Management of Neurosurgical Cases in a Tertiary Care Referral Hospital During the COVID-19 Pandemic: Lessons from a Middle-Income Country

Lessons learned during COVID-19 pandemic, a worldwide survey: evolution of global neurosurgical practice

BACKGROUND

During the COVID-19 pandemic, a multitude of surveys have analyzed the impact virus spreading on the everyday medical practice, including neurosurgery. However, none have examined the perceptions of neurosurgeons towards the pandemic, their life changes, and the strategies they implemented to be able to deal with their patients in such a difficult time.

METHODS

From April 2021 to May 2021 a modified Delphi method was used to construct, pilot, and refine the questionnaire focused on the evolution of global neurosurgical practice during the pandemic. This survey was distributed among 1000 neurosurgeons; the responses were then collected and critically analyzed.

RESULTS

Outpatient department practices changed with a rapid rise in teleservices. 63.9% of respondents reported that they have changed their OT practices to emergency cases with occasional elective cases. 40.0% of respondents and 47.9% of their family members reported to have suffered from COVID-19. 56.2% of the respondents reported having felt depressed in the last 1 year. 40.9% of respondents reported having faced financial difficulties. 80.6% of the respondents found online webinars to be a good source of learning. 47.8% of respondents tried to improve their neurosurgical knowledge while 31.6% spent the extra time in research activities.

CONCLUSIONS

Progressive increase in operative waiting lists, preferential use of telemedicine, reduction in tendency to complete stoppage of physical clinic services and drop in the use of PPE kits were evident. Respondents' age had an impact on how the clinical services and operative practices have evolved. Financial concerns overshadow mental health.

COVID-19 and Surgical Practice in Slovenia: Managing the Crisis in Neurosurgery during the COVID-19 Pandemic

Worldwide, the novel coronavirus disease 2019 (COVID-19) has become a significant threat to global health. Worldwide, COVID-19 has affected the health service also in Slovenia. During this time, neurosurgery is facing difficulties in its service, both in emergency and elective surgeries. In the article, we describe the anti-COVID-19 measures taken at our neurosurgical department in a medical centre in Ljubljana, Slovenia, and analysed and compared the number of emergency and elective neurosurgical procedures during the time of the pandemic.

A look at the global impact of COVID-19 pandemic on neurosurgical services and residency training

Background

The COVID-19 pandemic has left an indelible effect on healthcare delivery and education system, including residency training. Particularly, neurosurgical departments worldwide had to adapt their operating model to the constantly changing pandemic landscape. This review aimed to quantify the reduction in neurosurgical operative volume and describe the impact of these trends on neurosurgical residency training.

Methods

We performed a comprehensive search of PubMed and EMBASE between December 2019 and October 2022 to identify studies comparing pre-pandemic and pandemic neurosurgical caseloads as well as articles detailing the impact of COVID-19 on neurosurgery residency training. Statistical analysis of quantitative data was presented as pooled odds ratio (OR) and 95% confidence intervals (CI).

Results

A total of 49 studies met the inclusion criteria, of which 12 (24.5%) were survey-based. The case volume of elective surgeries and non-elective procedures decreased by 70.4% (OR=0.296, 95%CI 0.210-0.418) and 68.2% (OR=0.318, 95%CI 0.193-0.525), respectively. A significant decrease was also observed in functional (OR=0.542, 95%CI 0.394-0.746), spine (OR=0.545, 95%CI 0.409-0.725), and skull base surgery (OR=0.545, 95%CI 0.409-0.725), whereas the caseloads for tumor (OR=1.029, 95%CI 0.838-1.263), trauma (OR=1.021, 95%CI 0.846-1.232), vascular (OR=1.001, 95%CI 0.870-1.152), and pediatric neurosurgery (OR=0.589, 95%CI 0.344-1.010) remained relatively the same between pre-pandemic and pandemic periods. The reduction in caseloads had caused concerns among residents and program directors in regard to the diminished clinical exposure, financial constraints, and mental well-being. Some positives highlighted were rapid adaptation to virtual educational platforms and increasing time for self-learning and research activities.

Conclusion

While COVID-19 has brought about significant disruptions in neurosurgical practice and training, this unprecedented challenge has opened the door for technological advances and collaboration that broaden the accessibility of resources and reduce the worldwide gap in neurosurgical education.

A Review Pertaining to SARS-CoV-2 and Autoimmune Diseases: What Is the Connection?

Coronavirus disease 2019 (COVID-19) is an infectious viral disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It is known that infection with SARS-CoV-2 can lead to various autoimmune and autoinflammatory diseases. There are few reports in the literature on the association between SARS-CoV-2 and autoimmune diseases, and the number of reports has been increasing since 2020. Autoimmune diseases and SARS-CoV-2 infections are intertwined in several ways. Both conditions lead to immune-mediated tissue damage, the immune response is accompanied by the increased secretion of inflammatory cytokines and both conditions can be treated using immunomodulatory drugs. Patients with certain autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes, cardiac sarcoidosis, idiopathic pulmonary fibrosis, autoimmune hepatitis, multiple sclerosis and others, are more susceptible to SARS-CoV-2 infection, either because of the active autoimmune disease or because of the medications used to treat it. Conversely, SARS-CoV-2 infection can also cause certain autoimmune diseases. In this paper, we describe the development of autoimmune diseases after COVID-19 and the recovery from COVID-19 in people with autoimmune diseases.

Management of neurosurgical patients during coronavirus disease 2019 pandemics: The Ljubljana, Slovenia experience

The novel coronavirus disease 2019 (COVID-19) is an emerging disease, caused by severe acute respiratory syndrome coronavirus-2. It bears unique biological characteristics, clinical symptoms and imaging manifestations, therefore presenting an important and urgent threat to global health. As a result, a new public health crisis arose, threatening the world with the spread of the 2019 novel coronavirus. Despite the maximal worldwide public health responses aimed at containing the disease and delaying its spread, many countries have been confronted with a critical care crisis, and even more, countries will almost certainly follow. In Slovenia, the COVID-19 has struck the health system immensely and among all the specialities, neurosurgery has also been experiencing difficulties in the service, not only in regular, elective surgeries but especially during emergencies. The management of these neurosurgical patients has become more difficult than ever. We describe our protocol in the management of neurosurgical patients in the University Medical Centre Ljubljana, Slovenia and how neurosurgical pathology was tackled during the pandemics.

Triage admission protocol with a centralized quarantine unit for patients after acute care surgery during the COVID-19 pandemic: A tertiary center experience in Taiwan

BACKGROUND

During the COVID-19 surge in Taiwan, the Far East Memorial Hospital established a system including a centralized quarantine unit and triage admission protocol to facilitate acute care surgical inpatient services, prevent nosocomial COVID-19 infection and maintain the efficiency and quality of health care service during the pandemics.

MATERIALS AND METHODS

This retrospective cohort study included patients undergoing acute care surgery. The triage admission protocol was based on rapid antigen tests, Liat® PCR and RT-PCT tests. Type of surgical procedure, patient characteristics, and efficacy indices of the centralized quarantine unit and emergency department (ED) were collected and analyzed before (Phase I: May 11 to July 2, 2021) and after (Phase II: July 3 to July 31, 2021) the system started.

RESULTS

A total of 287 patients (105 in Phase I and 182 in Phase II) were enrolled. Nosocomial COVID-19 infection occur in 27 patients in phase I but zero in phase II. More patients received traumatological, orthopedic, and neurologic surgeries in phase II than in phase I. The patients' surgical risk classification, median total hospital stay, intensive care unit (ICU) stay, intraoperative blood loss, operation time, and the number of patients requiring postoperative ICU care were similar in both groups. The duration of ED stay and waiting time for acute care surgery were longer in Phase II (397 vs. 532 minutes, p < 0.0001). The duration of ED stay was positively correlated with the number of surgical patients visiting the ED (median = 66 patients, Spearman's ρ = 0.207) and the occupancy ratio in the centralized quarantine unit on that day (median = 90.63%, Spearman's ρ = 0.191).

CONCLUSIONS

The triage admission protocol provided resilient quarantine needs and sustainable acute care surgical services during the COVID-19 pandemic. The efficiency was related to the number of medical staff dedicated to the centralized quarantine unit and number of surgical patients visited in ED.

Practice Patterns in Surgical Neuro-Oncology Among Low- and Middle-Income Countries During the Coronavirus Disease 2019 Pandemic: A Scoping Review and Situational Report from the Philippines

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the outcomes of surgical neuro-oncology patients worldwide. We aimed to review the practice patterns in surgical neuro-oncology in low- and middle-income countries (LMICs). We also present a situational report from our own country.

METHODS

A scoping review was performed following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines.

RESULTS

Twelve studies were included in the review. Most of the studies were from Asia (India, China, Iran, and Turkey), and 1 was from Brazil. Quantitative reports showed a decrease in the number of surgical neuro-oncology operations between pre-COVID-19 and post-COVID-19 time frames, but similar proportions of neuro-oncology procedures. Qualitative review showed similar practice patterns between LMICs and high-income countries, except for limitations in resources such as negative-pressure operating rooms and intensive care units, and maintenance of face-to-face consults despite the adoption of telemedicine. Limited data on adjuvant therapy were available in LMICs.

CONCLUSIONS

In our review, we found that the practice patterns in surgical neuro-oncology in LMICs during the COVID-19 pandemic are similar to those in high-income countries, except for a few modifications because of resource limitation and patient preferences.

Surgical Management During the COVID-19 Era at a Private Tertiary Care Hospital of Karachi, Pakistan: A Cross-Sectional Study

Background

The coronavirus disease 2019 (COVID-19), declared a pandemic in March 2020, has affected the entire healthcare system, including the surgical practice. Guidelines for the management of surgical patients during this COVID-19 era need to be established to provide timely yet safe surgical care. In this study, we aimed to evaluate the outcomes of the COVID-19 testing algorithm established for surgery patients presenting to a tertiary care hospital in Karachi, Pakistan, and to compare the outcomes among patients who underwent elective versus emergency surgery.

Methodology

This is a cross-sectional study conducted at a tertiary care hospital in Pakistan to apply and assess the outcomes of the COVID-19 testing algorithm established for patients presenting for surgery. We included all patients who underwent any surgery from May to October 2020. The total sample size was 6,846. The data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA). The categorical variables were assessed using the chi-square or Fisher’s exact test. A p-value of <0.05 was considered significant.

Results

A total of 6,846 surgeries were performed from May 1 to October 31, 2020. In total, 74% of the surgeries were elective procedures. We observed that a significantly higher proportion of emergency surgery patients tested positive for COVID-19 (4.2%) compared to elective surgery patients (25/5,063, 0.5%). A higher proportion of surgeries were performed in September (1,437, 21%) and October (1,445, 21%) while the lowest number of surgeries were performed in May (625, 9.1%). From week one to week five, a higher proportion of emergency surgeries were performed (32%) compared to elective surgeries (25%). Only 1.9% of the patients who were undergoing surgery were COVID-19 positive, with the highest number of COVID-19 cases presenting in June. Overall, 74 (4.2%) of the COVID-19-positive patients underwent emergency surgeries.

Conclusions

The timely establishment of well-defined guidelines for surgical management during the pandemic allowed us to provide timely and effective surgical care to patients with the priority of minimizing the spread of COVID-19 and preventing unnecessary deferral of surgeries.

Acute Endovascular Management of a Ruptured Choroidal Artery Arteriovenous Malformation in a Peripartum COVID-19-Positive Patient

Coronavirus disease 2019 (COVID-19) pandemic has led to significant reduction in specialty care causing delayed presentations and decreased resources for elective procedures. We present here a case of a 29-year-old female, 34 weeks primigravida who presented with a twice ruptured right choroidal artery arteriovenous malformation (AVM). She underwent an immediate external ventricular drain placement followed by an emergency cesarean. She underwent a diagnostic angiogram showing a right choroidal AVM with a feeder artery aneurysm along with small supply to its cortical component by the M4 segment of right middle cerebral artery, draining into the basal vein of Rosenthal and vein of Labbe. The patient underwent embolization of the aneurysm and the choroidal feeders. She improved symptomatically following the procedure with external cerebrospinal fluid diversion for 5 days. At follow-up magnetic resonance imaging, the residual AVM remained stable and is planned for Gamma knife radiosurgery. The newborn was taken care at a neonatal intensive care unit and was started on breastfeed on 16th day of birth once the mother had a negative COVID-19 reverse transcription polymerase chain reaction. In this study, we highlight our experience with the above-mentioned patient profile, the multidisciplinary effort during the pandemic, and the measures taken (isolation ward, COVID-19 dedicated Cath-lab and personal precautions) and advised for tackling COVID-19 patients for endovascular procedures.

Impact of COVID-19 pandemic on the management of glioma patients around the world. An evidence-based review

Background

The coronavirus pandemic has affected many health care services worldwide since the emergence of the first case in Wuhan. Surgical neuro-oncology care is a fundamental part of hospital services, making it susceptible to strategic changes amid the COVID-19 pandemic.

Methods

An electronic search on several databases (PubMed/Medline, Scopus, and Google Scholar) from the beginning of the pandemic to the end of 2020, each paper was reviewed independently. The publication inclusion and exclusion criteria were done using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.

Results

Eight studies were found to be eligible for our meta-analysis. Most of the studies were on a retrospective basis, except one which was retrospective and prospective. An overall of 951 glioma patients’ were included for surgical admission from the beginning of the pandemic until 2020. Seventy-four patients' had mortality outcomes, and 250 patients had complications for both surgical admitted and non-surgical admitted purposes.

Conclusions

To our knowledge, we made the first systematic review and meta-analysis regarding the management of glioma patients’ during the pandemic of COVID-19. Our main findings are that the number of surgical admissions for glioma patients’ did not significantly differ between COVID-19 negative and COVD-19 positive cases; however, surprisingly, we found that both overall complications and mortality outcomes were more significant COVID-19 negative patients’ from the reported studies.