University of Missouri-Columbia of successful transition of all in-person clinic visits to telehealth visits within a span of 2 weeks with a collaborative effort of clinic staff and the leadership. Within a month of launch, 18 clinic providers with no prior telehealth experience conducted 1451 telehealth visits, which was the 2nd highest number of telehealth visits conducted by any department at the University of Missouri-Columbia Health Care system. Lack of connectivity, poor video/audio quality, and unavailability of smart devices among rural populations were the important shortcomings identified during our telehealth experience. Our study highlighted the need for expansion of high-speed internet access across rural Missouri. We hope our experience will help other health care facilities to learn and incorporate telehealth technology at their facilities, overcome the associated challenges, and serve patient needs while limiting the spread of the COVID-19.

Support Needs and Interventions for Family Caregivers of Patients with Amyotrophic Lateral Sclerosis (ALS): A Narrative Review with Report of Telemedicine Experiences at the Time of COVID-19 Pandemic

Family caregivers of people with amyotrophic lateral sclerosis (ALS), a severely disabling neurodegenerative disease due to the degeneration of both upper and lower motor neurons, have a very demanding role in managing their relatives, thereby often experiencing heavy care burden. Previous literature has widely highlighted that this situation reduces caregivers’ quality of life and increases their psychological distress and risk of health problems, but there are relatively few studies that focus on psychological interventions for these situations. Family support is more—not less—important during crisis. However, during the COVID-19 pandemic, maintaining public safety has required restricting the physical presence of families for hospitalized patients. Caregivers of ALS patients felt increased sense of loneliness and experienced greater difficulties in the access to both hospital and home assistance. In response, health systems rapidly adapted family-centric procedures and tools to circumvent restrictions on physical presence. In this regard, internet-based and telehealth solutions have been adopted to facilitate the routine, predictable, and structured communication, crucial to family-centered care. This narrative review aims at addressing more current matters on support needs and interventions for improving wellbeing of caregivers of ALS patients. In particular, we aimed at highlighting several gaps related to the complex needs of caregivers of ALS patients, to the interventions carried out in order to respond to these needs, and to the changes that COVID-19 pandemic caused from 2020 to nowadays in clinical managing of ALS patients. Finally, we report ongoing experiences of psychological support for family caregivers of ALS patients through telehealth solutions, which have been reinforced in case of needing of physical distancing during the COVID-19 pandemic.

Single-centre study surveying neurology trainees' and faculty's perceptions of the impact of the COVID-19 pandemic on residents' medical education

Objective

To assess perceptions of our neurology residents and faculty regarding training experience and medical education during the early COVID-19 pandemic.

Methods

We distributed two online, voluntary and anonymous surveys to trainees and teaching faculty of our Neurology Department at Henry Ford Hospital. Surveys inquired about trainees’ stress, well-being, clinical experience and satisfaction with medical education and available support resources during the first wave of the COVID-19 pandemic in Michigan (mid-March to June 2020).

Results

A total of 17/31 trainees and 25/42 faculty responded to the surveys. Eight (47%) trainees reported high stress levels. Nine (57%) were redeployed to cover COVID-19 units. Compared with non-redeployed trainees, redeployed residents reported augmented medical knowledge (89% vs 38%, p=0.05). There was no difference in the two groups regarding overall satisfaction with residency experience, stress levels and didactics attendance. Twenty-one (84%) faculty felt that the redeployment interfered with trainees education but was appropriate, while 10 (59%) trainees described a positive experience overall. Both trainees and faculty believed the pandemic positively impacted trainees’ experience by increasing maturity level, teamwork, empathy, and medical knowledge, while both agreed that increased stress and anxiety levels were negative outcomes of the pandemic. Twelve (70%) trainees and 13 (52%) faculty were interested in pursuing more virtual didactics in the future.

Conclusion

Our findings provide an objective assessment of residents' experience during the COVID-19 pandemic and can guide teaching programmes in their medical education response in the face of future global crises.

Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits

BACKGROUND AND OBJECTIVES

To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.

METHODS

Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).

RESULTS

Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.

DISCUSSION

Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

Neurohospitalist Practice and Well-Being During the COVID-19 Pandemic

Background and Purpose

Neurohospitalists play an important role in, and have been variably affected by, the ongoing COVID-19 pandemic. In this study, we survey neurohospitalists to characterize practice changes and the impact of the pandemic on their well-being.

Methods

A 22-item survey was distributed to neurohospitalists through the Neurohospitalist Society and the American Academy of Neurology Neurohospitalist, Stroke & Vascular Neurology, and Critical Care & Emergency Neurology Sections.

Results

After 2 weeks of collection, 123 responses were received, with 57% of respondents practicing in academic settings, 23% in private practice, and 7% in community hospitals. A minority of neurohospitalists (8%) were redeployed to care for COVID-19 or non-COVID-19 medicine patients. The most common neurologic diagnoses they reported in COVID-19 patients were delirium (85%), cerebrovascular events (75%), and seizure (35%); however, most neurohospitalists (59%) had evaluated fewer than 10 patients with COVID-19. Respondents observed that fewer patients with unrelated neurological diseases were admitted to the hospital compared to before the pandemic. Neurohospitalists experienced changes in administrative (27%), educational (15%), and research duties (11%), and had overall worse well-being and work-life balance (77%).

Conclusions

The most common neurologic diagnoses seen in COVID-19 patients by neurohospitalists in this sample are delirium, cerebrovascular disease, and seizure. Though the majority of survey respondents reported not being primary frontline providers, they report key clinical and operational roles during the pandemic, and report worse well-being as compared to before the pandemic. Our data suggests that there are opportunities to improve neurohospitalists' experience through flexible work practices and providing family care support.

Association between environmental factors and COVID-19 in Shanghai, China

The outbreak of coronavirus disease 2019 (COVID-19) continues to spread worldwide and has led to recession, rising unemployment, and the collapse of the health-care system. The aim of this study was to explore the exposure-response relationship between daily confirmed COVID-19 cases and environmental factors. We used a time-series generalized additive model (GAM) to investigate the short-term association between COVID-19 and environmental factors by using daily meteorological elements, air pollutant concentration, and daily confirmed COVID-19 cases from January 21, 2020, to February 29, 2020, in Shanghai, China. We observed significant negative associations between daily confirmed COVID-19 cases and mean temperature (Tave), temperature humidity index (THI), and index of wind effect (K), whereas air quality index (AQI), PM2.5, PM10 NO2, and SO2 were significantly associated with the increase in daily confirmed COVID-19 cases. A 1 °C increase in Tave, one-unit increase in THI, and 10-unit increase in K (lag 0-7 days) were associated with 4.7, 1.8, and 1.6% decrease in daily confirmed cases, respectively. Daily Tave, THI, K, PM10, and SO2 had significant lag and persistence (lag 0-7 days), whereas the lag and persistence of AQI, PM2.5, and NO2 were significant at both lag 0-7 and 0-14 days. A 10-μg/m3 increase in PM10 and 1-μg/m3 increase in SO2 was associated with 13.9 and 5.7% increase in daily confirmed cases at lag 0-7 days, respectively, whereas a 10-unit increase in AQI and a 10-μg/m3 increase in PM2.5 and NO2 were associated with 7.9, 7.8, and 10.1% increase in daily confirmed cases at lag 0-14 days, respectively. Our findings have important implications for public health in the city of Shanghai.

Update on the management of multiple sclerosis during the COVID-19 pandemic and post pandemic: An international consensus statement

In this consensus statement, we provide updated recommendations on multiple sclerosis (MS) management during the COVID-19 crisis and the post-pandemic period applicable to neurology services around the world. Statements/recommendations were generated based on available literature and the experience of 13 MS expert panelists using a modified Delphi approach online. The statements/recommendations give advice regarding implementation of telemedicine; use of disease-modifying therapies and management of MS relapses; management of people with MS at highest risk from COVID-19; management of radiological monitoring; use of remote pharmacovigilance; impact on MS research; implications for lowest income settings, and other key issues.

Neurologic Manifestations of COVID-19

Neurological manifestations of novel coronavirus disease (COVID-19) are reported to occur in as much as 37% of the affected patients. These manifestations range from headache and dizziness to altered mental status and consciousness, anosmia, ageusia, sensory disturbances, and stroke. The mechanisms by which the neurological symptoms arise are not yet determined but may either proceed as an indirect consequence of systemic hyperinflammation or result from the direct invasion of the virus to neural and glial cells. The neural invasion can explain both the retrograde pathway of encephalitis and the early manifestation of anosmia by invading the olfactory bulb. Moreover, in the case of attacking the brain stem, it may take part in the early apnea manifestation reported by patients. Additionally, neurotropism of the virus could be the cause of acute hemorrhagic encephalitis. Hyperinflammation can have acute and prolonged effects in the nervous system, such as acute demyelination and predisposition to multiple sclerosis. Moreover, the pro-inflammatory state contributes to hypercoagulation, which in turn could result in cerebrovascular injuries in COVID-19 patients. This chapter would discuss that the neurologic manifestations of the COVID-19 are to be looked at as a multifactorial entangled phenomenon.

Management of patients with neuromuscular disorders at the time of the SARS-CoV-2 pandemic

The novel Coronavirus disease-19 (COVID-19) pandemic has posed several challenges for neuromuscular disorder (NMD) patients. The risk of a severe course of SARS-CoV-2 infection is increased in all but the mildest forms of NMDs. High-risk conditions include reduced airway clearance due to oropharyngeal weakness and risk of worsening with fever, fasting or infection Isolation requirements may have an impact on treatment regimens administered in hospital settings, such as nusinersen, glucosidase alfa, intravenous immunoglobulin, and rituximab infusions. In addition, specific drugs for SARS-CoV2 infection under investigation impair neuromuscular function significantly; chloroquine and azithromycin are not recommended in myasthenia gravis without available ventilatory support and prolonged prone positioning may influence options for treatment. Other therapeutics may affect specific NMDs (metabolic, mitochondrial, myotonic diseases) and experimental approaches for Coronavirus disease 2019 may be offered "compassionately" only after consulting the patient's NMD specialist. In parallel, the reorganization of hospital and outpatient services may change the management of non-infected NMD patients and their caregivers, favouring at-distance approaches. However, the literature on the validation of telehealth in this subgroup of patients is scant. Thus, as the first wave of the pandemic is progressing, clinicians and researchers should address these crucial open issues to ensure adequate caring for NMD patients. This manuscript summarizes available evidence so far and provides guidance for both general neurologists and NMD specialists dealing with NMD patients in the time of COVID-19.

Preparedness and impact of COVID 19 infection at tertiary care neurology centers in Pakistan

Objective

We aimed to assess the response and impact of covid 19 pandemic at tertiary care centers in Pakistan especially pertaining to neurological care, facilities and training.

Methods

A pre-tested survey form was sent to 40 neurology tertiary care centers in all the provinces in the country in the first week of July 2020. 33 filled forms were received, out of which 18 were public (government) and 15 were private hospitals.

Results

Estimated 1300 HCW (faculty, medical officers, trainees and nurses) work at these 33 participating centers. There were 17 deaths among HCW (1.3%) at ten centers. Sufficient personal protective equipment (PPE) were provided to 158 HCW (12%). 129 (10%)HCW tested positive for COVID 19 at 31 centers including trainees/medical officers (39), consultants (29) and nursing and other staff (61). Due to low neurology admissions, 23/33 hospitals (70%) posted neurology trainees in COVID 19 units to contribute to covid care. Less than 50% hospitals did covid screening PCR before admission to neurology wards. Only 10% hospitals provide training and regular update to HCW. Neurology tele-health services were started for clinically stable patients at 15 (45%) centers. Only 60% neurology training programs were able to start online training. Ongoing research studies and trials focusing neurological manifestations of COVID-19 were done at 10 (30%) centers. Modification of facilities for COVID patients showed that 24(72%) hospitals strictly reduced the number of attendants accompanying patients. Only 10 (30%) centers had neurophysiological tests being conducted on COVID-19 patients. Mental health support services to HCW were provided at 12 (36%) centers.

Conclusions

Among HCW 10% tested positive for covid and 1.3% died. Mental health support services offered for HCW were available in 36% institutions. Neurology training was substantially affected due to low admissions, limited ward rounds and limited availability of online training.

Ambulatory care for epilepsy via telemedicine during the COVID-19 pandemic

OBJECTIVE

To assess feasibility, patient satisfaction, and financial advantages of telemedicine for epilepsy ambulatory care during the current COVID-19 pandemic.

METHODS

The demographic and clinical characteristics of all consecutive patients evaluated via telemedicine at a level 4 epilepsy center between March 20 and April 20, 2020 were obtained retrospectively from electronic medical records. A telephone survey to assess patient satisfaction and preferences was conducted within one month following the initial visit.

RESULTS

Among 223 telehealth patients, 85.7% used both synchronous audio and video technology. During the visits, 39% of patients had their anticonvulsants adjusted while 18.8% and 11.2% were referred to laboratory/diagnostic testing and specialty consults, respectively. In a post-visit survey, the highest degree of satisfaction with care was expressed by 76.9% of patients. The degree of satisfaction tended to increase the further a patient lived from the clinic (p = 0.05). Beyond the pandemic, 89% of patients reported a preference for continuing telemedicine if their epilepsy symptoms remained stable, while only 44.4% chose telemedicine should their symptoms worsen. Inclement weather and lack of transportation were factors favoring continued use of telemedicine. An estimated cost saving to patient attributed to telemedicine was $30.20 ± 3.8 per visit.

SIGNIFICANCE

Our findings suggest that epilepsy care via telemedicine provided high satisfaction and economic benefit, without compromising patients' quality of care, thereby supporting the use of virtual care during current and future epidemiological fallouts. Beyond the current pandemic, patients with stable seizure symptoms may prefer to use telemedicine for their epilepsy care.

Virtual Care for Neurological Practice

The COVID-19 crisis has worsened the pre-existing barriers to accessing neurological specialist care in Low and middle income countries. Telemedicine has been available for well over 2 decades but has not been widely adopted in LMIC's due to issues around cost, feasibility, infrastructure and regulation. Virtual care is an offshoot of traditional telemedicine leveraging the widely available internet enabled devices to connect patients with their healthcare providers. In this manuscript, we provide an overview of the virtual care, relevance to neurology and some guidance on implementing virtual care in an Indian context.

Disaster Neurology Update: Focus on the COVID-19 Pandemic

In 2013, the term disaster neurology was introduced to describe a new practice opportunity for neurologists interested in providing needed, nonsurgical neurologic care in regions affected by natural or human-influenced disasters. Although previously presented as an option for interested neurologists, the coronavirus disease 2019 (COVID-19) pandemic has made it clear that every neurologist should be prepared to take on the unique challenges of disaster neurology. Examining the role of neurologists on the frontlines of the COVID-19 pandemic response represents an opportunity to review and apply key features of disaster neurology, including recognizing the categories of neurologic cases expected to be seen during a disaster, adapting inpatient and outpatient workflows, and accommodating the needs of vulnerable populations. Relating principles of disaster neurology to the response of neurologists to the current pandemic informs best practices for neurologic care as COVID-19 cases continue to surge throughout the United States and abroad.

Management and Prevention of Cerebrovascular Accidents in SARS-CoV-2-Positive Patients Recovering from COVID-19: a Case Report and Review of Literature

We discuss the current understanding of COVID-19’s neurological implications, their basis, and the evolving clinical consensus with a focus on cerebrovascular stroke. We further illustrate the potential significance of these implications with the aid of an accompanying case report outlining the disease course and treatment of a COVID-19 patient suffering from ischemic stroke and pulmonary embolism. The ever-growing strain on the global healthcare system due to the spread of the novel coronavirus SARS-CoV-2 requires focused attention on urgent care of independent, coexisting, and associated comorbidities, including cerebrovascular accidents. For illustration purposes, we outline the case of a 68-year-old female presenting with COVID-19 subsequently complicated by bilateral pulmonary embolism and a right-sided cerebrovascular accident. The patient was successfully managed pharmacologically and discharged without significant neurological deficit. The evidence for a hypercoagulable state in this patient along with discussion of mechanistic bases, corroborative evidence from the literature, along with relevant guidance on screening, treatment, and prophylaxis is offered. Greater study of the pathogenesis of COVID-19-related cerebrovascular complications and revisiting current guidelines on their management including potentially heightened levels of thromboprophylaxis are warranted.

Patterns and Perceptions of Smartphone Use Among Academic Neurologists in the United States: Questionnaire Survey

Background

Smartphone technology is ubiquitous throughout neurologic practices, and numerous apps relevant to a neurologist’s clinical practice are now available. Data from other medical specialties suggest high utilization of smartphones in routine clinical care. However, the ways in which these devices are used by neurologists for patient care–related activities are not well defined.

Objective

This paper aims to characterize current patterns of smartphone use and perceptions of the utility of smartphones for patient care–related activities among academic neurology trainees and attending physicians. We also seek to characterize areas of need for future app development.

Methods

We developed a 31-item electronic questionnaire to address these questions and invited neurology trainees and attendings of all residency programs based in the United States to participate. We summarized descriptive statistics for respondents and specifically compared responses between trainees and attending physicians.

Results

We received 213 responses, including 112 trainee and 87 attending neurologist responses. Neurology trainees reported more frequent use of their smartphone for patient care–related activities than attending neurologists (several times per day: 84/112, 75.0% of trainees; 52/87, 59.8% of attendings; P=.03). The most frequently reported activities were internet use, calendar use, communication with other physicians, personal education, and health care–specific app use. Both groups also reported regular smartphone use for the physical examination, with trainees again reporting more frequent usage compared with attendings (more than once per week: 35/96, 36.5% of trainees; 8/58, 13.8% of attendings; P=.03). Respondents used their devices most commonly for the vision, cranial nerve, and language portions of the neurologic examination. The majority of respondents in both groups reported their smartphones as “very useful” or “essential” for the completion of patient care–related activities (81/108, 75.0% of trainees; 50/83, 60.2% of attendings; P=.12). Neurology trainees reported a greater likelihood of using their smartphones in the future than attending neurologists (“very likely”: 73/102, 71.6% of trainees; 40/82, 48.8% of attendings; P=.005). The groups differed in their frequencies of device usage for specific patient care–related activities, with trainees reporting higher usage for most activities. Despite high levels of use, only 12 of 184 (6.5%) respondents reported ever having had any training on how to use their device for clinical care. Regarding future app development, respondents rated vision, language, mental status, and cranial nerve testing as potentially being the most useful to aid in the performance of the neurologic examination.

Conclusions

Smartphones are used frequently and are subjectively perceived to be highly useful by academic neurologists. Trainees tended to use their devices more frequently than attendings. Our results suggest specific avenues for future technological development to improve smartphone use for patient care–related activities. They also suggest an unmet need for education on effectively using smartphone technology for clinical care.

Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation

BACKGROUND

Telemedicine has been used for decades. Despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. However, the COVID-19 pandemic prompted health care systems worldwide to reconsider traditional health care delivery. To safeguard health care workers and patients, many health care systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.

OBJECTIVE

To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess adoption, acceptability, appropriateness, and perceptions of potential sustainability.

METHODS

Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semistructured interviews with providers (n=30) completed between March and May 2020.

RESULTS

Video visits were adopted rapidly; overall, 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted their satisfaction. Video visits were reported to be more convenient for patients, families, and caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.

CONCLUSIONS

Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

Impact of Covid-19 on Stroke Code Activations, Process Metrics, and Diagnostic Error

Background and Purpose

In a comprehensive stroke center, we analyzed the stroke code activations (SCA), assessed the impact of Covid-19, and the measures taken by the local government to lessen the spread of the disease.

Methods

We retrospectively reviewed SCA and classified them into 2 groups: pre-pandemic activations (February 15 to March 10) and Covid-19 pandemic activations (March 11 to April 30). The primary outcome was the ratio of true positive diagnoses of stroke relative to the total number of SCA in the 2 time periods.

Results

Among the 212 SCA, 83 (39.2%) were from the pre-pandemic period, whereas 129 (60.8%) were from the pandemic period, 147 (69.3%) in the Emergency Department (ED) versus 65 (30.7%) in the inpatient service. In the ED cohort, a rapid decrease in the number of SCA at the beginning of the pandemic was followed by a gradual increase to pre-pandemic levels and a significant increase in the number of true positive strokes over time (44.2% vs 61.1%, p = 0.037). An increase in door-to-CT time (p = 0.001) and an increase in the rate of diagnostic error in patients admitted from the ED (p = 0.016) were also seen. The in-hospital cohort had a sustained decrease in the number of SCA following the pandemic declaration, with no difference in the rate of true positive stroke.

Conclusions

We observed a rapid decline and slow recovery in ED SCA with a shift toward increased true positive cases following the Covid-19 pandemic. Also, delays in obtaining CT and diagnostic error was increased, however, no difference in early clinical outcomes were seen between groups.

Comfort Always: The Importance of Providing Psychological Support to Neurology Staff, Patients, and Families During COVID-19

BACKGROUND

Although the impact of COVID-19 disruption on healthcare staff is increasingly understood, there has been no discussion of how it affects neurological patients and their families. This study sought to understand the impact of COVID-19 on staff, patients and families.

METHODS

The Department of Neuropsychology at the National Hospital for Neurology and Neurosurgery established three new support services for staff, patients and families. Semi-structured interviews elicited concerns and if these were affected by COVID-19. Staff members were asked to complete the General Health Questionnaire-12.

RESULTS

Few staff members presented for support, but nearly all indicated significant distress, reflecting increased anxiety and reduced social support. Patients described exacerbated emotional, cognitive and physical concerns, and greater vulnerability to isolation and economic hardship. Families and carers reported increased distress arising from hospital lockdown.

CONCLUSION

COVID-19 disruption affects staff, patients and families. Patients and families described additional challenges, which emphasize the importance of providing psychological support during these extraordinary times.

Serum triglyceride level and hypertension are highly associated with the recovery of COVID-19 patients

The coronavirus disease-19 (COVID-19) has been a global pandemic and caused thousands of deaths worldwide. So far, although some studies suggested some medications may be helpful, there is no effective treatment for COVID-19. It is critical to find important risk factors that affects the recovery or severity of COVID-19 and guide the treatment for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we recruited these discharged patients with COVID-19 from hospitals. We collected clinical data and analyzed the time from disease onset to the positive-to-negative transmission (TPNT) of nucleic acid tests and its related clinical variables. TPNT was considered as an important indicator for the recovery of COVID-19 patients from SARS-CoV-2 infection. COVID-19 patients were divided into short TPNT group and long TPNT group. There were significant differences on hypertension, abidol treatment, serum alanine aminotransferase (ALT), lymphocyte counts, and serum triglyceride (TG) between two groups (P<0.05). Patients in low TPNT group had higher serum triglyceride and less proportion of hypertension. Further logistic regression analysis showed that TPNT was highly associated with serum TG level and hypertension that were related to the expression of ACE2, the targeting protein for the invasion of SARS-CoV-2. Therefore, our findings demonstrate that serum triglyceride level and hypertension were important influencing factors for the recovery from SARS-CoV-2 infection. Therefore, diet changes and antihypertensive medications can be translational to the treatment of COVID-19 and promote the recovery of COVID-19 patients.

Emergent Carotid Artery Stenting Following Intravenous Alteplase Infusion After Rapid Negative Diagnosis for COVID-19 by Loop-Mediated Isothermal Amplification Assay

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, a rapid screening method for COVID-19 detection is needed to decide the appropriate strategy to treat stroke patients. In acute ischemic stroke treatment, the efficacy and safety of emergent carotid artery stenting (eCAS) for hyperacute ischemic stroke (hAIS) due to internal carotid artery stenosis (ICS) have not been sufficiently established.

CASE DESCRIPTION

A 71-year-old man with hAIS caused by severe ICS was treated via intravenous alteplase infusion. The patient underwent screening for COVID-19 by the loop-mediated isothermal amplification (LAMP) assay shortly after arrival at our institution. The LAMP result was obtained within 90 minutes, during intravenous alteplase infusion, and turned out to be negative. The symptom of hemiplegia worsened during alteplase infusion, and he, therefore, underwent eCAS after administration of aspirin (200 mg). Recanalization was achieved successfully by eCAS, and dual antiplatelet therapy and argatroban were administrated following eCAS. Hemorrhagic complications or restenosis/occlusion of the carotid artery were not observed. He was discharged without neurologic deficits 15 days following eCAS. Because of the rapid negative diagnosis for COVID-19 using the LAMP method, eCAS could be performed following standard procedures, along with infectious defense, without delay.

CONCLUSIONS

This case report suggests that eCAS for hAIS due to ICS following intravenous alteplase can be an effective treatment, along with appropriate antiplatelet medication and management in select patients. During the COVID-19 pandemic, the LAMP assay for COVID-19 detection might be a suitable diagnostic strategy preceding stroke treatment because of the rapid turnaround time.

Telemedicine for management of patients with amyotrophic lateral sclerosis through COVID-19 tail

Over the last months, due to coronavirus disease (COVID-19) pandemic, containment measures have led to important social restriction. Healthcare systems have faced a complete rearrangement of resources and spaces, with the creation of wards devoted to COVID-19 patients. In this context, patients affected by chronic neurological diseases, such as amyotrophic lateral sclerosis (ALS), are at risk to be lost at follow-up, leading to a higher risk of morbidity and mortality. Telemedicine may allow meet the needs of these patients. In this commentary, we briefly discuss the digital tools to remotely monitor and manage ALS patients. Focusing on detecting disease progression and preventing life-threatening conditions, we propose a toolset able to improve ALS management during this unprecedented situation.

Education Research: Effect of the COVID-19 pandemic on neurology trainees in Italy: A resident-driven survey

OBJECTIVE

To assess the effect of the coronavirus disease 2019 (COVID-19) outbreak on neurology resident training in Italy.

METHOD

We created a web-based survey regarding changes in clinical, research, and educational activity of neurology trainees in Italy during the COVID-19 pandemic and the preventive measures undertaken by local institutions to reduce the risk of contagion.

RESULTS

Seventy-nine residents working in Italy completed the survey. A total of 87.3% of trainees reported a substantial reduction in their neurologic duties since COVID-19 appeared in Italy, and 17.8% were also recruited or volunteered for COVID-19-dedicated wards. Likewise, more than 60% of trainees experienced a reduction or interruption in research activity. As regards the perceived effect of the COVID-19 outbreak on their neurologic training, almost 70% of surveyed trainees believe that the COVID-19 pandemic had or will have a negative effect on their formation as neurologists, for different reasons. Furthermore, trainees reported a consistent exposure (69.6%) to confirmed positive COVID-19 cases at work, with divergent surveillance and preventive measures taken by local institutions.

CONCLUSIONS

Overall, the survey shows that the COVID-19 pandemic in Italy has had a subjective negative effect on neurology residents on didactics, clinical, and research training as well as training abroad. The COVID-19 outbreak poses many challenges to academic institutions and training programs, and addressing these issues promptly is crucial to ensure continued quality of trainees' neurologic education. Sharing solutions and ideas among the international neurologic community might help neurology training programs worldwide to better counteract these problems.

Coronavirus 2019 (COVID-19)-Associated Encephalopathies and Cerebrovascular Disease: The New Orleans Experience

BACKGROUND

The coronavirus 2019 (COVID-19) pandemic has had a dramatic impact on health care systems and a variable disease course. Emerging evidence demonstrates that severe acute respiratory syndrome coronavirus 2 is associated with central nervous system disease. We describe central nervous system manifestations in critical patients with COVID-19 at our tertiary center.

METHODS

We conducted a single-center retrospective analysis of all actively critical patients with COVID-19 admitted to our tertiary care academic center in New Orleans, Louisiana, on April 22, 2020, with new onset of neurologic disease. Patients were grouped into 1 of 3 categories according to imaging and clinical features; encephalopathy, acute necrotizing encephalopathy, and vasculopathy.

RESULTS

A total of 27 of 76 (35.5%) critical patients with COVID-19 met inclusion criteria. Twenty patients (74%) were designated with COVID-19-associated encephalopathy, 2 (7%) with COVID-19-associated acute necrotizing encephalopathy, and 5 (19%) with COVID-19-associated vasculopathy. Sixty-three percent of neurologic findings were demonstrated on computed tomography, 30% on magnetic resonance imaging, and 44% on electroencephalography. Findings most often included ischemic strokes, diffuse hypoattenuation, subcortical parenchymal hemorrhages, and focal hypodensities within deep structures. Magnetic resonance imaging findings included diffuse involvement of deep white matter, the corpus callosum, and the basal ganglia. For patients with large-territory ischemic stroke, all but one displayed irregular proximal focal stenosis of the supraclinoid internal carotid artery.

CONCLUSIONS

Analysis of active critical COVID-19 admissions at our revealed a high percentage of patients with new neurologic disease. Although variable, presentations followed 1 of 3 broad categories. A better understanding of the neurologic sequalae and radiographic findings will help clinicians mitigate the impact of this disease.

[Impact of COVID-19-pandemic on Clinical Care, Work Flows and Staff at a University Hospital: Results of an Interview-study at the UKE]

OBJECTIVES

The study investigates the impact of the COVID-19 pandemic on health services with and without specific health care of COVID-19 patients through the eyes of leading physicians at the University Medical Center Hamburg-Eppendorf (UKE).

METHODS

From April 30 to May 12, 2020, four interviewers conducted 38 expert interviews via telephone, video or face-to-face by using a semi-standardized questionnaire. The standardized answers were analysed descriptively. The free text-answers were subject to a qualitative content analysis. The categories were analysed via quantitative frequency distributions.

RESULTS

All chief physicians with responsibility for inpatient and outpatient health care at the UKE took part in this study (N=38). The leading physicians reported numerous changes regarding occupancy in the hospital, patient composition, work flows and diagnostic as well as therapeutic measures. Additionally, various arrangements were necessary to cover the needs of prevention, treatment and follow-up care as well as protection of staff. Measures showed, on the one hand, a strong reduction in occupancy and workload in most inpatient and outpatient clinics. On the other hand, the amount of work also increased by fundamental transitions of work flows, communication, staff structure and hygiene measures. Many respondents commented positively on the rapid and efficient setup of a digital communication structure. Partially, staff was strained by the pandemic itself and by the associated measures.

CONCLUSION

The results of the study help to understand and assess the effects of the pandemic on health care, work flows and staff. The findings may support the specification and adaptation of prospective measures and processes for pandemic crisis situations. Future studies should investigate how staff beneath the highest executive level experienced and evaluated this crisis and consequences.

Folding a neuroscience center into streamlined COVID-19 response teams: Lessons in origami

In response to the COVID-19 pandemic epicenter in Bronx, NY, the Montefiore Neuroscience Center required rapid and drastic changes when considering the delivery of neurologic care, health and safety of staff, and continued education and safety for house staff. Health care leaders rely on principles that can be in conflict during a disaster response such as this pandemic, with equal commitments to ensure the best care for those stricken with COVID-19, provide high-quality care and advocacy for patients and families coping with neurologic disease, and advocate for the health and safety of health care teams, particularly house staff and colleagues who are most vulnerable. In our attempt to balance these principles, over 3 weeks, we reformatted our inpatient neuroscience services by reducing from 4 wards to just 1, in the following weeks delivering care to over 600 hospitalized patients with neuro-COVID and over 1,742 total neuroscience hospital bed days. This description from members of our leadership team provides an on-the-ground account of our effort to respond nimbly to a complex and evolving surge of patients with COVID in a large urban hospital network. Our efforts were based on (1) strategies to mitigate exposure and transmission, (2) protection of the health and safety of staff, (3) alleviation of logistical delays and strains in the system, and (4) facilitating coordinated communication. Each center's experience will add to knowledge of best practices, and emerging research will help us gain insights into an evidence-based approach to neurologic care during and after the COVID-19 pandemic.

Clinician's Perception of Practice Changes for Stroke During the COVID-19 Pandemic

Background

Approach to acute cerebrovascular disease management has evolved in the past few months to accommodate the rising needs of the 2019 novel coronavirus (COVID-19) pandemic. In this study, we investigated the changes in practices and policies related to stroke care through an online survey.

Methods

A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication.

Results

Respondants from 39 states completed 206 surveys with the majority (82.5%) from comprehensive stroke centers. Approximately half stated some change in transport practices with 14 (7%) reporting significant reduction in transfers. Common strategies to limit healthcare provider exposure included using personal protective equipment (PPE) for all patients (127; 63.5%) as well as limiting the number of practitioners in the room (129; 64.5%). Most respondents (81%) noted an overall decrease in stroke volume. Many (34%) felt that the outcome or care of acute stroke patients had been impacted by COVID-19. This was associated with a change in hospital transport guidelines (OR 1.325, P = 0.047, 95% CI: 1.004–1.748), change in eligibility criteria for IV-tPA or mechanical thrombectomy (MT) (OR 3.146, P = 0.052, 95% CI: 0.988–10.017), and modified admission practices for post IV-tPA or MT patients (OR 2.141, P = 0.023, 95% CI: 1.110–4.132).

Conclusion

Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.

Impact of COVID-19 on U.S. and Canadian neurologists' therapeutic approach to multiple sclerosis: a survey of knowledge, attitudes, and practices

Objective

To report the understanding and decision-making of neuroimmunologists and their treatment of patients with multiple sclerosis (MS) during the early stages of the SARS-CoV-2 (COVID-19) outbreak.

Methods

A survey instrument was designed and distributed online to neurologists in April 2020.

Results

There were 250 respondents (response rate 21.8%). 243 saw >  = 10 MS patients in the prior 6 months (average 197 patients) and were analyzed further (92% USA, 8% Canada; average practice duration 16 years; 5% rural, 17% small city, 38% large city, 40% highly urbanized). Patient volume dropped an average of 79% (53–11 per month). 23% were aware of patients self-discontinuing a DMT due to fear of COVID-19 with 43% estimated to be doing so against medical advice. 65% of respondents reported deferring >  = 1 doses of a DMT (49%), changing the dosing interval (34%), changing to home infusions (20%), switching a DMT (9%), and discontinuing DMTs altogether (8%) as a result of COVID-19. Changes in DMTs were most common with the high-efficacy therapies alemtuzumab, cladribine, ocrelizumab, rituximab, and natalizumab. 35% made no changes to DMT prescribing. 98% expressed worry about their patients contracting COVID-19 and 78% expressed the same degree of worry about themselves.  > 50% believed high-efficacy DMTs prolong viral shedding of SARS-CoV-2 and that B-cell therapies might prevent protective vaccine effects. Accelerated pace of telemedicine and practice model changes were identified as major shifts in practice.

Conclusions

Reported prescribing changes and practice disruptions due to COVID-19 may be temporary but could have a lasting influence on MS care.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10045-9) contains supplementary material, which is available to authorized users.

Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.

COVID-19, SARS and MERS: A neurological perspective

Central to COVID-19 pathophysiology is an acute respiratory infection primarily manifesting as pneumonia. Two months into the COVID-19 outbreak, however, a retrospective study in China involving more than 200 participants revealed a neurological component to COVID-19 in a subset of patients. The observed symptoms, the cause of which remains unclear, included impaired consciousness, skeletal muscle injury and acute cerebrovascular disease, and appeared more frequently in severe disease. Since then, findings from several studies have hinted at various possible neurological outcomes in COVID-19 patients. Here, we review the historical association between neurological complications and highly pathological coronaviruses including SARS-CoV, MERS-CoV and SARS-CoV-2. We draw from evidence derived from past coronavirus outbreaks, noting the similarities and differences between SARS and MERS, and the current COVID-19 pandemic. We end by briefly discussing possible mechanisms by which the coronavirus impacts on the human nervous system, as well as neurology-specific considerations that arise from the repercussions of COVID-19.

COVID-19 prevention and multiple sclerosis management: The SAFE pathway for the post-peak

BACKGROUND

We hereby report on our experience from Naples (South Italy), where the peak of coronavirus disease 2019 (COVID-19) has already passed.

METHODS

Assuming that COVID-19 will be circulating until vaccination and/or herd immunity is achieved (possibly not earlier than 2021), we have developed a protocol for the long-term management of multiple sclerosis (MS).

RESULTS

We have defined a pathway for the access to the MS Centre with logistic, preventative and clinical recommendations, and have also included 14-day self-isolation and COVID-19 testing before some disease modifying treatments.

DISCUSSION

Overall, we believe our experience could be helpful for MS management in the upcoming months.

Assessing disability and relapses in multiple sclerosis on tele-neurology

BACKGROUND

As a consequence of the coronavirus disease 2019 (COVID-19) pandemic, a large amount of consultations will be delivered through tele-medicine, especially for diseases causing chronic disability and requiring immunomodulatory treatments, such as multiple sclerosis (MS).

METHODS

We have hereby reviewed available tools for tele-neurology examination in MS, including components of neurological examination that can be assessed through video, patient-reported outcome measures (PROMs), and digital technology.

RESULTS

Overall, we have suggested a battery for assessing MS disability and relapses on tele-medicine, which brings together conventional examination, PROMs (e.g., Patient Determined Disease Steps, MS Impact Scale), and cognitive tests (Symbol Digit Modalities Test) that can be delivered remotely and in multiple languages.

DISCUSSION

The use of common tools for neurological examination could improve tele-neurology practice for both general neurologists and MS specialists, and quality of care for people with MS.

COVID-19: An Early Review of Its Global Impact and Considerations for Parkinson's Disease Patient Care

While many infectious disorders are unknown to most neurologists, COVID-19 is very different. It has impacted neurologists and other health care workers, not only in our professional lives but also through the fear and panic within our own families, colleagues, patients and their families, and even in the wider public. COVID-19 affects all sorts of individuals, but the elderly with underlying chronic conditions are particularly at risk of severe disease, or even death. Parkinson's disease (PD) shares a common profile as an age-dependent degenerative disorder, frequently associated with comorbidities, particularly cardiovascular diseases, so PD patients will almost certainly fall into the high-risk group. Therefore, the aim of this review is to explore the risk of COVID-19 in PD based on the susceptibility to severe disease, its impact on PD disease severity, potential long-term sequelae, and difficulties of PD management during this outbreak, where neurologists face various challenges on how we can maintain effective care for PD patients without exposing them, or ourselves, to the risk of infection. It is less than six months since the identification of the original COVID-19 case on New Year's Eve 2019, so it is still too early to fully understand the natural history of COVID-19 and the evidence on COVID-19-related PD is scant. Though the possibilities presented are speculative, they are theory-based, and supported by prior evidence from other neurotrophic viruses closely related to SARS-CoV-2. Neurologists should be on high alert and vigilant for potential acute and chronic complications when encountering PD patients who are suspected of having COVID-19.

Inter-generational Effects of Technology: Why Millennial Physicians May Be Less at Risk for Burnout Than Baby Boomers

PURPOSE OF REVIEW

Younger generations of physicians are using technology more fluently than previous generations. This has significant implications for healthcare as these digital natives become a majority of the population's patients, clinicians, and healthcare leaders.

RECENT FINDINGS

Historically, healthcare has been slow to adopt new technology. Many physicians have attributed burnout symptoms to technology-related causes like the EMR. This is partly due to policies and practices led by those who were less familiar and comfortable with using new technologies. Younger physicians will drive technological advancement and integration faster than previous generations, allowing technology to adapt more quickly to serve the needs of clinicians and patients. These changes will improve efficiency, allow more flexible working arrangements, and increase convenience for patients and physicians. The next generation of physicians will use technology to support their work and lifestyle preferences, making them more resilient to burnout than previous generations.