Clinical factors associated with need for neurosurgical care in young children with imaging for macrocephaly: a case control study.

BACKGROUND: Macrocephaly is present in 2.3% of children with important neurosurgical conditions in the differential diagnosis. The objective of this study was to identify clinical associations with actionable imaging findings among children with head imaging for macrocephaly. METHODS: We conducted a case-control study of head imaging studies ordered for macrocephaly among children 24 months and younger in a multistate children's health system. Four neurosurgeons reviewed the images, determining cases to be a 'concern' if neurosurgical follow-up or intervention was indicated. Electronic health records were reviewed to collect patient-level data and to determine if surgery was performed. Controls were matched 3:1 to cases of 'concern' in a multivariate model using conditional logistic regression. RESULTS: In the study sample (n = 1293), 46 (4%) were concern cases, with 15 (1%) requiring surgery. Significant clinical factors associated with neurosurgical concern were bulging fontanel [aOR 7.47, (95% CI: 2.28-24.44), P < 0.001], prematurity [aOR 21.26, (95% CI: 3.76-120.21), P < 0.001], any delay [aOR 2.67, (95% CI: 1.13-6.27), P = 0.03], and head-weight Z-score difference (W_diff, defined as the difference between the Z-scores of head circumference and weight) [aOR 1.70, (95% CI: 1.22-2.37), P = 0.002]. CONCLUSIONS: Head imaging for macrocephaly identified few patients with findings of concern and fewer requiring surgery. A greater head-weight Z-score difference appears to represent a novel risk factor for neurosurgical follow-up or intervention.

Evaluation of the Fast Prior Authorization Technology Highway.

BACKGROUND: Prior authorization (PA) is a utilization management tool used by health plans and pharmacy benefit managers where the payer requires additional documentation from health care providers before authorization of payment for a medication or procedure. PA processes are hypothesized to be more efficient if electronic transmission is utilized instead of manual submission. OBJECTIVE: To evaluate the impact of electronic PA (ePA) on approval rate and time to decision and to assess health care provider perception of using ePA. METHODS: America's Health Insurance Plans selected 2 technology companies, Availity and Surescripts, and used an independent research organization (Research Triangle Institute [RTI]) to conduct a provider survey and analyze over 40,000 PA transactions from participating health plans. RTI examined processing time, provider experience, and other measures for PAs both before and after provider implementation of ePA. RESULTS: Providers used these tools for roughly 62% of PAs in the 6 months after implementation. The median time from PA request to decision fell from 18.7 hours to 5.7 hours. Providers using ePA reported observing some benefits relative to the number of phone calls and faxes required after ePA implementation. CONCLUSION: The primary benefit of ePA implementation was reduced time to decision. Additional benefits may occur with greater adoption since 38% of PAs were still manual after implementation of ePA.

COVID-19 risk factors and outcomes in individuals with stiff person syndrome spectrum disorders before and after omicron.

BACKGROUND: Stiff person syndrome spectrum disorders (SPSD) are rare, disabling disorders of the nervous system that are associated with risk factors for Coronavirus disease 2019 (COVID-19). However, limited data exist on the overall impact of COVID-19 on SPSD. METHODS: Patients with SPSD and COVID-19 who are followed at Johns Hopkins SPS Center were included. Demographics and SPSD characteristics along with COVID-19-specific data were recorded. RESULTS: Thirty-five cases of SPSD with COVID-19 cases were reported during the study time period. Mean age of the cohort was 56 (SD ± 10) and most were female (66.7%). Eighty percent of the COVID-19 cases were confirmed with testing, and the rest were highly suggestive of COVID-19. COVID-19 comorbidities among patients were hypertension (n = 6), diabetes (n = 6), obesity (n = 5), and cardiovascular disease (n = 4). The majority of participants were on immune therapies and/or benzodiazepines. Out of the cases reported, only 2 required hospitalization, both of whom had diabetes, and one was on immunosuppressive therapy. The majority of cases were post-full-vaccination cases. Fever was the most common COVID-19-associated symptom. Transient neurological symptoms were also reported. CONCLUSION: Risk factors for developing severe COVID-19 in SPSD appear to be the same as historical data in the general population. Importantly, COVID-19 did not appear to be associated with worsening SPSD post-COVID-19. Vaccination may have played a role in preventing severe cases of COVID-19.

Prevalence of non-neurological autoantibodies and related comorbidities in stiff person spectrum disorders.

Background: Stiff Person Syndrome Spectrum Disorders (SPSD) are a group of rare neurological disorders that can present alongside other autoimmune conditions. However, not much is known about the breadth of non-neurological autoantibodies seen in SPSD nor the observed prevalence of co-existing autoimmune comorbidities and their impact on SPSD. Objective: This study aimed to investigate the prevalence of non-neurological autoantibodies and associated conditions in a large cohort of people with SPSD. Methods: A retrospective review of 205 patients with suspected/definitive SPSD seen at Johns Hopkins Hospital from 1997 to 2023 was performed as part of an ongoing, observational study. Relevant demographics, clinical data (e.g., SPSD phenotypes, comorbid conditions, and dates of diagnoses), and laboratory values were collected from electronic medical records. Lab values were excluded if completed within 6 months of receiving intravenous immunoglobin treatment. Summary statistics were performed and assessment for any associations between autoimmune comorbidities and disease burden (modified Rankin score [mRS] and ambulation status) was performed. Results: The majority of participants had classic SPS (66%), followed by SPS-plus (18%) and PERM (6%) with less than 5% each of the remaining phenotypes and suspected SPS. The average age at symptom onset in this cohort was 44.1 ± 14.5 years (mean ± standard deviation). The majority of the cohort was white (66%) and female patients (75%). The mean mRS was 2.5, and over 70% required assistive devices for ambulation. The most commonly identified non-neurological autoantibodies were anti-nuclear (ANA) (31%), thyroperoxidase (30%), thyroglobulin (20%), and anti-parietal cell (18%) autoantibodies. The most common comorbid autoimmune conditions were autoimmune thyroiditis (38%), insulin-dependent diabetes mellitus (26%), and pernicious anemia (10%). Having more autoimmune comorbidities was weakly associated with higher mRS and a greater need for ambulatory assistance. Conclusion: The results of this study will hopefully help promote awareness of which autoantibody and medical comorbidity clinicians should be aware of and monitor people with SPSD. Further research is needed to identify if poorly controlled non-neurological autoimmune disorders contribute to disease burden in SPSD and/or if the timing of being diagnosed with one of these conditions plays a role in future disability.

Gender differences in diabetes self-management: a mixed-methods analysis of a mobile health intervention for inner-city Latino patients.

BACKGROUND: The benefit of mobile health (mHealth) on diabetes management among low-income, inner-city patients is largely unknown, particularly for Latino patients. TExT-MED (Trial to Examine Text Message for Emergency Department Patients with Diabetes) is a text message-based program designed to improve disease knowledge, self-efficacy, and glycemic control among low-income, inner-city Latinos. In phase I, 23 patients participated in an acceptability and feasibility study. Contrary to our model, there was no increase in knowledge despite increases in self-efficacy and healthy behaviors. In phase II, we performed a mixed-methods analysis to understand how TExT-MED achieved these seemingly contradictory findings. METHOD: We performed a qualitative analysis of focus groups with patients from phase I. We explored patients' receipt of health information from TExT-MED and other information sources. We used these qualitative findings to perform a mixed-methods analysis of the outcomes from phase I, reanalyzing the quantitative measures of self-efficacy, diabetes knowledge, and healthy behaviors. RESULTS: We conducted two focus groups, one in English and one in Spanish. Through qualitative analysis, we found gender differences in information sources, dietary self-efficacy, and desired educational content. Applying this knowledge, we re-stratified phase I outcomes by gender and found differential changes in diabetes knowledge, self-efficacy, and behaviors. Men had increased self-efficacy while women showed increased knowledge. CONCLUSIONS: The efficacy of mHealth on diabetes management was affected by gender. Specifically, men and women differ in their dietary self-efficacy, information sources, and desired topics in future mHealth interventions. To achieve maximal impact, future mHealth interventions should be mindful of this gender difference.