Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home.

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study.

BACKGROUND: A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. METHODS: This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. RESULTS: Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02). CONCLUSIONS: In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

Provider Experience with Teleneurology in an Academic Neurology Department.

Introduction: Teleneurology has become widely adopted during severe acute respiratory syndrome coronavirus 2 pandemic. However, provider impressions about the teleneurology experience are not well described. Methods: A novel questionnaire was developed to collect provider impressions about video teleneurology encounters. All providers in the University of Pennsylvania Health System (UPHS) Neurology Department (N = 162) were asked to complete a questionnaire after each video teleneurology patient encounter between April and August 2020. Individual patient and encounter-level data were extracted from the electronic medical record. Results: One thousand six hundred three surveys were completed by 55 providers (response rate of 10.12%). The history obtained and the ability to connect with the patient were considered the same or better than an in-person visit in almost all encounters. The quality of the physician-patient relationship was good or excellent in 93%, while the overall experience was the same as an in-person visit in 73% of visits and better in 12%. Sixty-eight percent of respondents reported that none of the elements of the neurological examination if performed in person would have changed the assessment and plan. Assessment of the visit as the same or better increased from 83% in April to 89% in July and 95% in August. Headache (91%), multiple sclerosis and neuroimmunology (96%), and movement disorder (89%) providers had the highest proportion of ratings of same or better overall experience and neuromuscular providers the lowest (60%). Conclusions: Provider impressions about the teleneurology history, examination, and provider-patient relationship are favorable in the majority of responses. Important differences emerge between provider specialty and visit characteristics groups.

A Department Approach to Teleneurology.

The coronavirus disease-19 (COVID-19) pandemic has compelled health care practices and academic departments to evaluate the suitability of telemedicine for various specialties and attempt rapid implementation to enable continuation of health care that is safe for providers and patients. Many patients with neurological disorders are well suited to evaluations through video. The department of neurology at the University of Pennsylvania (Penn Neurology), with the support of the health system, rapidly expanded telemedicine services to meet the needs of our patient population. This accomplishment required the complex coordination of multiple disciplines and roles within the department and the health care system, including faculty, residents, administrative staff, research and technical staff, information services, and the connected health team. Procedures for provider and patient education were established. Surveys of the provider and patient experience were developed and deployed. The process has demonstrated the vital role telemedicine in neurology (teleneurology) should play in the care of neurological patients beyond the pandemic. We describe our experience as a template for other departments and practices seeking to establish teleneurology programs, as well as an illustration of the challenges and barriers to its implementation.

Acute Cerebrovascular Events in Hospitalized COVID-19 Patients.

BACKGROUND AND PURPOSE: Initial reports suggest a significant risk of thrombotic events, including stroke, in patients hospitalized with coronavirus disease 2019 (COVID-19). However, there is little systematic data on stroke incidence and mechanisms, particularly in racially diverse populations in the United States. METHODS: We performed a retrospective, observational study of stroke incidence and mechanisms in all patients with COVID-19 hospitalized from March 15 to May 3, 2020, at 3 Philadelphia hospitals. RESULTS: We identified 844 hospitalized patients with COVID-19 (mean age 59 years, 52% female, 68% Black); 20 (2.4%) had confirmed ischemic stroke; and 8 (0.9%) had intracranial hemorrhage. Of the ischemic stroke patients, mean age was 64 years, with only one patient (5%) under age 50, and 80% were Black. Conventional vascular risk factors were common, with 95% of patients having a history of hypertension and 60% a history of diabetes mellitus. Median time from onset of COVID symptoms to stroke diagnosis was 21 days. Stroke mechanism was cardioembolism in 40%, small vessel disease in 5%, other determined mechanism in 20%, and cryptogenic in 35%. Of the 11 patients with complete vascular imaging, 3 (27%) had large vessel occlusion. Newly positive antiphospholipid antibodies were present in >75% of tested patients. Of the patients with intracranial hemorrhage, 5/8 (63%) were lobar intraparenchymal hemorrhages, and 3/8 (38%) were subarachnoid hemorrhage; 4/8 (50%) were on extracorporeal membrane oxygenation. CONCLUSIONS: We found a low risk of acute cerebrovascular events in patients hospitalized with COVID-19. Most patients with ischemic stroke had conventional vascular risk factors, and traditional stroke mechanisms were common.

D-dimer and Body CT to Identify Occult Malignancy in Acute Ischemic Stroke.

BACKGROUND AND AIM: Patients with acute ischemic stroke associated with cancer have D-dimer elevations greater than those with acute ischemic stroke or cancer alone. While D-dimer has been proposed as a screening tool to identify such patients, its use in clinical practice to identify malignancy and to inform the use of CT scanning has not been well characterized. METHODS: We conducted a retrospective cohort study of patients with acute ischemic stroke to evaluate how D-dimer levels and CT chest, abdomen, and pelvis scanning were used in practice to screen for occult malignancy. Patients were excluded if they had known active cancer and or received tPA. RESULTS: Of 480 patients, 254 (53%) had D-dimer measured, 49 (10%) underwent CT screening for cancer, and 11 (2%) had findings concerning for malignancy. There was no difference in D-dimer level between patients who underwent CT evaluation for cancer and those who did not (median 1.01 vs 0.85 p = 0.19). Patients with CT concerning for cancer had higher D-dimer levels than those with a negative CT (median 2.52 vs 0.74 p = 0.01). D-dimer demonstrated moderate discrimination with a c-statistic of 0.77. Selecting a cut point of >1.2 ug/mL (60th percentile of our cohort and 2.4-times the upper limit of normal for our institution's D-dimer assay) provided a sensitivity of 85% and specificity of 65%, a positive likelihood ratio of 2.32, and an odds ratio of 9.6 (95% confidence interval 2.1-44.1, p = 0.004) for having a CT scan concerning for malignancy. CONCLUSIONS: Elevated D-dimer levels are suggestive of occult malignancy in acute ischemic stroke patients and should inform selective use of CT to screen for cancer.

Prevalence of Nonstenotic Carotid Plaque in Stroke Due to Atrial Fibrillation Compared to Embolic Stroke of Undetermined Source.

BACKGROUND: Embolic stroke of undetermined source (ESUS) accounts for about 20% of strokes. Nonstenotic cervical arterial plaque may be a mechanism of stroke in a subset of these patients. METHODS: A cohort of consecutive patients with ischemic stroke was retrospectively identified from a stroke registry. Patients with unilateral anterior circulation embolic stroke due to atrial fibrillation (AF) or consistent with ESUS who underwent computed tomographic neck angiography were included. The prespecified primary outcome was a comparison of the prevalence of carotid plaque greater than or equal to 3 mm thickness ipsilateral versus contralateral to the infarct side. RESULTS: Of 772 screened patients, 96 patients with ESUS and 99 patients with AF were included. Plaque greater than or equal to 3 mm was more frequently ipsilateral than contralateral to the infarct in patients with ESUS (41% versus 29%, P = .03), and plaque thickness was greater ipsilateral compared to contralateral (median 2.5 versus 2.2 mm, P = .02). No significant differences in plaque characteristics ipsilateral compared to contralateral were found in patients with AF. The prevalence of ipsilateral versus contralateral plaque was greater in ESUS patients less than or equal to 65 years old (48% versus 19%, P < .01), but no different in patients greater than 65 years old (35% versus 39%, P = .57). CONCLUSIONS: Nonstenotic cervical carotid plaque is more common ipislateral to the infarction in patients with ESUS, but not in patients with AF, supporting an underlying atheroembolic mechanism in a subset of ESUS patients. This association might be greater in younger ESUS patients.

A Characterization of Neurology Consults for Inpatients with SARS-CoV-2 Infection Compared to Other Respiratory Viruses.

Introduction: Neurological consultation for patients infected with SARS-CoV-2 is common; it is currently unknown whether the neurologist's approach to inpatient consultation of patients with SARS-CoV-2 should differ from the paradigm used to evaluate hospitalized patients with similar respiratory viruses. The goal of the present study is to determine if the preponderance of new neurologic diagnoses differs between inpatients with SARS-CoV-2 and similar non-SARS-CoV-2 respiratory viruses for whom neurology is consulted. Methods: We performed a retrospective chart analysis of inpatient neurologic consultations at three major Philadelphia-based hospitals. We compared the final neurologic diagnosis of 152 patients infected with SARS-CoV-2 to 54 patients with a similar ubiquitous non-SARS-CoV-2 respiratory virus (influenza A, influenza B, respiratory syncytial virus, rhinovirus, or adenovirus, the most commonly tested respiratory viruses at our institution). Secondary metrics included age, sex, level of care, prior neurologic diagnoses, and mortality. A multinomial logistic regression model was utilized to evaluate the relative difference between diagnostic category groups on all metrics. Results: The proportion of patients with seizure who were infected with SARS-CoV-2 admitted to an intensive care unit (ICU) was significantly higher than those who were admitted to a medical-surgical floor. SARS-CoV-2 was also associated with increased risk for ICU admission compared to other common respiratory viruses. SARS-CoV-2 inpatients requiring neurologic consultation were also more likely to be older and female as compared to the non-SARS-CoV-2 cohort. In other domains, the proportion of neurologic diagnoses between SAR-CoV-2 and non-SARS-CoV-2 respiratory viruses showed no significant difference. Conclusion: Patients requiring inpatient neurologic consultation with a diagnosis of SARS-CoV-2 infection or another respiratory virus were found to be remarkably similar in terms of their ultimate neurologic diagnosis, with the exception of a larger preponderance of seizure in critical-care-level patients with SARS-CoV-2 infection. Our study suggests that the neurological approach to patients hospitalized with SARS-CoV-2 should be similar to that for patients with similar common respiratory infections, noting that seizure was seen more frequently in critically ill patients infected with SARS-CoV-2.

Long term outcomes of percutaneous coronary intervention vs coronary artery bypass grafting in patients with diabetes mellitus with multi vessels diseases: A meta-analysis.

Aims: Long term cardiovascular outcome comparison of multivessel coronary disease among patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) is limited. The objective of this study was to compare the long-term cardiovascular outcome PCI vs CABG among DM patients with multivessel disease. Method and results: Online databases were explored to identify studies that compared cardiovascular outcomes between PCI and CABG among patients with DM. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), rate of revascularization, cardiac death, and cerebrovascular accident (CVA). A total of 27 studies with 37,091 (PCI n = 19,838 (53 %) and CABG n = 17,253 (47 %)) patients were included. The mean age was 64 ± 5.9 years for PCI group and 63.8 ± 5.3 years for CABG group; and, predominantly male (71.22 % vs 74.29 %) for PCI and CABG respectively. The most common comorbidity was hypertension (64.35 % vs 62.88 %) in both PCI and CABG respectively. Compared with CABG, PCI group had a higher odds of overall all-cause mortality (OR 1.18, 95 % CI 1.02-1.37, p = 0.03), MACCE (OR 1.52, 95 % CI 1.31-1.75, p = 0.00), MI (OR 1.85, 95 % CI 1.46-2.36, p = 0.00), repeat revascularization (OR 3.08, 95 % CI 2.34-4.05, p = 0.00) and cardiac death (OR 1.27, 95 % 1.02-1.59, p = 0.04), while CVA (0.57, 95 % CI 0.37-0.86, p = 0.01) was higher with CABG. Conclusion: Diabetic patients with multivessel coronary artery disease have worse outcomes undergoing PCI as compared to CABG. However, CVA was significantly higher with CABG. CABG remains the preferred management among eligible patients with multivessel disease and DM.

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing: A Cluster Randomized Clinical Trial.

Importance: Statins reduce the risk of major adverse cardiovascular events, but less than one-half of individuals in America who meet guideline criteria for a statin are actively prescribed this medication. Objective: To evaluate whether nudges to clinicians, patients, or both increase initiation of statin prescribing during primary care visits. Design, Setting, and Participants: This cluster randomized clinical trial evaluated statin prescribing of 158 clinicians from 28 primary care practices including 4131 patients. The design included a 12-month preintervention period and a 6-month intervention period between October 19, 2019, and April 18, 2021. Interventions: The usual care group received no interventions. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text message delivered 4 days before the visit. The combined nudge included the clinician and patient nudges. Main Outcomes and Measures: The primary outcome was initiation of a statin prescription during the visit. Results: The sample comprised 4131 patients with a mean (SD) age of 65.5 (10.5) years; 2120 (51.3%) were male; 1210 (29.3%) were Black, 106 (2.6%) were Hispanic, 2732 (66.1%) were White, and 83 (2.0%) were of other race or ethnicity, and 933 (22.6%) had atherosclerotic cardiovascular disease. In unadjusted analyses during the preintervention period, statins were prescribed to 5.6% of patients (105 of 1876) in the usual care group, 4.8% (97 of 2022) in the patient nudge group, 6.0% (104 of 1723) in the clinician nudge group, and 4.7% (82 of 1752) in the combined group. During the intervention, statins were prescribed to 7.3% of patients (75 of 1032) in the usual care group, 8.5% (100 of 1181) in the patient nudge group, 13.0% (128 of 981) in the clinician nudge arm, and 15.5% (145 of 937) in the combined group. In the main adjusted analyses relative to usual care, the clinician nudge significantly increased statin prescribing alone (5.5 percentage points; 95% CI, 3.4 to 7.8 percentage points; P = .01) and when combined with the patient nudge (7.2 percentage points; 95% CI, 5.1 to 9.1 percentage points; P = .001). The patient nudge alone did not change statin prescribing relative to usual care (0.9 percentage points; 95% CI, -0.8 to 2.5 percentage points; P = .32). Conclusions and Relevance: Nudges to clinicians with and without a patient nudge significantly increased initiation of a statin prescription during primary care visits. The patient nudge alone was not effective. Trial Registration: ClinicalTrials.gov Identifier: NCT04307472.

Impact of a fitness intervention on medical students.

OBJECTIVE: It is known that regular exercise improves both physical and mental health. This study sought to determine the impact of a fitness intervention on the levels of exercise and well-being of medical students. METHODS: In 2011, the authors conducted a prospective cohort study involving medical students at the Johns Hopkins School of Medicine. Intervention students experienced a 7-week, team-based, fitness competition and recorded exercise data online. Incentives were given to teams reaching an average of 150 minutes per teammate per week, an exercise goal recommended by the US Department of Health and Human Services. Both groups completed baseline and follow-up surveys about physical activity and well-being, using validated scoring methods. RESULTS: A total of 100 students (71 in the intervention group and 29 in the control group) participated fully, recording their exercise behaviors and completing both the pre- and postsurveys. In the intervention group, the percentage of individuals successfully reaching the exercise target of 150 minutes per week varied by week from 30% to 61%. Intervention students showed a significant improvement in their International Physical Activity Questionnaire scores (1669.4 ± 154.9 vs 2013.6 ± 174.6; P = 0.02) and levels of irritability on the subsection of the Positive Affect and Negative Affect Scale score (2.2 ± 0.1 vs 2.0 ± 0.1, P = 0.03). By contrast, the control group did not show any improvements in any of these measures across the same time period (all P > 0.05). CONCLUSIONS: A well-orchestrated student-designed fitness intervention can effectively augment medical students' exercise practices and positively affect well-being.

Molluscum contagiosum in the setting of Fingolimod: The experience at one institution.

Fingolimod treatment has been associated with opportunistic infections, most notably PML and cryptococcal meningitis. There are rare reports of other infections like molluscum contagiosum which are typically associated with impaired cellular immunity as seen in AIDS. Upon review of our multiple sclerosis patient database, we identified eight patients undergoing fingolimod treatment who developed molluscum contagiosum infections. We suspect that this association is a class effect and may also be observed with other S1P receptor modulators. While molluscum contagiosum infection is not life-threatening, it can be extremely distressing for patients, and resolution may require discontinuation of fingolimod.

FDA Approaches in Monitoring Drug Quality, Forces Impacting the Drug Quality, and Recent Alternative Strategies to Assess Quality in the US Drug Supply.

Since the US Food and Drug Administration (FDA) began monitoring the quality of pharmaceutical manufacturing by enforcing current good manufacturing practices roughly 60 years ago, forces related to the global economy have changed, rendering the task of monitoring quality more difficult. Alternative strategies by groups like Valisure, LLC, and the University of Kentucky Drug Quality Study to monitor the quality of the currently circulated US drug supply through end-product testing and screening have resulted in several concerning findings. Given the successful approaches of identifying quality defects in pharmaceuticals by non-regulatory bodies, and considering the changing landscape and pressures on manufacturing, the FDA, large buying groups, and the US Department of Defense should consider these alternative strategies as a means to augment current regulatory activities.

Predictors of Recurrent Venous Thrombosis After Cerebral Venous Thrombosis: Analysis of the ACTION-CVT Study.

BACKGROUND AND OBJECTIVE: Cerebral venous thrombosis (CVT) is a rare cause of stroke carrying a nearly 4% risk of recurrence after 1 year. There are limited data on predictors of recurrent venous thrombosis in patients with CVT. In this study, we aim to identify those predictors. METHODS: This is a secondary analysis of the ACTION-CVT study which is a multicenter international study of consecutive patients hospitalized with a diagnosis of CVT over a 6-year period. Patients with cancer-associated CVT, CVT during pregnancy, or CVT in the setting of known antiphospholipid antibody syndrome were excluded per the ACTION-CVT protocol. The study outcome was recurrent venous thrombosis defined as recurrent venous thromboembolism (VTE) or de novo CVT. We compared characteristics between patients with vs without recurrent venous thrombosis during follow-up and performed adjusted Cox regression analyses to determine important predictors of recurrent venous thrombosis. RESULTS: Nine hundred forty-seven patients were included with a mean age of 45.2 years, 63.9% were women, and 83.6% had at least 3 months of follow-up. During a median follow-up of 308 (interquartile range 120-700) days, there were 5.05 recurrent venous thromboses (37 VTE and 24 de novo CVT) per 100 patient-years. Predictors of recurrent venous thrombosis were Black race (adjusted hazard ratio [aHR] 2.13, 95% CI 1.14-3.98, p = 0.018), history of VTE (aHR 3.40, 95% CI 1.80-6.42, p < 0.001), and the presence of one or more positive antiphospholipid antibodies (aHR 3.85, 95% CI 1.97-7.50, p < 0.001). Sensitivity analyses including events only occurring on oral anticoagulation yielded similar findings. DISCUSSION: Black race, history of VTE, and the presence of one or more antiphospholipid antibodies are associated with recurrent venous thrombosis among patients with CVT. Future studies are needed to validate our findings to better understand mechanisms and treatment strategies in patients with CVT.

Automated Text-Based Symptom Monitoring With Rapid Clinician Triage for Patients With Cancer and Suspected or Confirmed COVID-19.

PURPOSE: Patients with cancer are at greater risk of developing severe symptoms from COVID-19 than the general population. We developed and tested an automated text-based remote symptom-monitoring program to facilitate early detection of worsening symptoms and rapid assessment for patients with cancer and suspected or confirmed COVID-19. METHODS: We conducted a feasibility study of Cancer COVID Watch, an automated COVID-19 symptom-monitoring program with oncology nurse practitioner (NP)-led triage among patients with cancer between April 23 and June 30, 2020. Twenty-six patients with cancer and suspected or confirmed COVID-19 were enrolled. Enrolled patients received twice daily automated text messages over 14 days that asked "How are you feeling compared to 12 hours ago? Better, worse, or the same?" and, if worse, "Is it harder than usual for you to breathe?" Patients who responded worse and yes were contacted within 1 hour by an oncology NP. RESULTS: Mean age of patients was 62.5 years. Seventeen (65%) were female, 10 (38%) Black, and 15 (58%) White. Twenty-five (96%) patients responded to ≥ 1 symptom check-in, and overall response rate was 78%. Four (15%) patients were escalated to the triage line: one was advised to present to the emergency department (ED), and three were managed in the outpatient setting. Median time from escalation to triage call was 11.5 minutes. Four (15%) patients presented to the ED without first escalating their care via our program. Participant satisfaction was high (Net Promoter Score: 100, n = 4). CONCLUSION: Implementation of an intensive remote symptom monitoring and rapid NP triage program for outpatients with cancer and suspected or confirmed COVID-19 infection is possible. Similar tools may facilitate more rapid triage for patients with cancer in future pandemics.

Neurology consults in emergency departments: Opportunities to streamline care.

OBJECTIVE: To use the variations in neurology consultations requested by emergency department (ED) physicians to identify opportunities to implement multidisciplinary interventions in an effort to reduce ED overcrowding. METHODS: We retrospectively analyzed ED visits across 3 urban hospitals to determine the top 10 most common chief complaints leading to neurology consultation. For each complaint, we evaluated the likelihood of consultation, admission rate, admitting services, and provider-to-provider variability of consultation. RESULTS: Of 145,331 ED encounters analyzed, 3,087 (2.2%) involved a neurology consult, most commonly with chief complaints of acute-onset neurologic deficit, subacute neurologic deficit, or altered mental status. ED providers varied most in their consultation for acute-onset neurologic deficit, dizziness, and headache. Neurology consultation was associated with a 2.3-hour-longer length of stay (LOS) (95% CI: 1.6-3.1). Headache in particular has an average of 6.7-hour-longer ED LOS associated with consultation, followed by weakness or extremity weakness (4.4 hours) and numbness (4.1 hours). The largest estimated cumulative difference (number of patients with the specific consultation multiplied by estimated difference in LOS) belongs to headache, altered mental status, and seizures. CONCLUSION: A systematic approach to identify variability in neurology consultation utilization and its effect on ED LOS helps pinpoint the conditions most likely to benefit from protocolized pathways.

Impact of cervical stenosis on multiple sclerosis lesion distribution in the spinal cord.

OBJECTIVE: To determine whether demyelinating lesions attributable to multiple sclerosis (MS) occur more commonly in regions of pre-existing cervical stenosis (CS). DESIGN/METHODS: One hundred comorbid MS/CS patients and 100 MS-only controls were identified via ICD codes and radiology reports from a retrospective chart review of the records of the University of Pennsylvania Hospital System (UPHS) from January 1st, 2009 to December 31st, 2018. For each patient, axial and sagittal T2 sequences of cervical MRI scans were examined. The cervical cord was split into 7 equal segments comprising the disc space and half of each adjacent vertebral body. Each segment was assessed for the presence of MS lesions and grade 2 CS or higher by previously published criteria. Lesions which were concerning for spondylotic-related signal change based on imaging characteristics were excluded (n=6, 3.2%). Clinical data was extracted from the electronic medical record. RESULTS: Average age at the time of MRI was 57.0 +/- 10.5 years and average time with MS diagnosis was 15.3 +/- 9.2 years. The majority of patients had a diagnosis of relapse-remitting MS (81.0%) and the F:M ratio was 3.5. Eighty-five percent of patients were on treatment at the time of MRI, most often glatiramer acetate (35.0%). Spinal segments with at least grade 2 stenosis were significantly associated with the presence of an MS lesion in the same segment (χ2 = 19.0, p < 0.001, OR = 2.6, 95% CI 1.8-3.7). CONCLUSIONS: Our data suggest there is a significant association between segments of spinal cord with at least moderate CS and segments with MS lesions. Further analysis is required to assess if cervical stenosis is a causative or aggravating factor in multiple sclerosis.

W-Doped TiO2 for photothermocatalytic CO2 reduction.

TiO2 is one of the most widely used photocatalysts and photothermocatalysts. Tailoring their structure and electronic properties is crucial for the design of high-performance TiO2 catalysts. Herein, we report a strategy to significantly enhance the performance of TiO2 in the photothermocatalytic reduction of CO2 by doping high crystalline nano-TiO2 with tungsten. A variety of tungsten doping concentrations ranging from 2% to 10% were tested and they all showed enhanced catalytic activities. The 4% W-doped TiO2 exhibited the highest activity, which was 3.5 times greater than that of the undoped TiO2 reference. Structural characterization of these W-doped TiO2 catalysts indicated that W was successfully doped into the TiO2 lattice at relatively low dopant concentration. Synchrotron X-ray absorption spectroscopy at both the W L3- and Ti K-edges was further used to provide insight into the local structure and bonding properties of the catalysts. It was found that the replacement of Ti with W led to the formation of Ti vacancies in order to maintain the charge neutrality. Consequently, dangling oxygen and oxygen vacancies were produced that acted as catalytically active sites for the CO2 reduction. As the W doping concentration increased from 2% to 4%, more such active sites were generated which thus resulted in the enhancement of the catalytic activity. When the W doping concentration was further increased to 10%, the extra W species that cannot replace the Ti in the lattice aggregated to form WO3. Due to the lower conduction band of WO3, the catalytic O sites were deactivated and CO2 reduction was inhibited. This work presents a useful strategy for the development of highly efficient catalysts for CO2 reduction as well as new insights into the catalytic mechanism in cation-doped TiO2 photothermocatalysis.

O-coordinated W-Mo dual-atom catalyst for pH-universal electrocatalytic hydrogen evolution.

Single-atom catalysts (SACs) maximize the utility efficiency of metal atoms and offer great potential for hydrogen evolution reaction (HER). Bimetal atom catalysts are an appealing strategy in virtue of the synergistic interaction of neighboring metal atoms, which can further improve the intrinsic HER activity beyond SACs. However, the rational design of these systems remains conceptually challenging and requires in-depth research both experimentally and theoretically. Here, we develop a dual-atom catalyst (DAC) consisting of O-coordinated W-Mo heterodimer embedded in N-doped graphene (W1Mo1-NG), which is synthesized by controllable self-assembly and nitridation processes. In W1Mo1-NG, the O-bridged W-Mo atoms are anchored in NG vacancies through oxygen atoms with W─O─Mo─O─C configuration, resulting in stable and finely distribution. The W1Mo1-NG DAC enables Pt-like activity and ultrahigh stability for HER in pH-universal electrolyte. The electron delocalization of W─O─Mo─O─C configuration provides optimal adsorption strength of H and boosts the HER kinetics, thereby notably promoting the intrinsic activity.