Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA

Summary Background The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. On the basis of knowledge of other coronaviruses, especially those that caused the severe acute respiratory syndrome and Middle East respiratory syndrome epidemics, cases of CNS and peripheral nervous system disease caused by SARS-CoV-2 might be expected to be rare. Recent developments A growing number of case reports and series describe a wide array of neurological manifestations in 901 patients, but many have insufficient detail, reflecting the challenge of studying such patients. Encephalopathy has been reported for 93 patients in total, including 16 (7%) of 214 hospitalised patients with COVID-19 in Wuhan, China, and 40 (69%) of 58 patients in intensive care with COVID-19 in France. Encephalitis has been described in eight patients to date, and Guillain-Barre syndrome in 19 patients. SARS-CoV-2 has been detected in the CSF of some patients. Anosmia and ageusia are common, and can occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 2–6% of patients hospitalised with COVID-19. So far, 96 patients with stroke have been described, who frequently had vascular events in the context of a pro-inflammatory hypercoagulable state with elevated C-reactive protein, D-dimer, and ferritin. Where next? Careful clinical, diagnostic, and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease (eg, hypoxic encephalopathy and critical care neuropathy) from those caused directly or indirectly by the virus, including infectious, para-infectious, and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barre syndrome. Recognition of neurological disease associated with SARS-CoV-2 in patients whose respiratory infection is mild or asymptomatic might prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will probably remain small. However, these patients might be left with severe neurological sequelae. With so many people infected, the overall number of neurological patients, and their associated health burden and social and economic costs might be large. Health-care planners and policy makers must prepare for this eventuality, while the many ongoing studies investigating neurological associations increase our knowledge base.

Neurological Associations of COVID-19

Background and purpose COVID-19 is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Apart from respiratory complications, acute cerebrovascular disease (CVD) has been observed in some patients with COVID-19. Therefore, we described the clinical characteristics, laboratory features, treatment and outcomes of CVD complicating SARS-CoV-2 infection. Materials and methods Demographic and clinical characteristics, laboratory findings, treatments and clinical outcomes were collected and analysed. Clinical characteristics and laboratory findings of patients with COVID-19 with or without new-onset CVD were compared. Results Of 219 patients with COVID-19, 10 (4.6%) developed acute ischaemic stroke and 1 (0.5%) had intracerebral haemorrhage. COVID-19 with new onset of CVD were significantly older (75.7±10.8 years vs 52.1±15.3 years, p Conclusion Acute CVD is not uncommon in COVID-19. Our findings suggest that older patients with risk factors are more likely to develop CVD. The development of CVD is an important negative prognostic factor which requires further study to identify optimal management strategy to combat the COVID-19 outbreak.

https://svn.bmj.com/content/svnbmj/5/3/279.full.pdf

Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study

Background: The COVID-19 pandemic, caused by SARS-CoV-2, is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. Based on knowledge of other coronaviruses, especially those that caused the SARS and MERS epidemics, we might expect to see rare cases of central nervous system (CNS) and peripheral nervous system (PNS) disease caused by SARS-CoV-2.

Recent developments: A growing number of case reports and series describe a wide array of neurological manifestations, but many lack detail, reflecting the challenge of studying such patients. Encephalopathy is relatively common, being reported for 93 patients in total, including 16 (7.5%) of 214 hospitalised COVID-19 patients in Wuhan, China, and 40 (69%) of 58 in intensive care with COVID-19 in France. Encephalitis has been described in 8 patients to date, and Guillain-Barre syndrome in 19 patients. SARS-CoV-2 is detected in the cerebrospinal fluid of some patients. Anosmia and ageusia are common and may occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 1.6-6% of hospitalised COVID-19 cases. So far, 88 patients have been described, mostly with ischaemic stroke, who frequently have vascular events in the context of a pro-inflammatory hypercoagulable state with elevated CRP, D-dimer, and ferritin.

Where next?: Careful clinical, diagnostic and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease, such as hypoxic encephalopathy and critical care neuropathy, from those caused directly or indirectly by the virus; these include infectious, para- and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barre syndrome. Recognising SARS-CoV-2 neurological disease in patients whose respiratory infection is mild or asymptomatic may prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will remain small. However, these patients may be left with severe neurological sequelae. With so much of the population infected, the overall number of neurological patients, and their associated health, social and economic costs, may be large. Healthcare planners and policymakers must prepare for this eventuality. The many ongoing studies investigating the neurological association will increase our knowledge base.

/pdf/neurological-associations-of-covid-19-o39p8yig6g.pdf


 Background:
 Telestroke hospitals in the southern Arkansas Delta participating in the American Heart Associations (AHA) Get With the Guidelines® (GWTG) are challenged with medically disadvantaged, vulnerable patient populations. The Delta is largely rural with a poverty rate higher than the US National average and residents suffer a 10 year lower life expectancy of when compared to neighboring northern counties. To determine the Delta’s influence on stroke recognition and outcomes, we examined 3-digit zip code, age at stroke occurrence, race, transport mode to diagnosing hospital, patient disposition at discharge, and stroke type in calendar years (CY) 2019 to 2021.
 
 
 Methods:
 We retrospectively reviewed the AHA GWTG Stroke data for the University of Arkansas for Medical Sciences (UAMS) Institute for Digital Health & Innovation (IDHI) - Telestroke Program 2019 to 2021, from 47 of the Programs 58 participating hospital sites. Transport mode included transfers from other hospitals, emergency medical services (EMS) transport, or privately owned vehicle/taxi (POV). Patient age significance was determined using ANOVA and categorical differences with chi square analysis.
 
 
 Results:
 Data totals were 13,721 entries with 4,571, 4,478 and 4,672 entries by CY. Ages at stroke onset were among the lowest in the zip codes from Delta areas with a median age of 66 compared to the median age of 69 for Arkansas as a whole. Percentages of stroke among Black or African Americans were the highest in Delta areas in all CYs p=0.002, p<0.0001 and p<0.0001, respectively. Patient disposition at discharge with increased discharges home vs. hospice was significant by race at all CY’s p=0.01; =0.017; =0.012, respectively. Black or African Americans had an increased %death vs. Whites in 2021, 3.7% vs. 2.8%, respectively. Transport mode was significant in 2021 with increased percentages of EMS transport of ischemic and hemorrhagic strokes and increased POV transport of transient ischemic attacks (< 24 hours) TIAs X
 2
 =535; p<0.0001. Delta regions experienced a higher percentage of TIAs and ischemic strokes X
 2
 =836; p<0.0001.
 
 
 Conclusions:
 Delta areas remain at risk for increased stroke mortality for Black or African Americans and younger populations.


Abstract WP85: Stroke Prevalence In Arkansas's Delta

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

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

<h3>Objective:</h3> In this study, we aim to identify predictors of a no-show in neurology clinics at our institution. We conducted a retrospective review of neurology clinics from July 2013 through September 2018. <h3>Background:</h3> No-show in ambulatory neurology clinics does not only affect the efficiency and quality of workflow, but it also directly impacts the revenue and healthcare resources available to other patients. Moreover, clinic no show has significant implications on patients including delayed diagnosis and treatment, clinical worsening, and affects the management of medications that require close laboratory follow up such as anticonvulsant medications and immunotherapies. <h3>Design/Methods:</h3> We compared the odds ratio of patients who missed appointments (no-show) to those who were present at appointments (show) in terms of age, lead-time, subspecialty, race, gender, quarter of the year, insurance type, and distance from hospital. <h3>Results:</h3> There were 60,012 (84%) show and 11,166 (16%) no-show patients. With each day increase in lead time, odds of no-show increased by a factor of 1.0019 (p &lt; 0.0001). Odds of no-show were higher in younger (p ≤ 0.0001, OR = 0.49) compared to older (age ≥ 60) patients and in women (p &lt; 0.001, OR = 1.1352) compared to men. They were higher in Black/African American (p &lt; 0.0001, OR = 1.4712) and lower in Asian (p = 0.03, OR = 0.6871) and American Indian/Alaskan Native (p = 0.055, OR = 0.6318) as compared to White/Caucasian. Patients with Medicare (p &lt; 0.0001, OR = 1.5127) and Medicaid (p &lt; 0.0001, OR = 1.3354) had higher odds of no-show compared to other insurance. <h3>Conclusions:</h3> Young age, female, Black/African American, long lead time to clinic appointments, Medicaid/Medicare insurance, and certain subspecialties (resident and stroke clinics) are associated with high odds of no show. Possible suggested interventions include better communication and flexible appointments for the high-risk groups as well as utilizing telemedicine. <b>Disclosure:</b> Dr. Dhasakeerthi has nothing to disclose. Dr. Elkhider has nothing to disclose. Dr. Sharma has nothing to disclose. Dr. Thatikala has nothing to disclose. Dr. Nalleballe has nothing to disclose. Dr. Onteddu has nothing to disclose. 

Predictors of No-show in Neurology clinics (P1-5.032)

Idiopathic generalized epilepsy is a group of epilepsies accounting for about 20 to 40% of all epilepsies. This group of epilepsies is clinically characterized by the presence of absence seizures, generalized tonic-clonic seizures, and myoclonic seizures with an electroencephalographic pattern of generalized epileptiform spike and wave or polyspike and wave discharge, at times with a shifting predominance on a normal background.Based on the latest International League Against Epilepsy (ILAE) classification, idiopathic generalized epilepsies include childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, and generalized tonic-clonic seizures alone.Juvenile absence epilepsy is an idiopathic generalized epilepsy syndrome that is recognized by the ILAE (International League Against Epilepsy) that typically starts in adolescence around puberty and is characterized by absence seizures and generalized tonic-clonic seizures. In some patients, there may be additional myoclonic jerks as well.

Juvenile Absence Epilepsy

Background Hormone replacement therapy (HT) for post-menopausal women is associated with increased incidence of ischemic stroke risk. Effects of HT on stroke related deficits and functional outcomes in acute ischemic stroke (AIS) are uncertain. We retrospectively examined female consult data for HT use and National Institutes of Health Stroke Score (NIHSS) at baseline and recovery for 2015 and 2016 in a large stroke telemedicine program. Hypothesis The age of women who acknowledged HT use will negatively impact stroke severity and outcomes. Methods We analyzed consult data from two consecutive years for all women and included HT use, current age, and baseline and 24 h NIHSS's. We included all women consults regardless of IV Alteplase treatment. 24 h NIHSS and three month modified Rankin scale (mRS) were included from women given IV Alteplase. Results Strokes were identified in 523 women and 244 women received Alteplase therapy. Women without HT use numbered 459 and 64 women listed HT use. Mean NIHSS scores regardless of HT use significantly improved 24 h NIHSS vs. baseline NIHSS (p<0.0001). Baseline NIHSS scores were significantly improved in women on HT vs. non-HT users (p=0.01) in women age 50 to 79 years. Although mean NIHSS scores at 24h was not different from HT to no HT use (4.9 ± 1.6 vs. 7.8 ± 0.6, p=0.08) a trend was present for lower NIHSS scores for women 50-79 years. The mRS scores at three months indicated significant improvements among HT users vs. non-HT use (1.46 ± 0.4 vs. 2.51 ± 0.2, p=0.05). Conclusion While cautions persist on the use, route and dosage of HT for risks of ischemic stroke, the HT moderation of AIS deficits and outcomes in women <80 years of age warrants further investigation.

Krishna Nalleballe

Papers

Abstract WP85: Stroke Prevalence In Arkansas's Delta

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

Predictors of No-show in Neurology clinics (P1-5.032)

Juvenile Absence Epilepsy

Women on Hormone Therapy with Ischemic Stroke, Effects on Deficits and Recovery.