Letter to the Editor Regarding: 'Impact of COVID-19 on an Academic Neurosurgery Department: The Johns Hopkins Experience'

The Impact of the COVID-19 Pandemic in Postoperative Neurosurgical Infections at a Reference Center in México

The COVID-19 pandemic has had a major global impact on the treatment of hospitalized surgical patients. Our study retrospectively evaluates the impact of the COVID-19 pandemic at a neurosurgical reference center in Mexico City. We compared the number of neurosurgeries, the rate and type of postoperative infections, the causative microorganisms and in-hospital mortality rates in a 4-year period, from the pre-pandemic year 2019 until 2022. A total of 4150 neurosurgical procedures were registered. In 2020 the total number of surgeries was reduced by 36% compared to 2019 OR = 0.689 (95% CI 0.566-0.834) p ≤ 0.001, transnasal/trans sphenoidal pituitary resections decreased by 53%, and spinal surgeries by 52%. The rate of neurosurgical infections increased from 3.5% in 2019 to 5.6% in 2020 (p = 0.002). Regarding the microorganisms that caused infections, gram positive cocci accounted for 43.5% of isolates, Klebsiella spp. and Pseudomonas spp. caused one third of the infections. No significant differences were found for in-hospital mortality nor patterns of resistance to antibiotics. The number of surgeries increased in the last two years, although the infection rate has returned to pre-pandemic levels. We observed a lower impact from subsequent waves of COVID-19 and despite an increase in the number of surgeries, the surgeries have not amounted to the full pre-pandemic levels.

Optimizing international neurosurgical outreach missions: 15-year appraisal of operative skill transfer in Lima, Peru

Background:

While several medical outreach models have been designed and executed to alleviate the unmet need for international neurosurgical care, disparate strategies have evolved. There is a need to determine the optimal pediatric neurosurgical outreach model through which resources are efficiently utilized while imparting the largest possible impact on global health. This study evaluates the efficacy of an international pediatric neurosurgery outreach model at transferring operative skill in a sustainable and scalable manner in Lima, Peru over a 15-year duration.

Methods:

Three 1-week neurosurgical missions were carried out (2004–2006) in Lima, Peru to teach neuroendoscopic techniques and to provide equipment to host neurosurgeons, equipping the hosts to provide care to indigent citizens beyond the duration of the missions. Follow-up data were obtained over a 15 year span, with collaboration maintained over email, two in-person visits, and video-conferencing services.

Results:

Since the outreach missions in 2004–2006, the host neurosurgeons demonstrated sustainability of the neuroendoscopic instruction by independently performing neuroendoscopic operations on a growing caseload: at baseline, 0 cases were performed in 2003, but since 2012 and onwards, 40–45 cases have been performed annually. Scalability is illustrated by the fact that the institution established a rigorous neuroendoscopy training program to independently pass on the techniques to resident physicians.

Conclusion:

The described international pediatric neurosurgical outreach model, centered around teaching operative technique as opposed to solely providing care to citizens, allowed operative skill to be sustainably transferred to surgeons in Lima, Peru. Having served the neuroendoscopic needs of hundreds of citizens, the strategic design is replicable and should be mirrored by future medical endeavors seeking to substantially impact the deficit in global surgical care.

Getting Neurosurgery Services Back on Its Feet: "Learning to Live" with COVID-19

Background:

Cancellation/postponement of ”non-emergent” surgeries during coronavirus disease of 2019 (COVID-19) pandemic has created a huge backlog of patients waiting for surgery and has put them at risk of disease progression. We share our institute's policy and our department's attempt to resume ”non-emergent” surgeries.

Materials and Methods:

We collected details of all patients operated under department of neurosurgery since the onset of COVID-19 pandemic in India and categorized them into ”lockdown” and ”unlock” groups for comparison. COVID-19 tests done in these patients were also analyzed. We also compared our surgical volume with the number of COVID-19 cases in the state.

Results:

One hundred and forty-eight patients (97 males, 51 females) with mean age of 37.8 years (range-2 months-82 years) underwent surgery in our department during the study period. The operative volume per week increased by 37% during the ”unlock” period as compared to ”lockdown” period. The proportion of elective/”non-emergent” surgeries increased from 11.3% during ”lockdown” to 34.7% during the ”unlock” period (P = 0.0037). During ”lockdown” period, number of surgeries declined steadily as the number of COVID-19 cases rose in the state (rs(8) = −0.914, P = 0.000). Whereas there was a trend toward increased number of cases done per week despite increase in the number of cases in the state during the “unlock” period. During the ”unlocking” process, in-patient department admissions and surgeries performed per month increased (P = 0.0000) and this increase was uniform across all specialties. COVID-19 test was done (preoperatively or postoperatively) for all surgeries during ”unlock” period compared to 12 (22.6%) surgeries during ”lockdown” period. Three neurosurgery patients who underwent surgery during the ”unlock” period tested positive for COVID-19.

Conclusions:

Our experience shows that proper evidence-based protocols, setting up of adequate COVID-19 testing facilities and provision of ample personal protective equipments are instrumental in re-starting “nonemergent” surgeries.

Lessons from failure: neurosurgical outreach in Managua, Nicaragua

With respect to the tremendous deficit in surgical care plaguing developing nations, it is critical that medical outreach models be organized in such a fashion that sustainable advancements can be durably imparted beyond the duration of targeted missions. Using a didactic framework focused on empowering host neurosurgeons with an enhanced surgical skillset, a mission was launched in Managua, Nicaragua, after previous success in Kiev, Ukraine, and Lima, Peru. Unfortunately, the failure to critically assess the internal and external state of affairs of the region's medical center compromised the outreach mission. Herein lies the visiting team's lessons from failure and insights on facilitating effective communication with host institutions, circumventing geopolitical instability, and utilizing digital collaboration and video-conferencing tools in the post-COVID-19 era to advance the surgical care of developing regions in a fashion that can be generationally felt.

Deployment of Neurosurgeons at the Warfront Against Coronavirus Disease of 2019 (COVID-19)

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has taken the world by storm, especially the health care system. Medical practitioners of all specialties are being assigned to treat patients of COVID-19. In this article, two authors (T.V. and N.G.) from the Department of Neurosurgery who were deployed in the COVID-19 testing ward between April 25 and May 31, 2020 share their experience.

METHODS

A prospective observational study was conducted including all those who were admitted in this ward. The patients were studied according to their demographic profiles, diagnoses, admitting departments, travel history, and presence/absence of COVID-19-related symptoms. Relevant history regarding occupation, contact with patient with known COVID-19, and comorbid illness was noted. Those who tested positive for COVID-19 were studied further. The data from the institute's official record were updated until August 14, 2020.

RESULTS

During the study period, there were 256 admissions in the ward, of whom 148 (92 male, 56 female) were patients and 108 were patients' attendants/relatives. Most patients were admitted under the departments of internal medicine (33, 22.3%) and general surgery (19, 12.8%). Of 148 patients, 46 (31.1%) were admitted as they were planned for a surgery/intervention. Among 148 patients, 29 (19.6%) had history of travel to or were residents of a red zone, 4 (2.7%) had history of contact with a confirmed case of COVID-19, whereas 6 (4.1%) were health care workers. One hundred four patients (70.2%) showed no COVID-19-related symptoms. Thirty-four patients (22.9%) had associated comorbid conditions. Eight patients (5 male, 3 female) with mean age of 37.6 years (range 4-69 years) tested positive for COVID-19.

CONCLUSIONS

The authors share their experience and their institute's protocol in various facets during this war against COVID-19 pandemic. Preadmission and presurgical testing of patients is important in preventing the spread of the disease amongst health care workers.

"Locked up inside home" - Head injury patterns during coronavirus disease of 2019 pandemic

BACKGROUND

As citizens have been forced to stay home during coronavirus disease of 2019 (COVID-19) pandemic, the crisis created unique trends in the neurotrauma patterns with changes in mode, severity, and outcome of head injured patients.

METHODS

Details of neurotrauma admissions under the neurosurgery department at our institute since the onset of COVID-19 pandemic in the country were collected retrospectively and compared to the same period last year in terms of demographic profile, mode of injury, GCS at admission, severity of head injury, radiological diagnosis, management (surgical/conservative), and outcome. The patients were studied according to which phase of pandemic they were admitted in - "lockdown" period (March 25 to May 31, 2020) or "unlock" period (June 1 to September 15, 2020).

RESULTS

The number of head injuries decreased by 16.8% during the COVID-19 pandemic. Furthermore, during the lockdown period, the number of admissions was 2.7/week while it was 6.8/week during the "unlock" period. RTA was the mode of injury in 29.6% patients during the lockdown, while during the unlock period, it was 56.9% (P = 0.000). Mild and moderate head injuries decreased by 41% and severe head injuries increased by 156.25% during the COVID-19 pandemic (P = 0.000). The mortality among neurotrauma patients increased from 12.4% to 22.5% during the COVID-19 era (P = 0.009).

CONCLUSION

We observed a decline in the number of head injury admissions during the pandemic, especially during the lockdown. At the same time, there was increase in the severity of head injuries and associated injuries, resulting in significantly higher mortality in our patients during the ongoing COVID-19 pandemic.