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Gupta A, Goyal-Honavar A, Jonathan GE, Prabhu K, Varghese GM, Rupali P, Chacko AG. Adapting management strategies for sellar-suprasellar lesions during the COVID-19 pandemic: a pragmatic approach from the frontline. Br J Neurosurg 2024; 38:596-603. [PMID: 34148450 DOI: 10.1080/02688697.2021.1940852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/04/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE During the ongoing COVID-19 pandemic, endonasal surgeries for sellar-suprasellar lesions were discouraged due to the risk of transmission of the disease. We reviewed the changes in our management protocol for these lesions as our disease understanding and preparedness evolved. MATERIALS AND METHODS This was a retrospective observational study including patients with sellar-suprasellar and clival lesions presenting to us between March and October 2020. Management protocols were divided into three phases based on the prevalence of the disease and the number of mandatory preoperative COVID-19 tests being conducted. The surgical approach used was analyzed in relation to the preferred approach during pre-COVID times, and surgical outcomes and complications were noted. RESULTS A total of 31 cases were operated during this period. During Phase I (low prevalence; no preoperative COVID testing) endonasal surgeries were largely abandoned in favor of transcranial approaches. In Phase II (medium prevalence; one preoperative COVID test) we gradually resumed endonasal surgeries for 'emergent' and 'essential' cases, and subsequently in Phase III (high prevalence; two preoperative COVID tests), we had no hesitation in performing 'elective' endonasal surgeries with additional barriers for prevention of aerosol transmission. No patient developed COVID-19 infection postoperatively. Eight HCWs in our department acquired the disease during this period, none of whom were directly involved in the surgeries for the above cohort of patients. CONCLUSIONS With a strict preoperative COVID testing protocol, adherence to proper drilling techniques and using additional barriers to prevent droplet and aerosol spread, endonasal surgeries for sellar-suprasellar lesions are safe during this COVID-19 pandemic.
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Affiliation(s)
- Ankush Gupta
- Section of Neurosurgery, Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| | - Abhijit Goyal-Honavar
- Section of Neurosurgery, Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| | - Gandham Edmond Jonathan
- Section of Neurosurgery, Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| | - Krishna Prabhu
- Section of Neurosurgery, Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| | - George M Varghese
- Department of Infectious Diseases, Christian Medical College Hospital, Vellore, India
| | - Priscilla Rupali
- Department of Infectious Diseases and Hospital Infection Control Committee, Christian Medical College Hospital, Vellore, India
| | - Ari George Chacko
- Section of Neurosurgery, Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
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Zanin L, Ius T, Panciani PP, Esposito F, Gori A, Fontanella MM, Tropeano MP, Raco A, Angileri FF, Sabatino G, Olivi A, Esposito V, Pessina F. The impact of COVID-19 pandemic on surgical neuro-oncology: A survey from the Italian society of neurosurgery (SINch). World Neurosurg X 2023; 20:100233. [PMID: 37456685 PMCID: PMC10289824 DOI: 10.1016/j.wnsx.2023.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/14/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background The COVID-19 pandemic and its impact on hospitals' activity and organization has imposed a vast change in standard neurosurgical oncology practice to accommodate for shifting resources. Aims This investigation aims to analyse the nationwide capability in reorganizing the surgical neuro-oncological activity during the COVID-19 pandemic to evaluate whether COVID-19-pandemic influenced the surgical management in these patients. Method A web-based dataset model organized by the Italian Neurosurgical Society (SINCh) was sent to all the Italian neurosurgical departments in May 2021, requesting to report the types and numbers of surgical procedures performed in the pre-pandemic period (from March 9th 2019 to March 9th 2020) compared to the pandemic period (from March 10th 2020 to March 10th 2021). Results This multicentre investigation included the surgical activity of 35 Italian Neurosurgical Departments in a pre-pandemic year versus a pandemic year. During the COVID period, 699 fewer neuro-oncological patients were operated on than in the pre-COVID period. We noted a slight increase in urgency and a more severe decrease in elective and benign pathology. None of these differences was statistically significant. Surgically treated patients who tested positive for SARS-CoV-2 were 36, of which 11 died. Death was found to be COVID-related only in 2 cases. Conclusion The reorganization of the Italian Neurosurgical Departments was able to guarantee a redistribution of the CNS tumors during the inter-pandemic periods, demonstrating that patients even in the pandemic era could be treated without compromising the efficacy and safety of the surgical procedure.
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Affiliation(s)
- Luca Zanin
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Tamara Ius
- Neurosurgery Unit, Department of Neurosciences, Santa Maria Della Misericordia University Hospital, Udine, Italy
| | - Pier Paolo Panciani
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Felice Esposito
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Marco Maria Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Maria Pia Tropeano
- Neurosurgical Department-Humanitas Clinical and Research Center - IRCCS, Via Manzoni 56, 20089, Rozzano, Mi, Italy
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Antonino Raco
- Division of Neurosurgery, AOU Sant’Andrea, Department of NESMOS, Sapienza University, Rome, Italy
| | | | - Giovanni Sabatino
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
- Division of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Catholic University, Rome, Italy
| | - Vincenzo Esposito
- Department of Neurosurgery "Giampaolo Cantore"-IRCSS Neuromed, Pozzilli, Italy
- Department of Human Neurosciences-"Sapienza" University of Rome, Italy
| | - Federico Pessina
- Neurosurgical Department-Humanitas Clinical and Research Center - IRCCS, Via Manzoni 56, 20089, Rozzano, Mi, Italy
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
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Airth A, Whittle JR, Dimou J. How has the COVID-19 pandemic impacted clinical care and research in Neuro-Oncology? J Clin Neurosci 2022; 105:91-102. [PMID: 36122487 PMCID: PMC9452416 DOI: 10.1016/j.jocn.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/08/2022] [Accepted: 09/03/2022] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic has challenged the continued delivery of healthcare globally. Due to disease risk, clinicians were forced to re-evaluate the safety and priorities of pre-pandemic care. Neuro-oncology presents unique challenges, as patients can deteriorate rapidly without intervention. These challenges were also observed in countries with reduced COVID-19 burden with centres required to rapidly develop strategies to maintain efficient and equitable care. This review aims to summarise the impact of the pandemic on clinical care and research within the practice of Neuro-oncology. A narrative review of the literature was performed using MEDLINE and EMBASS and results screened using PRISMA guidelines with relevant inclusion and exclusion criteria. Search strategies included variations of ‘Neuro-oncology’ combined with COVID-19 and other clinical-related terms. Most adult and paediatric neurosurgical centres experienced reductions in new referrals and operations for brain malignancies, and those who did present for treatment frequently had operations cancelled or delayed. Many radiation therapy and medical oncology centres altered treatment plans to mitigate COVID-19 risk for patients and staff. New protocols were developed that aimed to reduce in-person visits and reduce the risk of developing severe complications from COVID-19. The COVID-19 pandemic has presented many challenges to the provision of safe and accessible healthcare. Despite these challenges, some benefits to healthcare provision such as the use of telemedicine are likely to remain in future practice. Neuro-oncology staff must remain vigilant to ensure patient and staff safety.
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Affiliation(s)
- Angus Airth
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - James R Whittle
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia; Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - James Dimou
- Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Heatherington E, Zhao X, Goyal N, Ounaies Z, Frecker M. On the Design and Testing of an Origami Inspired Nasal Cover: Mitigating Aerosol Risks During Endoscopic Sinus Procedures. J Med Device 2022. [DOI: 10.1115/1.4055251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Aerosols generated during endoscopic sinus procedures present a concern to the health and safety of healthcare personnel especially with the presence of COVID-19. The purpose of this study is to describe the design and testing of a nasal cover to restrict aerosolized pathogens. The nasal cover was designed to sit overtop the nose with conformal slits for insertion of endoscopic instrumentation. Polydimethylsiloxane (PDMS) was chosen as the nasal mask material and its composition, thickness, and slit geometry were selected using a Taguchi experimental design and survey with clinical collaborators at Penn State Milton S. Hershey Medical Center. The nasal cover was designed using principles of origami engineering to be manufactured flat then folded into its operating state. Form and functionality were evaluated by surgeons, fellows, and residents in the aforementioned survey. Aerosol containment was evaluated by measuring smoke, representative of surgical aerosols, with an optical particle counter. A 25:1 composition PDMS with 3mm thickness and vertical slit geometry was chosen for the nasal cover design. Survey results demonstrated that the origami cover sat well on the nose and did not significantly impact the surgical conditions with single instrumentation. On average, this nasal cover was found to restrict more than 93% of 0.3µm aerosols, and more than 99% of all aerosols larger than 0.5µm in size. Use of a patient worn nasal cover has the potential to drastically reduce the risk to hospital personnel during endonasal surgeries by reducing aerosol generation and potential pathogen spread.
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Affiliation(s)
- Evan Heatherington
- Department of Mechanical Engineering, The Pennsylvania State University, University Park , PA, USA
| | - Xiaoyue Zhao
- Department of Mechanical Engineering, The Pennsylvania State University, University Park , PA, USA
| | - Neerav Goyal
- Department of Otolaryngology-Head and Neck Surgery, Penn State College of Medicine , 500 University Dr, MC, Hershey, PA 17033, USA
| | - Zoubeida Ounaies
- Department of Mechanical Engineering, The Pennsylvania State University, University Park , PA, USA
| | - Mary Frecker
- Department of Mechanical Engineering, The Pennsylvania State University, University Park , PA, USA
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Zahid N, Baig E, Lakhani G, Zafar H, Latif A, Enam SA. Surgical Management During the COVID-19 Era at a Private Tertiary Care Hospital of Karachi, Pakistan: A Cross-Sectional Study. Cureus 2022; 14:e21012. [PMID: 35154984 PMCID: PMC8818301 DOI: 10.7759/cureus.21012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Outcomes and Surgical Considerations for Neurosurgical Patients Hospitalized with COVID-19-A Multicenter Case Series. World Neurosurg 2021; 154:e118-e129. [PMID: 34237448 PMCID: PMC8257398 DOI: 10.1016/j.wneu.2021.06.147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 12/31/2022]
Abstract
Objective Neurosurgical patients are at a higher risk of having a severe course of coronavirus disease 2019 (COVID-19). The objective of this study was to determine morbidity, hospital course, and mortality of neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic in a multicenter health care system. Methods A retrospective observational study was conducted to identify all hospitalized neurosurgical patients positive for COVID-19 from March 11, 2020 to November 2, 2020 at Mayo Clinic and the Mayo Clinic Health System. Results Eleven hospitalized neurosurgical patients (0.68%) were positive for COVID-19. Four patients (36.6%) were men and 7 (63.3%) were women. The mean age was 65.7 years (range, 35–81 years). All patients had comorbidities. The mean length of stay was 13.4 days (range, 4–30 days). Seven patients had a central nervous system malignancy (4 metastases, 1 meningioma, 1 glioblastoma, and 1 schwannoma). Three patients presented with cerebrovascular complications, comprising 2 spontaneous intraparenchymal hemorrhages and 1 ischemic large-vessel stroke. One patient presented with an unstable traumatic spinal burst fracture. Four patients underwent neurosurgical/neuroendovascular interventions. Discharge disposition was to home in 5 patients, rehabilitation facility in 3, and hospice in 3. Five patients had died at follow-up, 3 within 30 days from COVID-19 complications and 2 from progression of their metastatic cancer. Conclusions COVID-19 is rare among the inpatient neurosurgical population. In all cases, patients had multiple comorbidities. All symptomatic patients from the respiratory standpoint had complications during their hospitalization. Deaths of 3 patients who died within 30 days of hospitalization were all related to COVID-19 complications. Neurosurgical procedures were performed only if deemed emergent.
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Alvarez R, Kotecha R, McDermott MW, Siomin V. Awake craniotomy for glioblastoma in COVID-19–positive patients and delivering the standard of care: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21246. [PMID: 35854955 PMCID: PMC9272361 DOI: 10.3171/case21246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/05/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Providing the standard of care to patients with glioblastoma (GBM) during the novel coronavirus of 2019 (COVID-19) pandemic is a challenge, particularly if a patient tests positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Further difficulties occur in eloquent cortex tumors because awake speech mapping can theoretically aerosolize viral particles and expose staff. Moreover, microscopic neurosurgery has become difficult because the use of airborne-level personal protective equipment (PPE) crowds the space between the surgeon and the eyepiece. However, delivering substandard care will inevitably lead to disease progression and poor outcomes. OBSERVATIONS A 60-year-old man with a left insular and frontal operculum GBM was found to be COVID-19 positive. Treatment was postponed pending a negative SARS-CoV-2 result, but in the interim, he developed intratumoral hemorrhage with progressive expressive aphasia. Because the tumor was causing dominant hemisphere language symptomatology, an awake craniotomy was the recommended surgical approach. With the use of airborne-level PPE and a surgical drape to protect the surgeon from the direction of potential aerosolization, near-total gross resection was achieved. LESSONS Delaying the treatment of patients with GBM who test positive for COVID-19 will lead to further neurological deterioration. Optimal and timely treatment such as awake speech mapping for COVID-19–positive patients with GBM can be provided safely.
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Affiliation(s)
- Reinier Alvarez
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Rupesh Kotecha
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; and
| | - Michael W. McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
| | - Vitaly Siomin
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; and
- Department of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
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Sadhasivam S, Arora RK, Rekapalli R, Chaturvedi J, Goyal N, Bhargava P, Mittal RS. A Systematic Review on the Impact of the COVID-19 Pandemic on Neurosurgical Practice and Indian Perspective. Asian J Neurosurg 2021; 16:24-32. [PMID: 34211863 PMCID: PMC8202370 DOI: 10.4103/ajns.ajns_379_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19. MATERIALS AND METHODS A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as "COVID-19" and "Neurosurgery." RESULTS Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms. CONCLUSION In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.
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Affiliation(s)
- Saravanan Sadhasivam
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rajnish Kumar Arora
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rajasekhar Rekapalli
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Jitender Chaturvedi
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nishant Goyal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Pranshu Bhargava
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Radhey Shyam Mittal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Eichberg DG, Basil GW, Di L, Shah AH, Luther EM, Lu VM, Perez-Dickens M, Komotar RJ, Levi AD, Ivan ME. Telemedicine in Neurosurgery: Lessons Learned from a Systematic Review of the Literature for the COVID-19 Era and Beyond. Neurosurgery 2020; 88:E1-E12. [PMID: 32687191 PMCID: PMC7454774 DOI: 10.1093/neuros/nyaa306] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evolving requirements for patient and physician safety and rapid regulatory changes have stimulated interest in neurosurgical telemedicine in the COVID-19 era. OBJECTIVE To conduct a systematic literature review investigating treatment of neurosurgical patients via telemedicine, and to evaluate barriers and challenges. Additionally, we review recent regulatory changes that affect telemedicine in neurosurgery, and our institution's initial experience. METHODS A systematic review was performed including all studies investigating success regarding treatment of neurosurgical patients via telemedicine. We reviewed our department's outpatient clinic billing records after telemedicine was implemented from 3/23/2020 to 4/6/2020 and reviewed modifier 95 inclusion to determine the number of face-to-face and telemedicine visits, as well as breakdown of weekly telemedicine clinic visits by subspecialty. RESULTS A total of 52 studies (25 prospective and 27 retrospective) with 45 801 patients were analyzed. A total of 13 studies were conducted in the United States and 39 in foreign countries. Patient management was successful via telemedicine in 99.6% of cases. Telemedicine visits failed in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to patients requiring further face-to-face evaluation or treatment. A total of 16 studies compared telemedicine encounters to alternative patient encounter mediums; telemedicine was equivalent or superior in 15 studies. From 3/23/2020 to 4/6/2020, our department had 122 telemedicine visits (65.9%) and 63 face-to-face visits (34.1%). About 94.3% of telemedicine visits were billed using face-to-face procedural codes. CONCLUSION Neurosurgical telemedicine encounters appear promising in resource-scarce times, such as during global pandemics.
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Affiliation(s)
- Daniel G Eichberg
- Correspondence: Daniel G. Eichberg, MD University of Miami Miller School of Medicine, Department of Neurosurgery University of Miami Hospital 1321 N.W. 14th Street West Building, Suite 306 Miami, FL 33125, USA.
| | - Gregory W Basil
- University of Miami, Department of Neurosurgery, Miami, Florida
| | - Long Di
- University of Miami, Department of Neurosurgery, Miami, Florida
| | - Ashish H Shah
- University of Miami, Department of Neurosurgery, Miami, Florida
| | - Evan M Luther
- University of Miami, Department of Neurosurgery, Miami, Florida
| | - Victor M Lu
- University of Miami, Department of Neurosurgery, Miami, Florida
| | | | - Ricardo J Komotar
- University of Miami, Department of Neurosurgery, Miami, Florida
- Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Allan D Levi
- University of Miami, Department of Neurosurgery, Miami, Florida
| | - Michael E Ivan
- University of Miami, Department of Neurosurgery, Miami, Florida
- Sylvester Comprehensive Cancer Center, Miami, Florida
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Raheja A, Agarwal N, Mohapatra S, Tandon V, Borkar SA, Chandra PS, Kale SS, Suri A. Preparedness and guidelines for neurosurgery in the COVID-19 era: Indian perspective from a tertiary care referral hospital. Neurosurg Focus 2020; 49:E3. [PMID: 33260133 DOI: 10.3171/2020.9.focus20564] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/24/2020] [Indexed: 11/06/2022]
Abstract
The COVID-19 pandemic has severely impacted healthcare systems globally. The need of the hour is the development of effective strategies for protecting the lives of healthcare providers (HCPs) and judicious triage for optimal utilization of human and hospital resources. During this pandemic, neurosurgery, like other specialties, must transform, innovate, and adopt new guidelines and safety protocols for reducing the risk of cross-infection of HCPs without compromising patient care. In this article, the authors discuss the current neurosurgical practice guidelines at a high-volume tertiary care referral hospital in India and compare them with international guidelines and global consensus for neurosurgery practice in the COVID-19 era. Additionally, the authors highlight some of the modifications incorporated into their clinical practice, including those for stratification of neurosurgical cases, patient triaging based on COVID-19 testing, optimal manpower management, infrastructure reorganization, evolving modules for resident training, and innovations in operating guidelines. The authors recommend the use of their blueprint for stratification of neurosurgical cases, including their protocol for algorithmic patient triage and management and their template for manpower allocation to COVID-19 duty, as a replicable model for efficient healthcare delivery.
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Affiliation(s)
| | | | - Sarita Mohapatra
- 2Microbiology, All India Institute of Medical Sciences, New Delhi, India
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11
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Roy CF, Kay-Rivest E, Nguyen LH, Sirhan D, Tewfik MA. Aerosolization in Endoscopic Sinus Surgery and Risk Mitigation in the COVID-19 Era: A Scoping Review. J Neurol Surg B Skull Base 2020; 83:137-144. [DOI: 10.1055/s-0040-1718768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/03/2020] [Indexed: 01/25/2023] Open
Abstract
Abstract
Background The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a dire need for rapid reorganization of health care delivery within surgical services. Ensuing initial reports of high infection rates following endoscopic sinus and skull base surgery, various expert and societal guidelines have emerged. We hereby provide a scoping review of the available literature on endoscopic sinus and skull base surgery, exploring both the risk of aerosolization and expert recommendations on surgical management during the pandemic.
Methods A literature search of the PubMed database was performed up until May 9th, 2020. Additionally, websites and published statements from otolaryngology associations were searched for recommendations. This scoping review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews.
Results A total of 29 peer-reviewed publications and statements from expert recommendations or professional associations were included. Current expert guidance relies mainly on scarce, anecdotal evidence, and two cadaveric studies, which have demonstrated potential aerosolization during transnasal surgery. General consensus exists for delaying surgery when possible, ascertaining COVID-19 status preoperatively and donning of adequate personal protective equipment by all operating room staff (including at minimum an N95 mask). Cold, nonpowered surgical instruments are deemed the safest, while thermal instruments (electrocautery and laser) and high-speed drills should be minimized. Conflicting recommendations emerge for use of microdebriders.
Conclusion Endoscopic sinus and skull base surgery impart a potential risk of aerosolization. Hence, surgical indications, protective measures for health care workers, and surgical instrumentation must be adapted accordingly in the COVID-19 context.
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Affiliation(s)
- Catherine F. Roy
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily Kay-Rivest
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lily H.P. Nguyen
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Denis Sirhan
- Department of Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montréal, Canada
| | - Marc A. Tewfik
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Agarwal N, Raheja A, Suri A. Guidelines for Preoperative Testing for Neurosurgery in Coronavirus Disease 2019 (COVID-19) Era: Indian Viewpoint Amidst Global Practice. World Neurosurg 2020; 146:103-112. [PMID: 33283759 PMCID: PMC7584495 DOI: 10.1016/j.wneu.2020.10.086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 12/18/2022]
Abstract
Preoperative testing and evaluation for coronavirus disease 2019 (COVID-19) have been an enigmatic challenge for the neurosurgical community during the pandemic. Since the beginning of the pandemic, laboratory diagnostic methods have evolved substantially, and with them has been the necessity for readily available, fast, and accurate preoperative testing methods. In this article, we provide an overview of the various laboratory testing methods that are presently available and a comprehensive literature review how various institutes and neurosurgical communities across the globe are employing them to ensure safe and effective delivery of surgical care to patients. Through this review, we highlight the guiding principles for preoperative testing, which may serve as a road map for other medical institutions to follow. In addition, we provide an Indian perspective of preoperative testing and share our experience in this regard.
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Affiliation(s)
- Nitish Agarwal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amol Raheja
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
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13
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Pelargos PE, Chakraborty AR, Adogwa O, Swartz K, Zhao YD, Smith ZA, Dunn IF, Bauer AM. An Evaluation of Neurosurgical Practices During the Coronavirus Disease 2019 Pandemic. World Neurosurg 2020; 146:e91-e99. [PMID: 33065352 PMCID: PMC7550862 DOI: 10.1016/j.wneu.2020.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022]
Abstract
Objective We sought to understand how the coronavirus disease 2019 pandemic has affected the neurosurgical workforce. Methods We created a survey consisting of 22 questions to assess the respondent's operative experience, location, type of practice, subspecialty, changes in clinic and operative volumes, changes to staff, and changes to income since the pandemic began. The survey was distributed electronically to neurosurgeons throughout the United States and Puerto Rico. Results Of the 724 who opened the survey link, 457 completed the survey. The respondents were from throughout the United States and Puerto Rico and represented all practices types and subspecialties. Nearly all respondents reported hospital restrictions on elective surgeries. Most reported a decline in clinic and operative volume. Nearly 70% of respondents saw a decrease in the work hours of their ancillary providers, and almost one half (49.1%) of the respondents had had to downsize their practice staff, office assistants, nurses, schedulers, and other personnel. Overall, 43.6% of survey respondents had experienced a decline in income, and 27.4% expected a decline in income in the upcoming billing cycle. More senior neurosurgeons and those with a private practice, whether solo or as part of a group, were more likely to experience a decline in income as a result of the pandemic compared with their colleagues. Conclusion The coronavirus disease 2019 pandemic will likely have a lasting effect on the practice of medicine. Our survey results have described the early effects on the neurosurgical workforce. Nearly all neurosurgeons experienced a significant decline in clinical volume, which led to many downstream effects. Ultimately, analysis of the effects of such a pervasive pandemic will allow the neurosurgical workforce to be better prepared for similar events in the future.
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Affiliation(s)
- Panayiotis E Pelargos
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Arpan R Chakraborty
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Karin Swartz
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Yan D Zhao
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Andrew M Bauer
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
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Marini A, Iacoangeli M, Dobran M. Letter to the Editor Regarding "Coronavirus Disease 2019 (COVID-19) and Neurosurgery: Literature and Neurosurgical Societies Recommendations Update". World Neurosurg 2020; 141:536-537. [PMID: 32470608 PMCID: PMC7255196 DOI: 10.1016/j.wneu.2020.05.160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/17/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Alessandra Marini
- Clinic of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedali Riuniti, and Department of Neurosurgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy.
| | - Maurizio Iacoangeli
- Clinic of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedali Riuniti, and Department of Neurosurgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Mauro Dobran
- Clinic of Neurosurgery, Università Politecnica delle Marche, Azienda Ospedali Riuniti, and Department of Neurosurgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
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15
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Liu C, Zhao Y, Okwan-Duodu D, Basho R, Cui X. COVID-19 in cancer patients: risk, clinical features, and management. Cancer Biol Med 2020; 17:519-527. [PMID: 32944387 PMCID: PMC7476081 DOI: 10.20892/j.issn.2095-3941.2020.0289] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/29/2020] [Indexed: 01/08/2023] Open
Abstract
A novel coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread across the world, prompting the World Health Organization to declare the coronavirus disease of 2019 (COVID-19) a public health emergency of international concern. Cancer patients are regarded as a highly vulnerable population to SARS-CoV-2 infection and development of more severe COVID-19 symptoms, which is possibly due to the systemic immunosuppressive state caused directly by tumor growth and indirectly by effects of anticancer treatment. Currently, much effort has been directed toward studying the pathogenesis and treatment of COVID-19, but the risk profiles, prognoses, and treatment outcomes in cancer patients remain unclear. Based on the current literature, we summarize the risk profiles, clinical and biochemical characteristics, and therapy outcomes of COVID-19 infections in cancer patients. The challenges in the clinical care of cancer patients with COVID-19 are discussed. The goal of this review is to stimulate research to better understand the biological impact and prognoses of COVID-19 infections in cancer patients, thus facilitating improvement of the clinical management of these patients.
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Affiliation(s)
- Cuiwei Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Yanxia Zhao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Derick Okwan-Duodu
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Derick Okwan-Duodu
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Reva Basho
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Xiaojiang Cui
- Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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16
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Cassell III AK, Cassell LT, Bague AH. Management of cancer patients during the COVID-19 pandemic: A comprehensive review. Artif Intell Cancer 2020; 1:8-18. [DOI: 10.35713/aic.v1.i1.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/22/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023] Open
Abstract
The novel 2019 corona virus disease also called severe acute respiratory syndrome coronavirus 2 has caused a global pandemic and more than 2.5 million people have been affected globally with over 100000 deaths. The disease has caused an escalation in hospitalization with growing need for hospital beds and intensive care unit for severe cases. Recent evidence has shown that a significant proportion of cancer patients affected by the corona virus present with severe respiratory pneumonia-like illness with need for subsequent intensive care unit ventilation and higher mortality risk. This susceptibility may be due to the immunosuppressive state of patients with malignancy confounded by chemotherapy, immunotherapy and targeted therapy. Many solid tumors (lung cancer, pancreatic cancer) as well as hematological malignancies (leukemias) may require prompt diagnosis and treatment based on the disease aggression and progression. Many centers lack clear guideline on the management of cancer during the pandemic. The objective of this review is to synthesize the available literature and provide recommendations on the management of various soft tissue and hematological malignancies. The review will also assess the management guidelines for hospitalized cancer patients; cancer patients in the outpatient setting as well as available modalities for follow-up.
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Affiliation(s)
- Ayun K Cassell III
- Department of Urology and Andrology, Hopital General de Grand Yoff, Dakar 3270, Senegal
| | - Lydia T Cassell
- Department of Public Health, Cuttington University, Graduate School and Professional Studies, Monrovia 10010, Liberia
| | - Abdoul Halim Bague
- Unit of Surgical Oncology, Department of General Surgery, Yalgado Ouedraogo Teaching Hospital, Ouagadougou 160, Burkina Faso
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17
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Mazzatenta D, Zoli M, Cavallo MA, Ferro S, Giombelli E, Pavesi G, Sturiale C, Tosatto L, Zucchelli M. Remodulation of neurosurgical activities in an Italian region (Emilia-Romagna) under COVID- 19 emergency: maintaining the standard of care during the crisis. J Neurosurg Sci 2020; 66:234-239. [PMID: 32525290 DOI: 10.23736/s0390-5616.20.05018-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The impact of COVID-19 outbreak in the neurosurgical practice has been dramatic, imposing several limitations. The aim of this study is to present how the neurosurgical departments of Emilia-Romagna, a northern Italian region, have re-set their organization to maintain the higher standard of care as possible. METHODS All OR and out-patients activities performed during the COVID-19 emergency in the neurosurgical department of Emilia-Romagna have been collected and compared to the means of the same timeframe in 2018 and 2019. RESULTS In 2020, 205 surgical procedures and 466 out-patients consultations have been performed, representing respectively 28.8% and 26.4% of the previous biennium. The most of OR procedures had been emergencies/urgencies and oncological patients (respectively 113 and 66 vs 164.5 and 84.5 of the previous biennium), while elective surgeries decrease up to -97.1%, as for spinal nerves and endoscopic skull base procedures. The patients phone contacts and telemedicine evaluations of their examinations have permitted to reduce the hospital access for outpatients of 75.6%, but these modalities have, also, permitted to follow-up a large number of cases. CONCLUSIONS The outbreak of COVID-19 has imposed several limits to our current practice, however this should not represent an excuse to reduce the standard of care. In our experience, the net integration of different local centers has permitted for each of them to effectively cope the crisis, managing the local cases requiring a prompt surgery and keeping the care continuity with already discharged patients.
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Affiliation(s)
- Diego Mazzatenta
- Center for the Diagnosis and Treatment of Hypothalamic-Pituitary Diseases, Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Matteo Zoli
- Center for the Diagnosis and Treatment of Hypothalamic-Pituitary Diseases, Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy - .,Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Michele A Cavallo
- Neurosurgery Division, Department of Morphology, Surgery, and Experimental Medicine, Hospital S. Anna, Ferrara University, Ferrara, Italy
| | - Salvatore Ferro
- Department of Hospital Services, Emilia-Romagna Regional Health Authority, Bologna, Italy
| | - Ermanno Giombelli
- Department of Neurosurgery, Azienda Ospedaliero-Universitaria, Parma, Italy
| | - Giacomo Pavesi
- Unit of Neurosurgery, Department of Neurosciences, NOCSAE Modena Hospital, Modena, Italy
| | - Carmelo Sturiale
- Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigino Tosatto
- Neurosurgery Department, "Maurizio Bufalini" Hospital, Cesena, Italy
| | - Mino Zucchelli
- Center of Pediatric Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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18
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Angileri FF, Sabatino G, Cavallo LM, Pessina F, Ius T, DE Divitiis O, Esposito F, Grimod G, Raffa G, Spena G, Cardali S, Esposito V, GermanÒ A, Maiuri F, Fontanella M, Cenzato M. Natura non facit saltus: a phase 2 proposal to manage brain tumors cases from the Neuro-oncology section of the Italian Society of Neurosurgery (SINch®). J Neurosurg Sci 2020; 65:1-7. [PMID: 32525292 DOI: 10.23736/s0390-5616.20.05054-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The Coronavirus (COVID-19) pandemic has fast spread throughout the world in more than 200 countries, resulting in the need for a de-prioritization of elective medical care to face the demands of the global health crisis. Although the acute and catastrophic phase of the pandemic seems to have been left behind, it is also clear that the virus will not disappear soon, and we must live with it for a period of unpredictable length, the COVID-19 era. In this setting, a common coordinated approach to treat patients harboring brain tumors is urgently required to guarantee the best updated oncological care and to reduce the risk of viral infection during hospitalization. The study group on Neuro-oncology of Italian Society of Neurosurgery, SINCh gathered pieces of evidence and data and would like to suggest a practice protocol of care for neurosurgical oncologic procedures in the COVID-19 era. The present document aimed at summarizing current evidence and expert opinions to help neurosurgeons in taking decisions on their patients harboring different brain tumors.
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Affiliation(s)
- Filippo F Angileri
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy -
| | - Giovanni Sabatino
- Unit of Neurosurgery, Department of Neurosciences, Sacred Heart Catholic University, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Medicine and Surgery, Federico II University, Naples, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, IRCCS Humanitas Clinic, Rozzano, Milan, Italy
| | - Tamara Ius
- Unit of Neurosurgery, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Oreste DE Divitiis
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Medicine and Surgery, Federico II University, Naples, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Medicine and Surgery, Federico II University, Naples, Italy
| | - Gianluca Grimod
- Unit of Neurosurgery, Department of Neurosciences, A. Manzoni Hospital, Lecco, Italy
| | - Giovanni Raffa
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Giannantonio Spena
- Unit of Neurosurgery, Department of Neurosciences, A. Manzoni Hospital, Lecco, Italy
| | - Salvatore Cardali
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Vincenzo Esposito
- Sapienza University, Rome, Italy.,G. Cantore Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Antonino GermanÒ
- Unit of Neurosurgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Francesco Maiuri
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, School of Medicine and Surgery, Federico II University, Naples, Italy
| | - Marco Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Cenzato
- Department of Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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