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Tuesday, July 7, 2020

The move to limit transfers to regional medical centers to avoid exposure to COVID-19 may carry with it a silver lining—a new appreciation for just how well community hospitals can care for many strokes, given the right selection criteria and the availability of telemedicine, according to a June 29 editorial in JAMA Neurology.

            For years, the authors argue, emergency medical service teams in many networks have been increasingly bypassing community hospitals due to "decision algorithms and imperfect screening protocols that place a high value on the sensitivity of diagnosis as opposed to specificity, which may allow for an unknown degree of overtriage to tertiary care centers," the editorialists wrote.

            Even when patients are sent initially to a community hospital capable of delivering tissue plasminogen activator (tPA), too many emergency departments transfer patients with small stroke or transient ischemic attack who could be cared for at community hospitals with the resources needed for routine diagnosis and management.

            The trend toward overtriage and unnecessary transfers not only raises overall costs to the health care system, it also inconveniences families and potentially exposes patients to unnecessary risks, according to the editorial.

            "There is a huge opportunity for stroke neurologists to say maybe this patient doesn't need to be transferred, but we're not going to leave him alone. We can round on this patient virtually, we can bring the expertise to him at his local hospital," said Adam Kelly, MD, FAAN, associate professor of neurology and director of teleneurology and regional development at the University of Rochester Medical Center, who co-authored the editorial with fellow Rochester neurologist Benjamin P. George, MD, MPH.

            The experience of hospitals in his region dealing with the COVID-19 crisis, Dr. Kelly said, bodes well for how they can meet the challenge of deciding which patients should be treated at which institution.

            "We approached hospitals in our area about trying to manage more of their patients remotely during our preparations for the surge," he said. "Patients were also saying they didn't want to be transferred to a 'COVID' hospital in a big city. So far it seems to have worked out well. The outcome for those patients has been quite good."

            Neurologists familiar with the paper said they welcomed its message of avoiding excessive triage and transfers, although some noted that, in so many words, the devil is in the details.

            "I'm very supportive of the concept, but I think it's a little more complex than the way they have laid it out," said Lee H. Schwamm, MD, FAHA, FANA, executive vice chair of neurology and director of the Center for TeleHealth at Massachusetts General Hospital. "We have to make sure we do it right; we can't just make a blanket policy of turning down transfers for certain conditions." 

 

Study Details

Acute care transfer rates for neurologic disease are twice that of most other conditions, the editorial noted. Drs. George and Kelly cited three steps that must be taken if stroke and other neurological emergency patients are going to be treated in the most appropriate setting: optimizing the use of telemedicine, reducing overtriage, and creating "innovative strategies to minimize risks during and after interhospital patient transfer."

            To optimize telemedicine, they wrote, medical networks must "identify trained telemedicine clinicians, expand available technology, and create distance medicine relationships with community hospitals and emergency departments," the paper states.  

            To reduce overtriage, decision algorithms must be modified to balance high sensitivity, "designed to capture any and all LVO [large vessel occlusion] patients, to higher-specificity protocols that focus on mobilizing only those patients who absolutely need comprehensive stroke center or tertiary care services."

For patients with transient ischemic attacks (TIAs), they recommend ceasing their automatic transfer and establishing a set of criteria that would qualify or exclude them from moving to a comprehensive stroke center. Qualifying criteria for transfer, they suggest, would include "the urgent need for intervention (eg, thrombectomy, carotid revascularization, or hemicraniectomy), highly specialized monitoring if unavailable at a distance (eg, critical care electroencephalography), or intensive care needs (eg, mechanical ventilation or shock)."

Nonqualifying criteria for transfer, Drs. Kelly and George proposed, would include small stroke or TIA "with no indication for intervention (eg, those without high-grade stenosis on vascular imaging), stroke mimics such as partial seizure or migraine, minor head trauma (eg, small traumatic subarachnoid hemorrhage at low risk of hemorrhagic expansion), or any patients with an anticipated short length of stay."

They also noted that patients with severe disease and very poor prognosis may not benefit from transfer. For example, they stated, "large completed hemispheric strokes or large intracranial hemorrhage in elderly patients should have emergent goals of care discussions facilitated by experts at specialized centers to prevent burdensome transfers at the end of life."

To minimize the risks and maximize quality of care during and after transfer, the editorial recommended that family members or surrogates be fully informed that unless they can travel to the new hospital, their interactions with the patient and physicians will be limited to telephone, video conferencing or the like. Even if they can travel, many medical centers are not permitting visitors during COVID-19 precautions. And just because the receiving hospital has greater capacity to treat more complex cases, close attention should still be paid to their performance on evidence-based metrics and to patient experience surveys.

In sum, the editorial argues that the disruptions to neurologic care in the  COVID-19 era may carry with it a "silver lining" by inspiring ways to reduce overtriage.

             

Expert Commentary

Dr. Schwamm, who published an editorial two years ago in JAMA Neurology on optimizing prehospital triage for patients with LVO, said that while reducing unnecessary triage is a worthy goal, "The problem is that when treating with thrombectomy or tPA, time is critical. The longer it takes the patient to receive treatment, the worse the patient does. And community hospitals take longer—longer to evaluate, longer to treat."

            Massachusetts General's teleneurology program works with about 30 hospitals in northern New England, he said. "Telemedicine is a really good way to make stroke expertise portable, to get a second opinion without moving the patient. After we do consults, more than 60 percent of patients stay at the community hospital. We have actually shortened the length of stay substantially for the patients at those hospitals because of the timely nature of our providing an opinion and having a definite recommendation."

            On the other hand, Dr. Schwamm added, "I worry a lot about increasing the barrier for access to specialty services. If they aren't going to get the care, they need at the community hospital, then not moving them could sentence them to a life of disability.

            Lawrence Wechsler, MD, FAAN, professor of neurology at the Perelman School of Medicine at the University of Pennsylvania, called the paper "very timely." But as useful as telemedicine can be for preventing unnecessary transfers, he said, "The small hospitals out in rural America that need it most are probably the least able to afford it."   

Artificial intelligence programs that can read CT angiograms and offer recommendations could also help improve the triage of stroke patients, said James J. Conners, MD, MS, FAHA, medical director of the Comprehensive Stroke Program and interim clinical vice chair of neurology at Rush University Medical Center. But due to the COVID-19 crisis, he added, "It's going to be hard to invest in new technology in the short-term."

            Mona Bahouth, MD, PhD, medical director of the Brain Rescue Unit and assistant professor of neurology at the Johns Hopkins School of Medicine, commended the authors for bringing attention to the issue of triage using telemedicine when evaluating the risk/benefit ratio for hospital-to-hospital transfer. But she urged caution in changing prehospital systems that are designed to expedite the delivery of time-sensitive stroke treatments.

            "It should spark a thoughtful discussion about hospital-to-hospital transfer across the country," Dr. Bahouth said. "Even during 'normal' times, any transfer to a facility away from a patient's home should be made carefully, since it separates patients from their family and support system. During this time of an infectious epidemic, the risks of transfer are additionally increased as patients are exposed to two different geographic regions."   

Haitham Hussein, MD, medical director of the Regions Hospital Comprehensive Stroke Center in St. Paul, MN, presented two papers last year at the International Stroke Conference examining the risks and benefits of transfers to tertiary care centers. Decisions should be made not solely on the distance to those institutions, he found in one study, but also on measures of the receiving center's quality and efficiency. Tools designed to predict LVO in the prehospital setting, he found in another study, will improve care for most LVO patients, but will likely lead to a delay in door-to-needle time for a significant proportion of patients, "raising the concern for potential harm."

            "I have been one of the people opposed to rushing toward bypassing the community and primary stroke centers without evidence," Dr. Hussein told Neurology Today. Since the benefits of tPA were demonstrated in 1995, he said, "the entire stroke field has been emphasizing that time is brain. To get tPA to patients as soon as possible, we've built networks of hospitals capable of giving it.

"Now all of a sudden, we are changing course, subjecting many stroke patients to delay in receiving tPA for the sake of helping a proportion of them achieve recanalization quickly. This deprives the primary stroke centers and stroke-ready hospitals of potential tPA patients. They not only lose an important community-service role and source of revenue; they lose the experience and skill to manage these patients. COVID-19's silver lining is that it is forcing us tore-examine our processes."

Disclosures: Drs. Kelly received honoraria from the AAN as a CME editor for Neurology and a question writer for educational programs. Dr, Conners and Bahouth had no relevant disclosures. Dr. Schwamm reported relationships relevant to research grants or companies that manufacture products for telemedicine, thrombolysis or thrombectomy: scientific consultant and member of steering committee for Genentech; user interface design and usability to LifeImage (privately held teleradiology company); stroke systems of care to the Massachusetts Department of Public Health; member of a data safety monitoring board for Penumbra; principal investigator (PI) of multicenter trial of stroke prevention for Medtronic; PI for late window thrombolysis trial for NINDS and the StrokeNet Network.

Link Up for More Information


Tuesday, July 7, 2020

AAN member James J. Sejvar, MD, a neurologist and epidemiologist at the US Centers for Disease Control and Prevention (CDC), has been working on COVID-19 since early January when the first reports of illness were announced in China. Actively monitoring and tracking reports of neurologic illness related to COVID-19, the CDC has recently launched a Neuro-COVID unit and placed him in charge.  Neurology Today spoke to him in early July to learn about the activities currently underway at his unit and to get an update on what the CDC has learned since the pandemic began.

We last spoke at the end of March. What do we know now, three months later, about the SARS-CoV-2 virus?

We've learned several things.  There appears to have been a minor mutation in the virus that allows it to be more easily spread between people.  This makes it somewhat more contagious, but, of note, it does not appear to impact the severity of disease with the virus.  There is a great deal of evidence suggesting that not following social distancing and wearing masks can and does lead to increased numbers of cases; this has been very apparent in the United States where jurisdictions that have not emphasized these protective measures have seen a spike in cases.

Have there been advances in antibody tests?

Labs continue to work on serologic (antibody) tests in order to increase the sensitivity and specificity of the assays.  There are still some challenges to some of the assays currently available, but various labs throughout the world continue to develop antibody tests.

What have been the epidemiologic trends?

Places that have enforced strict public health measures, including social distancing, mask use, and the avoidance of crowded areas have had very good control over the spread of SARS-CoV-2; this includes the European Union and Asia.  On the other hand, places in which these measures have sometimes been curtailed in an effort to lift sheltering regulations, including the United States and Brazil, continue to see significant ongoing spread of the virus. In addition, it continues to appear that minorities in the United States appear to have poorer outcomes.

How close are we to a vaccine?

There are several vaccines that are in Phase II trials, looking at safety.  Although there is an international push to develop a vaccine quickly, it will in all likelihood be many months before we see a safe and effective vaccine for SARS-CoV-2, and once identified, it will take time to manufacture enough doses to administer to a large population.

Why did the CDC decide to launch a neuro-COVID team?

There have been increasing reports, in the form of case reports or small case series, associating various neurological conditions and COVID-19.  However, these are generally limited due to incomplete information, non-systematized data collection, and questionable information on causality.  The CDC has endeavored to take a more systematic approach to these reports, and determine whether there is likely to be a causal association between SARS-CoV-2 and the neurologic illness, and to try to determine whether there are any neurologic conditions that appear to be occurring at a higher-than-expected rate, suggesting a red flag for increased frequency of a particular neurologic illness.

What do you intend to study?

We intend to look at various databases, as well as to conduct a retrospective/prospective case ascertainment, to look for neurologic illnesses of interest, and try to determine causality and frequency of occurrence.

How will you approach those studies and data collection?

We will assess several databases and surveillance platforms which the CDC currently already operates to see if we can determine the epidemiologic and clinical features of Neuro-COVID cases. We are also partnering with a number of clinical and academic medical centers to perform a bi-directional retrospective/prospective case investigation in order to more fully characterize the various neurologic illnesses which appear to be associated with COVID-19, and to look at frequency of occurrence of these neurologic illnesses.

Which neurologic symptoms are on your radar for study and why?

There have been a number of neurologic illnesses that have appeared as case reports or as parts of small series, including encephalopathy/encephalitis, Guillain-Barré syndrome (GBS), stroke, myelitis, and others.  I think we are mainly interested in stroke, since there appears to be some data suggesting that SARS-CoV-2 can produce or result in strokes in very young individuals (age <50 years).  We would like to try to substantiate this further.  Another thing that we will be looking for is GBS, since, in rare instances, GBS can be triggered by a vaccine. We would want to have very good background data on the incidence of GBS prior to initiation of a vaccination campaign, so that we can use this to monitor vaccine safety for a SARS-CoV-2 vaccine.  Finally, we are interested in encephalitis; it will be important to try to document whether SARS-CoV-2 can be associated with neurotropic disease as this could substantially impact the overall burden of illness with COVID-19.

If neurologists identify one of those symptoms, who can they contact to help with the effort?

If neurologists would like to report an unusual case of neurologic illness possibly in association with COVID-19, they can reach out to CDC-INFO at https://www.cdc.gov/cdc-info/index.html.  The CDC-INFO line is staffed 24/7, and can be used by clinicians to report cases, ask questions, or otherwise get additional information from the CDC.

What is the most actionable advice you can give to neurologists in practice today?

We are not out of the woods yet, and it is too early to get complacent.  It is still very important to maintain social distancing and mask wearing, as well as frequent hand washing and cough hygiene.  Use proper personal protection equipment (PPE) when examining persons with known or suspected COVID-19 to protect yourself and your other patients.  Also, when evaluating your patients with acute neurologic illness, consider SARS-CoV-2 in the differential, since we are still unaware of the actual frequency and occurrence of neurologic illness associated with COVID-19.

Tuesday, July 7, 2020

COVID-19 damages neurons in a significant fraction of patients, even among those without clinical neurological symptoms, according to a new study in the June 16 online issue of Neurology.

The evidence comes from measurement of neurofilament light chain (NfL), a marker of neuronal injury, and glial fibrillary acidic protein (GFAp), a marker for astrocyte activation, in the plasma of 47 COVID-19 patients across the severity spectrum.

"These findings are important because they are some of the first data to suggest that in otherwise neurologically asymptomatic patients, there could be under-appreciated injury in the central nervous system," said Serena Spudich, MD, professor of neurology and division chief of neurological infections and global neurology at Yale University School of Medicine in New Haven, CT, who was not involved in the study.

"A relatively large number of COVID-19 patients have some neurological involvement, such as confusion, but on the other hand, these are patients who are severely ill," so it has been difficult to know whether the disease is causing actual injury to the central nervous system, said lead study author Magnus Gisslen, MD, PhD, professor of infectious diseases at the University of Gothenburg, Sweden, and chief physician at Sahlgrenska University Hospital.

            To date, out of concern for transmission, there has been little post-mortem examination of the CNS to assess the effects of infection in patients dying of the disease.

 

Study Details

To assess the potential of direct damage to the CNS, Dr. Gisslen and colleagues measured plasma levels of NfL and GFAp in COVID-19 patients, including 20 with mild, nine with moderate, and 18 with severe disease. They defined mild disease  as not requiring hospitalization, moderate disease as requiring hospitalization and supplemental oxygen, and severe disease as requiring intubation and mechanical ventilation, or in one case, dying from the disease before treatment commenced.

The ages of patients ranged from 37 to 72 years; about two-thirds were male. As seen more broadly with the disease, more severely affected patients tended to have more comorbid conditions, including hypertension, heart disease, obesity, and diabetes.

Four of the severely affected patients displayed confusion before admission to the intensive care unit, and one had had a single seizure before ICU admission, with no signs of seizure activity the following day. Because of the concern for transmission, no MRIs were done, and full neurologic exams were not performed, Dr. Gisslen noted.

GFAp and NfL were assessed in plasma samples, a more recent technique than assessing the same markers in cerebrospinal fluid. Both are widely accepted markers of CNS injury; elevation of NfL is seen in multiple neurodegenerative diseases as well as ischemic stroke. Samples were taken at a mean of 13 days after onset of symptoms. Levels in COVID-19 patients were compared to those in age-matched healthy controls.

As expected, levels of both markers correlated with age, in both patients and controls. Plasma GFAp was elevated in patients with both moderate and severe disease compared to controls (204, 206, and 141 picograms/milliliter, respectively; p=0.03 for moderate and p=0.001 for severe), while NfL was significantly elevated in patients with severe disease compared to controls (32.7 and 13.1 pg/mL, respectively; p<0.001).

A second assessment, at a median of 13 days after the first, was performed in a subset of patients. In the severely affected patients, GFAp decreased while NfL increased. No changes in either marker were seen over time in either less severely affected group.

The results suggest that astrocytic activation may be a common and early feature in most cases of COVID-19, Dr. Gesslen said, while neuronal injury may occur later and in the more severely affected patients.

Much remains unclear, he added, including the likely outcome for affected patients, and whether the virus is causing damage through direct infection of neurons or astrocytes, or instead is acting indirectly. "We really don't know yet," Dr. Gesslen said. Direct invasion of the CNS seems unlikely, he said, because the cellular receptor the virus relies on to enter cells is expressed at very low levels in the CNS. Hypoxia due to respiratory failure, microthrombotic events, or immune activation-mediated damage seem more likely to him. "But this remains an open question," he added.

Neither is it known whether the neurofilament marker will revert to normal levels over time, but work is underway to track that in COVID-19 patients. "It will be very interesting to see if corticosteroid treatment affect these markers," Dr. Gesslen said.

 

Expert Commentary

"This is an important paper, because these two markers are reflecting central nervous system injury," commented Paola Cinque, MD, PhD, professor of infectious diseases and senior physician in the neurovirology unit at San Raffaele Scientific Institute in Milan, Italy. "However, it does not tell us about the mechanism. Hypoxemia may be the most probable one."

 "It is also not yet possible to correlate these signs of injury with the type and severity of neurologic symptoms reported in COVID-19 patients," he said, adding, "Those associations will have to come over time."

The clinical picture remains concerning, said Pranusha Pinna, DO, a neurology resident at Rush University Medical Center and first author on a recent large case series on neurologic manifestations in COVID-19 patients.

 "Patients who have been critically ill with COVID-19 may have a hard time regaining function," she said. "We are seeing a lot of requests for consults about that. Unfortunately, it is very difficult to comment on prognosis when the underlying cause of the neurologic symptoms is a disease we don't understand very well. The finding of biochemical manifestations of the illness reported here is important, although its meaning is still unclear."

Given the number of patients worldwide whose illness has met the criterion in this paper for moderate disease—hospitalized but without intubation—there may be a significant public health implication from these findings, Dr. Spudich of Yale said.

"Whenever we see neuronal injury, we know some brain cells are taking a hit," Dr. Spudich continued, "so I think the clinical implications of this paper is that if there is neuronal injury, whether or not the patient presents with severe neurological symptoms, there may be consequences for how the brain functions after recovery. Will there be long-term effects in these patients? That is an important question for us as neurologists.

Disclosures: Drs. Gisslen, Pinna, Cinque, and Spudich have no relevant disclosures.

Link Up for More Information:

Kanberg N, Ashton NJ, Andersson LM, et al. Neurochemical evidence of astrocytic and neuronal injury commonly found in COVID-19. Neurology 2020; Epub 2020 Jun 16.

Pinna P, Grewal P, Hall JP, et al. Neurological manifestations and COVID-19: Experiences from a tertiary care center at the Frontline. J Neurol Sci 2020;415:116969


Tuesday, July 7, 2020

As COVID-19 surges and recedes in different parts of the country, the one thing that remains consistent is this—the pandemic has brought tremendous stress on neurologists and other heath care workers—whether they are directly caring for patients with COVID-19, or have had their jobs and lives disrupted by changes in the way they worked.

Chethan P. Venkatasubba Rao, MD, FNCS, section head of neurocritical care and vascular neurology at Baylor College of Medicine in Houston, is one of them. He recalled it was that 54-year-old patient he saw in the neuro-ICU early on that underscored that stress. For the first eight hours of care, the patient was relatively stable, said Dr. Rao, who was at bedside.

"I saw this patient go downhill so fast. He required not one critical care provider, but about four intensivists, including neurologists, cardiovascular specialists, and even surgical intensivists," Dr. Rao explained.

"You could not anticipate what's coming next, especially with the initial wave of COVID patients; you had to be on your toes," Dr. Rao said. "Dealing with these extremely challenging cases can be kind of jarring," Dr. Rao added.

"And then imagine, not being primarily trained in medical critical ICU management and then having to learn all these advanced skills on the job," he said.  

"We had to make treatment decisions on the spot as there is no proven literature and no obvious methodology to treat so that can be a second layer of stressor for the providers," he told Neurology Today.

Then, he added, we had to go home to our families and worry about possibly getting them sick. "We are health care providers, but at the same time, we are just regular people too."

Amid the COVID-19 pandemic, neurologists and other clinicians are seeing more patients, working longer hours, and juggling family obligations—and they are experiencing burnout, depression and post-traumatic stress disorders.

In interviews with Neurology Today, neurologists and researchers discussed the ways in which their institutions have responded to increased demand for mental health support by bolstering and launching programs to help neurologists and other front-line workers as they navigate the demands of the COVID-19 pandemic.

UCSF: Caring for Caregivers

This is a stressful time for not only attendings but also for trainees as well as fellows, residents, and medical students who are on the front-line caring for patients, said S. Andrew Josephson, MD, FAAN, chair of the department of neurology at UCSF. 

Financial strains and the inability to carry on business as usual caring for patients during the pandemic has added to this stress for neurologists—whether they work in academia or community practice, Dr. Josephson said.

Dr. Josephson pointed out that UCSF has long had a number of resources and initiatives aimed at decreasing burnout and helping clinicians cope with trying times in the hospitals but once COVID-19 started the department of psychiatry developed a number of resources for front-line workers.

The UCSF psychiatry department teamed up with the UCSF Center for Digital Health Innovation and Human Resources to establish a new initiative for UCSF staff, trainees, and faculty called the UCSF Employee Coping and Resilency Program.

The program uses a confidential online assessment tool to connect UCSF employees to a number of emotional support services such as interventions for people that required specialized help, timely acess to online clinical treatment and evaluation for individuals with moderate to severe symptoms, and a curated trove of online self-management resources like videos, webinars, and apps.

As a leader in his department, Dr. Josephson worked hard to create a culture in which honest conversations were welcome, so that all his team members could feel comfortable opening up about any concerns surrounding mental health and well-being, he said.

"We're really lucky locally at UCSF to have a culture for many years that cares for our caregivers—but when I look nationally, clearly there is a major issue throughout all of medicine to ensure our doctors are well, because ultimately if we're not well, how are we going to provide good care for our patients?"

Another UCSF program, "Caring for the Caregiver," was launched in 2017 to help clinicians and staff deal with the emotional strain of patient care by providing them support and resources. With COVID-19, it became clear that the need was more acute than ever. The program has seen a rise in the number of people seeking one-on-one support since COVID-19.

One of the program's signature initiatives is a peer-support program. "When we realized that COVID was coming and that people were feeling a lot of stress related to what was unknown and what might happen in terms of their clinical environment, we thought it would be a great time to start working with our peer supporters in different clinical areas," said Kiran Gupta, MD, MPH, the medical director of patient safety and Caring for the Caregiver at UCSF.

The peer suporters are volunteers who are trained to meet with staff, as needed, from numerous clinical experiences, areas, and departments, including pharmacy, physical therapy, nursing, social work, hospital supervisors, spiritual care, and respiratory therapy.

In most cases, through the COVID-19 crisis, peer supporters opted to hold weekly check-in meetings for their team members, Dr. Gupta added.

For a large organization, it can be difficult to know what an experience will be like for a particular individual or clinical setting, emphasized Dr. Gupta. "But you can train people who work in different clinical areas throughout an organization to have some heightened awareness for what things might happen that could be hard for their team members, what to say in the moment, and to be knowledgeable about all the support resources available," she said.

"You can start to really normalize the stressful reactions that people have and get them the support they need. This can promote resiliency at work and help mitigate burnout, which does take a huge toll on those working in health care," Dr. Gupta continued. 

Support Hotlines

To help its health care providers cope with the pandemic, the University of North Carolina has offered a range of supportive programs, including mindfulness training and weekly support groups, said  Jason Tuell, MSW, LCSW, a clinical social worker at the  university. In addition, the university offers a cache of resources—including everything from financial aid resources, child care support, to tools for coping with loss, Tuell explained.

"It's intended to not only refer a person to a specific resource, but also to offer a brief intervention to help support someone through what may be a moment of distress, where it's not quite pushing them to visit a primary care provider or go in for maybe a visit for mental health. But they know that they need a warm voice in somebody to talk to and share what's going on," Tuell told Neurology Today.

Tuell said several people within his department were pulled aside by clinicians for support and guidance as they struggled to cope with all of the stress and general work fatigue associated with COVID-19—stressors related to not knowing what to do, dealing with rigorous and strict protcols around infection, or the challenges of triaging patients. These incidents prompted the department to develop a hotline, he said.

The Healing Heroes Hotline, which has been in place for a few months, aims to address more acute incidents of distress, Tuell noted. It is a call-in resource offered weekdays from 8 am to 7 pm to UNC health professionals across the state. Through the helpline, health professionals are connected to a mental health worker that will assist them by referring them to resources, connecting them to confidential faculty run support groups, offering skills-based consultation, or a direct referral to the appropriate therapy.

Aware of the stigma around seeking mental health support as a health care professional, Tuell noted that the hotline is completely confidential and free so there is no contact with insurance.

Communication and Compassion to Strength Teams

Burnout has affected both nurses and physicians, noted Dimitri Krainc, MD, PhD, chairman of the department of neurology at Northwestern Memorial Hospital in Chicago. Nationally, there has been an increase in depression and suicide among health care workers, Dr. Krainc explained.

Across the board both the general public and health care workers have limited access to mental health care because of the COVID-19 pandemic, noted Dr. Krainc. "There is normally a shortage of mental health care professionals that was only exacerbated by the COVID pandemic," Dr. Krainc told Neurology Today.

The initial shortage of personal protective equipment led to fear and anxiety among some health care workers, Dr. Krainc explained. However, once there was an adequate amount of PPE, things quickly improved, he added.

In the neurology department, we foster a community for engagement through very open communication in a number of ways, Dr. Krainc emphasized. "Sometimes these difficult times can serve as a very strong unifying force, for people to pull together and to work through things together."

Dr. Krainc pointed out that navigating challenging times like these requires compassion, open communication, and flexibility especially for people arranging care  for child. "In addition to that, we have services that are dedicated to health care professionals that have mental health problems to help them out."

"If people are engaged, if we have communication and use this difficult time as an opportunity to get more unified, to get more engaged with each other, and really to focus on our values and commitment to serving our patients, and to helping each other, that's the day to day activity that will have a positive impact on the post-COVID situation," he said.

Not taking this approach during the pandemic, could lead to problems later, Dr. Krainc noted. "We take this very seriously, and we try to prevent any PTSD that would occur post-COVID. Hopefully, we will be successful, but I can't predict that right now."

Supporting Trainees During the Pandemic

In mid-March, neurologists at University of California. Los Angeles (UCLA) had their first COVID-19 positive stroke case. The residents and the stroke team went into the emergency department and noticed evolving use and application of PPE, noted S. Thomas Carmichael, MD, PhD, professor and chair of neurology at the David Geffen School of Medicine at UCLA.

In some cases, the application of PPE was not quite clear in the setting of an acute stroke case, with patient transport to adjacent imaging sites and then back again. Residents were at the front lines of this situation and had questions that required fairly immediate actions, Dr. Carmichael noted.         

Some of the non-COVID-19 causes of stress and burnout have been exacerbated by the pandemic, he noted. "The two main things are essentially a lack of local control in those two areas and possibly anxiety over ultimately getting the disease and not knowing how to completely eliminate that possibility," Dr. Carmichael told Neurology Today.

UCLA has offered wellness classes, free lunches, sponsored coffees, and dedicated town halls to express concerns to the leadership in an effort to support clinicians through these difficult times, noted Dr. Carmichael.

For clinicians who are apprehensive about stepping forward to use such resources, Dr. Carmichael suggests, that there be an opportunity for "a critical, open and unencumbered listening session" for faculty and staff. Many times these sessions need to be done privately and anonymously through anonymous surveys and in some cases in a town hall setting. This creates an opportunity for leadership to understand what's producing the burnout or mental health issues among faculty and staff, he emphasized.         

From there, Dr. Carmichael recommends operationalizing the information in a second phase by offering meditation, small discussion groups, stress and resiliency training.

Within his department, Dr. Carmichael's faculty, staff and institution have offered mindfulness, well-being, and yoga sessions for neurology trainees and neurology faculty. However, the attendance hasn't been ideal, so efforts are underway to ensure things are more individually tailored, he explained.

Baylor University's Dr. Rao pointed out that sometimes the simplest of gestures can assuage stress. He pointed to a local high school student who started an initiative through which local restaurants that were closed down due to the pandemic provided hot meals for health care workers.

"A warm bowl of pasta in the middle of your work, because all the restaurants are closed, can make a big difference. Sometimes we used to go eight to 10 hours or 12 hours without drinking or eating because you don't want to scrub in and out and you don't want to go home for a bite. So that small bowl of pasta really does make a big difference," he said.

Tuesday, July 7, 2020

Less rapid eye movement (REM) sleep is linked with a greater risk of mortality, according to a population-based, cross-sectional study published on July 6 in JAMA Neurology.

The researchers set out to assess if REM sleep is linked with an increased risk of death in two independent study groups compared with non-REM sleep stages N1, N2, and N3, and to determine if another sleep phase could have an impact on the results.

The research team evaluated two independent groups. The Wisconsin Sleep Cohort (WSC) included 1,386 participants, of which 54.3 percent were male. Mean age was 51.5 years. The Outcomes of Sleep Disorders in Older Men Sleep Study (MrOS) included 2,675 patients, all of whom were male. Mean age was 76.3 years.

In the MrOS cohort, there was a 13 percent increased mortality rate for each 5 percent decrease in REM sleep over 12.1 years after adjusting for sleep, health, and multiple demographic covariates. These results were replicated in the WSC cohort over 20.8 years of follow-up despite the inclusion of women, longer follow up, and younger age, reported Eileen B. Leary, PhD, RPSGT, of Stanford University in Palo Alto, CA, and colleagues.

These findings were comparable for both cardiovascular and other causes of mortality, the investigators found.  

The three phases of non-REM sleep include N1, N2, and N3. The N1 stage is the lightest stage and begins when low-amplitude mixed frequency activity takes the place of over 50 percent of alpha waves. The N2 stage is a moderate sleep stage at which body temperature and heart rate decrease. The N3 stage is the deepest stage of sleep and can be identified by its delta waves and high amplitude signals.

These data are consistent with other research findings that associate REM sleep to other age-associated conditions and diseases, Dr. Leary's group noted. A prior investigation showed that less time in REM sleep and increased time in N1 sleep were linked with declining cognitive performance in MrOS, they added.

Moreover, other reports indicated that men with clinically significant depressive symptoms were more likely to spend less time in REM sleep and more in N2 sleep. On the other hand, another study showed that cognitive decline was significantly linked with a short average sleep cycle length, they continued.

"Accelerated brain aging may result in less REM sleep, making it a marker rather than a direct mortality risk factor; however, mechanistic studies are needed. Strategies to preserve REM sleep may influence clinical therapies and reduce mortality risk, particularly for adults with less than 15 percent REM," the investigators wrote.  

Limitations of the study include potential residual or unmeasured confounding and limited generalizability to other races and ethnicities, the researchers noted. Another limitation is that the study population included community-dwelling adult volunteers who could have been healthier when compared to the general population at large, they added.

The association between mortality and REM sleep persisted across multiple sensitivity analyses and varying causes of death, the authors noted. "Given the complex underlying biologic functions, further studies are required to understand whether the relationship is causal," they concluded.

Disclosures: Dr. Leary reported no disclosures.

Link Up For More Information:

Leary EB, Watson KT, Ancoli-Israel S, et al. Association of rapid eye movement sleep with mortality in middle-aged and older adults. JAMA Neurol 2020; Epub 2020 July 6.