The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?

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 pandemic & neurosciences in India- the CoINstudy: Impact of the pandemic on research related to the neurosciences

Background & objectives We aimed to assess the impact of COVID-19-related disruptions on ongoing and future projects related to neuroscience research and young researchers in India. Methods We conducted a countrywide online survey using a structured, self-administered questionnaire involving medical trainees, post-doctoral fellows, PhD students, early career faculty members and basic neuroscience researchers. The purpose was to assess the impact of the COVID-19 pandemic on the respondents' ongoing/planned research activities and capture their concerns related to future research. Results Five hundred and four valid responses were analyzed. More than three-fourths of the respondents were in their early careers - 64.1 per cent were resident doctors, and 19.8 per cent were early career consultants. Maximum responses were received from respondents working in neurology (228; 45.2%), followed by psychiatry (192; 38.1%) and neurosurgery (49; 9.7%). More than three-fourths [83.5%, 95% confidence interval (CI): 0.8-0.867] of the respondents reported that the pandemic had affected their research. About one-third of the respondents (171; 33.9%) reported delays in completing research studies. Respondents adapted to the pandemic's circumstances by making methodological changes in their research (155; 30.8%). Most respondents (301; 59.6%) reported being diverted from their traditional work settings to COVID-19-related clinical services. Respondents conducting prospective studies and randomized controlled trials and those diverted to COVID-related services were significantly more likely to report the adverse research impact. Interpretation & conclusions In our survey, an overwhelming majority of the respondents reported that the pandemic adversely impacted their study. This trend was independent of sex, designation, and research output of individual subjects. The serious impact of the COVID-19 pandemic on neurosciences research warrants the attention and concerted efforts of the research supervisors, institutional heads, funding agencies and other stakeholders.

Decentralizing healthcare in Norway to improve patient-centered outpatient clinic management of rheumatoid arthritis - a conceptual model

A growing population of older adults and improved effective treatments for inflammatory rheumatic diseases will increase the demand for more healthcare resources that already struggle with staggering outpatient clinic waiting times. Transformative delivery care models that provide sustainable healthcare services are urgently needed to meet these challenges. In this mini-review article, a proposed Lifelong Treatment Model for a decentralized follow-up of outpatient clinic patients living with rheumatoid arthritis is presented and discussed.Our conceptual model follows four steps for a transformative care delivery model supported by an Integrated Practice Unit; (1) Diagnosis, (2) Treatment, (3) Patient Empowered Disease Management, and (4) Telehealth. Through an Integrated Practice Unit, a multidisciplinary team could collaborate with patients with rheumatoid arthritis to facilitate high-value care that addresses most important outcomes of the patients; (1) Early Remission, (2) Decentralization, (3) Improved Quality of Life, and (4) Lifelong Sustain Remission.The article also addresses the growing challenges for the healthcare delivery system today for patients with rheumatoid arthritis and proposes how to reduce outpatient clinic visits without compromising quality and safety.

Effects of the First COVID-19 Lockdown on Ophthalmological Patient Care

PURPOSE

To determine the effect of lockdown on medical care, with the example of ophthalmology.

METHODS

Patients in a period during the first lockdown were compared to a non-lockdown period, with a total of 12 259 patients included in an observational study. Changes in different areas (elective, emergency, inpatients, surgeries) and eye care subspecialties were compared. Emergency patients were analyzed according to severity and urgency. Patients showing hints requiring treatment for urgent cardiovascular diseases were determined. Differences in patients who would have suffered severe vision loss without treatment were identified and the QALY (quality-adjusted life years) loss was determined accordingly. A model to prioritize patient visits after the end of lockdown or in future lockdown scenarios was developed. Data were collected at the University Eye Hospital LMU Munich and patient files were reviewed individually by ophthalmologists.

RESULTS

The average patient number decreased by - 59.4% (p < 0.001), with a significant loss in all areas (elective, emergency, inpatients, surgeries; p < 0.001). There was a decline of - 39.6% for patients at high risk/high severity. Patients with indications of a risk factor of future stroke declined significantly (p = 0.003). QALY loss at the university eye hospital was 171, which was estimated to be 3160 - 24 143 for all of Germany. Working up high losses of outpatients during these 8 weeks of projected lockdown in Germany would take 7 - 23 weeks under normal circumstances, depending on ophthalmologist density. The prioritization model can reduce morbidity by up to 78%.

CONCLUSION

There was marked loss of emergency cases and patients with chronic diseases. Making up for the losses in examinations and treatments will theoretically take weeks to months. To reduce the risk of morbidity, we recommend a prioritization model for rescheduling and future lockdown scenarios.

Impact of COVID-19 on Elective Cleft Surgery in Low- and Middle-income Countries

Background:

The COVID-19 pandemic disrupted health systems worldwide, including in low- and middle-income countries (LMICs). Many countries limited the delivery of elective surgery. To date, COVID-19’s impact on elective surgery in LMICs has been unquantified. We use operative data from a large international non-government cleft organization to compare case volume for 2019 and 2020 to quantify the impact of COVID-19.

Methods:

Smile Train supports a partner network of over 1100 partners globally to deliver treatment to children with cleft lip and cleft palate (CLP). Treatment data is documented into a proprietary digital platform, Smile Train Express. We compared monthly treatment data for 2019 to 2020, by country, and by World Bank Income group to describe the effect that the COVID-19 pandemic has had on CLP surgery in LMICs.

Results:

Our analysis shows 25,444 (31.4%) fewer primary operations performed between January and December 2020 than in the same period in 2019 with the most significant decline in procedures observed in April 2020. Many countries resumed elective surgery for CLP procedures from May onward and volume approximated that of pre-pandemic baseline by November of 2020.

Conclusions:

The emergence of the COVID-19 pandemic had a large impact on health systems and service delivery across the world. We find that this is evident in the delivery of CLP surgery in LMICs. The impact is characterized by a dramatic decrease in surgery rates in April of 2020 with a recovery of surgical volume from July 2020 onwards. The rate of surgical rate recovery is consistent across World Bank Income groups.

Epilepsy surgery in COVID times-a unique conundrum

The COVID-19 pandemic has forced hospitals to prioritize admissions. Epilepsy surgeries have been postponed at most centers. As the pandemic continues with no definite end in sight in the near future, the question arises until when such patients should be denied appropriate treatment. A 12-year-old child with left-sided Rasmussen's encephalitis with drug refractory epilepsy (DRE) presented at the height of the pandemic, with worsening of seizure frequency from 4-5/day to 20/day, with new-onset epilepsia partialis continua. She demonstrated features of progressive cognitive decline. The pros and cons of operating during the pandemic were discussed with the parents by a multidisciplinary team. She underwent endoscopic left hemispherotomy. Postoperatively she became seizure free but developed hospital-acquired mild COVID infection for which she was treated accordingly. Chosen cases of severe DRE, as the one illustrated above, who are deemed to benefit from surgery by a multidisciplinary team of physicians, should be re-categorized into the most severe class of patients and scheduled for surgery as soon as possible. The risk benefit ratio of the seizures being mitigated by surgery on one hand and possibility of acquiring COVID infection during hospital stay has to be balanced and a decision made accordingly.

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

Background

The novel coronavirus disease 2019 (COVID-19) pandemic has been at its peak for the past 8 months and has affected more than 215 countries around the world. India is now the second most-affected nation with more than 48,000,000 cases and 79,000 deaths. Despite this, and the fact that it is a lower-middle-income nation, the number of deaths is almost one third that of the United States and one half that of Brazil. However, there has been no experience published from non−COVID-19−designated hospitals, where the aim is to manage noninfected cases with neurosurgical ailments while keeping the number of infected cases to a minimum.

Methods

We analyzed the number of neurosurgical cases (nontrauma) done in the past 5 months (March−July 2020) in our institute, which is the largest neurosurgical center by volume in southern India, and compared the same to the concurrent 5 months in 2019 and 5 months preceding the pandemic. We also reviewed the total number of cases infected with COVID-19 managed during this time.

Results

We operated a total of 630 cases (nontrauma) in these 5 months and had 9 COVID-19 infected cases operated during this time. There was a 57% (P = 0.002) reduction in the number of cases operated as compared with the same 5 months in the preceding year. We employed a dual strategy of rapid antigen testing and surgery for cases needing emergency intervention and reverse transcriptase-polymerase chain reaction test for elective cases. The hospital was divided into 3 zones (red, orange, and green) depending on infectivity level with minimal interaction. Separate teams were designated for each zone, and thus we were able to effectively manage even infected cases despite the absence of pulmonology/medical specialists.

Conclusions

We present a patient management protocol for non−COVID-19−designated hospitals in high-volume centers with the constraints of a lower-middle-income nation and demonstrate its effectiveness. Strict zoning targeted testing and effective triage can help in management during the pandemic.