Showing papers by "Krishna Nalleballe published in 2021"

A review of pathophysiology and neuropsychiatric manifestations of COVID-19.

Abstract: The outbreak of coronavirus disease 2019 (COVID-19) has become one of the most serious pandemics of the recent times. Since this pandemic began, there have been numerous reports about the COVID-19 involvement of the nervous system. There have been reports of both direct and indirect involvement of the central and peripheral nervous system by the virus. To review the neuropsychiatric manifestations along with corresponding pathophysiologic mechanisms of nervous system involvement by the COVID-19. Since the beginning of the disease in humans in the later part of 2019, the coronavirus disease 2019 (COVID-19) pandemic has rapidly spread across the world with over 2,719,000 reported cases in over 200 countries [World Health Organization. Coronavirus disease 2019 (COVID-19) situation report-96.,]. While patients typically present with fever, shortness of breath, sore throat, and cough, neurologic manifestations have been reported, as well. These include the ones with both direct and indirect involvement of the nervous system. The reported manifestations include anosmia, ageusia, central respiratory failure, stroke, acute inflammatory demyelinating polyneuropathy (AIDP), acute necrotizing hemorrhagic encephalopathy, toxic–metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. These data were derived from the published clinical data in various journals and case reports. The neurological manifestations of the COVID-19 are varied and the data about this continue to evolve as the pandemic continues to progress.

A neuromuscular-based analysis of the open payments program

Abstract: Introduction In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. Method Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. Results The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. Discussion A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Risk of coronavirus disease 2019 (COVID-19) from hospital admission during the pandemic.

Abstract: Krishna Nalleballe MD1 , Suman Siddamreddy MD2, Sukanthi Kovvuru MD1, Poornachand Veerapaneni MD1, Bhaskar Roy MD3 and Sanjeeva Reddy Onteddu MD1 1Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, 2Department of Medicine, University of Arkansas for Medical Sciences/Baptist Health Program, North Little Rock, Arkansas and 3Department of Neurology, Yale School of Medicine, New Haven, Connecticut

Continued Underutilization of stroke care during the COVID-19 pandemic.

Abstract: Objective This study aims to investigate the utilization of acute ischemic stroke (AIS) services during the Corona Virus Disease 2019 (COVID-19) pandemic. Based on early observations among healthcare utilization on stroke and other healthcare services, we hypothesized that there would be a persistent significant decline in AIS patients presenting to hospitals as the pandemic has progressed for over a year. Method TriNetX, a large research network, is used to collect real-time electronic medical data. Data on utilization of acute ischemic stroke service was collected for the years 2018, 2019, and 2020 for variables including overall stroke volume and the number of patients that received intravenous tissue plasminogen activator (tPA) and mechanical thrombectomy (MT). Result We found a 13.2-15.4% decrease in total number of AIS patients in 2020 (n 77231) compared with the years 2018 and 2019 (n 88948 and 91270 respectively, p ​< ​0.001). In the year 2020 Stroke volume was significantly lower in Q4 comparing to Q1 (Q1 vs Q4, p ​< ​0.01, while there were no significant differences in stroke volume between Quarters 2, 3, and 4 in 2020 (Q2 vs Q3, p ​= ​0.39, Q2 vs Q4, p ​= ​0.61, Q3 vs Q4, p ​= ​0.18). The Proportion of patients receiving tPA in 2020 was significantly lower compared to prior years (5.4% in 2020 vs 6.4% in 2018 and 6.0% in 2019, p ​< ​0.01), however, the proportion of patients receiving MT was significantly higher in 2020 than in 2018 (0.024 vs 0.022, p ​< ​0.01). Conclusion Despite significant alteration in practices to optimize healthcare delivery and mitigate the collateral impact of the pandemic on care for other conditions, a persistent decline in AIS volumes remains. Delayed presentation, fear-of-contagion, reallocation, and poor availability of health care resources are potential contributors. Prospective evaluation and further investigation for these trends is needed.

Critically Ill Neurologic Patients During The COVID-19 Pandemic: A Short Communication

Abstract: Purpose We aimed to evaluate utilization of inpatient hospital and critical care services among critically ill neurologic patients during the COVID-19 pandemic. We hypothesized, based on prior observations among ischemic stroke patients, that there would be significant decline in critically ill neurologic patients presenting to hospitals during the pandemic which may impact outcomes. Methods We used TriNetX, a large research network, collecting real-time electronic medical records data. We extracted data on utilization of critical care and hospital inpatient services among cohorts of patients with common neurocritical conditions between January-June 2020 and compared it to data from similar time-frames in previous years. We also compared clinical outcomes, comprising need for intubation and 30-day mortality, among these cohorts. Results We found a 28.1% reduction in intensive care unit (ICU) admissions with critical neurologic illnesses in 2020 when compared to 2019 (8568 vs. 11,917 patients, p ​< ​0.0001) and a 34.4% reduction compared to 2018 (8568 vs. 13,064 patients, p ​< ​0.0001). However, there was no statistically significant difference in mortality (2020: 12.2 vs. 2019: 12.4%; p ​= ​0.7; vs. 2018: 12.6%; p ​= ​0.62) or intubation rates across the years among patients using critical care services. There was 1% increase in mortality among non-ICU patients with similar diagnoses in 2020 compared to previous years (2020: 3.9% vs. 2019: 2.9% vs. 2018: 3.1%; p ​< ​0.0001, p ​= ​0.0001), but no difference in intubation rates. Conclusion There was a significant reduction in hospital and ICU admissions among patients with acute neurologic emergencies in 2020, after onset of COVID-19 pandemic, compared to previous years. While we did not find a significant difference in mortality among patients admitted to the ICU, there was slightly higher mortality among non-ICU patients with same diagnoses in 2020 compared to previous years. Prospective evaluation and further investigation into the reasons for these trends is needed.

Cost-Effectiveness of Emergent MRI during Stroke Alert to Diagnose Stroke Mimics: Single-Center Experience.

Abstract: Objective The aim of this article was to assess the role of emergent magnetic resonance imaging (MRI) for stroke mimics during a stoke alert (within 45 minutes) in reducing direct cost of management and duration of inpatient stay Methods We did a retrospective chart review of all the patients who received emergent MRI brain during a stroke alert to help make decision about intravenous tissue-type plasminogen activator (IV tPA) administration from January 2013 to December 2015 Using the patient financial resource data and with the help of billing department, we calculated the approximate money saved in taking care of the patients who may have received IV tPA if emergent MRI brain was not available to diagnose stroke mimics as they presented with acute neurologic deficit within IV tPA time window Results Ninety seven out of 1,104 stroke alert patients received emergent MRI Of these only 17 (175%) were diagnosed with acute ischemic stroke (AIS), and 80 (825%) as stroke mimics By doing emergent MRI for suspected stroke mimics, our study showed an approximate total saving of $1,005,720 to $1,384,560, that is, $12,571 to $17,307 per patient in medical expenditure Discussion We suggest modification of stroke pathway from current algorithm “CT+CTA≥IV-tPA/neurointervention≥MRI” to “MRI+MRA≥IV-tPA/neurointervention” for possible stroke mimics, which can reduce the cost, radiation exposure, and duration of hospital stay for stroke mimics Conclusion Emergent MRI is a cost-effective tool to evaluate IV-tPA eligibility for suspected stroke mimics during a stroke alert

Industry Payments to Nephrologists in the United States.

Abstract: Background Industry payments to physicians raise concerns about conflicts of interest that have the potential to impact patient care. In this study, we explored nonresearch and nonownership payments from industry to nephrologists to identify trends in compensation. Methodology Using data from the Centers for Medicare and Medicaid Services (CMS), we explored financial relationships between industry and US nephrologists from 2014 to 2018. We analyzed payment characteristics including payment categories, payment distribution among physicians, regional trends, and biomedical manufacturers. Results In this retrospective study, a total of $75,174,999 was paid to nephrologists in the United States during the study period (i.e., 2014-2018). The number of board-certified nephrologists receiving payment from the industry increased from 11,642 in 2014 to 13,297 in 2018. Among board-certified nephrologists, 56% to 63% received industry payments during the study period. The total payments to nephrologists increased from $13,113,512 in 2014 to $16,467,945 in 2017, with consulting fees (24%) and compensation for services other than consulting (35%) being the highest-paid categories. The top 10% of physician beneficiaries collected 90% of the total industry payments. Conclusions A small proportion of US nephrologists consistently received the majority of industry payments, the value of which grew over the study period.

Trends in Demographics of Neurology House Staff in the United States.

Abstract: Background The lack of an adequate number of neurologists is a worldwide problem. As populations age, the prevalence of neurological disorders will likely increase, thereby increasing the demand for neurologists. In addition to the growing demand, inadequate diversity in the neurology healthcare workforce still exists. The purpose of this study is to examine the demographic characteristics of neurology residents and fellows. Methodology This cross-sectional study used data from the following publicly available databases: Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, and the United States Census Bureau. Trends (from 2007 to 2018) in demographic characteristics were assessed using the slope and the associated p-value of a simple linear regression model, with the year as the independent variable. All p-values of <0.05 were considered significant. Results From 2007 through 2018, the percentage of US medical school graduates in neurology residency decreased from 58% to 55% (slope = -0.25; p = 0.0004), while the percentage of international medical graduates (IMGs) decreased from 36% to 32% (slope = -0.29; p = 0.0141) and doctor of osteopathy (DO) graduates increased from 6% to 13% (slope = 0.58; p < 0.0001). Although the percentage of female neurology residents increased from 39.5% in 2007 to 43.1% in 2018 (slope = 0.03; p = 0.8659), female physicians were underrepresented in vascular neurology fellowship (34% in 2018). Collectively, the percentage of underrepresented minorities in neurology residencies was low and increased only slightly over time (from 8% in 2011 to 9% in 2018; slope = 0.17; p = 0.0788). In 2018, the proportion of underrepresented minorities was smaller in neurology fellowships (5.5% neurophysiology, 12.5% epilepsy, 10.4% neuromuscular, and 12.4% vascular) compared to the population as a whole (31.3%). Conclusions IMGs still play an important role in filling a significant portion of the neurology residencies and fellowships. DO graduates have slowly increased in neurology residencies and fellowships. Members of several racial/ethnic minority groups and women are underrepresented in neurology house staff and efforts need to be taken to increase diversity.

EEG Benign Variants

Abstract: Electroencephalogram (EEG) is one of the most important tools in the care of patients with epilepsy. EEG plays a significant role in the diagnosis of seizures and psychogenic non-epileptic spells. One of the most important aspects of interpreting EEGs is distinguishing between pathologic activity and similar-appearing normal physiologic findings. Various terminologies are used, such as: "normal variants," "benign variants," "pseudo-epileptiform patterns," or "epileptiform patterns without proven relation to seizures."

Isolated primary neurolymphomatosis with cranial multineuritis: a case presentation.

Abstract: Isolated primary neurolymphomatosis (NL) of cranial multineuritis is a very rare condition that refers to the lymphomatous invasion of cranial nerves only. There are sparse cases of isolated cranial nerves NL reported worldwide. We present magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) findings of a 63-year-old female patient suffering from isolated neurolymphomatosis of cranial multineuritis with a wide constellation of syndromes including binocular diplopia, left facial paralysis and pain, syncope episodes, and progressive dysphagia. A contrasted MRI brain showed multiple cranial nerves enhancement. Extensive workup for infectious, autoimmune, neoplastic, paraneoplastic, or inflammatory etiologies had been unrevealing except CSF cytology revealed large atypical monotypic B cells that were suspicious for non-Hodgkin lymphoma on the third large volume tap. The decision of biopsy was deferred after the risks and benefits discussion. Following the four cycles of empiric methotrexate-based induction chemotherapy, the patient’s symptoms resolved, and a complete radiographic response was achieved without whole-brain radiation or autologous hematopoietic cell transplantation. In the latest follow-up, she is independent with her daily activities and remains in clinical and radiographic remission more than 3 years since initial chemotherapy. Isolated NL of cranial nerves can present diagnostic and management pitfalls for the neurologist, neurosurgeons, and oncologists. Since current diagnostic modalities have modest sensitivity and a pathological diagnosis is often difficult, empiric treatment once other possibilities are ruled out can carry a good prognosis.

Before attributing COVID_19-related ischemic stroke to hypercoagulability alternative causes should be excluded.

Abstract: We thank Landstrasse et al. for their interest in our work and for raising concerns regarding attributing Corona Virus Disease 2019 (COVID-19) related ischemic stroke to hypercoagulability. All the four patients describedwere on continuous cardiac monitoring during hospitalization and EKG on admission showed no atrial fibrillation or other arrhythmias. Patient 1 had elevated hypercoagulability and inflammatory markers except fibrinogen levels. He was monitored with an event monitor which did not show atrial fibrillation. Patient 2 was encephalopathic on presentation most likely due to severe COVID-19 and respiratory failure. Severe COVID-19 can cause encephalopathy (Umapathi et al., 2020; Shah et al., 2020). Magnetic resonance imaging (MRI) of the brain was not performed as mentioned in the article because the patient deteriorated rapidly and eventually passed away. The findings on CT scan of this patient are in the left MCA distribution which is more suggestive of ischemic stroke than encephalitis. The lesions on this CT scan don’t look like old lesions. It is important to mention that this scan was reviewed and reported as a stroke by a neuro-radiologist. Brain MRI of patient 3 is suggestive of embolic vs border zone infarctions. It was also mentioned in the article that hypotension is a possible cause of infarction in this patient. He didn’t have any signs of heart failure and as mentioned in the article, no low blood pressure was recorded during hospitalization. The cardiac mass was mentioned as a possible cause of stroke in patient 4 in the article in addition to COVID-19. The nature of the cardiac mass is unknown because the patient declined further work up prior to having the stroke and autopsy wasn’t performed. HBA1C was 9.8%, 6.0%, 6.1% and 14% for patients 1,2,3 and 4 respectively. Patient 3 is an ex-smoker and the other patients never smoked. All the reported patients had vessel imaging as mentioned in the article and table 1. None of them had vasculitis. As mentioned in the article, patient 1 and 2 had a CT angiogram of the head and neck, patient 3 and 4 had a magnetic resonance angiogram (MRA) of the head and neck. The article concluded that stroke can be a complication of severe COVID-19 because the 4 reported patients had severe infection with