Faculty Bibliography

OBJECTIVE:Increasingly, patients are seeking same-day care at urgent care (UC) facilities. Little is known about the health care utilization patterns of patients who visit UC facilities for headache and migraine. We examined the frequency of headache and migraine visits and revisits at UC facilities. METHODS:We conducted a retrospective cohort study of headache not otherwise specified (NOS) and migraine visits from 67 NYC UC facilities over an eight-month period. We report descriptive analyses, the frequency of headache NOS revisits, and the elapsed time to revisits. RESULTS:There were 10,240 patients who visited UC facilities for headache NOS or migraine within the eight-month period. The majority of patients, 6,994 (68.3%), were female, and the mean age (SD) was 35.1 (15.0) years. Most (93.9%) patients (N = 9,613) lived within 60 miles of NYC; 5.5% (N = 564) had at least one revisit, and among re-visitors, there was an average (SD) of 2.2 (0.7) visits to UC facilities during the study period and an average time to revisit (SD) of 61.3 (55.2) days. CONCLUSIONS:In just eight months, there were >10,000 headache NOS and migraine visits to UC facilities in NYC, with half of revisits occurring within 90 days. Future work should examine headache management in UC facilities.

BACKGROUND:We sought to evaluate how Muslim allied healthcare professionals view death by neurologic criteria (DNC). METHODS:We recruited participants from two listservs of Muslim American health professionals to complete an online survey questionnaire. Survey items probed views on DNC and captured professional and religious characteristics. Comparative statistical analyses were performed after dichotomizing the sample based on religiosity, and Chi-squared, Fisher's exact tests, likelihood ratios and the Kruskal-Wallis test were used to assess differences between the two cohorts. RESULTS:There were 49 respondents (54%) in the less religious cohort and 42 (46%) in the more religious cohort. The majority of respondents (84%) believed that if the American Academy of Neurology guidelines are followed and a person is declared brain dead, they are truly dead; there was no difference on this view based on religiosity. Less than a quarter of respondents believed that outside of organ donation, mechanical ventilation, hydration, nutrition or medications should be continued after DNC; again, there was no difference based on religiosity of the sample. Importantly, half of all respondents believed families should be able to choose whether an evaluation for DNC is performed (40% of the less religious cohort and 60% of the more religious cohort, p = 0.09) and whether organ support is discontinued after DNC (49% of both cohorts, p = 1). CONCLUSIONS:Although the majority of allied Muslim healthcare professionals we surveyed believe DNC is death, half believe that families should be able to choose whether an evaluation for DNC is performed and whether organ support should be discontinued after DNC. This provides insight that can be helpful when making medical practice policy and addressing legal controversies surrounding DNC.

OBJECTIVES/OBJECTIVE:Guidelines recommend to initiate anticoagulation within 4-14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation such as infarct size, hemorrhagic transformation, or high risk features on echocardiography. METHODS:We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days) and outcomes were recurrent stroke/TIA/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. RESULTS:Among 2084 patients, 1289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the three groups: 0-3 days [10.3% (64/617)], 4-14 days [(9.7%) 52/535)], >14 days [10.2% (14/137), p=0.933]. In adjusted models, patients started on anticoagulation between 4-14 days did not have a lower rate of sICH (vs. 0-3 days) (OR 1.49 95% CI 0.50 - 4.43) neither did they have a lower rate of recurrent ischemic events (vs. > 14 days) (OR 0.76 95% CI 0.36 - 1.62, p = 0.482). INTERPRETATION/CONCLUSIONS:In this multicenter real world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation. This article is protected by copyright. All rights reserved.

We report a 20-year-old female with SARS-CoV-2 encephalitis who presented with 4 days of upper respiratory symptoms, fevers and sudden acute altered mental status. An extensive work up led to the most likely cause for the neurologic decompensation to be viewed as SARS-CoV-2 symptomology.

OBJECTIVE:To build a national Headache Medicine fellowship opportunities website that promotes a unified application timeline and a more transparent application process. BACKGROUND:In July 2019, the Consortium of Academic Headache Program Directors unanimously accepted the recommendations of the American Academy of Neurology Fellowship Application Timing Position Statement. To implement the unified application timeline, the American Headache Society agreed to host a fellowship opportunities website with information on the application process and resources for each fellowship program. METHODS:We designed a main landing page that features the unified timeline for applications and offers. The page also features icons for all participating US fellowship programs (identified using the United Council for Neurologic Subspecialties certification database). The icons serve as links to each fellowship program's individual webpage. We sent an electronic form to each fellowship program director, asking them to submit program information to be included on each fellowship program's individual webpage. Key contents on each program webpage include an image of the program, brief program description, names of applicants who have filled positions, and open positions. Each institution webpage also includes an electronic form that allows applicants to directly send their name, contact, and a brief message to the program director. RESULTS:We launched the website on May 15, 2020. As of June 19, 2020, the website featured 24 participating headache fellowship programs, including 5 pediatric programs and 19 adult training programs, from all regions of the US. CONCLUSION/CONCLUSIONS:The website serves as a central resource for Headache Medicine fellowship applicants and promotes a unified application timeline and a more transparent application process.

Background/UNASSIGNED:In the current consensus diagnostic criteria, the diagnosis of probable multiple system atrophy (MSA) is based solely on clinical findings, whereas neuroimaging findings are listed as aid for the diagnosis of possible MSA. There are overlapping phenotypes between MSA-parkinsonian type and Parkinson's disease, progressive supranuclear palsy, and dementia with Lewy bodies, and between MSA-cerebellar type and sporadic adult-onset ataxia resulting in a significant diagnostic delay and misdiagnosis of MSA during life. Objectives/UNASSIGNED:In light of an ongoing effort to revise the current consensus criteria for MSA, the Movement Disorders Society Multiple System Atrophy Study Group performed a systematic review of original articles published before August 2019. Methods/UNASSIGNED:We included articles that studied at least 10 patients with MSA as well as participants with another disorder or control group for comparison purposes. MSA was defined by neuropathological confirmation, or as clinically probable, or clinically probable plus possible according to consensus diagnostic criteria. Results/UNASSIGNED:We discuss the pitfalls and benefits of each diagnostic test and provide specific recommendations on how to evaluate patients in whom MSA is suspected. Conclusions/UNASSIGNED:This systematic review of relevant studies indicates that imaging and autonomic function tests significantly contribute to increasing the accuracy of a diagnosis of MSA.

Background: To assess acute clinical effects and safety of single-dose oral ampreloxetine, a novel, long-acting, selective norepinephrine reuptake inhibitor in subjects with neurogenic orthostatic hypotension (nOH).
Method(s): In a 5-day dosing study, subjects received placebo on Day 1, followed by ascending doses of ampreloxetine (range:1-20 mg). A subset of subjects were randomized to placebo or ampreloxetine in a 1-day double-blind study. Assessments included change in seated and standing systolic blood pressure (SBP), and Orthostatic Hypotension Symptom Assessment-Item 1 (OHSA#1; dizziness, lightheadedness, feeling faint).
Result(s): Of 34 subjects (mean age, 66 years), 15 and 13 subjects received ampreloxetine 10 and 20 mg, respectively, as maximum tolerated dose. Ampreloxetine 10 mg showed the most consistent response for increase in seated SBP relative to placebo (mean [SD] change in seated SBP 4.9 [20.1] mmHg more than placebo 4 hours post-dose). In the double-blind study (ampreloxetine, n=5 [median dose, 10 mg]; placebo, n=5), relative to placebo, for the ampreloxetine treatment group, increase in seated (mean difference from placebo, 29.9 mmHg at 4 hours post-dose; p < 0.05) and 3-minute standing SBP (mean difference, 35.0 mmHg at 4 hours post-dose) was more pronounced for the ampreloxetine treatment group to 9 hours and 10 hours post-dose, respectively, and 3-minute standing SBP was more pronounced for subjects randomized to ampreloxetine up to 10 hours post-dose. Twice as many subjects in the ampreloxetine treatment arm reported symptom improvement on OHSA#1. Most common adverse events were headache and urinary tract infection, with no serious events.
Conclusion(s): In subjects with nOH, 10 mg ampreloxetine produced a consistent increase in seated SBP relative to placebo. Compared to placebo, ampreloxetine showed greater increase in seated and standing SBP up to 10 hours post-dose, and greater symptom improvement. Ampreloxetine was well tolerated. These results support assessment of longer-term effects of ampreloxetine in nOH.
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Acute-onset and severe sensory and autonomic deficits with no motor dysfunction, typically preceded by a febrile illness, with poor recovery, and often fatal outcome are the hallmark features of acute sensory and autonomic neuronopathy (ASANN). Pathologically and electrophysiologically, ASANN is characterized by an extensive ganglionopathy affecting sensory and autonomic ganglia with preservation of motor neurons. Consequently, patients, usually children or young adult, develop acute-onset profound widespread loss of all sensory modalities resulting in automutilations, as well as autonomic failure causing neurogenic orthostatic hypotension, neurogenic underactive bladder, and gastroparesis and constipation. The diagnosis is clinical with support of nerve conduction studies and autonomic testing, as well as spinal cord magnetic resonance imaging showing characteristic posterior cord hyperintensities. Although the presumed etiology is immune-mediated, further studies are required to clarify the physiopathology of the disease. We here performed a systematic review of the epidemiology, pathophysiology, diagnosis, and management of ASANN, with three representative cases that recently presented at our clinic. All three patients had the typical clinical manifestations of ASANN but in different combinations, illustrating the variable phenotype of the disorder. Immunosuppression is seldom effective. Management options are limited to supportive and symptomatic care with the goal of minimizing complications and preventing death.