Perception of In-Person Prerounding Amongst Neurology Residents Across Two Academic Centers.

Background and Purpose: In-person prerounding has long been a routine practice for residents in the field of neurology. However, with the emergence of the COVID-19 pandemic, many institutions, including our two academic neurology centers, have shifted to computer rounding. This study aims to assess the effects of computer rounding alone compared to a combination of computer rounding and in-person prerounding from the perspective of neurology residents. Methods: A mixed-methods approach was employed, including a survey administered to 79 neurology residents and a qualitative thematic analysis of their responses. Results: The quantitative analysis revealed that residents who engaged in inperson prerounding spent significantly more time on prerounding and computer rounding compared to those who did not. The majority of residents reported a neutral effect of in-person prerounding on their relationship with patients and bedside time, but a significant impact on personal lives and other tasks. Qualitative analysis identified four key themes: accessibility to team members, learning opportunities gained and lost, inefficiency, and sleep disturbance. Conclusions: Overall, residents perceived in-person prerounding as inefficient and causing sleep disruption for both patients and themselves. While some residents valued the face-to-face interaction and improved accessibility, others felt that computer rounding allowed for thorough review of patient data, improving preparedness and efficiency. The potential elimination of in-person prerounding from residents' routines may enhance their overall wellbeing. Further research is needed to assess the advantages and drawbacks of removing this classic approach to caring for patients from the perspective of residents, attendings and patients.

Impact of the COVID-19 Pandemic on Inpatient Utilization for Acute Neurologic Disease.

Background and Objective: The initial months of the Corona Virus 2019 (COVID-19) pandemic resulted in decreased hospitalizations. We aimed to describe differences in hospitalizations and related procedures across neurologic disease. Methods: In our retrospective observational study using the California State Inpatient Database and state-wide population-level estimates, we calculated neurologic hospitalization rates for a control period from January 2019 to February 2020 and a COVID-19 pandemic period from March to December 2020. We calculated incident rate ratios (IRR) for neurologic hospitalizations using negative binomial regression and compared relevant procedure rates over time. Results: Population-based neurologic hospitalization rates were 29.1 per 100,000 (95% CI 26.9-31.3) in April 2020 compared to 43.6 per 100,000 (95% CI 40.4-46.7) in January 2020. Overall, the pandemic period had 13% lower incidence of neurologic hospitalizations per month (IRR 0.87, 95% CI 0.86-0.89). The smallest decreases were in neurotrauma (IRR 0.92, 95% CI 0.89-0.95) and neuro-oncologic cases (IRR 0.93, 95% CI 0.87-0.99). Headache admissions experienced the greatest decline (IRR 0.62, 95% CI 0.58-0.66). For ischemic stroke, greater rates of endovascular thrombectomy (5.6% vs 5.0%; P < .001) were observed in the pandemic. Among all neurologic disease, greater rates of gastrostomy (4.0% vs 3.5%; P < .001), intubation/mechanical ventilation (14.3% vs 12.9%, P < .001), and tracheostomy (1.4 vs 1.2%; P < .001) were observed during the pandemic. Conclusions: During the first months of the COVID-19 pandemic there were fewer hospitalizations to varying degrees for all neurologic diagnoses. Rates of procedures indicating severe disease increased. Further study is needed to determine the impact on triage, patient outcomes, and cost consequences.

41-Year-Old Male with Sub-Acute Encephalopathy, Seizures, and End Stage Renal Disease: A Unifying Diagnosis and Response to Therapy.

We describe a case of a 41-year-old male with a history of end-stage renal disease, hypertension, epilepsy, ischemic stroke, and traumatic brain injury transferred to our tertiary care center for subacute, progressive cognitive impairment. He was found to have disproportionate brain atrophy, focal seizures, and refractory hypertension. Given suspicion for an underlying genetic etiology, a genetic panel for progressive renal disease was sent, revealing two known pathogenic variants in a gene for a cobalamin metabolism disorder, Cobalamin C deficiency. He was started on targeted metabolic supplementation with subsequent improvement in his cognition. Our case highlights the crucial need to expand diagnostic workup to include genetic and metabolic causes in patients with neurologic disease, atypical features, relevant family history and multi-organ dysfunction.

Diagnostic Challenges of Lyme Neuroborreliosis in Inpatient Neurology: A Case Series.

Lyme disease is a multisystem disorder transmitted through the Ixodes tick and is most commonly diagnosed in northeastern and mid-Atlantic states, Wisconsin, and Minnesota, though its disease borders are expanding in the setting of climate change. Approximately 10%-15% of untreated Lyme disease cases will develop neurologic manifestations of Lyme neuroborreliosis (LNB). Due to varying presentations, LNB presents diagnostic challenges and is associated with a delay to treatment. We discuss three cases of LNB admitted to our referral center in a traditionally low-incidence state to highlight clinical pearls in LNB diagnosis. Three patients from low-incidence areas with prior diagnostic evaluations presented in August with neurologic manifestations of radiculoneuritis, cranial neuropathies, and/or lymphocytic meningitis. MRI findings included cranial nerve, nerve root, and leptomeningeal enhancement leading to broad differential diagnoses. Lumbar puncture demonstrated lymphocytic pleocytosis (range 85-753 cells/uL) and elevated protein (87-318 mg/dL). Each patient tested positive for Lyme on two-tiered serum testing and was diagnosed with LNB. All three cases were associated with a delay to health care presentation (mean 20 days) and a delay to diagnosis and treatment (mean 54 days) due to under-recognition and ongoing evaluation. With the geographic expansion of Lyme disease, increasing awareness of LNB manifestations and acquiring detailed travel histories in low-incidence areas is crucial to prompt delivery of care. Clinicians should be aware of two-tiered serum diagnostic requirements and use adjunctive studies such as lumbar puncture and MRI to eliminate other diagnoses. Treatment with an appropriate course of antibiotics leads to robust improvement in neurological symptoms.

Differences in Interfacility Transfer from Emergency Department and Inpatient Services for Inpatient Neurologic Care.

Introduction: Interhospital transfer is an important mechanism for improving access to specialized neurologic care but there are large gaps in our understanding of interhospital transfer for the management of non-stroke-related neurologic disease. Methods: This observational study included consecutive patients admitted to an adult academic general neurology service via interhospital transfer from July 1, 2015 to July 1, 2017. Characteristics of the referring hospital and transferred patients were obtained through the American Hospital Association Directory, a hospital transfer database maintained by the accepting hospital, and the electronic medical record. The analyses used descriptive statistics to examine the cohort overall and compare characteristics of patients transferred from an emergency department and inpatient service. Results: 504 patients were admitted via interhospital transfer during the study period. Of these, 395 patients (78.4%) were transferred because the referring hospital lacked capability, and 139 patients (27.6%) were transferred from an emergency department as opposed to inpatient service. Seizures was the most common diagnosis (23.8%). Patients who were transferred from an emergency department had a higher proportion covered by Medicaid (44.6%) than those transferred from an inpatient service (28.8%) and had a shorter median length of stay (3 days; IQR 2-7 vs 7 days; IQR 4-12). Conclusions: The majority of observed interhospital non-stroke neurologic transfers occurred to improve access to specialized neurological care for patients, though patients transferred from the ED, as opposed to an inpatient service, had lower health care utilization, and this will be important to consider when developing systems of care and in future research.

An Unusual Case of Bilateral Subperiosteal Orbital Hemorrhage.

Subperiosteal orbital hemorrhage usually occurs in the setting of facial or orbital trauma. Non-traumatic subperiosteal orbital hemorrhage (NTSOH) has rarely been reported in literature. The proposed mechanism of NTSOH is the transmission of sudden increase in cranial venous pressure to the orbital veins, which are valveless. We present a case of a 37 year old right-handed woman with a past medical history significant for type 1 diabetes, end-stage renal disease, peripheral artery disease and hypertension who developed NTSOH following an elective revision of a clotted right upper extremity arteriovenous fistula. During this procedure, she had acute eye pain, bilateral complete vision loss and emesis. CT of the orbits revealed large heterogeneously hyperdense lesions in the bilateral orbital apex extending anteriorly along the roof of the orbit, concerning for hemorrhage. Cultures obtained through nasal endoscopy were negative for a bacterial or fungal infection involving the sinuses. Ophthalmology was consulted and she underwent bilateral canthotomy and lateral cantholysis. Postoperatively, she was started on systemic and topical ocular antihypertensives, as well as prophylactic antibiotics. Visual acuity remained poor with finger counting on the right eye and lack of consistent response to light on the left eye. This case highlights periprocedural increase in systemic venous pressure secondary to a fistula repair procedure as a potential cause of NTSOH.

Continuous EEG monitoring detects nonconvulsive seizure and Ictal-Interictal Continuum abnormalities in moderate to severe ICANS following systemic CAR-T therapy.

Background and Purpose: Immune Cell Effector Associated Neurotoxicity Syndrome (ICANS) is common amongst patients receiving CD19 targeted Chimeric Antigen Receptor T-cell (CAR-T) therapy. The purpose of this study is to characterize the incidence of seizures and ictal-interictal continuum (IIC) abnormalities in patients with ICANS. Methods: Retrospective review of consecutive patients treated with axicabtagene ciloleucel (axi-cel) for recurrent high-grade systemic lymphoma at Stanford Medical Center between 2/2016-6/2019. Electronic medical records (EMR) were reviewed for clinical features, treatment information, EEG data, CRS (cytokine release syndrome)/ICANS severity, and clinical outcomes. Results: Fifty-six patients met inclusion criteria. 85.7% of patients developed CRS, and 58.9% developed ICANS. Twenty-eight patients had EEG monitoring, of whom 26 had ICANS. Median duration of EEG monitoring was 30 hours (range .5-126 hours). Four patients (7.1%) had seizures (1 patient had a clinical generalized seizure, 2 patients had clinical and nonconvulsive seizures, and 1 patient had an isolated non-convulsive seizure). Ictal-interictal continuum abnormalities were common, of which generalized periodic discharges (GPDs) with triphasic morphology and GPDs with epileptiform morphology were most frequently seen. Generalized periodic discharges with triphasic wave morphology were found across Grade 2-3 peak ICANS severity, however the majority (86%) of patients with epileptiform GPDs had Grade 3 peak ICANS severity. Conclusions: Among patients receiving axi-cel, seizure occurred in 7.1% of the total cohort, representing 12% of patients with ICANS. Ictal-interictal continuum abnormalities are also seen in patients with ICANS, most commonly GPDs. 75% of patients with seizures had nonconvulsive seizures supporting the use of continuous video EEG monitoring in this population.

Adding Nocturnal Advanced Practice Providers to an Academic Inpatient Neurology Service Improves Residents' Educational Experience.

Background and Objectives: In the inpatient academic medical center, increased demand for clinical services often equates to an increased workload for trainees, which could have a positive or negative impact on their educational experience. In 2020, our academic medical center hired Advanced Practice Providers (APPs) to provide continuous additional overnight coverage for our neurology ward teaching service. We hypothesized that adding APPs and reducing overnight clinical workload for residents would have a positive impact on resident education. Methods: We performed a mixed-methods, prospective study that included needs-assessments by residents, semi-structured interviews with both residents and APPs, and surveys to residents and nursing staff. In addition, we collected quantitative data such as hours of sleep, number of admissions, and number of pages to capture the impact of APPs on resident overnight shifts. Results: The addition of APPs overnight increased the median hours of sleep overnight from 1 hour to 3 hours (P < .001) and decreased the median number of pages overnight from 31.5 to 17 (P < .001). The median number of patients the resident was responsible for cross-covering overnight decreased from 24 patients to 14 patients (P < .001). The majority of resident responses (94%) agreed that the addition of APPs benefited their education by reducing workload and increasing time allotted to reading and formulating plans for overnight admissions. 88% of residents agreed that the addition of APPs improved quality of life and reduced risk of burnout. Conclusion: Advanced Practice Providers significantly reduced resident workload, leading residents to report improvements in the educational experience overnight and reduced perceived risk of burnout.

Reversible Cerebral Vasoconstriction Syndrome Exacerbation After Calcitonin Gene-Related Peptide Inhibitor Administration.

Background: Reversible cerebral vasoconstriction syndrome (RCVS) is a non-inflammatory vasculopathy. While most patients have good clinical outcomes, RCVS can be associated with severe brain injury from ischemic stroke, subarachnoid, and intracerebral hemorrhage. Purpose: A number of vasoactive medications have been implicated in RCVS, including triptans, amphetamines, antidepressants, and decongestants. Given the role of CGRP in modulating cerebral vasodilation, the possibility of CGRP inhibitors contributing to RCVS has been raised. Research Design: Case report at the University of Pennsylvania. Study Sample: Patient at the University of Pennsylvania. Results: We report a patient with RCVS in which severe exacerbation resulting in multifocal ischemic stroke occurred following administration of the calcitonin gene-related peptide (CGRP) inhibitor fremanezumab. Conclusions: It is unclear whether fremanezumab played a role in this patient's case, but CGRP-inhibitor use should be considered as a potential precipiating factor.

An Electronic Health Record Intervention to Limit Viral Testing of Cerebrospinal Fluid.

Meningitis and encephalitis are neurologic emergencies that require immediate management and current guidelines recommend empiric treatment with broad-spectrum antimicrobials. Cerebrospinal fluid (CSF) testing algorithms are heterogeneous and largely institution-specific, reflecting a lack of consensus on how to effectively identify CSF pathogens while conserving resources and avoiding false positives. Moreover, many lumbar punctures (LPs) performed in the inpatient setting are done for noninfectious workups, such as evaluation for leptomeningeal metastasis. As such, tailoring CSF testing to clinical context has been a focus of multiple prior reports and several healthcare systems have focused on efforts to limit low-yield diagnostic testing when a positive result is unlikely. To curb ordering viral PCRs when pre-test probability is low, some peer institutions have implemented pleocytosis criteria for virus-specific polymerase chain reaction (PCR) tests from CSF. In this report, we retrospectively analyzed the diagnostic testing of CSF from patients who had an LP while admitted to a single, large academic medical center and found that many cases of Herpes Simplex Virus (HSV) meningoencephalitis were diagnosed by non-neurologists. The rate of positive virus-specific PCR tests was very low, and tests were frequently ordered in duplicate with a multiplexed meningitis/encephalitis PCR panel (M/E panel, BioFire, Salt Lake City, UT). We designed and implemented a systems-level intervention to promote a revised stepwise testing algorithm that minimizes unnecessary tests. This intervention led to a significant reduction in the number of low-yield virus-specific PCR tests ordered without implementing a policy of cancelling virus-specific PCRs.

Inpatient Telemedicine for Neurology Consultation at Satellite Hospitals: Patient and Provider Perspectives.

Background and Purpose: Describe an inpatient teleneurology consultation service novel to our hospital system, and capture feedback from patients, ordering providers, and consulting neurologists. Methods: A single cohort of teleneurology consult patients was surveyed via telephone. Ordering and consulting providers completed online surveys. Quantitative survey data was reported using descriptive statistics and free-response survey data was summarized. Patient demographics and consult data were gathered via retrospective chart review. Results: Telephone survey was obtained from 25 of 53 patients receiving teleneurology consults from June 1-September 30, 2020. Patient-reported benefits included better understanding of condition (72%) and ability to remain close to home. Online surveys were completed by 11 ordering providers and by consulting neurologists on 20 telemedicine encounters. Ordering providers reported they were likely to use the service again (98.7%), agreed it added value to patient care (91%) and was valued by patients (82%), with concern for missed diagnosis (46%) and potential patient transfer (36%) without the service. In contrast, fewer consulting neurologists predicted need for transfer (5%) or missed diagnosis (10%) in the absence of teleneurology, though 20% indicated that length of stay may increase without the service. Conclusion: We confirm feasibility of an inpatient teleneurology service run by an academic medical center. Satisfaction was high among all key stakeholders, with few transfers to a tertiary care center. This service is valuable to patients, ordering providers, and potentially the hospital network, as a community based care model of neurological care, centered on the needs of the patient and hospitalist.

Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience.

OBJECTIVE: To describe the characteristics of pediatric intensive care neurologists and their practice in the United States and Canada. METHODS: We performed a survey-based study of child neurologists who self-identify as 'intensive care neurologists'. The survey included questions about demographics, training, pediatric neurocritical care service and job structure, teaching, academics, challenges, and views on the future of pediatric neurocritical care. RESULTS: We analyzed 55 surveys. Most respondents were 31-50 years of age with ≤10 years of practice experience. Fifty-four percent identified as female. Most completed subspecialty training after child neurology residency. The majority practice at highly resourced centers with >45 intensive care unit beds. Respondents cover a variety of inpatient (critical and noncritical care) services, at times simultaneously, for a median of 19.5 weeks/y and work >70 hours/wk when on service for pediatric neurocritical care. The top 3 challenges reported were competing demands for time, excess volume, and communication with critical care medicine. Top priorities for the "ideal pediatric neurocritical care service" were attendings with training in pediatric neurocritical care or a related field and joint rounding with critical care medicine. CONCLUSION: We report a survey-based analysis of the demographics and scope of practice of pediatric critical care neurologists. We highlight challenges faced and provide a framework for the further development of this rapidly growing field.

Implementing a Neurohospitalist Program Improves Stroke Care Metrics and Patient Satisfaction Scores.

Objective: Compare the differences in health outcomes and patient satisfaction between a neurohospitalist model of care and a community-based neurologists model at a single community-based teaching hospital among in-patients diagnosed with a cerebrovascular accident (CVA). Methods: Data was collected from the Stamford Hospital's electronic medical records system. An assessment of patient health outcomes and satisfaction scores was conducted, comparing both discrete and continuous variables between the two time periods. An omnibus P-value of 0.05 (P < 0.05) was considered statistically significant. Results: The sample consisted of 341 patients between the two periods, pre-period n = 168 (49.3%) post-period n = 173 (50.7%). Door to lab and door to tPA times decreased significantly between pre- and post-periods (P = 0.003 and P = 0.002, respectively) as did the number of MRIs (P < 0.001). In addition, statistically significant increases were found between pre-period and post-period percentages, all increasing over time: stroke education (P < 0.001), discharged on anticoagulant medication (P < 0.001), and discharged on anti-thrombolytic medication (P = 0.019). Patient satisfaction scores demonstrated mean gain across both periods for five of six items. Two items "Doctor's Concern of my Questions/Worries" and "Skill of Doctors" demonstrated statistical significance (P = 0.020 and P = 0.029, respectively). Conclusions: The introduction of a neurohospitalist service at a community-based teaching hospital improved patient health outcomes on time to intervention, stroke education, discharge medications as well as patient satisfaction. Therefore, it may be beneficial for hospitals to implement a neurohospitalist model of care for their patients presenting with CVA.

Outcomes of a Neurohospitalist Program at an Academic Medical Center.

Background and Purpose: The purpose is to determine the impact of an academic neurohospitalist service on clinical outcomes. Methods: We performed a retrospective, quasi-experimental study of patients discharged from the general neurology service before (August 2010-July 2014) and after implementation of a full-time neurohospitalist service (August 2016-July 2018) compared to a control group of stroke patients. Primary outcomes were length of stay and 30-day readmission. Using the difference-in-difference approach, the impact of introducing a neurohospitalist service compared to controls was assessed with adjustment of patients' characteristics. Secondary outcomes included mortality, in-hospital complications, and cost. Results: There were 2706 neurology admissions (1648 general; 1058 stroke) over the study period. The neurohospitalist service was associated with a trend in reduced 30-day readmissions (ratio of ORs: .52 [.27, .98], P = .088), while length of stay was not incrementally changed in the difference-in-difference model (-.3 [-.7, .1], P = .18). However, descriptive results demonstrated a significant reduction in mean adjusted LOS of .7 days (4.5 to 3.8 days, P < .001) and a trend toward reduced readmissions (8.9% to 7.6%, P = .42) in the post-neurohospitalist cohort despite a significant increase in patient complexity, shift to higher acuity diagnoses, more emergent admissions, and near quadrupling of observation status patients. Mortality and in-hospital complications remained low, patient satisfaction was stable, and cost was not incrementally changed in the post-neurohospitalist cohort. Conclusions: Implementation of a neurohospitalist service at an academic medical center is feasible and associated with a significant increase in patient complexity and acuity and a trend toward reduced readmissions.

Recurrent Status Epilepticus in the Setting of Chimeric Antigen Receptor (CAR)-T Cell Therapy.

Axicabtagene ciloleucel (AC) is an FDA-approved anti-CD19 autologous chimeric antigen receptor T-cell (CAR-T) therapy for refractory diffuse large B cell lymphoma (DLBCL). While its efficacy in DLBCL has been promising, neurotoxicity remains a significant concern. We present a case of a 22-year-old woman with chemotherapy-refractory DLBCL who exhibited Grade IV neurotoxicity in the setting of sepsis, after undergoing AC infusion. Despite prophylactic levetiracetam given per guidelines,1,2 she experienced a precipitous mental status decline on post-infusion day 8 (D8) followed by hypoxic respiratory failure in the setting of clinical status epilepticus on D11 and nonconvulsive status epilepticus (NCSE) on D18. While neuroimaging was unremarkable, EEG demonstrated diffuse slowing and 2.5-3 Hz generalized periodic discharges consistent with NCSE. Seizures were initially refractory to lorazepam, increasing doses of levetiracetam, and phenobarbital, requiring a midazolam drip titrated to 50-70% burst suppression for resolution. Methylprednisolone and tocilizumab were used to treat neurotoxicity and cytokine release syndrome, respectively. Empiric antibiotics were used for sepsis. After cessation of sedatives on D19, mental status improved to near baseline. PET/CT just prior to discharge showed a complete response of the DLBCL (Deauville 3). She was discharged on D37 with no further seizure activity. Unfortunately, a 3-month interval PET/CT demonstrated disease progression which continued through salvage pembrolizumab eventually leading to death 1.2 years post-CAR-T infusion. This case illustrates the clinical management challenges of a complex and rare neurotoxic side effect of CAR-T cell therapy, namely NCSE following status epilepticus.

Who Should Make Medical Decisions When a Patient Lacks an Advance Directive?

Patients admitted to the hospital with neurological problems are sometimes incapacitated and unable to make end-of-life decisions. In these instances, without an advanced directive from the patient, clinicians and family members must make critical medical decisions without input from the patient. This paper looks at two cases - one child and one adult - in which neuroprognosis was uncertain, and physician and family members' beliefs on end-of-life care clash. We provide insight into these disagreements and reflect on how best to manage them. We argue that when considering withdrawing treatment, respecting autonomy is of paramount importance, while decision-making about continuing life-sustaining treatment requires clinicians to ensure surrogates are adequately educated about the principle of beneficence.

Quality Improvement Metrics and Methods for Neurohospitalists.

Measurement of clinical performance is largely driven by the requirements of the Centers for Medicare and Medicaid Services and accrediting bodies like The Joint Commission. Performance measures include length of stay, readmission rate, mortality rate, hospital-acquired complications, and stroke core measures. Hospital rankings also depend heavily on quality and patient safety indicators. Becoming facile with these measures can aid neurohospitalists in understanding their value and garnering resources to support improvement projects. Neurohospitalists can apply a structured A3-based method to define a clinical problem, perform systematic analysis, then design and test solutions to drive improved outcomes for patients with neurologic disease.

Leveraging Trends in Neurology Admissions for Departmental Planning During the COVID-19 Pandemic.

The COVID-19 pandemic has led to shifts in healthcare utilization for patients both with and without COVID-19. We aimed to determine how trends in neurology service admissions during the pandemic may aid in departmental planning by predicting future clinician staffing and other needs. We examined all admissions to the general neurology, stroke, and neurocritical care services from January 31 to May 16, 2020 at our tertiary-care hospital using an electronic health record query, comparing these to analogous data in 2019. We trended admission rates and projected future censuses using logarithmic regression, tracked changes in length of stay (LOS), and quantified shifts in presentations of specific diagnoses. Daily rates of admissions declined sharply during the week of March 13, 2020 (the week after pandemic status was declared by the World Health Organization). On the censoring date, we projected a return to pre-pandemic censuses in the week of June 21 and used this information to make decisions regarding neurology resident schedules. There was a trend toward increased LOS for general neurology and stroke patients between March 27 and April 9, 2020 compared to in 2019, with subsequent decline coinciding with early hospital initiatives. Since March 13, 2020, there has been a trend toward reduced presentations of ischemic stroke, suggesting a need for community education on stroke awareness. Characterizing early trends in neurology admissions may allow physician administrators to plan local and community-level responses to the pandemic.

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.

Influence of Autoimmune Antibody Testing on the Use of Immunotherapy on an Inpatient Neurology Service.

OBJECTIVE: To determine the frequency of autoimmune antibody testing in an inpatient neurology setting and its influence on immunotherapy use on an inpatient neurology service. METHODS: A retrospective descriptive cohort study of patients admitted to the neurology inpatient service at a large tertiary academic medical center who had autoimmune and/or paraneoplastic antibody testing performed between 10/1/2017 and 10/1/2018. Characteristics of patients' initial clinical presentation, antibody testing results, test timing in relation to initiating immunotherapy, and final diagnosis using consensus criteria were extracted and analyzed. Case reports of patients with positive antibody panels are presented. RESULTS: Of 1,604 patients, 50 patients (3.1%) had an antibody panel sent. Tests resulted after an average of 17 days (range 7-27). The most common clinical presenting symptom in those with a panel sent was encephalopathy. There were 5 (10%) positive serum panels and no positive CSF panels. Only one of these 5 patients had autoimmune encephalitis and was treated with immunotherapy. Of those with negative serum and CSF panels, 15 were treated acutely with empiric immunotherapy and the remainder with supportive care. Of those treated with immunotherapy, 14/15 (93%) were treated before the panel tests resulted. Four patients who had negative panels but were empirically treated met consensus criteria for an autoimmune-mediated neurologic process. CONCLUSION: Our study suggests that the results of antibody testing did not influence inpatient neurologists' decision to treat with immunotherapy as most treatments began prior to final results being available.