Neurological Care Research Articles

Telemedicine applied to neurology, a syndromic approach

Introduction: Telemedicine has proven invaluable, especially in cases like stroke, where it expedites accurate diagnosis and thrombolytic treatment initiation, thereby reducing mortality rates. Objectives: Evaluate the efficacy of telemedicine in diagnosing neurological syndromes among patients receiving outpatient care through teleneurology. Methodology:A systematic literature review was conducted using a qualitative and descriptive approach, guided by the "PICO" search and analysis strategy. The study population comprised patients seeking outpatient neurological care, with the primary interest being the assessment of telemedicine's efficiency in diagnosing neurological syndromes. Data were collected from PubMed, Scopus, and BVS databases using predefined inclusion and exclusion criteria. Results: Several studies demonstrated the successful application of telemedicine in neurological care. For instance, teleconsultations with patients diagnosed with cognitive impairment yielded positive outcomes, reducing demands while delaying symptom progression. However, the feasibility of telemedicine varied across different regions and patient demographics, highlighting socio-economic factors as determinants of accessibility and acceptance. Additionally, telemedicine showed promise in managing complex neurological conditions such as cerebellar ataxia, Parkinson's disease, and myasthenia gravis, albeit with certain limitations in physical examination capabilities. Conclusion: In conclusion, telemedicine has emerged as a crucial tool in neurology, overcoming geographical barriers and enhancing access to specialized care. Despite its widespread adoption, challenges persist, particularly in ensuring equitable access across diverse populations. Moving forward, addressing these challenges and advancing telemedicine infrastructure will be paramount in optimizing neurological care delivery and improving patient outcomes.

Efficiency of telemedicine in referral from primary to secondary and tertiary care in neurology in Brazil

Introduction: Telemedicine is the practice of medicine mediated by digital information and communication technologies, for the purposes of care, education, research, disease and injury prevention, management and health promotion. One of its modalities is teleconsultation. Objective: Systematic and integrative review of the literature on the efficiency of telemedicine in referral from primary to secondary and tertiary care in Brazil, in the context of neurology. Method: The "PICO" search and analysis strategy was used, with the guiding question: "How efficient is telemedicine when applied as a tool to guide the referral of patients with neurological conditions from primary to secondary and tertiary centers?” using the descriptors “telemedicine, referral, Brazil, neurology, and consultation” in the boolean form “AND” and “OR”, in PubMed and BVS in English and Portuguese. Results: 16 articles were included. Conclusion: Research indicates that the use of telemedicine proves to be an important tool for improving the efficiency of referrals from primary to secondary and tertiary care, promoting cost reduction, reducing waiting lists and promoting alternative medical care for the population.

Clinician perspectives on characteristics and care of traumatic brain injury among asylum seekers and refugees

Purpose Traumatic brain injury (TBI) disproportionately affects asylum-seekers and refugees (ASR), although underdiagnosed and undertreated. Our study assesses clinicians’ perspectives on characteristics and management of TBI among ASR, with the hope of improving TBI management in this population. Materials and Methods We conducted six focus groups of 16 clinicians across two academic medical centers in Boston, Massachusetts, United States. Clinicians in our sample included primary care clinicians, nurse practitioners, social workers, psychologists, neurologists, psychiatrists, and neuropsychologists. We analyzed the qualitative data following a hybrid inductive-deductive thematic analytic approach. Results Clinicians characterized TBI among ASR as mostly mild and remote, involving head strikes, perpetrated predominantly by interpersonal violence and strangulation-related brain injury, and involving symptom overlap with mental health diagnoses, challenging diagnosis. Clinicians also described inadequate screening, the importance of connecting the physical and psychological symptoms of the brain injury rather than viewing them as distinct, and addressing diagnosis-related stigma and shame. Finally, they discussed lack of TBI-specific knowledge among providers and patients alike, and resource limitations affecting the continuum of care for this population. Conclusion Integrating clinicians’ perspectives in caring for this population allows us to best meet their needs, including in TBI recovery.

Adherence to practice parameters in Medicare beneficiaries with amyotrophic lateral sclerosis.

Physician adherence to evidence-based clinical practice parameters impacts outcomes of amyotrophic lateral sclerosis (ALS) patients. We sought to investigate compliance with the 2009 practice parameters for treatment of ALS patients in the United States, and sociodemographic and provider characteristics associated with adherence. In this population-based, retrospective cohort study of incident ALS patients in 2009-2014, we included all Medicare beneficiaries age ≥20 with ≥1 International Classification of Diseases, Ninth Revision, Clinical Modification ALS code (335.20) in 2009 and no prior years (N = 8,575). Variables of interest included race/ethnicity, sex, age, urban residence, Area Deprivation Index (ADI), and provider specialty (neurologist vs. non-neurologist). Outcomes were use of practice parameters, which included feeding tubes, non-invasive ventilation (NIV), riluzole, and receiving care from a neurologist. Overall, 42.9% of patients with ALS received neurologist care. Black beneficiaries (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.67), older beneficiaries (OR 0.964, 95% CI 0.961-0.968 per year), and those living in disadvantaged areas (OR 0.70, 95% CI 0.61-0.80) received less care from neurologists. Overall, only 26.7% of beneficiaries received a feeding tube, 19.2% NIV, and 15.3% riluzole. Neurologist-treated patients were more likely to receive interventions than other ALS patients: feeding tube (OR 2.80, 95% CI 2.52-3.11); NIV (OR 10.8, 95% CI 9.28-12.6); and riluzole (OR 7.67, 95% CI 6.13-9.58), after adjusting for sociodemographics. These associations remained marked and significant when we excluded ALS patients who subsequently received a code for other diseases that mimic ALS. ALS patients treated by neurologists received care consistent with practice parameters more often than those not treated by a neurologist. Black, older, and disadvantaged beneficiaries received less care consistent with the practice parameters.

Improved Accuracy/Completeness of EHR Race/Ethnicity Data: A Requisite Step to Address Disparities in Care.

Accurate and complete racial/ethnic data in the electronic health record are a requisite step to addressing disparities in neurologic care, and at local, regional, and national levels. The current data pertaining to the patients' race and ethnicity contained in the electronic health record are inadequate. This article outlines recommendations at the individual practice and electronic health record vendor level to improve documentation of race and ethnicity.

Spectrum of Magnetic Resonance Imaging Findings in Acute Pediatric Traumatic Brain Injury - A Pictorial Essay.

Head trauma (HT) in pediatric patients is the number one cause of mortality and morbidity in children. Although computer tomography (CT) imaging provides ample information in assessing acute traumatic brain injuries (TBIs), there are instances when magnetic resonance imaging (MRI) is needed. Due to its high sensitivity in diagnosing small bleeds, MRI offers a well-documented evaluation of primary acute TBIs. Our pictorial essay aims to present some of the latest imaging protocols employed in head trauma and review some practical considerations. Injury mechanisms in accidental HT, lesions' topography, and hematoma signal variability over time are also discussed. Acute primary intra- and extra-axial lesions and their MRI aspect are showcased using images from patients in our hospital. This pictorial essay has an educational purpose. It is intended to guide young emergency and intensive care unit doctors, neurologists, and neurosurgeons in diagnosing acute primary TBIs on MRI while waiting for the official radiologist's report. The presentation focuses on the most frequent traumatic lesions encountered in acute pediatric head trauma.

Operational Impact of Neurology Rural Access Model: Reflections on the Importance of Demand-Shaping.

Demand for specialty neurologic care has been steadily increasing over the past several decades, and health systems are needing to meet the demands of their patients while managing a dwindling workforce. This retrospective study investigates the operational impact of a regional neurology clinic staffed by advanced practice providers with remote physician oversight in a "hub and spoke" delivery model to serve lower complexity patients. A retrospective, cross-sectional study was conducted to evaluate outcomes. Descriptive analysis of referral volumes, cancellation/no-show rates, and patient complexity as determined by the reason for referral were used to evaluate patients who received referrals from rural counties north of the primary neurology practice before and after the opening of the regional clinic. These metrics were evaluated longitudinally from counties of interest and for differences in patients seen at the regional clinic vs primary neurology practice. Referral volumes from the northern counties increased at significantly higher rates after the opening of the regional clinic than other counties in the serviced area. This resulted in an increase in patients seen in the hub clinics and spoke clinic. The regional clinic did see patients who were less complex than the primary practice; however, the total volume of low-complexity patients scheduled at the primary practice did not decrease. Cancellation and no-show rates did not seem to be affected in either clinic. The opening of a regional "spoke" clinic resulted in the generation of greater referral volumes that exceeded the capacity created by the clinic. Owing to this, there was an increase in the number of patients seen from the regional counties in the hub clinics, negating the potential benefit of improving access for high-complexity patients. Importance of demand-shaping and appropriate utilization as part of the value equation are discussed, followed by discussion of mitigation strategies.

D.6 Neurological care and outcomes of pregnant patients with epilepsy in a Canadian tertiary care center (2014-2020)

Background: Limited data exists on neurological care and outcomes of Canadian pregnant patients with epilepsy (PPWE). This study provides Canadian data to inform practice patterns and observed outcomes for PPWE at a tertiary care center. Methods: PPWE receiving care at the University Health Network (Toronto, Canada) epilepsy clinic from January 1, 2014 to November 20 2020 were retrospectively identified with demographics and neurological data and outcomes collected. Results: A total of 195 cases were identified, with a median maternal age of 32 years (SD 4.58), a median age at first seizure of 17 years (range 1 month – 36 years old), 52% were diagnosed with genetic generalized epilepsy and 50% endorsed 6 months of seizure freedom prior to conception. In pregnancy, 93% took ASM(s) with 77% receiving therapeutic drug monitoring (TDM) and drug dose adjustments reported in 69%. Most cases (73%) maintained a stable seizure frequency. Conclusions: This study provides new Canadian data on PPWE at a tertiary care center. PPWE are overall well controlled, more likely to have young adult onset, genetic generalized epilepsy with nearly all taking ASM(s) during pregnancy. While high rates of TDM and drug dose adjustments were observed, most experienced seizure stability in pregnancy.

P.019 A shared decision-model toolkit for pregnancy related care in neurology

Background: Shared decision-making (SDM) is a dynamic, patient-engaged approach to collaborative medical care. Limited SDM tools exist in pregnancy. We aimed to examine the need and usability of a novel SDM tool for pharmaco-therapeutic treatment of neurological conditions in pregnancy. Methods: This is an exploratory mixed-methods study. Non-pregnant women of any age were recruited using convenience, purposive sampling from an academic neurology clinic in Toronto. Participants reported the user friendliness of the SDM by completing the systems usability (SUS) questionnaire and participated in a focus group to further elaborate on their experience. Results: Eleven participants completed the survey 45% each between age 31-40, and 51-60. Median time spent on the tool was 17.2 minutes, and median SUS score 70 (<68 being not usable). Thematic data analysis from 2 focus groups, identified technical and content improvements: use of inclusive language, simplified design, and importance of patient engagement in SDM. Conclusions: Based on our preliminary results, a SDM web-tool for medication-related concerns of pregnant patients with neurological conditions is needed and usable. With integration of patients’ lived experiences, this novel tool may serve as an anchor point for future work in this field.

Disparities in Teleneurology Use in Medicaid Beneficiaries With Epilepsy by Practice Setting: Promoting Health Equity in Academic Centers.

Medicaid beneficiaries in many American academic medical centers can receive care in a separate facility than those not covered by Medicaid. We aimed to identify possible disparities in care by evaluating the association between facility type (integrated faculty practice or Medicaid-only outpatient clinic) and telehealth utilization in people with epilepsy. We performed retrospective analyses using structured data from the Mount Sinai Health System electronic medical record data from January 2003 to August 2021. We identified people of all ages with epilepsy who were followed by an epileptologist after January 3, 2018, using a validated ICD-9-CM/10-CM coded case definition. We evaluated associations between practice setting and telehealth utilization, an outcome measure that captures the evolving delivery of neurologic care in a post-coronavirus disease 2019 era, using multivariable logistic regression. We identified 4,586 people with epilepsy seen by an epileptologist, including Medicaid beneficiaries in the Medicaid outpatient clinic (N = 387), Medicaid beneficiaries in the faculty practice after integration (N = 723), and non-Medicaid beneficiaries (N = 3,476). Patients not insured by Medicaid were significantly older (average age 40 years vs 29 in persons seen in Medicaid-only outpatient clinic and 28.5 in persons insured with Medicaid seen in faculty practice [p < 0.0001]). Medicaid beneficiaries were more likely to have drug-resistant epilepsy (DRE), with 51.94% of people seen in Medicaid-only outpatient clinic, 41.63% of Medicaid beneficiaries seen in faculty practice, and 37.2% of non-Medicaid beneficiaries having DRE (p < 0.0001). Medicaid outpatient clinic patients were less likely to have telehealth visits (phone or video); 81.65% of patients in the Medicaid outpatient clinic having no telehealth visits vs 71.78% of Medicaid beneficiaries in the faculty practice and 70.89% of non-Medicaid beneficiaries (p < 0.0001). In an adjusted logistic regression analysis, Medicaid beneficiaries had lower odds (0.61; 95% CI 0.46-0.81) of using teleneurology compared with all patients seen in faculty practice (p = 0.0005). Compared with the Medicaid-only outpatient clinic, we found higher telehealth utilization in the integrated faculty practice with no difference by insurance status (Medicaid vs other). Integrated care may be associated with better health care delivery in people with epilepsy; thus, future research should examine its impact on other epilepsy-related outcomes.

Identifying Barriers and Facilitators to Accessing Care for Historically Marginalized Communities Affected by Parkinson Disease: A Qualitative Study.

Parkinson disease (PD) is the second most common neurodegenerative disease. Members of the Black Diaspora (MBD) and Hispanic/Latinx people are less likely to receive a timely diagnosis following the onset of symptoms and more likely to experience greater disease severity due to late diagnosis. Historically marginalized populations (i.e., MBD, Hispanic, and Latinx communities) are not accurately represented in research; this, along with many other barriers, compounds underreporting and lack of recognition of PD. It is important to understand barriers to early diagnosis and healthcare access for these historically marginalized populations from the community's perspective. Our team conducted two focus groups to identify barriers and facilitators to PD healthcare-seeking behavior. We sought to identify which barriers are modifiable to ultimately improve engagement in neurological care for MBD and Hispanic individuals affected by PD. We enrolled 15 participants (13 female; African/African American/Black n = 10, Hispanic/Puerto Rican n = 3, other n = 2) for two focus groups. Discussions revealed sources of barriers to healthcare-seeking behavior in three main domains: legacy of racism in the United States, ancestral cultural environment, and healthcare system access. These sources influenced individuals' PD knowledge and familiarity. Additionally, participants expressed a desire to know more about PD and called for increased community-based programming for education and awareness. This paper uses a community-based participatory research approach to describe the experiences of MBD, Hispanic, and Latinx people in Manhattan and the surrounding areas in relation to possible sources of healthcare disparities and delayed PD diagnosis. These sources have broad implications and should be addressed through collaborative community programming.

Integrated Care in Neurology: The Current Landscape and Future Directions.

The rising burden of neurological disorders poses significant challenges to healthcare systems worldwide. There has been an increasing momentum to apply integrated approaches to the management of several chronic illnesses in order to address systemic healthcare challenges and improve the quality of care for patients. The aim of this paper is to provide a narrative review of the current landscape of integrated care in neurology. We identified a growing body of research from countries around the world applying a variety of integrated care models to the treatment of common neurological conditions. Based on our findings, we discuss opportunities for further study in this area. Finally, we discuss the future of integrated care in Canada, including unique geographic, historical, and economic considerations, and the role that integrated care may play in addressing challenges we face in our current healthcare system.

Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care.

This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).

Assessing Knowledge and First-aid Practice Scores of Caregivers of Epilepsy Patients Before and After an Educational Programme in the Kingdom of Saudi Arabia

Background Although epilepsy is one of the most prevalent and severe neurologic disorders, our knowledge of its intricate pathophysiology and skills to manage are still limited. Recognising its early signs and symptoms are crucial skills for caregivers of epileptic patients to acquire. This study was aimed at assessing the effectiveness of an education programme on improvement in the caregivers’ knowledge of epilepsy and first-aid practices. The findings will assist caregivers of children with seizures who frequently experience fear and anxiety relative to their perceived confidence to manage seizures. Education to caregivers could improve their perceived level of self-efficacy. Methods A community-based, pre- and post-intervention survey was conducted at neurologic care clinics across Saudi Arabia. Data were collected using a pretested, semi-structured, interviewer-administered questionnaire. The educational intervention was aimed at disseminating information via a short talk and video demonstration of epilepsy-related first-aid good practices. Data were analysed using SPSS version 21. Results Pre-intervention survey of 586 caregivers revealed that nearly 60% had inadequate knowledge of epilepsy; this was reduced to 23.2% after education. Similarly, 84% of caregivers had inadequate knowledge of first-aid practices before the educational intervention, but this was reduced to 32.4% after that. Having resided in the Western regions was a negative predictor of good first-aid practice knowledge scores, both before and after education. A university degree or higher education was positive predictor of higher knowledge scores both before (T=-4.564; p&lt;0.001) and after education (T=-2.775; p=0.025). The oldest caregivers (&gt;50 years) exhibited a significantly lower mean first-aid practice knowledge score (F=7.771; p=0.001). Conclusion Caregivers’ general and first-aid practice knowledge were generally poor prior to but were both markedly improved after educational interventions. Targeted educational health promotion could bring awareness to those with lower levels of education and older caregivers living in particularly the Western regions of Saudi Arabia. (255 words)

Association between the quantity of stroke care units and the complement of neurosurgical and neurology specialists in Japan: A retrospective study

BackgroundStroke care units provide advanced intensive care for unstable patients with acute stroke. We conducted a survey to clarify the differences in stroke care units between urban and regional cities and the relationship between the number of stroke care unit beds and neurologists. MethodsThis retrospective observational study was conducted in 2,857 and 4,184 hospitals in urban and regional cities in 47 provinces of Japan, respectively, between January 2020 and August 2023. Tokyo and ordinance-designated cities in provinces were defined as urban cities, and those without such cities were defined as regional cities. The primary endpoint was the presence or absence of a stroke care unit. ResultsMultiple linear regression analysis revealed that the presence of stroke care units was significantly associated with the number of neurosurgical specialists. Receiver operating characteristic curve analysis was performed to predict the number of personnel required for stroke care unit installation based on the number of neurosurgical specialists. The area under the receiver operating characteristic curve, Youden index, sensitivity, and specificity were 0.721, 0.483, 0.783, and 0.700, respectively. ConclusionsOur study underscores the indispensability of SCUs in stroke treatment, advocating for a strategic allocation of medical resources, heightened accessibility to neurosurgical specialists, and a concerted effort to address geographic and resource imbalances. The identified cutoff value of 8.99 neurosurgical specialists per 100,000 population serves as a practical benchmark for optimizing SCU establishment, thereby potentially mitigating stroke-related mortality.

Burden of Neurologic Health Care and Incident Neurologic Diagnoses in the Year After COVID-19 or Influenza Hospitalization.

Following the outbreak of viral infections from the severe acute respiratory syndrome coronavirus 2 virus in 2019 (coronavirus disease 2019 [COVID-19]), reports emerged of long-term neurologic sequelae in survivors. To better understand the burden of neurologic health care and incident neurologic diagnoses in the year after COVID-19 vs influenza, we performed an analysis of patient-level data from a large collection of electronic health records (EMR). We acquired deidentified data from TriNetX, a global health research network providing access to EMR data. We included individuals aged 18 years or older during index event, defined as hospital-based care for COVID-19 (from April 1, 2020, until November 15, 2021) or influenza (from 2016 to 2019). The study outcomes were subsequent health care encounters over the following year for 6 neurologic diagnoses including migraine, epilepsy, stroke, neuropathy, movement disorders, and dementia. We also created a composite of the 6 diagnoses as an incident event, which we call "incident neurologic diagnoses." We performed a 1:1 complete case nearest-neighbor propensity score match on age, sex, race/ethnicity, marital status, US census region patient residence, preindex years of available data, and Elixhauser comorbidity score. We fit time-to-event models and reported hazard ratios for COVID-19 vs influenza infection. After propensity score matching, we had a balanced cohort of 77,272 individuals with COVID-19 and 77,272 individuals with influenza. The mean age was 51.0 ± 19.7 years, 57.7% were female, and 41.5% were White. Compared with patients with influenza, patients with COVID-19 had a lower risk of subsequent care for migraine (HR 0.645, 95% CI 0.604-0.687), epilepsy (HR 0.783, 95% CI 0.727-0.843), neuropathies (HR 0.567, 95% CI 0.532-0.604), movement disorders (HR 0.644, 95% CI 0.598-0.693), stroke (HR 0.904, 95% CI 0.845-0.967), or dementia (HR 0.931, 95% CI 0.870-0.996). Postinfection incident neurologic diagnoses were observed in 2.79% of the COVID-19 cohort vs 4.91% of the influenza cohort (HR 0.618, 95% CI 0.582-0.657). Compared with a matched cohort of adults with a hospitalization or emergency department visit for influenza infection, those with COVID-19 had significantly fewer health care encounters for 6 major neurologic diagnoses over a year of follow-up. Furthermore, we found that COVID-19 infection was associated with a lower risk of an incident neurologic diagnosis in the year after infection.

0491 Exploring COMISA, Sleep-related Symptoms, and Healthcare Utilization in Military Personnel

Abstract Introduction Insomnia and obstructive sleep apnea (OSA) are the two most common sleep disorders seen in clinical practice. Comorbid insomnia and OSA (COMISA) is a very common clinical presentation. The purpose of this study was to estimate the effect of COMISA on sleep, daytime symptoms, and healthcare resource utilization compared to OSA or insomnia alone among military personnel. Methods Military personnel with sleep problems were recruited from two military treatment facilities. Insomnia and OSA were defined using validated cutoffs on the Insomnia Severity Index and Berlin Questionnaire, respectively, and COMISA was defined as comorbid insomnia and OSA. Subjective and objective sleep were measured via standardized sleep diaries and a commercial wearable (Fitbit Inspire 2) over ten days. Daytime symptoms (e.g., sleepiness, depression, anxiety, pain) were assessed using standardized self-report questionnaires. Subjective cognition was assessed via three Likert items. Healthcare resource utilization (HCRU) was assessed using an established questionnaire tailored for this study. To compare differences between COMISA, OSA, and insomnia groups, one-way ANOVA was performed. Results The final sample included 201 participants (n=113, 43.8[%] men, mean age=44.5 [SD=12.7]) who self-reported being of White (111, 55.2%), Black (50, 24.9%), Hispanic (21, 10.5%) or Other (19, 9.5%) race. Of these, 22 (10.9%) were categorized as insomnia alone, 98 (48.8%) as OSA alone, and 81(40.3%) as COMISA. Relative to individuals with OSA, individuals with COMISA demonstrated worse subjective (but not objective) sleep; worse subjective daytime symptoms; worse subjective memory, attention, and executive function; and increased healthcare utilization including total HCRU and outpatient visits to internal medicine, neurology, emergency department, and urgent care. Some but few significant differences were observed between participants with insomnia relative to those with COMISA. Conclusion Among military personnel with sleep problems and relative to OSA alone, COMISA was associated with worse subjective sleep, worse daytime symptoms, worse subjective cognition, and greater HCRU. Future research should seek to seek to improve health and economic outcomes among individuals with COMISA. Support (if any) DoD (W81XWH1990006 via the Medical Technology Enterprise Consortium)

Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty?

BackgroundThe optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA. MethodsUsing an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience. ResultsThe risk of complications correlated more closely to the CDI (odds ratio (OR) 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table 1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table 2] [Figures 1A and 1B]. ConclusionsChronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.

Neurologic Emergencies in Pregnancy.

Neurologic emergencies in pregnancy require prompt evaluation and early, focused intervention to improve neurologic outcomes for the affected person and to avoid further injury. Neurologic events in pregnancy, although rare, present a time of extreme risk of permanent injury for the person who is pregnant. Therefore, obstetric clinicians should be well versed in the risk factors for potential neurologic events and understand the symptoms and events that should prompt evaluation for a neurologic event. In addition, they should support other specialties in aggressive and early neurologic care for the patient to improve outcomes while assessing fetal well-being and care optimization for the dyad. Obstetric clinicians can uniquely provide knowledge of changes in pregnancy physiology that can increase the risk of neurologic events, as well as change the treatment of these events. For all patients with neurologic events, "time is brain." Therefore, it is important to be aware of changes in common presenting pregnancy concerns that should prompt evaluation for other pathogeneses. Finally, pregnancy care teams should be prepared to begin the initial stabilization and management of acute neurologic emergencies, including seizure, stroke, and meningitis, while seeking aid from other medical and neurologic specialists who can support their care and interventions. Early and aggressive interventions for individuals with neurologic events during pregnancy and postpartum are critical to the overall well-being of the dyad.

Beyond Audio-Video Telehealth: Perspective on the Current State and Future Directions of Digital Neurological Care in the United States

Background The COVID-19 pandemic transformed neurological care by both requiring digital health modalities to reach patients and profoundly lowering barriers to digital health adoption. This combination of factors has given rise to a distinctive, emerging care model in neurology characterized by new technologies, care arrangements, and uncertainties. As the pandemic transitions to an endemic, there is a need to characterize the current and future states of this unique period in neurology. Objective We sought to describe the current state of the pandemic- and postpandemic-related changes in neurological care and offer a view of the possible future directions of the field. Methods We reviewed several themes across the “new digital normal” in neurology, including trends in technology adoption, barriers to technology access, newly available telehealth services, unresolved questions, and an outlook on the future of digital neurology. Results In this new era of neurological care, we emphasize that synchronous audio-video telehealth remains the predominant form of digital interaction between neurologists and patients, mainly due to pandemic-related regulatory changes and the preexisting, steady adoption of video platforms in the prepandemic era. We also identify a persistent digital divide, with audio-only telehealth remaining a necessity for preserving care access. Asynchronous telehealth methods and services, including care coordination, interprofessional consultations, remote patient monitoring, and teletreatment are becoming increasingly important for neurological care. Finally, we identify several unanswered questions regarding the future of this “new normal,” including the lasting effects of emergency regulatory changes, the value proposition of telehealth, the future of telehealth reimbursement in neurology, as well as privacy considerations and trade-offs in asynchronous neurological care models. Conclusions The COVID-19 pandemic has ushered in an era of digital adoption and innovation in neurological care, characterized by novel care models, services, and technologies, as well as numerous unresolved questions regarding the future.