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Introduction In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. Method Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. Results The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. Discussion A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Background The lack of an adequate number of neurologists is a worldwide problem. As populations age, the prevalence of neurological disorders will likely increase, thereby increasing the demand for neurologists. In addition to the growing demand, inadequate diversity in the neurology healthcare workforce still exists. The purpose of this study is to examine the demographic characteristics of neurology residents and fellows. Methodology This cross-sectional study used data from the following publicly available databases: Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, and the United States Census Bureau. Trends (from 2007 to 2018) in demographic characteristics were assessed using the slope and the associated p-value of a simple linear regression model, with the year as the independent variable. All p-values of

India is rich in its heritage and culture. It has many historical monuments and temples where the walls are made of inscribed stones and rocks. The stone inscriptions play a vital role in portraying about the ancient incidents. Hence, the digitization of these stone inscriptions is necessary and contributes much for the epigraphers. Recently, the digitizing of these inscriptions began with the binarization process of stone inscriptions. This process mainly depends on the thresholding technique. In this paper, the binarization of terrestrial and underwater stone inscription images is preceded by a contrast enhancement and succeeded by edge-based filtering that minimizes noise and fine points the edges. A new method called modified bi-level thresholding (MBET) algorithm is proposed and compared with various existing thresholding algorithms namely Otsu method, Niblack method, Sauvola method, Bernsen method and Fuzzy C means method. The obtained results are evaluated with the performance metrics such as peak signal-to-noise ratio (PSNR) and standard deviation (SD). It is observed that the proposed method has an improvement of 49% and 39%, respectively, on an average by the metrics considered.

Thromboembolism is one of the major complications of coronavirus disease 19 (COVID-19) [1]. Both arterial and venous thromboembolism involving various organs from COVID-19 related coagulopathy have been reported. While arterial ischemic strokes are common, cerebral venous sinus thrombosis (CVT) associated with COVID-19 has been increasingly recognized [2,3]. The true incidence of CVT in COVID-19 patients remains unknown. Various mechanisms of thromboembolism include elevated factor VIII, fibrinogen, D-dimer, prothrombotic microparticles like antiphospholipid antibodies, and inflammatory markers like C-reactive protein and interleukin-6 [4]. In this report, we aimed to determine the rates of CVT and its impact on outcomes in patients with COVID-19.

Objective To explore effectiveness of alternative methods of neurology resident electroencephalogram (EEG) learning during COVID-19 pandemic due to social distancing requirements which caused disruption of traditional in-person teaching. Methods Virtual EEG learning was instituted using Zoom platform. Residents participated in live, interactive virtual sessions for eight weeks. A pre-test and post-test were administered and a survey was performed at the end of the project. Results Based on pre-test and post-test results, there was a significant improvement on average resident test scores. On the survey, 100% agreed (81.8% strongly agreed, 18.2% agreed) that virtual EEG sessions provided a conducive learning environment with easy access while preserving effective communication with the instructor. When compared to traditional EEG reading, 100% agreed (81.8% strongly agreed and 18.2% agreed) that virtual sessions were more accessible, 72.7% agreed (54.5% strongly agreed, 18.2% agreed) that they were more interactive; 81.9% (45.5% strongly agreed, 36.4% agreed) felt more engaged and 90.9% agreed (81.8% strongly agreed, 9.1% agreed) that they were able to attend more sessions. Hundred percent residents (72.7% strongly agreed, 27.3% agreed) felt more confident in their EEG reading and all (81.8% strongly agreed and 18.2% agreed) would sign up for more virtual learning courses. Conclusions Virtual EEG education is an efficient method of resident education with improved ease of access while maintaining interactive discussion leading to increased confidence in learners. It should be considered even after resolution of the need for social distancing and its applications in other fields of learning should be further explored.

Background: It is uncertain if patients with prior ischemic stroke are vulnerable to coronavirus disease 2019 (COVID-19) and its complications. Methods: We used TriNetX, a global health collaborative clinical research platform with a large global COVID-19 database. COVID-19 infection was identified with a positive lab value for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and related ribonucleic acid (RNA). Findings: A total of 604,258 patients with history of ischemic stroke were identified, of which 891 patients (study cohort) were diagnosed with COVID-19. A control cohort with 32,136 patients diagnosed with COVID-19 after January 20th 2020 without a history of ischemic stroke were identified. A comparison between study cohort and control cohort showed patients with prior history of stroke (study cohort) were older (69.5 vs 47.8; p

Highlights • Neuropsychiatric manifestations in COVID-19 positive patients. • Among 40,469 COVID-19 patients, 22.5% had neuropsychiatric manifestations. • Common neurological manifestations are headache, sleep disorders, encephalopathy. • Common psychiatric manifestations are anxiety, mood disorders., Corona Virus Disease 2019 (COVID-19) emerged in December 2019 from Wuhan, China. It typically presents with mild upper respiratory tract infection symptoms and may have life threatening complications, including acute respiratory distress syndrome, acute stroke, myocardial infarction, kidney failure, shock, and even death. Coronavirus infections are known to have neuroinvasive potential with consequent neuropsychiatric manifestations. We analyzed COVID-19 adult patients in the TriNetX database, which is a global health collaborative clinical research platform collecting real-time electronic medical records data from a network of health care organizations (HCOs) from January 20, 2020 to June 10th, 2020. 40,469 patients were diagnosed with COVID-19 among whom 9086 (22.5%) patients had neuropsychiatric manifestations. The most common neurologic manifestations included headache (3.7%) and sleep disorders (3.4%), Encephalopathy (2.3%), Stroke and transient ischemic attack (TIA) (1.0%) and 0.6% had seizures. Most common psychiatric manifestations included anxiety and other related disorders (4.6%), mood disorders (3.8%), while 0.2% patients had suicidal ideation. Early recognition and prompt management of neuropsychiatric manifestations in these patients have a potential to decrease overall morbidity and mortality.

Background: The corona virus disease 2019 (COVID-19) pandemic has led to uncertainty regarding the best management practice for patients with chronic autoimmune neurological disorders (cANDs) who require immunosuppressive therapies (ISTs). While ISTs are often essential to control cANDs, there is concern that ISTs may make this patient population more susceptible to COVID-19 and related complications. Expert opinion consensus guidelines have emerged during the pandemic but there is a paucity of real-world data on the impact of COVID-19 in cANDs. Methods: We used TriNetX, which is a global health collaborative clinical research platform collecting real-time electronic medical records data, which has the largest known global COVID-19 database. We included patients with cANDs [multiple sclerosis (MS), myasthenia gravis (MG), inflammatory myositis, and chronic inflammatory neuropathies (CIN)], based on ICD-10 coding for one year before January 20th, 2020. We examined the rates of COVID- 19 infection, hospitalizations, intubations and deaths among these patients Findings: A total of 33,451 patients with autoimmune neuromuscular disorders (aNMDs) and 42,899 patients with MS were included. Among them, 111 (0.33%) patients with aNMDs and 115 patients (0.27%) with MS had COVID-19. Risk of COVID-19 was similar among patients with aNMD and MS. About one third of them required hospitalization. Immunosuppression did not appear to impact infection risk overall in either group; however, risk of hospitalization for immunosuppressed patients with aNMDs was higher (Odds ratio 2.86, p-value 0.011). Interpretation: Immunosuppression is unlikely to make patients with cANDs more vulnerable to COVID-19. ISTs can be continued during the pandemic, as previously suggested by expert opinion guidelines. However, it is important to consider individualizing immunotherapy regimens in some cases. Additional longitudinal physician reported registry-based data is needed to further confirm these findings. Funding Statement: None. Declaration of Interests: Dr. Kovvuru, Dr. Nalleballe, Dr. Onteddu, Dr. Sharma, Dr. Jasti, Dr. Kapoor, Dr. Veerapaneni, Dr. Yadala, Dr. Dandu, and Dr. Archer have no conflicts of interest to report. Dr. Nowak reports no conflicts directly related to this work. Dr. Nowak has received research support from the National Institutes of Health (NIH), Genentech, Alexion Pharmaceuticals, argenx, Annexon Biosciences, Ra Pharmaceuticals, Myasthenia Gravis Foundation of America, Momenta, Immunovant, and Grifols. He has served as consultant/advisor for Alexion Pharmaceuticals, argenx, CSL Behring, Grifols, Ra Pharmaceuticals, Immunovant, Momenta and Viela Bio. Dr. Roy reports no conflicts directly related to this work. He has served as a consultant for Alexion Pharmaceuticals. Ethics Approval Statement: The University of Arkansas Institutional Review Board (IRB) deemed this study to be ‘not human subject research’ (global de-identified COVID-19 Research Network data designated for research use), and gave it an exempt status.

Objective The purpose of this study was to determine reasons for not giving intravenous tissue plasminogen activator to eligible patients with acute ischemic stroke in a telestroke network. Methods We performed a retrospective analysis of prospectively collected data of patients who were seen as a telestroke consultation during 2015 and 2016 with the Arkansas Stroke Assistance through Virtual Emergency Support programme for possible acute ischemic stroke. Results Total consultations seen were 809 in 2015 and 744 in 2016, out of which 238 patients in 2015 and 247 patients in 2016 received intravenous tissue plasminogen activator. In 2015 and 2016, out of the remaining 571 and 497 patients, 294 and 200 patients respectively were thought to be cases of acute stroke based on clinical evaluation. The most common reasons for not being treated in 2015 and 2016, respectively, were; (a) minimal deficits in 42.17% and 49.5% cases, (b) falling out of the 4.5-hour time window in 22.44% and 22% cases, (c) patient/next of kin refusal in 18.02% and 16.5% cases. Less common reasons included limited functional status, abnormal labs (thrombocytopenia, elevated international normalised ratio (INR)/prothrombin time (PT)/partial thromboplastin time (PTT), hypo or hyperglycemia etc), recent surgery and symptoms being too severe etc. Conclusion ‘Minimal deficits’ and ‘out of time window’ continue to be the major causes for not receiving thrombolysis during acute ischemic stroke in both traditional and telestroke systems. Patient/next of kin refusal was high in our telestroke system when compared to traditional practices. Considering the increasing utility of telestroke this needs to be further looked into, along with the ways to address it.

Objective To study the risk of acquiring Corona Virus Disease 2019 (COVID-19) and its outcomes in patients on immunosuppressive therapy (IST) for chronic autoimmune neuromuscular disorders (aNMD) and multiple sclerosis (MS). Methods We used TriNetX, a global health collaborative clinical research platform collecting real-time electronic medical records data, which has one of the largest known global COVID-19 database. We included patients with chronic autoimmune neuromuscular disorders (aNMD) [myasthenia gravis (MG), inflammatory myositis, and chronic inflammatory neuropathies (CIN)] and MS, based on the International Classification of Disease-10 (ICD-10) coding for one year before January 20th, 2020. We examined the use of IST, rate of COVID- 19, hospitalization, intubation, and mortality among the patients with aNMD and MS. Results A total of 33,451 patients with aNMD and 42,899 patients with MS were included. Among them, 111 (0.33%) patients with aNMD and 115 patients (0.27%) with MS had COVID-19. About one third of them required hospitalization. IST did not appear to have a significant impact on overall infection risk in either group; however, risk of hospitalization for immunosuppressed patients with aNMD was higher (Odds ratio 2.86, p-value 0.011). Conclusions IST use does not appear to make patients with aNMD and MS more vulnerable to COVID-19. IST may be continued during the pandemic, as previously suggested by expert opinion guidelines. However, it is important to consider individualizing immunotherapy regimens in some cases. Additional physician reported registry-based data is needed to further confirm these findings., Highlights • Majority of patients with chronic autoimmune neurological disorders(cAND’s) likely have mild-to-moderate COVID-19. • Patients with cAND’s who had COVID-19, 33% were hospitalized 12.1% required intensive care unit stay and 8.5% died. • Immunosuppressive therapies did not appear to have a significant impact on overall infection risk.

The water quality parameters of Sulur Lake situated in Coimbatore District of Tamil Nadu (11° 01’ 40” N and 77° 07’20” E) have been studied from July 2015 to July 2016. The present paper dealt with the seasonal variation of productivity and its relation to Total Dissolved Solids (TDS), Chloride and Magnesium. In the present study, Total Dissolved Solids of the six stations varied from 490 mg/l to 950 mg/l, Chloride ranges between 249.92 mg/l and 445.88 mg/l and Magnesium varied from 20.9 mg/l to 65.2 mg/l during the study period. Gross Primary Productivity (GPP) ranged from 1.3601 gC/m3/hr to 3.1736 gC/m3/hr, Net Primary Productivity (NPP) varied between 0.7556 gC/m3/hr and 2.8713 gC/m3/hr and Community Respiration (CR) varied from 0.1511 gC/m3/hr to 0.9067 gC/m3/hr. The data on the physico-chemical characteristics of this aquatic wetland revealed that this water body needs immediate and broad water quality monitoring and to find the remedial measures to improve this important water body in the study area. The mathematic relationships of these factors were analyzed using CURVEXPERT software and the significant relationships are expressed and their significance in the prediction of water quality is discussed

Background: Thrombolytic treatment of stroke patients in telestroke can be enhanced by studying critical time interval requirements. We retrospectively examined 12 concurrent months of targeted time interval information from 2016 in a large 48 site telemedicine program. Telemedicine programs with new spoke sites added throughout the year must continually evaluate where improvements can be made to decrease the arrival to treatment time. Hypothesis: We hypothesized that referral data analysis would highlight areas for improvement to shorten time to treatment. Methods: We analyzed critical time targeted information during 12 months of 247 consecutive telestroke neurology referrals from AR SAVES spoke sites when tissue plasminogen activator (tPA) was given. Measured time intervals of: emergency department (ED) door to CT (ED2CT), ED door to call center (ED2CC) for initiation of consult and ED door to neurology call (ED2NeuroCall), neurology call to camera (NeuroCall2Cam), total consult (Con), ED door to tPA (ED2tPA) were studied. Results: Reported median times of door to CT [ED2CT, 8 min, IQR 4-15 min], door to call center [ED2CC, 37 min, IQR 26-53 min], door to neurology call time [ED2NeuroCall, 42 min, IQR 33-57 min], neurology call response time [NeuroCall2Cam, 3 min, IQR 2-5 min], and total time spent in consult [Con, 24 min, IQR 19-32 min] all contributed to a ED2tPA median time of 73 min [IQR 60-90]. Twenty-six percent of referral patients received tPA ≤ 60 min and an overall tPA treatment rate of 33.2% was reported. The largest delay in time were: arrival to neurology call time and in consult time, 27 minutes and 13 minutes respectively. Totaling 40 minutes in variation. Conclusion: Focus in either ED2NeuroCall or Con of these time areas, may produce the largest improvements and reduce the door to treatment time. A 20 minute reduction in time would dramatically reduce the door to treatment time and increase the percentage of tPA administration to well within the goal of 60 minutes or less.