Impact of the COVID-19 Pandemic on Inpatient Utilization for Acute Neurologic Disease

Background and Objective: The initial months of the Corona Virus 2019 (COVID-19) pandemic resulted in decreased hospitalizations. We aimed to describe differences in hospitalizations and related procedures across neurologic disease. Methods: In our retrospective observational study using the California State Inpatient Database and state-wide population-level estimates, we calculated neurologic hospitalization rates for a control period from January 2019 to February 2020 and a COVID-19 pandemic period from March to December 2020. We calculated incident rate ratios (IRR) for neurologic hospitalizations using negative binomial regression and compared relevant procedure rates over time. Results: Population-based neurologic hospitalization rates were 29.1 per 100,000 (95% CI 26.9-31.3) in April 2020 compared to 43.6 per 100,000 (95% CI 40.4-46.7) in January 2020. Overall, the pandemic period had 13% lower incidence of neurologic hospitalizations per month (IRR 0.87, 95% CI 0.86-0.89). The smallest decreases were in neurotrauma (IRR 0.92, 95% CI 0.89-0.95) and neuro-oncologic cases (IRR 0.93, 95% CI 0.87-0.99). Headache admissions experienced the greatest decline (IRR 0.62, 95% CI 0.58-0.66). For ischemic stroke, greater rates of endovascular thrombectomy (5.6% vs 5.0%; P < .001) were observed in the pandemic. Among all neurologic disease, greater rates of gastrostomy (4.0% vs 3.5%; P < .001), intubation/mechanical ventilation (14.3% vs 12.9%, P < .001), and tracheostomy (1.4 vs 1.2%; P < .001) were observed during the pandemic. Conclusions: During the first months of the COVID-19 pandemic there were fewer hospitalizations to varying degrees for all neurologic diagnoses. Rates of procedures indicating severe disease increased. Further study is needed to determine the impact on triage, patient outcomes, and cost consequences.

Characterization of sleep among deaf individuals

OBJECTIVES

Numerous health disparities are documented in deaf population research, but few empirical sleep assessments exist for this under-served population, despite knowledge that sleep contributes to physical and mental health disparities. We sought to document subjective and objective sleep in deaf adults with cross-sectional and prospective measures.

METHODS

Twenty deaf participants completed validated sleep and mental health questionnaires, 2-weeks of nightly sleep diaries and continuous wrist-worn actigraphy monitoring, and 1-week of nightly, reduced-montage EEG recordings.

RESULTS

Questionnaire data suggest high prevalence of insomnia (70%), poor sleep (75%), daytime sleepiness (25%) and nightmares (20%) among participants. Strong correlations were found between depression and sleep quality, fear of sleep, and insomnia severity (p's < .005). Objective sleep assessments suggest elevated wake after sleep onset and low sleep efficiency and sleep duration.

CONCLUSIONS

The prevalence of sleep disturbance recorded from self-report and objective sleep measures provides preliminary evidence of sleep health disparity among deaf adults.

The association between multidimensional sleep health and migraine burden among patients with episodic migraine

STUDY OBJECTIVES

Using the Sleep Regularity, Satisfaction, Alertness, Timing, Satisfaction, and Duration (Ru-SATED) sleep health framework, we examined the association between multidimensional sleep health and headache burden in a cohort of 98 adults with episodic migraine.

METHODS

Participants wore wrist actigraphs and completed twice-daily electronic diaries regarding sleep, headaches, and other health habits for 6 weeks. We calculated separate composite sleep health scores from diary and actigraphy assessed measures using the Ru-SATED framework. We used adjusted multivariable linear regression models to examine the association between composite sleep health scores and headache frequency, duration, and pain intensity.

RESULTS

Among 98 participants (mean age: 35 ± 12 years; 87.8% female), 83 had healthy ranges in ≥ 3 sleep dimensions. In models adjusted for age, sex, menopausal status, physical activity and alcohol intake, good sleep health was associated with fewer headache days/month (actigraphy: 3.1 fewer days; 95% confidence interval: 0.9, 5.7; diary: 4.0 fewer days; 95% confidence interval: 1.1, 6.9). Results did not change substantively with further adjustment for stress and depressive symptoms. We did not observe an association between sleep health and headache duration or intensity, respectively.

CONCLUSIONS

Among patients with episodic migraine, good multidimensional sleep health, but not the majority of singular dimensions of sleep, is associated with approximately 3-4 fewer headache days/month. In addition, there was no association with headache duration or intensity. These findings highlight the importance of assessing multiple dimensions of sleep and suggest that improving sleep health may be a potential clinical strategy to reduce headache frequency.

CITATION

Yoo A, Vgontzas A, Chung J, et al. The association between multidimensional sleep health and migraine burden among patients with episodic migraine. J Clin Sleep Med. 2023;19(2):309-317.

Institutional Variability in Representation of Women and Racial and Ethnic Minority Groups Among Medical School Faculty

IMPORTANCE

Bolstering the ranks of women and underrepresented groups in medicine (URM) among medical faculty can help address ongoing health care disparities and therefore constitutes a critical public health need. There are increasing proportions of URM faculty, but comparisons of these changes with shifts in regional populations are lacking.

OBJECTIVE

To quantify the representation of women and URM and assess changes and variability in representation by individual US medical schools.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study assessed US medical school faculty rosters for women and URM, including American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian or other Pacific Islander faculty. US allopathic medical schools participating in the Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System from 1990 to 2019 (updated December 31 for each year), were included. Faculty data were analyzed from yearly cross-sections updated as of December 31 for each year from 1990 to 2019. For census data, decennial census data were used for years 1990, 2000, and 2010. Intercensal estimates were used for all other years from 1990 to 2019.

MAIN OUTCOMES AND MEASURES

Trends and variability in representation quotient (RQ), defined as representation of a group within an institution's faculty compared to its respective US county.

RESULTS

There were 121 AAMC member institutions (72 076 faculty) in 1990, which increased to 144 institutions (184 577 faculty) in 2019. The median RQ of women faculty increased from 0.42 (IQR, 0.37-0.46) to 0.80 (IQR, 0.74-0.89) (slope, +1.4% per year; P < .001). The median RQ of Black faculty increased from 0.10 (IQR, 0.06-0.22) to 0.22 (IQR, 0.14-0.41) (slope, +0.5% per year; P < .001), but remained low. In contrast, the median RQ of Hispanic faculty decreased from 0.44 (IQR, 0.19-1.22) to 0.34 (IQR, 0.23-0.62) (slope, -1.7% per year; P < .001) between 1990 and 2019. Absolute total change in RQ of URM showed an increase; however, the 30-year slope did not differ from zero (+0.1% per year; P = .052). Although RQ of women faculty increased for most institutions (127 [88.2%]), large variability in URM faculty trends were observed (57 institutions [39.6%] with increased RQ and 10 institutions [6.9%] with decreased RQ). Nearly one-quarter of institutions shifted from the top to bottom 50th percentile institutional ranking by URM RQ with county vs national comparisons.

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that representation of women in academic medicine improved with time, while URM overall experienced only modest increases with wide variability across institutions. Among URM, the Hispanic population has lost representational ground. County-based population comparisons provide new insights into institutional variation in representation among medical school faculty.

Representation of Women and Underrepresented Groups in US Academic Medicine by Specialty

This cross-sectional study compares trends in representation of women and underrepresented groups in medicine in US academic medicine by specialty.

Strategies to optimize the performance of Robotic-assisted laparoscopic hysterectomy

A hybrid technique of robot-assisted, laparoscopic hysterectomy using the ENSEAL(®) Tissue Sealing Device is described in a retrospective, consecutive, observational case series. Over a 45 month period, 590 robot-assisted total laparoscopic hysterectomies +/- oophorectomy for benign and malignant indications were performed by a single surgeon with a bedside assistant at a tertiary healthcare center. Patient demographics, indications for surgery, comorbidities, primary and secondary surgical procedures, total operative and surgical time, estimated blood loss (EBL), length of stay (LOS), complications, transfusions and subsequent readmissions were analyzed. The overall complication rate was 5.9% with 35 patients experiencing 69 complications. Mean (SD) surgery time, operating room (OR) time, EBL, and LOS for the entire cohort were 75.5 (39.42) minutes, 123.8 (41.15) minutes, 83.1 (71.29) millilitres, and 1.2 (0.93) days, respectively. Mean surgery time in the first year (2009) was 91.6 minutes, which declined significantly each year by 18.0, 19.0, and 24.3 minutes, respectively. EBL and LOS did not vary -significantly across the entire series. Using the cumulative sum method, an optimization curve for surgery time was evaluated, with three distinct optimization phases observed. In summary, the use of an advanced laparoscopic tissue-sealing device by a bedside surgical assistant provided an improved operative efficiency and reliable vessel sealing during robotic hysterectomy.

Effects of calcium depletion and repletion on serum insulin-like growth factor I and binding protein levels in weanling rats

Previous studies in a weanling rat model indicated that dietary calcium depletion not only stimulated osteoclastic resorption but also inhibited bone formation. The present study sought to test whether the depletion-associated inhibition of bone formation is related to a reduction in serum insulin-like growth factor-I (IGF-I) and/or an increase in its binding proteins (IGFBPs). Twenty male weanling rats were divided into two weight-matched groups. The study group was subjected to a semisynthetic diet deficient in calcium (0.02% calcium) for 28 days, while the control group was pair-weighed on the same diet but containing 0.62% calcium. After the depletion phase, all rats were fed the same calcium-containing diet for an additional 14 days. Serum samples were obtained from each animal on a weekly basis and assayed for IGF-I and IGFBPs. During depletion, there was no statistically significant difference in serum IGF-I level between the study group and the control group. In contrast, the study group showed a statistically significant increase in several serum IGFBPs with apparent molecular size of 30-38 kD (IGFBP-3), 26-28 kD (IGFBP-1, -2, -5, and/or -6), and 24-25 kD (IGFBP-4), respectively, compared to the control group. There was no difference in nutritional intakes between the two groups of rats during depletion. During repletion, there was also no significant difference in serum IGF-I level between the control and study group. However, during the first 7 days of repletion, serum IGFBP-3 and the 26-28 kD IGFBP of the study group was significantly less than those of the control group, which then returned to the control level after 2 weeks of repletion. In summary: (1) calcium depletion in weanling rats increased several serum IGFBPs without an effect on IGF-I; and (2) calcium repletion induced an acute reduction in serum IGFBP-3. In conclusion, these findings represent the first evidence that the depletion-related inhibition of bone formation in the rat may be associated with an increase in several serum IGFBPs, which may act to inhibit the osteogenic actions of IGFs.

Dose-response study of dehydroepiandrosterone sulfate on dentate gyrus long-term potentiation

Neurosteroids are produced peripherally by endocrine glands, as well as enzymatically in the glia from steroid hormone substrates. GABA receptor sites and Ca2+ channel currents are prime targets for neurosteroid actions, and their effects are concentration dependent. For this reason, and the fact that treatment with one of them, sulfated dehydroepiandrosterone (DHEAS), improves performance in tasks involving memory in aged rats, we explored the effect of this hormone on dentate gyrus long term potentiation (LTP) in a dose-response mode. Intact anesthetized rats (urethane, 1.5 g/kg) were used. Electrodes were stereotaxically positioned in the perforant path and dentate gyrus for stimulation (bifocal) and recording (monofocal). DHEAS (10, 20, and 30 mg/kg, dissolved in Nutralipid 10%) was injected into the femoral vein. Ten animals were used to study the effects of each dose, one injection per animal. Twenty control animals were randomly interspersed within the experimental groups and were injected solely with Nutralipid. The results showed a significant increase in LTP at all doses in relation to baseline values. Further, there were significant increments in amplitude at 20 and 30 mg in relation to 10 mg. However, the data did not reveal significant differences between the 20- and the 30-mg-treated rats. Results are discussed in terms of effects of DHEAS on neurotransmitter and Ca2+ channel ion systems.

Mechanism of mitogenic action of aluminum ion on human bone cells: potential involvement of the insulin-like growth factor regulatory system

Aluminum ion at micromolar concentrations significantly stimulated the [3H]thymidine incorporation into human TE85 osteosarcoma cell DNA. Cells treated with mitogenic concentrations of aluminum ion for 48 h showed biphasic stimulation in secretion of IGFs (insulin-like growth factors) into the conditioned medium. Treatment of the human osteosarcoma TE85 cells with mitogenic doses of aluminum ion for 24 h also markedly and reproducibly increased the steady-state level of IGF-II mRNA in a dose-dependent, biphasic manner. The effect of aluminum ion on the steady-state level of IGF-I mRNA could not be determined since the IGF-I mRNA in these cells was not detectable with our oligodeoxynucleotide probes. To test whether the mitogenic effects of aluminum ion could be mediated through IGFs, the stimulation of [3H]thymidine incorporation of TE85 cells was evaluated in the presence and the absence of an inhibitory IGF binding protein (i.e., IGFBP-4). The presence of IGFBP-4 significantly reduced the stimulation in thymidine incorporation by a mitogenic concentration of aluminum ion. Western ligand blot analysis revealed that mitogenic concentrations of aluminum ion also inhibited the secretion of IGF-binding proteins, particularly the inhibitory IGFBP-4, which could lead to the potentiation of the overall activity of IGFs. In conclusion, these findings are consistent with the premise that the mitogenic action of aluminum ion on human bone cells is, in part, mediated by an increased local bone cell production and activity of IGFs.

Human astrocytes and cytokines: tumor necrosis factor alpha and interferon gamma do not promote astrocytic proliferation

Astrocyte cell cultures were established from human fetal brains and exposed to human recombinant tumor necrosis factor alpha (TNF alpha) and human recombinant interferon gamma (IFN gamma), and the proliferative response was assessed by bromodeoxyuridine-immunostaining technique. TNF alpha showed an inhibitory activity, while IFN gamma induced a slight increase in the number of astrocytes undergoing cell division. However, in both experiments differences were not statistically significant. Previous studies have demonstrated that TNF alpha and IFN gamma are potent mitogens for adult astrocytes in both in vivo and in vitro conditions. Our results suggest that in developing brain the immunomodulatory activity of cytokines, TNF alpha and IFN gamma, is different from that observed in adult brain.

Conversion of skeletal tartrate-sensitive acid phosphatases into tartrate-resistant isoenzymes in vitro

1. Chicken skeletal tartrate-sensitive (TsACP) and -resistant (TrACP) acid phosphatase isoenzymes could be separated from each other by carboxylmethyl-sepharose ion exchange chromatography. 2. Chicken skeletal TsACP showed a gradual time-dependent loss of sensitivity to tartrate inhibition when incubated at room temperature, but not at 4 degrees C. 3. The loss of sensitivity to tartrate inhibition was associated with an activation of the enzyme activity. 4. These changes were accompanied with a shift in the electrophoretic mobility of the enzyme activity from a large molecular sized form to a smaller molecular sized form that resembled the freshly prepared TrACP on the native acidic polyacrylamide electrophoresis gels, and on molecular sieve Superose-12 Fast Protein Liquid Chromatography. 5. Kinetic evaluations of the biochemical properties of the "converted" TsACP activity resembled the TrACP. 6. The apparent "conversion" was not unique to chicken TsACP, since similar "conversion" was observed with partially purified preparations of bovine bone matrix TsACP and of human osteoblastic TsACP. 7. Addition of several serine protease inhibitors did not prevent the "conversion". 8. These findings are consistent with the possibility that skeletal TsACPs are precursors of skeletal TrACPs.

Aluminum stimulates the proliferation and differentiation of osteoblasts in vitro by a mechanism that is different from fluoride

Micromolar concentrations of aluminum sulfate consistently stimulated [3H]thymidine incorporation into DNA and increased cellular alkaline phosphatase activity (an osteoblastic differentiation marker) in osteoblast-line cells of chicken and human. The stimulations were highly reproducible, and were biphasic and dose-dependent with the maximal stimulatory dose varied from experiment to experiment. The mitogenic doses of aluminum ion also stimulated collagen synthesis in cultured human osteosarcoma TE-85 cells, suggesting that aluminum ion might stimulate bone formation in vitro. The effects of mitogenic doses of aluminum ion on basal osteocalcin secretion by normal human osteoblasts could not be determined since there was little, if any, basal secretion of osteocalcin by these cells. 1,25 Dihydroxyvitamin D3 significantly stimulated the secretion of osteocalcin and the specific activity of cellular alkaline phosphatase in the human osteoblasts. Although mitogenic concentrations of aluminum ion potentiated the 1,25 dihydroxyvitamin D3-dependent stimulation of osteocalcin secretion, they significantly inhibited the hormone-mediated activation of cellular alkaline phosphatase activity. Mitogenic concentrations of aluminum ion did not stimulate cAMP production in human osteosarcoma TE 85 cells, indicating that the mechanism of aluminum ion does not involve cAMP. The mitogenic activity of aluminum ion is different from that of fluoride because (a) unlike fluoride, its mitogenic activity was unaffected by culture medium changes; (b) unlike fluoride, its mitogenic activity was nonspecific for bone cells; and (c) aluminum ion interacted with fluoride on the stimulation of the proliferation of osteoblastic-line cells, and did not share the same rate-limiting step(s) as that of fluoride. PTH interacted with and potentiated the bone cell mitogenic activity of aluminum ion, and thereby is consistent with the possibility that the in vivo osteogenic actions of aluminum ion might depend on PTH. In summary, low concentrations of aluminum ion could act directly on osteoblasts to stimulate their proliferation and differentiation by a mechanism that is different from fluoride.

Evidence that tartrate-resistant acid phosphatases from osteoclastomas and hairy cell leukemia spleen are members of a multigene family

1. Osteoclasts and hairy cell leukemia spleen both contain large amounts of a band 5-tartrate-resistant acid phosphatase (TrACP). 2. We have recently purified to homogeneity a band 5 TrACP from human osteoclastomas and two isoforms of band 5 TrACP (5a and 5b) from the spleen of a patient with hairy cell leukemia. 3. Although the N-terminal amino acid sequences and the apparent molecular weights of the osteoclastoma, hairy cell leukemia spleen TrACPs were identical, there were several differences in the physical and biochemical properties between the three isoenzymes. 4. Based on these findings, it is concluded that these isoenzymes are different enzymes, but that they could have originated from a similar ancestral gene. 5. It is proposed that the osteoclastoma and hairy cell leukemia band 5 TrACPs are members of a multigene family.