Altered mental status in COVID-19.

BACKGROUND: Altered mental status (AMS) is a common neurological manifestation of COVID-19 infection in hospitalized patients. The principal causes of AMS have yet to be determined. We aimed to identify the common causes of AMS in patients with COVID-19 presenting to the emergency department with AMS on arrival. METHODS: We conducted a retrospective observational study of patients presenting with AMS to three New York hospitals, from March 1 to April 16, 2020. Underlying causes of AMS on arrival to the emergency department (ED) were categorized as (1) neurological causes (stroke, seizure, encephalitis); (2) metabolic encephalopathy; (3) indeterminant. Multivariable analysis was used to assess independent predictors. RESULTS: Overall, 166 patients presented to the ED with AMS. Metabolic encephalopathy was diagnosed as the cause in 154 (92.8%), with 118 (71.1%) categorized as multifactorial ME and 36 (21.7%) with single-cause ME. Hypoxia 103 (62.0%) and renal failure 75 (45.2%) were the most common underlying mechanisms. Neurological causes of AMS occurred in a total 20 patients (12%) and as the sole factor in 5 (3.0%); 10 (6.0%) cases were seizure related and 10 (6.0%) were cerebrovascular events. Of the 7 patients with indeterminant causes, only 1 was suspicious for encephalitis (0.6%). Age, pre-existing dementia and cerebrovascular disease, and impaired renal function were independent predictors of AMS. CONCLUSION: In patients with COVID-19, AMS on presentation to the ED is most frequently caused by metabolic encephalopathy (delirium). Seizures and cerebrovascular events contribute to a lesser degree; encephalitis appears rare.

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.

A dedicated scholarly research program in an adult and pediatric neurology residency program.

OBJECTIVE: To describe and assess the effectiveness of a formal scholarly activity program for a highly integrated adult and pediatric neurology residency program. METHODS: Starting in 2011, all graduating residents were required to complete at least one form of scholarly activity broadly defined to include peer-reviewed publications or presentations at scientific meetings of formally mentored projects. The scholarly activity program was administered by the associate residency training director and included an expanded journal club, guided mentorship, a required grand rounds platform presentation, and annual awards for the most scholarly and seminal research findings. We compared scholarly output and mentorship for residents graduating within a 5-year period following program initiation (2011-2015) and during the preceding 5-year preprogram baseline period (2005-2009). RESULTS: Participation in scholarship increased from the preprogram baseline (24 of 53 graduating residents, 45.3%) to the postprogram period (47 of 57 graduating residents, 82.1%, p < 0.0001). Total scholarly output more than doubled from 49 activities preprogram (0.92/resident) to 139 postprogram (2.44/resident, p = 0.0002). The proportions of resident participation increased for case reports (20.8% vs 66.7%, p < 0.0001) and clinical research (17.0% vs 38.6%, p = 0.012), but were similar for laboratory research and topical reviews. The mean activities per resident increased for published abstracts (0.15 ± 0.41 to 1.26 ± 1.41, p < 0.0001), manuscripts (0.75 ± 1.37 to 1.00 ± 1.40, p = 0.36), and book chapters (0.02 ± 0.14 to 0.18 ± 0.60, p = 0.07). Rates of resident participation as first authors increased from 30.2% to 71.9% (p < 0.0001). The number of individual faculty mentors increased from 36 (preprogram) to 44 (postprogram). CONCLUSIONS: Our multifaceted program, designed to enhance resident and faculty engagement in scholarship, was associated with increased academic output and an expanded mentorship pool. The program was particularly effective at encouraging presentations at scientific meetings. Longitudinal analysis will determine whether such a program portfolio inspires an increase in academic careers involving neuroscience-oriented research.

Periodic Epileptiform Discharges Clarified for the Nonneurologist Intensivist: Clinical Implications and Current Management.

Periodic epileptiform discharges (PEDs) are frequently encountered during continuous electroencephalography monitoring in the intensive care unit. Their implications and management are variable and highly dependent on the clinical context. This article is intended for the nonneurologist intensivist, reviews basic terminology and clinical implications (including causes, prognosis, and association with seizures), and suggests an approach to management. Several case vignettes are included to illustrate the clinical variability associated with PEDs.

Olanzapine-associated myoclonus.

Olanzapine is an atypical antipsychotic drug that infrequently has been reported to cause seizures and myoclonus despite a small proconvulsant risk. This is the first report of generalized myoclonus induced in a patient who had been maintained on low dose olanzapine for over seven years without any change in her dose. Olanzapine was discontinued, and the myoclonic jerks completely resolved within 48 h.