Increased iron in the substantia nigra pars compacta identifies patients with early Parkinson'sdisease: A 3T and 7T MRI study.

Degeneration in the substantia nigra (SN) pars compacta (SNc) underlies motor symptoms in Parkinson's disease (PD). Currently, there are no neuroimaging biomarkers that are sufficiently sensitive, specific, reproducible, and accessible for routine diagnosis or staging of PD. Although iron is essential for cellular processes, it also mediates neurodegeneration. MRI can localize and quantify brain iron using magnetic susceptibility, which could potentially provide biomarkers of PD. We measured iron in the SNc, SN pars reticulata (SNr), total SN, and ventral tegmental area (VTA), using quantitative susceptibility mapping (QSM) and R2* relaxometry, in PD patients and age-matched healthy controls (HCs). PD patients, diagnosed within five years of participation and HCs were scanned at 3T (22 PD and 23 HCs) and 7T (17 PD and 21 HCs) MRI. Midbrain nuclei were segmented using a probabilistic subcortical atlas. QSM and R2* values were measured in midbrain subregions. For each measure, groups were contrasted, with Age and Sex as covariates, and receiver operating characteristic (ROC) curve analyses were performed with repeated k-fold cross-validation to test the potential of our measures to classify PD patients and HCs. Statistical differences of area under the curves (AUCs) were compared using the Hanley-MacNeil method (QSM versus R2*; 3T versus 7T MRI). PD patients had higher QSM values in the SNc at both 3T (padj = 0.001) and 7T (padj = 0.01), but not in SNr, total SN, or VTA, at either field strength. No significant group differences were revealed using R2* in any midbrain region at 3T, though increased R2* values in SNc at 7T MRI were marginally significant in PDs compared to HCs (padj = 0.052). ROC curve analyses showed that SNc iron measured with QSM, distinguished early PD patients from HCs at the single-subject level with good diagnostic accuracy, using 3T (mean AUC = 0.83, 95 % CI = 0.82-0.84) and 7T (mean AUC = 0.80, 95 % CI = 0.79-0.81) MRI. Mean AUCs reported here are from averages of tests in the hold-out fold of cross-validated samples. The Hanley-MacNeil method demonstrated that QSM outperforms R2* in discriminating PD patients from HCs at 3T, but not 7T. There were no significant differences between 3T and 7T in diagnostic accuracy of QSM values in SNc. This study highlights the importance of segmenting midbrain subregions, performed here using a standardized atlas, and demonstrates high accuracy of SNc iron measured with QSM at 3T MRI in identifying early PD patients. QSM measures of SNc show potential for inclusion in neuroimaging diagnostic biomarkers of early PD. An MRI diagnostic biomarker of PD would represent a significant clinical advance.

Subregional analysis of striatum iron in Parkinson's disease and rapid eye movement sleep behaviour disorder.

The loss of dopamine in the striatum underlies motor symptoms of Parkinson's disease (PD). Rapid eye movement sleep behaviour disorder (RBD) is considered prodromal PD and has shown similar neural changes in the striatum. Alterations in brain iron suggest neurodegeneration; however, the literature on striatal iron has been inconsistent in PD and scant in RBD. Toward clarifying pathophysiological changes in PD and RBD, and uncovering possible biomarkers, we imaged 26 early-stage PD patients, 16 RBD patients, and 39 age-matched healthy controls with 3 T MRI. We compared mean susceptibility using quantitative susceptibility mapping (QSM) in the standard striatum (caudate, putamen, and nucleus accumbens) and tractography-parcellated striatum. Diffusion MRI permitted parcellation of the striatum into seven subregions based on the cortical areas of maximal connectivity from the Tziortzi atlas. No significant differences in mean susceptibility were found in the standard striatum anatomy. For the parcellated striatum, the caudal motor subregion, the most affected region in PD, showed lower iron levels compared to healthy controls. Receiver operating characteristic curves using mean susceptibility in the caudal motor striatum showed a good diagnostic accuracy of 0.80 when classifying early-stage PD from healthy controls. This study highlights that tractography-based parcellation of the striatum could enhance sensitivity to changes in iron levels, which have not been consistent in the PD literature. The decreased caudal motor striatum iron was sufficiently sensitive to PD, but not RBD. QSM in the striatum could contribute to development of a multivariate or multimodal biomarker of early-stage PD, but further work in larger datasets is needed to confirm its utility in prodromal groups.

Association between limbic system lesions and anxiety in persons with multiple sclerosis.

BACKGROUND: Persons with Multiple Sclerosis (PwMS) have a higher rate of anxiety and depression than the general population. Depression has been associated with clinical relapses; temporal lesions were shown to predict depression severity. Anxiety is considerably understudied. The role of MS lesions in the limbic system is also understudied, partly due to difficulties identifying limbic lesions on standard 1.5 and 3 Tesla MRI. METHODS: This is a retrospective study of 23 PwMS who underwent 7T MRI on the same day as completing the Hospital Anxiety and Depression Scale (HADS). MRI was performed on a Siemens 7T MRI Plus and an 8-channel transmit coil with 32 receiver channels operating in pTx mode. MP2RAGE and DIR-SPACE sequences were analyzed to determine the number of lesions within the limbic system. RESULTS: The median number of lesions in the limbic system was 2.0 (range 0-7). When comparing the presence or absence of lesions in the limbic system, there was a significant relationship with anxiety (X2 (1, N = 23)=4.44, p = 0.035), but not for depression. CONCLUSION: Although only a small sample size, this study provides preliminary evidence that lesions in the limbic system are associated with the presence of anxiety in PwMS. This relationship warrants further investigation.

4E-BP1 expression in embryonic postmitotic neurons mitigates mTORC1-induced cortical malformations and behavioral seizure severity but does not prevent epilepsy in mice.

Hyperactivation of the mechanistic target of rapamycin complex 1 (mTORC1) pathway during neurodevelopment leads to focal cortical malformations associated with intractable seizures. Recent evidence suggests that dysregulated cap-dependent translation downstream of mTORC1 contributes to cytoarchitectural abnormalities and seizure activity. Here, we examined whether reducing cap-dependent translation by expressing a constitutively active form of the translational repressor, 4E-BP1, downstream of mTORC1 would prevent the development of cortical malformations and seizures. 4E-BP1CA was expressed embryonically either in radial glia (neural progenitor cells) that generate cortical layer 2/3 pyramidal neurons or in migrating neurons destined to layer 2/3 using a conditional expression system. In both conditions, 4E-BP1CA expression reduced mTORC1-induced neuronal hypertrophy and alleviated cortical mislamination, but a subset of ectopic neurons persisted in the deep layers and the white matter. Despite the above improvements, 4E-BP1CA expression in radial glia had no effects on seizure frequency and further exacerbated behavioral seizure severity associated with mTORC1 hyperactivation. In contrast, conditional 4E-BP1CA expression in migratory neurons mitigated the severity of behavioral seizures but the seizure frequency remained unchanged. These findings advise against targeting 4E-BPs by 4E-BP1CA expression during embryonic development for seizure prevention and suggest the presence of a development-dependent role for 4E-BPs in mTORC1-induced epilepsy.

TURBOMOLE: Today and Tomorrow.

TURBOMOLE is a highly optimized software suite for large-scale quantum-chemical and materials science simulations of molecules, clusters, extended systems, and periodic solids. TURBOMOLE uses Gaussian basis sets and has been designed with robust and fast quantum-chemical applications in mind, ranging from homogeneous and heterogeneous catalysis to inorganic and organic chemistry and various types of spectroscopy, light-matter interactions, and biochemistry. This Perspective briefly surveys TURBOMOLE's functionality and highlights recent developments that have taken place between 2020 and 2023, comprising new electronic structure methods for molecules and solids, previously unavailable molecular properties, embedding, and molecular dynamics approaches. Select features under development are reviewed to illustrate the continuous growth of the program suite, including nuclear electronic orbital methods, Hartree-Fock-based adiabatic connection models, simplified time-dependent density functional theory, relativistic effects and magnetic properties, and multiscale modeling of optical properties.

Outcomes of pregnant women exposed to Sotrovimab for the treatment of COVID-19 in the BA.1 Omicron predominant era (PRESTO).

BACKGROUND: Sotrovimab, a monoclonal antibody with efficacy against SARS-CoV-2 including certain Omicron variants, has been used in treatment of mild-moderate COVID-19. Limited data exists regarding its use in pregnant women. METHODS: Electronic medical record review of pregnant COVID-19 patients treated with sotrovimab from 12/30/21 - 1/31/22 (Yale New Haven Health Hospital System [YNHHS]) was performed. Included were pregnant individuals ≥ 12 years, weighing ≥ 40 kg, with positive SARS-CoV-2 test (within 10 days). Those receiving care outside YNHHS or receiving other SARS-CoV-2 treatment were excluded. We assessed demographics, medical history, and Monoclonal Antibody Screening Score (MASS). The primary composite clinical outcome assessed included emergency department (ED) visit < 24 h, hospitalization, intensive care unit (ICU) admission, and/or death within 29 days of sotrovimab. Secondarily, adverse feto-maternal outcomes and events for neonates were assessed at birth or through the end of the study period, which was 8/15/22. RESULTS: Among 22 subjects, median age was 32 years and body mass index was 27 kg/m2. 63% were Caucasian, 9% Hispanic, 14% African-American, and 9% Asian. 9% had diabetes and sickle cell disease. 5% had well-controlled HIV. 18%, 46%, and 36% received sotrovimab in trimester 1, 2, and 3, respectively. No infusion/allergic reactions occurred. MASS values were < 4. Only 12/22 (55%) received complete primary vaccination (46% mRNA-1273; 46% BNT162b2; 8% JNJ-78,436,735); none received a booster. CONCLUSIONS: Pregnant COVID-19 patients receiving sotrovimab at our center tolerated it well with good clinical outcomes. Pregnancy and neonatal complications did not appear sotrovimab-related. Though a limited sample, our data helps elucidate the safety and tolerability of sotrovimab in pregnant women.

HIV risk profile and prevention needs of individuals seeking monkeypox (mpox) vaccination in an urban clinic in the U.S.: a brief report.

BACKGROUND: Our study survey assessed HIV risk profile and pre-exposure prophylaxis (PrEP) use among HIV-negative individuals seeking mpox vaccination, elucidating HIV prevention gaps and opportunities. METHODS: Anonymous cross-sectional surveys were self-administered at an urban academic center clinic in New Haven, CT, U.S. (August 18-November 18, 2022). Inclusion criteria included adults presenting for mpox vaccination who consented to the study. The study assessed STI risk (sexual practices, STI history, substance use). For HIV-negative participants, PrEP knowledge, attitudes, and preferences were assessed. RESULTS: Eighty-one of 210 individuals approached completed surveys (survey acceptance and completion rate 38.6%). Majority were cisgender-male (76/81; 93.8%), Caucasian (48/79; 60.8%), with median age 28 years (IQR-15). Nine of 81 (11.5%) self-reported HIV-positivity. Median sexual partner number (6 months prior) was 4 (IQR-5.8). Majority, 89.9% and 75.9%, reported insertive and receptive anal intercourse, respectively. 41% reported lifetime STI history, of whom 12.3% had an STI 6 months prior. Majority (55.8%) used ≥ 1 illicit substance; 87.7% moderate alcohol use. Among HIV-negative respondents, most (95.7%) were aware of PrEP, but only 48.4% used PrEP. CONCLUSION: Individuals seeking mpox vaccination engage in behaviors placing them at increased STI risk and would benefit from PrEP assessment.

Meningo-cortical manifestations of myelin oligodendrocyte glycoprotein antibody-associated disease: Review of a novel clinico-radiographic spectrum.

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an inflammatory demyelinating disease that is distinct from multiple sclerosis. Initial manifestations of MOGAD that were reported in the literature included optic neuritis, myelitis, brainstem demyelination and encephalitis, with emphasis placed on acute disseminated encephalomyelitis (ADEM) as the primary encephalitic presentation. In 2017, however, Ogawa et al. described four patients with seizures, unilateral cortical hyperintensities on brain magnetic resonance imaging T2-fluid-attenuated inversion recovery sequences, and anti-MOG positivity, indicating a potentially novel form of encephalitis in MOGAD. In 2019, we systematically reviewed the literature to better characterize this unique syndrome, which we referred to as unilateral cortical FLAIR-hyperintense Lesions in Anti-MOG-associated Encephalitis with Seizures (FLAMES). Subsequently, anti-MOG positivity in patients with a variety of cortical and meningeal disease presentations has been reported, indicating a broader spectrum of meningo-cortical manifestations in MOGAD that we review herein.

Deep learning prediction of stroke thrombus red blood cell content from multiparametric MRI.

BACKGROUND AND PURPOSE: Thrombus red blood cell (RBC) content has been shown to be a significant factor influencing the efficacy of acute ischemic stroke treatment. In this study, our objective was to evaluate the ability of convolutional neural networks (CNNs) to predict ischemic stroke thrombus RBC content using multiparametric MR images. MATERIALS AND METHODS: Retrieved stroke thrombi were scanned ex vivo using a three-dimensional multi-echo gradient echo sequence and histologically analyzed. 188 thrombus R2*, quantitative susceptibility mapping and late-echo GRE magnitude image slices were used to train and test a 3-layer CNN through cross-validation. Data augmentation techniques involving input equalization and random image transformation were employed to improve network performance. The network was assessed for its ability to quantitatively predict RBC content and to classify thrombi into RBC-rich and RBC-poor groups. RESULTS: The CNN predicted thrombus RBC content with an accuracy of 62% (95% CI 48-76%) when trained on the original dataset and improved to 72% (95% CI 60-84%) on the augmented dataset. The network classified thrombi as RBC-rich or poor with an accuracy of 71% (95% CI 58-84%) and an area under the curve of 0.72 (95% CI 0.57-0.87) when trained on the original dataset and improved to 80% (95% CI 69-91%) and 0.84 (95% CI 0.73-0.95), respectively, on the augmented dataset. CONCLUSIONS: The CNN was able to accurately predict thrombus RBC content using multiparametric MR images, and could provide a means to guide treatment strategy in acute ischemic stroke.

Seizures in anti-Hu-associated extra-limbic encephalitis: Characterization of a unique disease manifestation.

Anti-Hu-associated neurologic autoimmunity most often occurs in the context of small cell lung cancer and typically presents with peripheral neuropathy, cerebellar ataxia, and/or limbic encephalitis. Extra-limbic encephalitis causing seizures is a rare disease manifestation, with only sparse reports in the literature. Herein we present a patient with seizures in anti-Hu-associated extra-limbic encephalitis, and review the literature for other cases to more fully characterize this entity. Among 27 patients we identified, the median age was 46 years (range: 2-69 years) and 18 of 27 (67%) were female. Focal motor seizures were most common, followed by ictal expressive speech difficulty. Seizure semiologies along with neuroimaging findings most frequently suggested the involvement of the peri-Rolandic cortex, more anterior frontal operculum, and insula, although other cortical regions were rarely affected as well. In contrast to other classical paraneoplastic neurologic syndromes, good response to treatment with attainment of seizure-free survival was often reported, although over one-third still died. A propensity for chronic seizures among children indicated the potential to develop autoimmune-associated epilepsy. The predilection for certain extra-limbic regions, as well as the possibility of good response to treatment, may reflect unique disease mechanisms that would benefit from further study.

Efficient Implementation of Density Functional Theory Based Embedding for Molecular and Periodic Systems Using Gaussian Basis Functions.

A practical and effective implementation of density functional theory based embedding is reported, which allows us to treat both periodic and aperiodic systems on an equal footing. Its essence is the expansion of orbitals and electron density of the periodic system using Gaussian basis functions, rather than plane-waves, which provides a unique all-electron direct-space representation, thus avoiding the need for pseudopotentials. This makes the construction of embedding potential for a molecular active subsystem due to a periodic environment quite convenient, as transformation between representations is far from trivial. The three flavors of embedding, molecule-in-molecule, molecule-in-periodic, and periodic-in-periodic embedding, are implemented using embedding potentials based on non-additive kinetic energy density functionals (approximate) and level-shift projection operator (exact). The embedding scheme is coupled with a variety of correlated wave function theory (WFT) methods, thereby providing an efficient way to study the ground and excited state properties of low-dimensional systems using high-level methods for the region of interest. Finally, an implementation of real time-time-dependent density functional embedding theory (RT-TDDFET) is presented that uses a projection operator-based embedding potential and provides accurate results compared to full RT-TDDFT for systems with uncoupled excitations. The embedding potential is calculated efficiently using a combination of density fitting and continuous fast multipole method for the Coulomb term. The applicability of (i) WFT-in-DFT embedding, in predicting the adsorption and excitation energies, and (ii) RT-TDDFET, in predicting the absorption spectra, is explored for various test systems.

Ruptured intracranial infectious aneurysms: Single Canadian center experience.

Background: Ruptured intracranial infected aneurysms (IIAs) are relatively rare, but they portend high mortality. To the best of our knowledge, there is no Canadian case series on IIA, as well there is a relative paucity of international published experiences. Our purpose is to share the experience of a single Canadian tertiary center in managing ruptured IIA and to conduct a systematic review. Methods: We did a retrospective case review series of adult patients with ruptured IIA treated at our institution. Second, we conducted a systematic review of the literature on ruptured IIA between 2011 and 2021 inclusive. Results: At our institution, of a total eight cases with ruptured IIA, four were treated endovascularly and two by surgical bypass. For the systematic review, we included nine noncomparative studies with a total of 509 patients (318 males) and at least 437 ruptured IIA aneurysms. Favorable outcome was specified for 63.3% of patients (n = 57). Regarding ruptured IIA, favorable clinical outcome was described in 59.3% (n = 16). Conclusion: This study highlights a single Canadian tertiary center experience in the management of IIA and compares it to the global trends of the past 10 years in a systematic review.

Can We Identify Predictors of Success in Contouring Education for Radiation Oncology Trainees? An Analysis of the Anatomy and Radiology Contouring Bootcamp.

PURPOSE: Although several different contouring instructional programs are available to radiation oncologists and trainees, very little is known about which methods and resources benefit learners most, and whether some learners may need alternate forms of instruction. This study aimed to determine the factors that were predictors of learners' success in anatomy, radiology, and contouring education. METHODS AND MATERIALS: Participants in the online and face-to-face Anatomy and Radiology Contouring (ARC) Bootcamp completed pre- and postintervention evaluations that assessed anatomy/radiology knowledge, contouring skills, self-confidence, and spatial ability. Baseline factors were assessed as predictors of outcomes across multiple educational domains. RESULTS: One hundred and eighty (face-to-face: n = 40; online: n = 140) participants enrolled in the ARC Bootcamp, and 57 (face-to-face: n = 30; online: n = 27) participants completed both evaluations. Of the participants enrolled, 37% were female, and most were radiation oncology residents (62%). In the anatomy/radiology knowledge testing, all quartiles (based on baseline performance) improved numerically; however, the largest improvements occurred in learners with the lowest baseline scores (P < .001). At the end of the Bootcamp, learners with lower-performing scores did not reach the level of learners with the highest baseline scores (Bonferroni-corrected P < .001). Regarding the contouring assessment, improvements were only evident for the participants with lower-performing baseline scores (P < .05). Spatial anatomy skills, as measured by the spatial anatomy task, were correlated to contouring ability. Overall, the greatest improvements were seen for learners in postgraduate year 1 to 3, those with no previous rotation experience in a given discipline, and those who attended from other programs (ie, medical physics residents and medical students). CONCLUSIONS: The ARC Bootcamp improved all levels of performers' anatomy and radiology knowledge but only lower-performers' contouring ability. The course alone does not help lower-performing learners reach the abilities of higher-performers. The ARC Bootcamp tends to be most beneficial for participants with less radiation oncology experience. Curriculum modifications can be made to help support ARC Bootcamp participants with lower performing scores.

Fecal microbiota transplantation is safe and tolerable in patients with multiple sclerosis: A pilot randomized controlled trial.

Background: Patients with MS have an altered gut microbiota compared to healthy individuals, as well as elevated small intestinal permeability, which may be contributing to the development and progression of the disease. Objective: We sought to investigate if fecal microbiota transplantation was safe and tolerable in MS patients and if it could improve abnormal intestinal permeability. Methods: Nine patients with MS were recruited and provided monthly FMTs for up to six months. The primary outcome investigated was change in peripheral blood cytokine concentrations. The secondary outcomes were gut microbiota composition, intestinal permeability, and safety (assessed with EDSS and MRI). Results: The study was terminated early and was subsequently underpowered to assess whether peripheral blood cytokines were altered following FMTs. FMTs were safe in this group of patients. Two of five patients had elevated small intestinal permeability at baseline that improved to normal values following FMTs. Significant, donor-specific, beneficial alterations to the MS patient gut microbiota were observed following FMT. Conclusion: FMT was safe and tolerable in this cohort of RRMS patients, may improve elevated small intestinal permeability, and has the potential to enrich for an MS-protective microbiota. Further studies with longer follow-up and larger sample sizes are required to determine if FMT is a suitable therapy for MS.

Experiences and challenges in accessing hospitalization in a government-funded health insurance scheme: Evidence from early implementation of Pradhan Mantri Jan Aarogya Yojana (PM-JAY) in India.

INTRODUCTION: Government-sponsored health insurance schemes can play an important role in improving the reach of healthcare services. Launched in 2018 in India, Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest government-sponsored health insurance schemes. The objective of this study is to understand beneficiaries' experience of availing healthcare services at the empaneled hospitals in PM-JAY. This study examines the responsiveness of PM-JAY by measuring the prompt attention in service delivery, and access to information by the beneficiaries; financial burden experienced by the beneficiaries; and beneficiary's satisfaction with the experience of hospitalization under PMJAY and its determinants. METHODS: The study was conducted during March-August 2019. Data were obtained through a survey conducted with 200 PM-JAY beneficiaries (or their caregivers) in the Indian states of Gujarat and Madhya Pradesh. The study population comprised of patients who received healthcare services at 14 study hospitals in April 2019. Prompt attention was measured in the form of a) effectiveness of helpdesk, and b) time taken at different stages of hospitalization and discharge events. Access to information by the beneficiaries was measured using the frequency and purpose of text messages and phone calls from the scheme authorities to the beneficiaries. The financial burden was measured in terms of the incidence and magnitude of out-of-pocket payments made by the beneficiaries separate from the cashless payment provided to hospitals by PMJAY. Beneficiaries' satisfaction was measured on a five-point Likert scale. RESULTS: Socio-economically weaker sections of the society are availing healthcare services under PM-JAY. In Gujarat, the majority of the beneficiaries were made aware of the scheme by the government official channels. In Madhya Pradesh, the majority of the beneficiaries got to know about the scheme from informal sources. For most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, hospitals in Gujarat performed significantly better than the hospitals in Madhya Pradesh. Similarly, for most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, public hospitals performed significantly better than private hospitals. Incidence and magnitude of out-of-pocket payments were significantly higher in Madhya Pradesh as compared to Gujarat, and in private hospitals as compared to the public hospitals. CONCLUSION: There is a need to focus on Information, Education, and Communication (IEC) activities for PM-JAY, especially in Madhya Pradesh. Capacity-building efforts need to be prioritized for private hospitals as compared to public hospitals, and for Madhya Pradesh as compared to Gujarat. There is a need to focus on enhancing the responsiveness of the scheme, and timely exchange of information with beneficiaries. There is also an urgent need for measures aimed at reducing the out-of-pocket payments made by the beneficiaries.

Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India.

BACKGROUND: Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India's Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme's operation. METHODS: Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019. RESULTS: Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background. CONCLUSIONS: There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme's IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

A Protocol for Carotid Artery Stenting in COVID Times. A Single Canadian Centre Experience.

OBJECTIVES: The COVID-19 pandemic has resulted in huge disruption to healthcare delivery worldwide. There is a need to balance the urgent needs of the neurovascular patient population with the desire to preserve critical inpatient hospital capacity. It is incumbent on neurointerventionalists to advocate for their patients to minimise future disability. Patients still require semiurgent carotid revascularisation after ischaemic embolic events. We present a review of a novel protocol for expediting patient flow through the carotid stenting process, in accordance with government directives to minimise nonessential inpatient admissions, ensure its efficacy, and evaluate its safety. We also evaluate the literature regarding complications with attention to the timing of these related to the procedure. METHODS: A retrospective review of 45 consecutive carotid stenting cases performed at London Health Sciences Centre between March 2020 and March 2021 for symptomatic extracranial internal carotid artery stenosis utilising a default same-day discharge policy was performed. Complications were plotted as a function of time. RESULTS: Twenty-four patients underwent carotid artery stenting with same-day discharge and 21 patients underwent stenting with an overnight inpatient stay. A single stent occlusion occurred 27 h post stenting. CONCLUSION: Simple modification of protocol for symptomatic carotid artery stenting during the COVID-19 outbreak with radial access as first approach appears to provide safe, efficacious care.