key: cord- -o h my authors: moscote-salazar, luis rafael; galindo-velasquez, hather; garcia-ballestas, ezequiel; agrawal, amit; rahman, md moshiur; sarwar, a.s.m. title: letter to the editor: sars-cov- and traumatic cervical acute spinal cord injury: an appraisal date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: o h my nan this year, , has been the start year of the first pandemic of the century. the outbreak was caused by viruses of the coronaviridae family, currently called sars-cov- . it produces a severe inflammatory syndrome and involving multiple organs, it has been established that this pathogen also affects the central nervous system and the spinal cord. it has been recognized that approximately - % of the world population will be infected. the cervical spine is an area susceptible to injury caused by trauma. it is estimated that approximately / , people have a spinal injury. in the united states, approximately , people suffer from spinal injuries with the respective neurological sequelae. the neurotropic potential of the coronavirus has been widely suggested. demyelination areas have been found in the spinal cord using magnetic resonance imaging (mri). it has been suggested that the virus triggers a neurotoxic hypoxic injury that can aggravate it in patients with a spinal injury. in patients infected with coronavirus and suffering from a traumatic spinal injury. as we found in evidence, a spinal cord injury is a dynamic process, where a cascade of events in the pathophysiology is critical in the deterioration of the clinical scenario of a patient. we have to remember the importance of neurogenic shock, defined as the autonomic dysregulation due to the sudden loss of control of the sympathetic tone and the overlapping of a parasympathetic response that appears in the context of a spinal cord injury. it seems that patients with trauma above the level of t are at higher risk of triggering the appearance of this shock than in other segments of the spinal column. , an initial management on the site of a traffic accident by using rigid collars and spine immobilization is recommended steps by the advanced trauma life support (atls) algorithms to prevent cervical spine displacement causing more damage and irreversible sequelae. due to the decrease in systemic vascular resistance preventing the vital organs to obtain the requirements of blood, an early identification followed by an aggressive treatment is the key to avoid secondary spinal injury. sars-cov- can contribute to neurological abnormalities during infection, with severity depending on neurocovid staging. there is a link between the response of the immune system in spinal cord injury, and how it contributes to neuronal and oligodendrocyte apoptosis and axonal demyelination. regarding the latter, it should be thoroughly investigated what is the actual role of the virus during the pathophysiology of the acute spinal cord injury and how it can affect the outcomes, and prognosis of the patient. a novel coronavirus from patients with pneumonia in china emergency department evaluation and treatment of the neck and cervical spine injuries merkel gives germans a hard truth about the coronavirus -the new york times neurotropism of sars-cov : mechanisms and manifestations sars-cov- can induce brain and spine demyelinating lesions emergency neurological life support: traumatic spine injury presentation of neurogenic shock within the emergency department early neurological care of patients with spinal cord injury neurobiology of covid- . j alzheimer's dis a review on response of immune system in spinal cord injury and therapeutic agents useful in treatment the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- - q zj c authors: marini, alessandra; iacoangeli, maurizio; dobran, mauro title: letter to the editor regarding 'coronavirus disease (covid- ) and neurosurgery: literature and neurosurgical societies recommendations update' date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: q zj c nan letter: epidemiological variations in neuro-oncological patients' presentation during the coronavirus crisis in the clinical department of neurosurgery of ancona dear editor, we read with great interest the original article by antonino germanò et al. "covid- and neurosurgery. literature and neurosurgical societies recommendations update". this paper provides a relevant insight into the management of neuro-oncological patients during the covid- pandemic, which has fast spread worldwide and critically impacted on the healthcare system. italy resulted one of the most affected countries, witnessing dramatic revolutions in the routine practice. in such intense atmosphere, neurosurgical departments are balancing between the urgent and emergency cases, public-opinion concerns about transmission and the safety of the staff and patients. regarding the neuro-oncological patients, as already reported by zoia et al., a priority criteria were established, in order to stratify the urgency of the cases: class a ++ are the patients who require immediate treatments, with intracranial or spinal oncological pathology (rapidly evolving intracranial hypertension with deteriorating state of consciousness, acute hydrocephalus, spinal cord compression with rapid tetra or paraparesis); class a + are the patients who requirie treatment within a maximum of - days, with intracranial tumors with mass effect or with progressive neurological deficit, without deterioration of consciousness and patients requiring treatment within a month, namely class a, with neurological alteration or suspected malignant lesion, related to a oncological pathology. we report a survey conducted by the neurosurgical team of the emergency regional hospital of ancona (italy) which serves approximately . million inhabitants. during the last three months, from february to april , despite the halving of the elective cases in the weekly schedule, due to the re-distribution of the staff, the number of oncological patients who underwent a surgical treatment in our department was approximately analogous to the same time-period in (february-april, patients in and patients in ). nonetheless, the amount of urgent or emergency cases, accessing from emergency room, substantially rocketed, reaching the , % compared to the , % in , as reported in the illustrative table. interestingly, the patients with spinal lesions were the most affected, recording the , % with emergency room access ( patients out of ), while the same feature in was slightly more than % ( patients out of ). as highlighted in the illustrative table, the most common symptom was a progressive paraparesis, and all the patients reported a previous history of neglected upper or low back pain. this data, in our survey, resulted to be related to a public health concern, in the patient point of view, about visiting hospitals during the covid- crisis, especially for not apparently alarming symptoms, usually related to degenerative spine pathologies, such as back pain. in addition, the temporary difficult access to radiological exams may have influenced, as well, the postponement in the diagnosis. this resulted in progression of the neurological symptoms, without an early neurosurgical evaluation, until the onset of acute deficit which actually led to the emergency room access. the same patient's attitude, even if with minor impact, was registered in the patients affected by brain lesions, in which the percentage of patients with acute onset, and subsequent via emergency room evaluation, dramatically increased in the last three months, compared to . as a matter of fact, the most common symptoms were consciousness alteration and seizures; in our survey approximately , % of the acute-onset patients reported to have previously refused the surgical treatment, in the weeks before, correlated to concerns about the hospitalization during the coronavirus emergency. even if it is widely known that time is essential for the clinical and neurological outcome, our survey did not have a sufficient follow-up to properly compared the outcomes between the two time periods analyzed, so further evaluations would be indispensable to appropriately investigated this aspect. in conclusion, during the covid- pandemic the neurosurgical urgent and emergency onset of neuro- oncological cases increased, in comparison to . our survey highlighted how this trend is minorly related to a combination of difficult access to radiological exams and mostly to patients' concerning about hospitalization. the consequent apprehension should be restoring the public health judgement, in order to re-balance this trend and subsequently improve the clinical outcome of the patients. a reasonable respond in this contest can be the intensification of telemedicine clinic visits, as well as ameliorating the clinic scheduling safety, concomitantly to the mass media impact on the public health opinion, in order to reestablish the confidence in the healthcare system, in such intense atmosphere of fear. alessandra marini, md prof maurizio iacoangeli, md prof mauro dobran, md references patients who underestimated their symptoms / ( , %) / ( , %) patients who had difficult access to radiological exams / ( , %) none patients who refused hospitalization due to the infection risk / ( , %) none illustrative table regarding the epidemiological variations in neuro-oncological patients' onset during the covid- crisis key: cord- -wa hdg u authors: pennington, zach; lubelski, daniel; khalafallah, adham; ehresman, jeff; sciubba, daniel m.; witham, timothy f.; huang, judy title: letter: changes to neurosurgery resident education following onset of the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: wa hdg u abstract background the covid- pandemic has led to the postponement of a large proportion of neurosurgical cases with an accordant radical change in resident experiences. as residents rely upon operative exposure and in-person didactic lectures for education, the disruptions caused by the pandemic have forced programs to revise how they educate residents. here we surveyed program directors (pds) to ascertain how they have altered the education and clinical care responsibilities of residents in response to the covid- pandemic. methods surveys were sent to the pds of all acgme-accredited neurosurgery programs. survey questions targeted changes in resident staffing and coverage, changes in didactic material delivery, and changes in resident wellness initiatives. pd concerns were also elicited. results of the program pds invited, responded ( . %). we found that most programs have reduced resident work weeks ( %) and in-hospital resident shift census ( %). few have redeployed residents and most are increasingly relying on teleconferencing solutions for meetings and resident education. most commonly programs are using faculty- ( %) or resident-led ( %) lectures, though nearly % are supplementing resident education with materials from the congress of neurological surgeons (cns). continuing education in spite of decreased case volume and maintaining resident morale are cited as the most common concerns of pds. conclusion here we find that there is great homogeneity in the responses of neurosurgical residency programs to the covid- pandemic. programs are increasingly incorporating teleconferencing platforms and third-party education materials, most commonly materials from the cns. additionally, most respondents indicated that their program has not redeployed residents in the care of covid- positive patients. the results of the present study may assist program directors in developing a uniform resident curriculum and consider wellness initiatives during this time of crisis. the covid- pandemic has led to the postponement of a large proportion of neurosurgical cases with an accordant radical change in resident experiences. as residents rely upon operative exposure and in-person didactic lectures for education, the disruptions caused by the pandemic have forced programs to revise how they educate residents. here we surveyed program directors (pds) to ascertain how they have altered the education and clinical care responsibilities of residents in response to the covid- pandemic. methods surveys were sent to the pds of all acgme-accredited neurosurgery programs. survey questions targeted changes in resident staffing and coverage, changes in didactic material delivery, and changes in resident wellness initiatives. pd concerns were also elicited. results of the program pds invited, responded ( . %). we found that most programs have reduced resident work weeks ( %) and in-hospital resident shift census ( %). few have redeployed residents and most are increasingly relying on teleconferencing solutions for meetings and resident education. most commonly programs are using faculty-( %) or resident- led ( %) lectures, though nearly % are supplementing resident education with materials from the congress of neurological surgeons (cns). continuing education in spite of decreased case volume and maintaining resident morale are cited as the most common concerns of pds. conclusion here we find that there is great homogeneity in the responses of neurosurgical residency programs to the covid- pandemic. programs are increasingly incorporating teleconferencing platforms and third-party education materials, most commonly materials from the cns. additionally, most respondents indicated that their program has not redeployed residents in the care of covid- positive patients. the results of the present study may assist program directors in developing a uniform resident curriculum and consider wellness initiatives during this time of crisis. with the onset of the covid- pandemic and the resultant cancellation of elective surgical cases nationwide, there have been significant changes to how neurosurgery is taught and practiced. the dramatic decrease in operative cases has significantly impacted the training of neurosurgical residents, who depend on elective surgical volume to hone their clinical and operative skills. as residents must meet minimum case volumes to demonstrate proficiency upon program completion, there is concern among both residents and program directors regarding the severity of the impact of covid- on neurosurgical resident education. recently, several centers have reported the significant changes that their departments have undergone as a result of the covid- pandemic. [ ] [ ] [ ] [ ] included in these changes are alterations to the methods for educating residents and the clinical care duties of residents. for example, weber et al at the medical university of south carolina and burke et al at the university of california san francisco described reorganizing their services to reduce the number of residents in the hospital at any one time. face-to-face patient handoffs have also been minimized and usual didactic programs have been shifted to videoconferencing platforms to reduce resident-to- resident contact. in spite of these single institution experiences, there has yet to be a description of how residency programs on the whole are dealing with the pressures exerted by the covid- pandemic. here we sought to address this outstanding need by polling program directors with the goal of using the information to help inform residency directors about how programs across the country are addressing resident education during the covid- pandemic. methods survey of program directors after obtaining irb approval, a survey was developed using redcap software (supplementary figure ). domains addressed by the survey included: program details (residency size, location, hospital size), covid- burden in the catchment area of the associated hospital/health system, changes in case volume and resident duties (e.g. shift changes, responsibility for care of covid- positive patients), and changes in resident wellness/support. we also included items about the exact interventions being employed to continue resident education during the covid- pandemic, including changes to regular meetings (e.g. grand rounds, morbidity and mortality (m&m) conferences), changes to didactic lectures, utilization of outside materials (e.g. materials published by the american association of neurological surgeons (aans) or congress of neurological surgeons (cns), and usage of tools to track resident participation/progress within the updated curriculum. the survey was sent to program directors of all acgme-accredited neurosurgery programs using redcap electronic data capture tools hosted at our institution. the survey elicited responses from ( . %) programs ( table ) . the median program size was residents per class, and the majority of programs were located in the midwest ( . %), northeast ( . %), or southeast ( . %). for responding programs, the median health system size was beds (interquartile range - beds). the inpatient burden of covid-positive patients at the time of response was that most programs had < covid-positive patients ( . %), or - covid-positive patients ( . %); few programs had > covid-positive patients. current case volume for most programs was < % of pre-covid volume ( . %); only a small minority of programs had > % of their baseline case volume ( . %). while programs with higher covid burdens tended to have greater reductions in their surgical volume, this difference was not statistically significant (χ²= . ; p= . ). there was no significant interaction between case volume and either geographic region or residency program size. changes in resident workload the majority of programs have reduced resident covid exposure risk by reducing the number of residents in the hospital at one time ( . %) and by reducing the number of days per week that each resident works ( . %) ( changes in resident support more than a third of programs ( %) reported that they have provided additional benefits to their residents since the onset of the covid pandemic. the most common newly added benefits were providing counseling or wellness smartphone application resources ( %), hotel vouchers ( %), and child care vouchers ( %). there was no significant association between covid patient burden and the odds of a program offering any of these additional benefits. of note, a significant proportion of programs were already offering counseling or wellness smartphone applications to their residents prior to the onset of the covid pandemic. changes in resident education nearly all programs were conducting grand rounds ( %) and m&m conferences ( %) using teleconferencing software ( table ) . the remaining programs either completely cancelled ( %) or had some small in-person meetings ( %). pds reported that didactic lectures were primarily live-streamed lectures led by faculty ( %) or residents ( %). a substantial percentage endorsed also sourcing lectures ( %) or grand rounds from outside institutions ( %), or previously recorded sessions ( %). in general, lecture materials were being selected by the program director ( %) or by the residents ( %), rather than by the speaker or a previously formalized curriculum. across all respondents there was a relatively equal distribution regarding the change in the quantity of lectures delivered ( % increased the number of lectures, % decreased), with the majority ( %) of programs delivering - hours of didactic material per week. there was no association between covid-positive patient burden and either the absolute number of hours of didactic material delivered per week or the reported change in the quantity of didactic material delivered from pre-covid onset to post-covid onset. resident participation was predominantly assessed via direct engagement of resident attendees by the lecturer ( %). some institutions also indicated that they were using mock oral boards ( %) and virtual polling ( %) features to further ensure resident engagement. the majority of programs were incorporating outside resources to supplement the education of their residents, most commonly in the form of the freely available complimentary online education offered by the cns ( %). program size was not significantly associated with odds of using any of the outside resources listed (all p> . ). roughly half of programs were including advanced practice providers ( %) and medical students ( %) in their resident didactic sessions. program director concerns program directors overwhelmingly reported that increased utilization of teleconferencing solutions is the biggest change to the methods employed to educate residents. the majority state their biggest concerns regarding the current crisis are: maintaining resident education in the face of decreased case volume, attempting to maintain resident morale, and reducing resident risk of developing the covid- infection. pds note one positive effect of the covid pandemic is increased utilization of teleconferencing solutions, which many report has increased attendance by both residents and faculty. consequently, some see these teleconferencing sessions as team- building exercises and a majority ( %) indicate that moving forward they will likely increase their use of teleconferencing systems to either improve attendance or increase the number of potential lecturers. additionally, while the covid pandemic has decreased operative volumes, several pds find that the increased off-service time has led to increased resident productivity in terms of clinical research activities. discussion here we present the results of a survey of pds for acgme-accredited neurosurgery residency programs regarding their responses to the covid- pandemic. in general, we found that most programs made similar changes to resident duties in response to the covid pandemic; most reduced the number of days per week worked by each resident and the number of residents in the hospital at any one time. additionally, redeployment of neurosurgery residents to care for either covid-positive or non-covid patients did occur. a percentage of programs newly introduced access to wellness/counseling apps in response to the covid pandemic, though most ( %) had already offered these benefits prior to the covid pandemic. at present, pds are optimistic that the covid pandemic will not prevent either current or incoming chief residents from reaching acgme case minimums. however, they also reported that residents would be transitioned from an in-person didactic program to a videoconferencing-based system with a minimum of -minutes of lecture led by senior residents using material assembled by staff neurosurgeons or sourced from online material. carter and chiocca described the implementation of similar curriculum changes at the harvard-affiliated programs. they described the implementation of daily "lunchtime lectures" using videoconferencing software. during these lectures, department staff and medical students are instructed using a combination of operative video, journal club, and didactics. in a separate publication, the authors additionally reported the continuation of normal resident lectures and m&m sessions using videoconferencing software. though less specific, similar changes were endorsed by eichberg and colleagues at the university of miami. lastly, bray and colleagues described the impact of covid- on resident education at emory. as with the above centers, they reported transition of grand rounds and didactic lectures to videoconferencing software. they additionally reported using this platform to stream daily case conferences for residents, fellows, and medical students, and for streaming third-party materials provided by the cns. in sum, the interventions reported by these programs appear to be similar to those reported by the majority of the survey respondents in the present study and demonstrate a strategy that could likely be implemented in all neurosurgical residencies. there has been a reported uptick in the number of electronic resources made available to neurosurgical residents. these include resources offered by professional societies, for example the grand round webinars and virtual visiting professor series offered by the cns and the free resident courses offered through the neurosurgery research & education foundation of the aans. additionally, there has been increased use of third-party resources, including the neurosurgical atlas, which has reported more than a % increase in users/viewers since the onset of the pandemic. here we found that a majority of programs are embracing lecture delivery via teleconferencing materials. additionally, nearly three-quarters of programs are incorporating the cns complimentary online education into their educational programs. this finding that programs are increasingly relying on video and other online materials is expected and reassuring given the limitations imposed by the covid crisis. while such education will never replace operative experience, video instruction has substantial precedent in both us academic centers as well as in limited resource settings. the authors reviewed the most popular applications and found them to be high-quality overall, with few instances of incompleteness and no instances of false statements. however, they did caution that care must be taken with widespread usage of the mobile applications, as they are not subject to the same rigorous peer review used for the primary literature. in the present survey we found that mobile applications appear to be only minimally utilized, with only % of programs reporting using them as part of their didactic curriculum. while it is possible that individuals are using them on their own, formalizing and raising awareness about such applications may represent an additional means of educating residents at a distance. an additional strategy that was not considered by the survey involves using mobile devices to aid residents in practicing operative skills. huotarinen et al described using a smartphone's camera in conjunction with suture and several household supplies to allow residents to individually improve their microsurgical skills. the authors found this training method to significantly improve resident skill using the conventional microscope. though the tested sample was extremely small, this represents a potential option for residents and programs that have been forced to reduce resident participation in surgical cases due to the covid- pandemic. resident wellness one aspect of the covid crisis that has been largely overlooked in the neurosurgery literature is work to maintain resident wellness. in this time of crisis, it is widely acknowledged that extreme physical and emotional stresses are being placed upon medical trainees at all levels. trainees report stress regarding the physical risks posed by having to care for covid-positive patients , as well as the potential impact that covid restrictions may have on future career prospects. neurosurgical residency is demanding, , and while overall attrition rates are below average ( % between and versus % for general surgery residents), , it has been noted that low operative volume and outside social stressors are associated with higher rates of burnout. this raises concern for increased resident burnout rates during the covid crisis. to address resident burnout, multiple programs have previously implemented resident wellness initiatives (table ) . , , , in the setting of this covid pandemic, it would seem that these wellness initiatives would be increasingly important. previous initiatives outside the covid pandemic have include implementation of gym memberships, group exercise sessions, regular lectures on wellness ( al. in subsequent publications, this group reported that such interventions were seen by residents as "very important," with the vast majority reporting the interventions to have positive impacts on their physical and mental health. they also reported team-building efforts to increase team-cohesiveness, and to improve scores on previously validated measures of anxiety and sleepiness. in response to this, louisiana state university implemented a similar exercise program for residents at their new orleans campus; two-thirds of the residents reported the intervention to significantly improve their job satisfaction. implementation of a mindfulness- based initiative at the university of florida was similarly reported to improve resident motivation and conflict-handling abilities. along these same lines, since the pandemic began, our institution began offering all students and trainees free mental telehealth counseling to deal with some of the new challenges and stressors. in the setting of the current covid pandemic, many of these initiatives may not be possible. however, similar interventions using videoconferencing software (e.g. group online fitness classes, etc.) can help foster the same level of camaraderie that has been found to boost resident performance and quality-of-life. additionally, pds responding to our survey noted that virtual social gatherings, happy-hours, and similar such events via videoconferencing software can help bolster resident morale and sense of community. ammar et al noted similar effects in their report on efforts to maintain wellness amongst neurosurgical residents at a new york city program. they endorsed the increased use of check-ins between faculty and residents and between residents as a means of maintaining contact during these times of social distancing. the authors also reported offering child care resources and flexible work scheduling to help reduce resident anxiety about non-clinical concerns. in the present survey, we found only a minority of programs are currently providing these. limitations the present study has several limitations inherent to all survey-based research. first, we had only a % response rate to our survey. while this is relatively high for such survey studies, it is possible that novel educational interventions being employed at centers are not captured here. additionally, many questions were set up as multiple-choice questions to simplify responding. as this can miss some of the nuances of open-ended answers, we intentionally included some areas for free text response to capture additional details of the response. as a result, there may be interventions being employed at some programs that were missed. conclusion the covid- pandemic has led to drastic changes in neurosurgical training and overall resident experience. here we provide the results of a survey of program directors describing both the interventions being pursued to continue resident education and the changes in resident involvement. we find that most programs have experienced large drops in their case volume and are attempting to compensate by moving didactic lectures to teleconferencing software and increasingly incorporating educational resources from outside sources. additionally, most programs are reducing resident in-hospital time and reducing the number of residents in-house at any one time to reduce risk of covid exposure. we hope that these results can help create transparency and consistency across neurosurgery residency programs for the benefit of all current trainees, as well as generate consideration of how the common adaptations adopted rapidly by programs will impact how neurosurgical education occurs in the future. acknowledgement we would like to thank all program directors who responded to the survey. we appreciate their participation and hope that additional collaborations of this nature will help to foster a unified response to the covid pandemic. tables table : profile of responding programs table : changes in resident roles and deployment in response to covid pandemic table : changes in resident educational sessions in response to covid pandemic table : previously described resident wellness initiatives non-emergent, elective medical services, and treatment recommendations letter: for whom the bell tolls: overcoming the challenges of the covid pandemic as a residency program trends in united states neurosurgery residency education and training over the last decade letter: maintaining neurosurgical resident education and safety during the covid- pandemic letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm covid- and academic neurosurgery innovations in neurosurgical education during the covid- pandemic: is it time to reexamine our neurosurgical training models? research electronic data capture (redcap)-a metadata-driven methodology and workflow process for providing translational research informatics support the redcap consortium: building an international community of software platform partners proclamation on declaring a national emergency concerning the novel coronavirus disease (covid- ) outbreak. white house proclamations declaration of state of emergency and existence of catastrophic health emergency -covid- complimentary online education american association of neurological surgeons toward the development of -dimensional virtual reality video tutorials in the french neurosurgical residency program. example of the combined petrosal approach in the french college of neurosurgery neurosurgery videos on online video sharing sites: the next best teacher? free-access open-source e-learning in comprehensive neurosurgery skills training virtual reality-based simulation training for ventriculostomy structured online neurosurgical education as a novel method of education delivery in the developing world the use of simulation in neurosurgical education and training mobile applications in neurosurgery: a systematic review, quality audit, and survey of canadian neurosurgery residents efficient, and mobile way to train microsurgical skills during busy life of neurosurgical residency in resource-challenged environment we signed up for this!" -student and trainee responses to the covid- pandemic a neurosurgery resident's response to covid- : anything but routine impact of covid- on neurosurgery resident research training incorporation of a physical education and nutrition program into neurosurgery a comparison of the existing wellness programs in neurosurgery and institution champion's perspectives analysis of national trends in neurosurgical resident attrition prevalence and causes of attrition among surgical residents factors associated with burnout among us neurosurgery residents: a nationwide survey pursuit of balance: the upmc neurosurgery wellness initiative impact of a residency-integrated wellness program on resident mental health, sleepiness, and quality of life perspectives from a residency training program following the implementation of a wellness initiative managing a specialty service during the covid- crisis how question types reveal student thinking: an experimental comparison of multiple-true-false and free-response formats • gym memberships • mind-body wellness sessions • team workout sessions medical university of south carolina • exercise lectures • mind-body wellness sessions • primary care appointments and bloodwork • spouse support programs • team workout sessions • teambuilding exercises tufts medical center • financial wellness lecture series • holiday parties and social events • team bonding experiences university of florida • exercise lectures • mind-body wellness sessions university of minnesota • conflict resolution skill sessions • exercise lectures • personal development and career planning sessions • teambuilding exercises university of pittsburgh • faculty mentorship program • gym memberships • team workout sessions • wellness and mindfulness lectures vanderbilt • exercise lectures • gym memberships • leadership lectures • teambuilding exercises and trips wake forest • exercise lectures • gym memberships • mind-body wellness sessions • quarterly resident/faculty events • team workout sessions • teambuilding exercises sources supplementary figure . survey utilized for gathering program director input on changes to resident education following onset of the covid- pandemic. ( . ) key: iqr -interquartile range †health system defines as all hospitals in institutions health system that are staffed by the program's neurosurgery residents prior to onset of the covid- pandemic ‡case volume defined as proportion of pre-covid case volume key: cord- - n wwle authors: khalafallah, adham m.; jimenez, adrian e.; mukherjee, debraj title: in reply to the letter to the editor regarding “impact of covid- on an academic neurosurgery department: the johns hopkins experience” date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: n wwle nan the authors thank dr. venkataram and colleagues for their thoughtful and thorough analysis of our recent study "impact of covid- on an academic neurosurgery department: the johns hopkins experience." as stated in our paper, we believe that publishing the unique experiences of different academic medical centers during the covid- pandemic is essential in clarifying the many challenges facing both american neurosurgery as well as neurosurgery across the world, and we also believe sharing such information is important for establishing a consensus regarding best practices as the situation continues to evolve. in their response to our study, the authors shared important information about the pandemic's effect on indian neurosurgery, comparing and contrasting their findings with our results. we thank the authors for their contribution, and we appreciate their comments on what a "way forward" may look like as travel restrictions and lockdown mandates are eased, and as neurosurgeons aim toward returning to pre-pandemic caseloads. we agree that it is crucial for neurosurgeons to begin clearing patient backlogs of canceled elective cases to avoid disease progression and worse prognosis among impact of covid- on an academic neurosurgery department: the johns hopkins experience the end of social confinement and covid- re-emergence risk expected impact of lockdown in Île-de-france and possible exit strategies an exit strategy for resuming nonemergency neurosurgery after severe acute respiratory syndrome coronavirus : a united kingdom perspective cancer surgery scheduling during and after the covid- first wave: the md anderson cancer center experience the return back to typical practice from the "battle plan" of the covid- pandemic: a comparative study tracking the volume of neurosurgical care during the covid- pandemic elective surgery cancellations due to the covid- pandemic: global predictive modelling to inform surgical recovery plans letter: safety considerations for neurosurgical procedures during the covid- pandemic letter: a guide to the prioritization of neurosurgical cases after the covid- pandemic sars-cov- impact on elective orthopaedic surgery: implications for post-pandemic recovery key: cord- -t v hng authors: al kasab, sami; almallouhi, eyad; spiotta, alejandro m. title: acute stroke management during the coronavirus disease (covid- ) pandemic: from trough of disillusionment to slope of enlightenment date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: t v hng nan s ince the initial report of infection with the coronavirus disease in december , the number of confirmed covi- cases has exceeded . million globally. without a vaccine in sight and given the success of social distancing, we expect the outbreak to last longer than originally projected. social distancing while at work remains a challenge of us all. mid-march, we implemented separate call teams, so that each of us only comes into contact with to coworkers at maximum over the course of the pandemic. these changes are necessary to maintain the workforce required to continue to be able to provide mechanical thrombectomy (mt) for our patients. every stroke care system must prepare for the worst-case scenario involving a surge that completely overwhelms the capacity of that system to function. over the last several weeks, we have been learning from our colleagues around the nation-first, news out of seattle and then new york city, and now most recently from detroit, with greater than providers testing positive for covid- at henry ford. with approximately % of health care providers being infected with the virus, we are faced with the challenge of providing the care our patients desperately require while ensuring the safety of our health care providers. we must be mindful that our selfless tendencies as dedicated frontline providers do not become our biggest vulnerability. this challenge requires that we adjust our mindset and also place at the forefront the safety of ourselves and our teams. we make up one of the smallest and most subspecialized units in our hospitals. as such, we are easily incapacitated with quarantine or illness; who will take care of our community then? this safeguarding requires major changes to our pre-covid- workflow, to which the current pandemic has added multiple layers of complexity. engagement of multiple specialties, including emergency department (ed) physicians, stroke neurologists, anesthesiologists and neurointensivists, is required. fears and anxieties are normal human responses to a pandemic, and each must be acknowledged and addressed, never dismissed. in the acute stroke setting, the stakes are greatest because every minute counts. although it may seem that there is not enough time to get it right, we must remember that this is also no time to get it wrong. that could mean being placed on diversion and not having the capacity to continue to treat our patients with stroke. it begins with not overly burdening an already-tenuous hospital system. in the current covid- crisis, there is critical bed shortage at greater level of care hospitals. we must therefore reduce the number of "futile transfers" from community hospitals and ensure that only patients who are likely to receive mt are transferred to the thrombectomy-capable center. turning down a transfer could be the difference between being able to accept the next. this will entail obtaining advanced imaging at spoke hospitals to confirm the presence of proximal large vessel occlusion (lvo) before transport. patients ruled out for lvo can remain at the spoke for routine care, even those who receive intravenous thrombolysis, particularly those spokes that are primary stroke center certified. even for patients in whom an lvo is confirmed, the criteria for transfer to the thrombectomy capable center should be decided on by a multidisciplinary team. during a pandemic and in the context of bed shortages, plus the prospect of bringing in vulnerable patients into an environment in which they might have a greater likelihood of acquiring the virus, hard decisions must be made. accept the hard truth that your center should be more stringent in your criteria for mt, particularly for patients who don't fall within the guideline recommendations. as a team, discuss how you will handle those falling outside the "trial criteria"-very elderly patients, patients with mild, yet disabling stroke symptoms, and patients with distal occlusions. only patients with a high likelihood of receiving thrombectomy should be transferred. once the patient with lvo who is an mt candidate arrives to your ed, all teams must be in alignment. pre-thrombectomy screening for covid- is a major challenge; often these patients are unable to provide a history and collateral information is typically lacking. the society of neurointerventional surgery currently recommends that patients with unknown covid- status should be screened for fever and respiratory symptoms. given that approximately % of patients with covid- are asymptomatic and the growing awareness that asymptomatic patients are able to transmit the virus, this screening might not be sufficient. it may therefore be prudent to consider is to obtain a computed tomography (ct) scan of the chest to evaluate for underlying infiltrates at the time of obtaining a ct angiogram and perfusion. although extending the ct to capture the entire chest entails additional radiation, identifying a lung infiltrate suggestive of likely covid- infection in an asymptomatic patient affords the health care team the ability to don the proper precautions before the procedure. another question that has sparked major debate is whether to intubate patients before mt. some proponents of an "intubate-all" approach argue that it protects the small and highly specialized mt team from exposure. although all valid points, this approach fails to consider the other facets and team members along the way. thrombectomy in and of itself is a low-risk procedure for contracting the virus, whereas the intubation and extubation are by far the greatest-risk components and would incur additional risk to your ed and neuro-intensive care unit (icu) colleagues, respectively. in addition, intubating an elderly patient adds morbidity, and the airway management would require negativepressure rooms in both the ed and the neuro-icu. these are resources expected to be either in very short supply or not available at all during peak surge. the lowest-risk pathway to the system as a whole is to get the lvo patient through the thrombectomy awake and cooperative without requiring pre-procedure intubation. however, the greatest potential risk to both the anesthesia and mt teams is in the event the thrombectomy unexpectedly transforms into an aerosolgenerating procedure. a patient coughing or vomiting mid-world neurosurgery -: ---, month www.journals.elsevier.com/world-neurosurgery procedure, would entail the worse possible scenario not just by the greatest-risk exposure to the providers but also in the delay it would incur. neuroangiography suites are positive-pressure rooms (exceptions would be hybrid angio/operating room suites), necessitating a clearing out of the room by personnel following an aerosol-generating procedure like an intubation. thus, the "lowest-risk" pathway is not necessarily the safest. finding the balance of risk to patient versus provider and resource use (negative-pressure rooms and personal protective equipment [ppe]) is delicate, and the decision of which patient should undergo preprocedural intubation is not straightforward. the society of neurointerventional surgery recommends a lower threshold for intubation for patients with suspected covid- , however, without specific criteria for intubation. we suggest that those patients at risk for converting an otherwise noneaerosolgenerating procedure (thrombectomy) to a greater-risk procedure due to airway compromise should be intubated before mt. these would include those with severe stroke symptoms, patients with receptive aphasia, any signs of respiratory distress, or vertebrobasilar occlusion should be intubated before mt. intubation ideally takes place in a negative-pressure room in the ed. patients should then be transferred to the icu with the same ventilator so that a closed circuit can be maintained. the emergence of a faster covid- test that provide results within minutes will provide us with a more efficient and reliable way to rapidly triage patients with lvo and avoid unnecessary intubations. however, until that test becomes widely available, following vigilant screening and maximizing precautions will be of paramount importance to protect our health care providers. another consideration is modification to your angio-suites for team protection. at our center, we have designated one of the biplanar rooms a "covid- " room, in which patients with suspected or confirmed covid- receive mt. the door to this room has been sealed off, making it impermeable to aerosolized particles to completely isolate it from the control room. we have rehearsed an elaborate protocol to deliver additional supplies and devices into that room should they be needed via the hallway, as well as donning/doffing of ppe for room entry/exit protocol. due to staff and ppe shortages, only essential personnel should be allowed into the covid room during the procedure. this means that only one nurse, one technologist, the interventionists, and anesthesiologist are the only staff member to be in the room. once the procedure is finished, patients are transferred to the icu, where they are extubated in a negative-pressure room. remarkable challenges lie ahead of us, but we remain optimistic knowing that our field is graced with tremendously devoted, talented, and innovative people. our solutions may not always be perfect, but these are also imperfect times, and we may have to do the best with what we can. however, one certainty remains: on reflecting back on these unprecedented times, it will be known that we answered the call for our patients. world health organization. coronavirus disease (covid- ) situation reports protecting health-care workers from subclinical coronavirus infection society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid- estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) key: cord- -ygd p authors: rothrock, robert j.; maragkos, georgios a.; schupper, alexander j.; mcneill, ian t.; oermann, eric k.; yaeger, kurt a.; gilligan, jeffrey; bederson, joshua b.; mocco, j. d. title: by the numbers analysis of covid- ’s effect on a neurosurgical residency at the epicenter date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: ygd p abstract background the sars-cov- pandemic has created challenges to neurosurgical patient care. despite editorials evaluating neurosurgery covid- responses, data reporting covid- ’s effects on case volume, census, and resident illness are lacking. objective to present areal-world analysis of neurosurgical volumes, resident deployment, and unique challenges encountered during the sars-cov- outbreak peak in new york city. methods daily census and case volume data were prospectively collected throughout the spring sars-cov- outbreak. neurosurgical census was compared against covid- system-wide data. neurosurgical cases during the crisis were analyzed and compared to seven-week periods from and . resident deployment and illness were reviewed. results from march -may , , residents participated in operations and endovascular procedures. this compares to operations and endovascular procedures in january-february and operations and endovascular procedures over march-may . there was a % reduction in neurosurgical census during the outbreak (median patients, . average total cases daily). covid- neurosurgical admissions peaked in concert with the system-wide pandemic. three residents demonstrated covid- symptomatology (no hospitalizations occurred) for a total workdays lost (median days). conclusion these data provide real-world guidance on neurosurgical infrastructure needs during a covid- outbreak. while re-deployment to support the covid- response was required, there remained a significant need to continue to provide critical neurosurgical service. daily census and case volume data were prospectively collected throughout the spring sars-cov- outbreak. neurosurgical census was compared against covid- system- wide data. neurosurgical cases during the crisis were analyzed and compared to seven-week periods from and . resident deployment and illness were reviewed. there was a % reduction in neurosurgical census during the outbreak (median patients, . average total cases daily). covid- neurosurgical admissions peaked in concert with the system-wide pandemic. three residents demonstrated covid- symptomatology (no hospitalizations occurred) for a total workdays lost (median days). these data provide real-world guidance on neurosurgical infrastructure needs during a covid- outbreak. while re-deployment to support the covid- response was required, there remained a significant need to continue to provide critical neurosurgical service. the global pandemic associated with the novel coronavirus sars-cov- , causing the coronavirus disease (ards). the majority of hospital and departmental resources were requested towards this effort. however, a significant burden of neurological disease was also encountered during this period. we report numerical real-world analysis of our neurosurgical resident experience during the peak of the sars-cov- outbreak in new york city. understanding volume and case mix of operative and neurointerventional procedures, daily patient census, icu coverage needs, and rate of resident safety concerns and sick days during this period will aid in understanding resource allocation during future outbreaks. the goal is to provide concrete real-world data that may help other departments prepare their response should they face subsequent second or third waves of the sars-cov- pandemic. (table and table ). case volume decreased during the system wide peak in covid- hospitalizations, and increased during the the most common categories of operative procedures were spine ( %), neuro-oncology ( . %), neuro-vascular ( . %), functional ( . %), and csf diversion ( . %). most patients were covid- negative ( . %), confirmed with mean . swabs. the remainder were unknown ( . %) and % were covid- positive. eighteen cases ( %) were taken as immediate surgical emergencies; all cases were considered urgent/non-elective. most endovascular procedures were interventions ( . %), with . % thrombectomy for acute stroke, . % lesional subarachnoid hemorrhage, and . % arteriovenous malformation. the majority of endovascular cases were considered immediate procedural emergencies ( . %). most patients were covid- negative ( . %), confirmed with mean . swabs. hospitalization patterns in the neurosurgical population correlated with system-wide system-wide data on hospital staff infection rates remain preliminary. as has been described elsewhere, there was an increase in ischemic stroke volume covid- and neurosurgical practice: an interim report md: declarations of interest: none ian t. mcneill, md: declarations of interest: none eric k key: cord- -c krlejx authors: josé antonio, soriano sánchez; tito, perilla; marcelo, zenteno; alvaro, campero; claudio, yampolsky; mauro, loyo varela; manuel eduardo, soto garcía; josé alberto israel, romero rangel title: early report on the impact of covid- outbreak in neurosurgical practice among members of the latin american federation of neurosurgical societies date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: c krlejx abstract background the covid- pandemic has caused severe economic consequences by local governmental measures to contain the outbreak we provide insight on the impact that healthcare restriction has made on neurosurgical activity in latin iberoamerica. methods: we performed an internet-based survey among presidents and members of the societies of the latin american federation of neurosurgical societies (flanc). we blindly analyzed information about local conditions and their impact on neurosurgical praxis using spss® software. results information came from countries. sixteen society presidents reported having suspended regular activities, and differing local scheduled congresses, fourteen reported mandatory isolation by government, and four instituted a telemedicine project. four-hundred eighty-six colleagues, mean age years, reported a mean % reduction in their neurosurgical praxis. seventy-six percent of neurosurgeons had savings to self-support for - months, if restrictions are long lasting. conclusions stopping activities among societies of the flanc, together with a drop of % of neurosurgical praxis, adds to deficits in provider´s protection equipment and increasing demand for attention in the healthcare systems; representing a huge financial risk for their sustainability. neurosurgeons should involve in local policies to protect health and economy. telemedicine represents an excellent solution, avoiding another pandemic of severe diseases across all-specialties as non-essential care can turn essential if left untreated. financial support and ethics code review is needed to battle this new disease, designated the occupational disease of the decade, that continues to struggle the healthcare systems. times of crisis are times of great opportunities for humanity to evolve. society, and four extracontinental european societies, whose primary languages (spanish, portuguese, italian and french) derive from latin . in other words, the flanc jointly represents the neurosurgical workforce of latin iberoamerica. by using the flanc as a platform, we aimed to provide an insight on the socioeconomic impact that healthcare restriction has made on latin iberomerican neurosurgical practice as a baseline to understand the potential financial burden it will imply (especially to other physicians involved in non-essential treatment) in terms of sustainability if these measures are to be overcome) this crisis. methods we performed an electronic internet-based survey among the members of the latin american federation of neurosurgical societies on a single day to obtain information in a historically early stage on the covid- outbreak in latin iberoamerica. as information changes abruptly from day to day in the pandemic we consider that transverse studies are mandatory to pose a baseline to compare the impact of health policies on economy. we collected information on an -item electronic questionnaire directed to the presidents of the societies of the flanc (table ) to obtain precise information on outbreak condition and governmental dispositions in each country, as well as information related to societal activities and covid- infection incidence among local neurosurgeons. we used another -item questionnaire for (neurosurgeons) members of the flanc ( chile % ( ); uruguay, and el salvador % ( ) each; spain % ( ); panama, and dominican republic %, ( ) each; usa, haiti, honduras, nicaragua and venezuela < % each ( , , , and responses respectively). the mean age of colleagues was . (min. the medical praxis has also been affected, as the world health organization has recommended reducing activity with the advance of epidemy in local countries to provide essential care to give the best use of resources to contain the outbreak and reduce infection rates . neurosurgery as a specialty has adopted these measures and has emitted recommendations to properly classify and select patients requiring emergent treatment during triage (whether covid is non-suspected, suspected, denied, or confirmed) - . our results demonstrate the dramatic consequences that these measures have provoked in neurosurgical practice, whether in the public or private, reaching rates as high as % in most of the countries. this fact proves right the estimates of the ilo , given that % of neurosurgeons in public health care system are suffering a degree of unrefunded work ( % partial reduction in salary, and % not receiving payment) as early as two elapsed months since the starting of the covid- epidemic in latin iberoamerica on february th , . we are most concerned about the sustainability of medical practice in neurosurgery as for that of many other specialties, having lesser percentages of essential-care. we agree with both, government decisions and who recommendations, in that containing measure must remain, yet, we also agree with ilo as many jobs are to be lost if this situation is to be billion investment is to be given in this first round to argentina, ecuador paraguay haiti, dominican republic, panama, and bolivia . this investment will help to strengthen the public health system and policies aiming to identify new cases and to prepare for increased levels of demand . we hope this help continue to be provided to the rest of latin america, and increasing project be directed to patients at risk as well as to physicians. this population has demonstrated to be at increased risk of morbidity, mortality but also to psychological distress by burnout and dealing with the disease in a scare security health system, too, as covid- is considered the new occupational illness in the decade . on the other hand, we must remain ethics for everyone needing medical care, whether covid- related or non-covid- related, as kim et al. recognized, we are living through truly novel times; however, ethical principles must remain the same . it is our belief and our best wisdom that current technology permits us to develop information as fast as never before, we must take this advantage that our predecessor did not have in previous pandemics. we have the opportunity to change the medical practice for the good of humanity, providing care even if physically apart, but joint in mind, as we all juried the hypocritic judgment . relying on providing essential care will ultimately affect the health of the whole humanity, driving to another pandemic of increasing essential care needs by suboptimal treatment (if any) of the non-essential care morbidities. as the natural course of illnesses describes, non-treatment provides increasing complications that ultimately impact health - . suboptimal treatment can theoretically turn non-essential care pathologies into essential care pathologies at an exponential growth rate, as massive or even more, than covid- pandemic. besides, keeping the usual healthcare of patients would prove against physicians self-right to preserve health, especially when protection equipment recommendations by who are not satisfied . our results show that neurosurgeons must acquire this equipment in a relation of % of self-investment, not to imagine if we were to attend the full spectrum of pathologies in the covid- outbreak. hopefully, telemedicine brings the opportunity to deliver health care to some extent, at least as for non-essential care , , , avoiding the complications and counter effects of no-treatment. it will also aid in reactivate medical praxis and contribute to the economy for sustaining a long-lasting pandemic. telemedicine can help people to preserve jobs (or create new ones ), economy, and health to counterattack the struggling financial crisis that has been held in the present and will affect the future for the many years to come. we also appeal to respect physicians' jobs and rights, as this pandemic has turned into a which hunters pandemic too. frustration and long waiting times are known causes that led to increase aggression from patients to healthcare providers . the fear of covid- has pushed people to take irrational measures to prevent infection from healthcare providers . in mexico, we have witnessed direct aggression to nurses on public transport, with people covering them with chloride rationality and respect must prevail to health care providers; we must search for local government policies that protect healthcare workers from aggressions too. pandemic: bold public health leadership, rapid innovations, and courageous on the coronavirus (covid- ) outbreak and the smart city network: universal data sharing standards coupled with . who. operational guidance for maintaining essential health services during an america: the implications of the first confirmed case in brazil covid- : why is the uk government ignoring who's advice? covid- : learning from experience hilsenrath pe. commentary ethics and economic growth in the age of covid : what is a just society to do ? covid- : uk government writes off £ . bn of hospital debts to ease pressures world bank's response to covid- (coronavirus) in latin america & caribbean factors associated with mental health outcomes veterans affairs por miedo a coronavirus, bañan con cloro y bajan de camiones a enfermeras en jalisco we want to express our most sincere acknowledgments to the following colleagues and friends… juan josé maria mezzadri argentine neurosurgery association key: cord- -wvgwf n authors: d’amico, randy s.; khatri, deepak; kwan, kevin; baum, griffin; serulle, yafell; silva, danilo; smith, michael l.; ellis, jason a.; levine, mitchell; ortiz, rafael; langer, david j.; boockvar, john a. title: neurosurgical/head and neck drape to prevent aerosolization of covid- - the lenox hill hospital/northwell health solution. date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: wvgwf n nan the "coronavirus disease " or covid- pandemic has resulted in dramatic changes in the way we practice medicine and neurosurgery. given its long incubation period, high transmission rate, and estimated % mortality, this virus will likely affect the way we live and work for the foreseeable future. , this has been particularly true in new york city which quickly became the global epicenter of the infection. while many departments have curtailed elective surgery, neurosurgical procedures that are deemed emergent, urgent, or semi-urgent will warrant intervention during these restrictive times. although covid- screening and testing guidelines have been proposed and adopted by many hospitals, these may not adequately protect the operating room personnel who are in proximity to the patient for prolonged periods. there are concerning reports of especially high transmission rates of covid- in trans-mucosal head and neck procedures conducted by otolaryngologists and neurosurgeons, despite attempts at wearing what constitutes appropriate ppe. here we describe the simple intraoperative technique we utilize at lenox hill hospital/northwell health for all cranial, endonasal, spinal, and neuro-interventional cases to limit the intraoperative transmission covid- to essential staff in the operating rooms and the endovascular suite who are at a substantially higher risk of exposure to the disease. , we expect that these covid- pandemic intraoperative precautions will extend into the covid- recovery period as well as hospitals attempt to prevent a return to widespread infection. formal screening and testing guidelines are currently being devised. we recommend that all patients should undergo testing within hrs of emergent/planned surgical procedures. these services may be provided by the hospital pre-op department or via at-home companies capable of performing the testing (i.e. labfly; https://www.northwell.edu/northwell-health-labs/labfly). aerosolization of the virus prior and during intubation and extubation deposits the virus into the air and on fomites in the operating room. , this is particularly important as transconjunctival spread has been reported. enhanced ppe precautions should be utilized by all personnel in the negative pressure operating room and endovascular suites. furthermore, all non-essential staff should leave the room during intubation and extubation. we are currently utilizing a large fluoroscope drape to cover the eyes, nose and mouth following intubation to limit potential dispersal of aerosolized virus (premiere guard fluoroscope drape, x cm; http://www.premierguard.com; houston, tx; figure a) . with the help of the selfadhesive edges, the clear drape is secured low on the brow and hangs down over the eyes, nose and mouth allowing visualization of the face and endotracheal tube ( figure b) . the application of this drape can be modified to accommodate necessary cranial incisions or secured at the neck for cases where the patient is positioned prone or lateral. after the drape application, the surgical site can be prepped and draped sterilely in the usual fashion ( figure c) . since the drape only covers the face and is not applied over the cranium, it leaves the whole cranium accessible for usual prepping which is performed after the application of this drape. any cranial incision can be easily marked and draped around using the sterile blue towels in the conventional manner. the drape does not restrict any surgical activity including the usage of a drill. the drape is carefully discarded at the end of the surgery prior to, or after extubation according to anesthesia's desired protocol. strong consideration should be giving to leaving the drape over the mouth and nose during extubation as preliminary reports support its utility in limiting aerosolization. this is particularly important in cranial cases where the surgeon and his assistant stand at the head of the bed, although we feel it should be used for all interventions using general anesthesia (cranial, spine, endovascular). notably, the mechanism of protection of this drape is proposed to limit aersolization from the oropharynx during intubation, extubation, and endonasal sinus cases. this is not proposed to protect the surgeon during drilling of aerosolized sinuses such as the mastoid bone. in all settings, and in particular these cases, we recommend maintanence of recommended ppe practices. infected patients have a high viral load in the upper airways and the risk of aerosolization of covid- may be extremely high during sino-nasal and upper airways procedures. this is particularly true when high-speed operative drills are employed. recently, the american association of otolaryngology-head and neck surgery (aao-hns) has recommended deferring endoscopic endonasal procedures unless emergent. in these scenarios, enhanced ppe should be utilized regardless of covid- testing status. in such cases, the prevention drape should be modified with a small aperture (horizontal slit) to allow instruments to pass into and out of the nares (figure ) . if an approach surgeon is utilized, we recommend all non-essential personnel remain outside of the or until adequate exposure has been achieved. recently, a negative-pressure otolaryngology viral isolation drape (novid) was utilized at another center for endoscopic skull base and transoral surgical procedures in four patients. compared to the novid, our technique offers a simple, commonly available alternative which avoids the use of additional retractor system. moreover, this technique can be utilized in all neurosurgical procedures. as we continue to work through the covid- pandemic and focus on recovery, sustained efforts to limit transmission will be necessary to protect physicians, staff, and patients. the covid- aerosolization prevention drape may limit intraoperative dispersal of covid- particles and add an additional layer of protection against the spread of the virus. in addition, its availability and cost effectiveness make this technique especially attractive to practical utilization in centers with limited resources. a novel coronavirus outbreak of global health concern clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study a framework for prioritizing head and neck surgery during the covid- pandemic. head neck staff safety during emergency airway management for covid- in hong kong consensus guidelines for managing the airway in patients with covid- : guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for covid- covid- and the key: cord- -ocz rzy authors: gilligan, jeffrey; gologorsky, yakov title: collateral damage during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: ocz rzy nan at our institution, similarly, we have seen both a huge decline in patients seeking care for neurological and neurosurgical diagnoses, as well as late presentation of life-threatening conditions. for example, a year-old caucasian female was brought to our emergency room with somnolence. by her husband's report, she developed severe headache days prior to presentation, with associated nausea and vomiting. she refused to seek care at the hospital due specifically to fear of contracting covid- . at presentation, she was obtunded, not following commands, and not protecting her airway. she was emergently intubated, and ct/cta demonstrated subacute subarachnoid hemorrhage most pronounced in the right sylvian fissure, a right carotid terminus aneurysm, and moderate multifocal vasospasm ( figure ). her sodium at presentation was mmol/l. despite endovascular embolization of the aneurysm and aggressive medical care, her exam remains poor. what remains unknown is how many patients with known or unknown pathologies are having progression of a deficit (i.e. worsening vision secondary to a supersellar mass or worsening cervical myelopathy) that would otherwise have brought them to seek urgent medical care. fortunately, we are seeing a significant decrease in admissions as the rate of new covid- cases has leveled out. in our own institution, resources and staff are finally being able to assist with non-covid patient duties. rather than being able to only perform emergent surgeries, we are starting to schedule urgent and semi-elective cases. faculty, house-staff, and physician extenders, who had been redeployed to help with the covid- pandemic, are slowly returning to their previous roles. in the next few weeks we will need to create an algorithm to identify patients whose surgeries must be prioritized. who should be scheduled first: a year-old with cervical spondylotic myelopathy, a year-old with a glioblastoma, or a year-old with an mca aneurysm? these decisions will be difficult to make, but, yet, must be made in the near future. patients with heart attacks, strokes and even appendicitis vanish from hospitals the untold toll -the pandemic's effects on patients without covid- quite likely, the greater challenge will be finding the people who are afraid to seek care to begin with. social distancing has led to isolation and fewer visits by friends and family members. the support network, that is often the catalyst to seek medical care, and also the system that provides for them in times of convalescence, must be reestablished. as the pandemic subsides, we will need to ask our leaders, public health officials, and the media to send a message to patients at risk: please seek help if you're not well or having worsening symptoms. key: cord- -ws xprt authors: ozoner, baris; gungor, abuzer; hasanov, teyyup; toktas, zafer orcun; kilic, turker title: neurosurgery practice during coronavirus disease (covid- ) pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: ws xprt abstract coronavirus disease (covid- ), caused by severe acute respiratory syndrome coronavirus (sars-cov- ), is a highly contagious, life-threatening condition with unprecedented impacts for worldwide societies and healthcare systems. since the first detection in china, it has spread rapidly worldwide. the increased burden has substantially impacted the neurosurgery practice and intensive modifications were required in surgical scheduling, inpatient and outpatient clinics, management of emergency cases, and even academic activities. in some systems, non-overlapping teams were created to minimize transmission among healthcare workers. in case of a massive burden, neurosurgeons may be needed to reassign to the covid- wards, or teams from other regions may be needed to send to severely affected areas. in outpatient practice, if possible, appointments should be turned into telemedicine. all staff assigned in the non-covid treatment unit should be clothed in level personal protective equipment. if possible, postponement is recommended for operations that do not require urgent or emergent intervention. all patients indicated for surgery must receive a covid- screening, including nasopharyngeal swab, and thorax computed tomography. level protection measures would be appropriate during covid- negative patients' operations. operations of covid- positive patients, and emergency cases, where screening can not be obtained, should be performed following level protective measures. during surgery, the use of high-speed drills and electrocautery should be reduced to minimize aerosol production. screening is crucial in all patients since the surgical outcome is highly mortal in covid- patients. all educational and academic conferences can be turned into virtual webinars. coronavirus disease (covid- ) is an exceedingly infectious, life-threatening condition and its outbreak is now constituting unprecedented extraordinary threats and difficulties for worldwide societies and healthcare systems. [ ] [ ] [ ] since the first detection in china in late december , it has spread rapidly to countries around the globe and reached approximately . . confirmed cases with more than . deaths on april , . the increased burden of this pandemic disease has substantially impacted the entire health system, including the neurosurgery practice in most countries. [ ] [ ] [ ] in neurosurgery practice, intensive modifications were required in surgical scheduling, administration of inpatient and outpatient clinics, management of emergency cases, and even academic & educational activities. the major goal of this review is to compose a comprehensive guide using existing guides and recommendations for reorganizing daily practice and the academic routine of neurosurgery during the covid- pandemic. this study also aimed to refine the substantial information for neurosurgery practice about this pandemic disease. an outbreak of pneumonia of unknown origin showed up in wuhan city, the capital of hubei province in people's republic of china, in late december . , on january , china isolated a new coronavirus formerly called novel coronavirus ( -ncov) and presented virus genome data to the international society. later, coincidentally, on february , the coronavirus study group of the international committee on taxonomy of viruses gave a new name to the virus "severe acute respiratory syndrome coronavirus " (sars-cov- ) and the world health organization designed a name for epidemic disease "coronavirus disease " . virology sars-cov- , a positive-sense single-stranded rna virus, a member of the subgenus betacoronaviruses, is the seventh determined coronavirus that infects humans. , , the genetic sequence of the sars-cov- presents approximately % analogy to sars-cov. sars-cov- comprises four structural proteins: n (nucleocapsid), e (envelope), m (membrane), and s (spike) proteins ( figure ). the n protein supports the rna genome, and e, m, and s proteins compose the viral envelope. the s protein also is responsible for binding to the angiotensin-converting enzyme receptor on the human cell membrane. the median incubation period is approximately days and practically all cases experience symptoms in days after exposure to sars-cov- . transmission occurs mainly through direct contact with the infected material or via droplets spread by sneezing or coughing. sars-cov- primarily targets the respiratory system. the main clinical symptoms of covid- are fever, cough, myalgia or fatigue, expectoration, and dyspnea. , minor symptoms include headache or dizziness, diarrhea, and nausea & vomiting. , dyspnea may be observed in critical patients and may proceed to severe acute respiratory syndrome, sepsis, and multiple organ dysfunction syndrome. reduced total leukocyte and lymphocyte counts, increased c-reactive protein and lactate dehydrogenase are common results in the laboratory tests. , the typical appearance is bilateral, subpleural, ground-glass opacities with air bronchograms on thorax computed tomography (ct). the viral load is elevated throughout the upper respiratory tract mucosa, including the nasal cavity, and naso-oropharynx. the viral ribonucleic acid (rna) can be identified in the sputum, saliva, as well as in the serum. the blood-brain barrier works as a natural barrier against pathogenic microorganisms and reduces the risk of intracranial infection. some human coronaviruses can invade the central nervous system (cns) through hematogenous or neuronal retrograde dissemination, leading to encephalitis and exacerbation of existing neurologic diseases. the brainstem involvement of sars cov has been described in both clinic and experimental studies. [ ] [ ] [ ] given the high analogy between sars cov and sars cov- , it clarifies that the cns spread of sars cov- may be partly responsible for acute respiratory failure in covid disease. a recent study from wuhan city, china reported that some severe covid- patients developed neurologic manifestations, such as acute cerebrovascular diseases ( . %), and impaired consciousness ( . %). cerebrovascular accidents may occur due to a systemic highly prothrombotic state of covid- . furthermore, sars-cov- was isolated in cerebrospinal fluid (csf) by gene sequencing from a covid- patient in beijing ditan hospital, china on march . since results of encephalitis are highly mortal, early diagnosis is essential. severely affected and comatose patients with neurologic symptoms should undergo brain imaging and csf examination. magnetic resonance imaging (mri) would yield the definitive marks about the presence of infectious intracranial processes. the regional hyperintense abnormalities on t weighted(w), t -w, flair, and diffusion-weighted images are considered suspicious for viral encephalitis. in case of suspected cns infections, lumbar puncture is indicated. the obtained csf can be investigated to detect viral genetic material through a polymerase chain reaction (pcr) examination or using antibody testing. viral encephalitis may also be presented with neurologic deterioration related to massive cerebral edema. , in case of conservative management (corticosteroids, hyperventilation, hypertonics, hypothermia, and barbiturate coma) fails, decompressive craniectomy can be considered an option for the last chance therapy in selected cases. , faculty planning the regional disease burden surges during the pandemic and the disease also shows a significant transmission to healthcare professionals. in the algorithm proposed by the university of california san francisco (ucsf), surgical scheduling is organized according to the ''surge level'' that correlates with the rising viral transmission between local community. using this system, the green, yellow, red, and black levels represent the lowest, moderate, high and highest levels of the surge, respectively. in the green level (< covid- + inpatients, and no staffing shortages), all elective operations proceed as scheduled. in the yellow level ( - covid- + inpatients, or < % staffing shortages), the schedule is rearranged as yielding a % reduction in the capacity of all elective procedures and all outpatient procedures is designated to an off-site (covid- free) hospital. in the red level (> covid- + inpatients, or > % staffing shortages), a % reduction is done in elective scheduling. finally, at the black level, in which significant assistance required from outside institutions to resist the outbreak, only emergent surgical cases will be performed. ucsf recommends a system, based on the "paired coverage model", designed to minimize patient and provider viral exposure while providing continuous inpatient coverage for neurosurgical emergencies. in this model, each department is covered by nonoverlapping teams (rotating in d cycles: d on, d off), in which members will have contact only within the same team. this model is activated by a red level of surge and includes an assigned alternate pool of providers to replace who show covid- prodrome. in case of a massive increase in covid- cases, non-specialized physicians in respiratory or infectious diseases, including neurosurgeons, may need to be reassigned to the covid- wards to initiate supplementary emergency responses. remodeling the hospital system by identifying concentration centers for neurosurgical activities would be necessary for managing emergent and urgent cases. an instance of this circumstance is present in lombardy, northern italy. lombardy health system was rearranged as a ''spoke-and-hub system''. [ ] [ ] [ ] [ ] the local neurosurgical network was assembled in hub hospitals ( for cranial or spinal emergencies, and one for oncological emergencies ). all the other neurosurgery departments have converted the spokes. in this way, hub hospitals are available to manage neurosurgical emergencies, whereas spoke hospitals concentrate on covid- patients. [ ] [ ] [ ] [ ] in this system, a huge increase may be expected in the number of patients treated in hub hospitals. according to an early report from the university of insubria, italy, there was an increase of % and %, respectively, of hospitalized and surgically treated neurosurgical emergencies. healthcare professionals from other areas may need to be sent to regions that are heavily affected by pandemics. during the outbreak, more than , medical staff including teams from other regions of china have been dispatched to hubei province, of which teams are comprised of neurosurgeons. owing to the newly appointed teams, emergency operations could be performed even during worst times of the epidemic peak. robertson et al. suggested a ''task shifting and task sharing'' method that involves training, practice, and maintenance phases for increasing workforce capacity during the pandemic. according to this method, the most experienced neurosurgeons who are also from the most vulnerable age groups may practice on telemedicine encounters, guiding ethical decisions on appropriate neurosurgical interventions, or neurosurgery-specific cases. and, residents skilled in neurocritical care may receive intensive skills training in endotracheal intubation and mechanical ventilator management. , residents may serve remotely when possible to perform virtual visits, record notes, give orders, and call consults. according to the physicians' preference, patient follow-up and appointments should be turned into telemedicine, if possible. , besides, remote examinations are reported that they are often applicable. according to the harvard medical school experience, more than % of the outpatient visits have been able to be switched to telemedicine. also, in a validation study by neumarkt clinic, germany, remote neurological examination consisting of items performed via audio-visual telemedicine presented comparable results to bedside examination. on occasions, the assist of a person may be required for the patient to perform some parts of the examination, such as the laségue test for the spinal examination. the transmission of patients' radiological images to the outpatient team via a data transfer method before telemedicine appointment would be beneficial. actual visits should be preserved for selected patients, such as patients requiring wound control and stitch removal. also, the use of absorbable sutures in neurosurgical surgeries could be considered to decrease the contacts among clinicians and patients after discharge. besides, patients aged > years should be encouraged to shun visiting the out-patient clinic. the out-patient facilities and personnel should be separated in non-covid and covid treatment units during the pandemic. the work schedule should be organized with as minimal staff as possible using the proper protective equipment. physicians and staff assigned in out-patient facilities should be clothed in level personal protective equipment (ppe) during their practice. ppe according to handbook of covid- prevention and treatment is presented in table . accompanies for pediatric or non-ambulatory patients should be reduced to one person. and, ambulatory individuals should visit the outpatient clinics alone. the ''lockdown'' and the ''stay at home'' strategies during pandemic dramatically reduced the spinal and cranial traumas allowing the medical professionals to focus on covid- patients. , also a reduction in surgical treatments for degenerative pathologies is present. the drop of traumatic events can be explained by the reduced traffic and work activities. two potential reasons have been argued by dobran et al. for the demand decrease in surgical treatment for spinal degenerative pathologies: ( ) the prevalent fear in the community that regarding hospitals as a risky place for a possible infection; and ( ) the patients' overrating their impairments and pains that resulting in surgical overtreatment. a global study, which conducted on the impact of covid- on neurosurgeons and generated an acuity index for the triaging strategy for non-emergent operations, surveyed respondents from countries. % of respondents reported that all elective cases canceled and their clinics closed down. % of respondents reported that their operative density reduced more than %, and this rate was % in the most affected countries. if possible, medical care methods requiring less invasive interventions such as endovascular treatment in neurovascular conditions, and radiosurgery in certain neuro-oncological diseases may be considered. endotracheal intubation or high-speed drill use is not required during stereotactic radiosurgery, which reduces the risk of exposure to aerosols compared to open surgeries. the summary of measures during the covid- pandemic is presented in table . healthcare personnel including operation room staff are at high-level risk of exposure to the sars-cov- . up to % of the confirmed cases were healthcare staff in the initial cohort reports. later, according to the report of the chinese center for disease control and prevention, which included more than , cases, . % of the confirmed cases were medical staff, and . % of them were in critical or severe condition. minimal or no symptoms are observed during the incubation period (first - days) in the majority of the cases. still, these asymptomatic patients are able to spread the virus. so, all patients indicated for surgery must receive a covid- screening, including measuring body temperature, symptoms investigation, sars-cov- pcr and antibody test, nasopharyngeal swab, and thorax ct scan. different recommendations are present for covid negative patients for the protection of medical staff in the operating theatre. according to a surgical neuro-oncology team perspective, patients from low-risk areas who are verified covid- negative can be operated following level precautions. other perspectives from tongji medical college, wuhan, china and heinrich-heine university, düsseldorf, germany recommended that medical staff should take level protection measures due to the long incubation period. , for patients who are suspected or confirmed covid- positive, or patients from a high-risk area, the operations should be performed under level precautions. , in emergency cases, the results of sars-cov- tests may not be obtained before the surgery, therefore the surgery should be performed following strict measures (level protective measures) to reduce potential exposure. the route from the ward to the operation room, including the elevators, should be cleared during the transfer of a covid (+) patient. the transfer should be performed by the covid- ward nurses in full personal protective equipment (ppe ). the operation room of covid- (+) patients should be separated. an operation room with negative atmospheric pressure setting, and with independent access should be designated for all confirmed or suspected covid- (+) cases. , during the pandemic, the same operating room, and the same continuous flow anesthetic machine should be used for only covid- (+) patients. since the endotracheal intubation can generate aerosols, the intubation should be performed via the method with the maximum possibility of first-time success using a video-laryngoscope to avoid multiple attempts. during the operation of confirmed or suspected covid- patients, all operating room staff must wear level ppe under a surgical gown to prevent contamination. ppe is obligatory for all interventions involving close contacts, such as surgery, endotracheal intubation, intravenous cannulation, cardiac catheterization, and regional anesthesia. using powered air-purifying respirators (papr) by the surgical team is recommended. all personnel should be trained about wearing and removing ppe to prevent contamination. after extubation, it is recommended that the patient is worn a surgical mask as soon as possible. the viral exposure load of the operating room staff can be considered to be proportional to the duration of the surgery. during the pandemic period, the staff number in the operating theatre must be reduced to the absolute minimum. also, all neurosurgical procedures ought to be designed to reduce the operating theater time. if possible, only a single experienced neurosurgeon beyond her/his learning curve ought to carry out the procedure to reduce operation time and to prevent exposure of other physicians. powered instruments such as the high-speed drills, which are commonly used tools for cranial and spinal procedures, had been demonstrated to produce blood-containing aerosols with the identification of hemoglobin in the ambient air. and viruses, such as human immunodeficiency virus- , was showed to be survival in the aerosols produced by surgical power instruments. since the coronaviral rna can be determined in plasma or lymphocytes of confirmed or asymptomatic patients, so these aerosols produced during neurosurgical operations can be contagious. also, a recent study used the bayesian regression model (a statistical model uses probability to represent all uncertainty within the model) indicated that aerosol transmission of sars-cov- is plausible. so, attention should be paid to minimize aerosol generation in operations performed during the pandemic period. upholding the increase of using traditional hand drills and rongeurs would be beneficial. more meticulous irrigation and reduction of drill speed are some precautions that should be taken if cranial or spinal drilling is necessary. special caution should be taken during anterior skull base surgeries, to avoid breach frontal or ethmoidal sinuses. the use of electrocautery creates a gaseous by-product containing aerosol commonly referred to as ''surgical smoke''. viral transmission of human papillomavirus from patients to treating physicians through surgical smoke has been demonstrated. , due to potential transmission risk, using time of monopolar and bipolar electrocautery should be reduced and their power settings ought to be minimized to decrease aerosol dispersal during the pandemic period. endonasal procedures, using debriders and drills inside the nasal cavity, generate highly hazardous aerosols. otolaryngologists are among the worst affected medical professionals in wuhan city, china, and even n / (filtering face piece) ffp masks did not prevent transmission. , also, a patient with a mass lesion in the sellar region that underwent endonasal endoscopic surgery in neurosurgery department, tongji medical college, wuhan city, china was diagnosed with covid- after surgery, and disease was confirmed in healthcare professionals in the same clinic afterwards. according to an initial perspective from the society of british neurological surgeons, endonasal transsphenoidal endoscopic surgical approaches should be avoided during the pandemic period. alternatives routes to endoscopic surgery should be considered for patients whose surgery can not be postponed: ( ) craniotomy; and ( ) microscopic endonasal transsphenoidal surgery, with the submucosal approach and non-drill techniques used during the endonasal and sellar phase. another recent perspective from singapore suggests that endonasal procedures should be managed according to the covid- test results. they suggested wearing n / ffp mask, eye protection (goggles and full-face shield), and standard personal level equipment (gown and gloves) in patients whose test results are negative. and in patients with positive test results, they recommended doning an additional papr by the entire surgical and anesthesia team, including the circulating nurse and operating room attendant. they also recommended using rongeurs and chisels instead of power instruments during surgical exposure, and avoiding the use of nasal pledgets, whose removal may stimulate gagging or coughing in the postoperative phase. also, gowns, n / ffp masks, and face shelters are recommended to use during all outpatient nasal endoscopies. since the disease is asymptomatic in some patients, covid- screening is crucial in all patients before the operation. because, in addition to protecting healthcare professionals, high mortality risk is present in covid- patients who have undergone surgical intervention. university of brescia, italy was reported that the mortality rate of chronic subdural hematoma was % in covid- (+) patients. this rate was reported as . % in the control group treated before the pandemic. a meta-analysis including nearly covid- patients revealed that lower platelet count was associated with severe covid- . the thrombocytopenia can lead to re-bleeding that resulting in a poor outcome. also, in subclinical covid- patients, surgical intervention could impair the immune system, leading to the emergence of the covid- disease. , interstitial pneumonia progression after the surgical intervention may worsen the outcome. the conservative strategy should be preferred whenever operation could be postponed. this situation may be different for the baby and children population. the general observation is that newborns, infants, and children are relatively resistant to covid- . a case report from milan, italy presented that an -month-old infant with complex hydrocephalus underwent two consequent shunt revision interventions while his nasopharyngeal swab was positive for sars-cov- . the baby, who underwent two operations under general anesthesia without respiratory complications, showed a favorable neurological course. web-based conferencing systems have emerged and reached primacy. , all in-person conferences such as resident education lectures, multidisciplinary board meetings, and weekly morbidity & mortality conferences should be converted to video teleconferences with an individual person participating in the conference from one site. , , many elements of medical students' lectures may be converted into virtual webinars. involving of neurosurgery-willing students in department educational video teleconferences would intensify student learning and provide accessibility of the department to students. our country, turkey, is among the most-affected countries by the pandemic. in our country, the pandemic burden is being managed by in collaboration of state and private health institutions. a substantial or all part of the many hospitals were modified to covid- wards. when necessary, some of the operation rooms were used as intensive care units. during the pandemic period, most of the neurosurgeons attended in the front lines. the urgent and emergent surgeries were performed and the schedule for elective procedures was postponed. in india, one of the most affected countries in asia, a consensus was suggested for neuro-interventional teams to switch coverage model including days on work and days of self-isolation cycles. in this consensus statement, the categorization of the patients based on priority and postponing non-essential elective surgeries and outpatient visits are advocated. in an experience report from iran, one of the most-affected countries, it was reported that out-patient clinics were shut down, elective surgeries were canceled, and postponed, neurosurgery residents were reassigned in covid- wards. according to the iran university of medical sciences and health services experience, a significant decrease ( %) was noticed in elective and emergency neurological surgeries. an experience report from germany declared that spine cases fell . % below baseline ( ) levels. with the increasing burden of covid- pandemic worldwide, the need for various modifications in neurosurgery practice will proceed. during the pandemic period, strict measures are essential for both medical staff safety and patient care. in this paper, we outline substantial information and recommendations for the daily outpatient and inpatient practice, severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges covid- outbreak: an analysis of international health regulations annual report data from countries on pandemics: the impact of covid- on the practice of neurosurgery covid- and neurosurgical practice: an interim report neurosurgical activity during covid- pandemic : an expert opinion from china a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster novel coronavirus ( -ncov ) situation report - the species and its viruses -a statement of the coronavirus study group. biorxiv (cold spring harb lab coronavirus disease (covid- ) situation report - a pneumonia outbreak associated with a new coronavirus of probable bat origin a new coronavirus associated with human respiratory disease in china analysis of therapeutic targets for sars-cov- and discovery of potential drugs by computational methods the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application covid- infection: origin, transmission, and characteristics of human coronaviruses the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak novel coronavirus patients' clinical characteristics, discharge rate and fatality rate of meta analysis radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study how do extracellular pathogens cross the blood-brain barrier? human coronaviruses: viral and cellular factors involved in neuroinvasiveness and neuropathogenesis severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ace lethal infection of k -hace mice infected with severe acute respiratory syndrome coronavirus detection of severe acute respiratory syndrome coronavirus in the brain: potential role of the chemokine mig in pathogenesis the neuroinvasive potential of sars-cov may be at least partially responsible for the respiratory failure of covid- patients neurologic manifestations of hospitalized patients with coronavirus disease characteristics of ischaemic stroke associated with covid- novel coronavirus and central nervous system diffusion-weighted mr imaging of viral encephalitis cranial imaging and lumbar puncture in patients with suspected central nervous system infection technological advances and changing indications for lumbar puncture in neurological disorders viral encephalitis: a clinician's guide decompressive craniectomy for encephalitis with brain herniation: case report and review of the literature neurosurgery and coronavirus (covid- ) epidemic: doing our part letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm neurosurgery during the covid- pandemic: update from lombardy, northern italy effects of covid- outbreak in northern italy neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) hub and spoke' lombardy neurosurgery group. may we deliver neuro-oncology in difficult times (e.g. covid- )? coronavirus disease (covid- ) outbreak: single-center experience in neurosurgical and neuroradiologic emergency network tailoring response to covid- in chinese neurosurgery and beyond task shifting and task sharing for neurosurgeons amidst the covid- pandemic a neurosurgery resident's response to covid- : anything but routine early lessons in the management of covid- for the pediatric neurosurgical community from the leadership of the american society of pediatric neurosurgeons letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic telemedicine in general neurology: interrater reliability of clinical neurological examination via audio-visual telemedicine telemedicine in neurosurgery during the novel coronavirus (covid- ) pandemic letter: neurosurgical management of spinal pathology via telemedicine during the covid- pandemic: early experience and unique challenges letter : the use of absorbable sutures in neurosurgical procedures in the time of covid- handbook of covid- prevention and treatment letter to the editor by dobran mauro, paracino riccardo, and iacoangeli maurizio regarding "neurosurgery during the covid- pandemic: update from lombardy, northern italy our darkest hours (being neurosurgeons during the covid- war) the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study the management of emergency spinal surgery during the covid- pandemic in italy safety instructions for neurosurgeons during covid- pandemic based on recent knowledge and experience letter: covid- pandemic: safety precautions for stereotactic radiosurgery clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention clinical features of patients infected with novel coronavirus in wuhan transmission of -ncov infection from an asymptomatic contact in germany experiences of practicing surgical neuro-oncology during the covid- pandemic strategies for prevention and control of novel coronavirus infection among medical staf lessons learned: special precautions for performing emergency cerebrovascular procedures amid the covid- pandemic what we do when a covid- patient needs an operation: operating room preparation and guidance patients with coronavirus (covid- ) and surgery: guidelines and checklist proposal staff safety during emergency airway management for covid- in hong kong outbreak of a new coronavirus: what anaesthetists should know lessons from china when performing neurosurgical procedures during the coronavirus disease (covid- ) pandemic evaluation of contamination by blood aerosols produced during various healthcare procedures human immunodeficiency virus (hiv ) in the vapors of surgical power instruments coronavirus disease : coronaviruses and blood safety aerosol and surface stability of sars-cov- as compared with sars-cov- letter: rongeurs, neurosurgeons, and covid- : how do we protect health care personnel during neurosurgical operations in the midst of aerosol-generation from high-speed drills? letter : transmission of covid- during neurosurgical procedures -some thoughts surgical smoke -a review of the literature. is this just a lot of hot air? laryngeal papillomatosis with human papillomavirus dna contracted by a laser surgeon risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts covid- and the otolaryngologist -preliminary evidence-based review a covid- patient who underwent endonasal endoscopic pituitary adenoma resection : a case endonasal neurosurgery during the covid- pandemic: the singapore perspective letter: precautions for endoscopic transnasal skull base surgery during the covid- letter : covid- infection affects surgical outcome of chronic subdural hematoma thrombocytopenia is associated with severe coronavirus disease (covid- ) infections: a meta-analysis the perioperative immune response does major surgery induce immune suppression and increase the risk of postoperative infection? clinical characteristics of novel coronavirus disease (covid- ) in newborns, infants and children correspondence neurosurgery in an infant with covid- editorial. covid- and academic neurosurgery academic neurosurgery department response to covid- pandemic: the university ofmiami/jackson memorial hospital letter : maintaining neurosurgical resident education and safety during the covid- letter : covid- impact on the medical student path to neurosurgery neurosurgery and neurology practices during the novel covid- pandemic: a consensus statement from india the authors would like to thank to mrs. senay guner ozoner for her illustrative figure work. all authors certify that they have no affiliations with or involvement in any organization or entity withany financial or non-financial interest in the subject matter or materials discussed in this manuscript key: cord- -rj z po authors: fontanella, marco m.; de maria, lucio; zanin, luca; saraceno, giorgio; terzi di bergamo, lodovico; servadei, franco; chaurasia, bipin; olivi, alessandro; vajkoczy, peter; schaller, karl; cappabianca, paolo; doglietto, francesco title: neurosurgical practice during the sars-cov- pandemic: a worldwide survey date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: rj z po abstract background and objective the sars-cov- pandemic has consistently changed medical practice throughout specialties, regardless of their contribution in facing the disease itself. we surveyed neurosurgeons worldwide to investigate the situation they are experiencing. design and participants a -question, web-based survey was administered to neurosurgeons worldwide through the wfns and the neurosurgery cocktail from march to april , by web link or e-mail invitation. questions were divided into three subgroups: general information, health system organization, and institutional plans for the sars-cov- outbreak. collected data was initially elaborated using survey monkey® software. country specific data were extracted from the who website. statistical analysis was performed using r version . . . results of the respondents, most were from italy ( %), india ( %), and pakistan ( %). surgical activity was significantly reduced in most centers ( %) and dedicated in-hospital routes were created for sars-cov- patients ( %). patient screening was performed only when there were symptoms ( %) and not routinely before surgery ( %). the preferred methods included a nasopharyngeal swab and chest x-ray. health professionals were rarely screened ( %) and sometimes, even if sars-cov- positive, were asked to work if asymptomatic ( %). surgical planning was changed in most institutions ( %), while indications were modified for non-urgent procedures ( %) and remained unchanged for subarachnoid hemorrhages ( %). conclusions most neurosurgeons worldwide reported work reorganization and practices that respond to current international guidelines. differences in practice might be related to the perception of the pandemic and significant differences in the health systems. sharing data and experiences will be of paramount importance to address the present moment and challenges in the near future. we are in the midst of a pandemic caused by a novel coronavirus, sars-cov- , first detected in wuhan (china) in december . since then, covid- has spread quickly, with more than , , confirmed cases and more than , deaths on april , with countries involved worldwide. given the serious public health risk, medical practice has consistently changed during sars-cov- pandemic. the impact of the covid- outbreak might change in relation to the diffusion of the virus, as well as the health system of the individual country; furthermore, this pandemic is influencing different medical specialties in a variety of ways. most surgical subspecialties are not primarily involved in fighting the disease itself, but they must still change their organization, as most national and international societies suggest stopping all elective activity, maintaining only emergent and urgent procedures. [ ] [ ] [ ] [ ] [ ] [ ] [ ] neurosurgeons might feel fairly useless during the sars-cov- pandemic. however, international guidelines have been introduced calling for a tailored triage according to the degree of emergency, , , and we believe that sharing information about the organization of neurosurgical activity throughout the world might be helpful at this time. furthermore, it might be interesting to investigate whether there is any association between the level of infection and consequent country reorganization of the neurosurgical system, as well as the neurosurgeons' practice. we, therefore, conducted an online survey that was submitted to neurosurgeons worldwide between march and april , through the world federation of neurosurgical societies (wfns) and the neurosurgery cocktail. [ ] [ ] [ ] the questions were divided into three subgroups: . information on the country and its involvement by neurosurgeons were asked about their country of practice, its involvement by the pandemic, and duration of the emergency; . health system organization and screening for health professionals: national and regional measures adopted to face the outbreak were queried, as well as the screening rate and precautions undertaken for sars-cov- positive health professionals; . institutional plans for the sars-cov- outbreak: any special measures adopted for sars-cov- positive neurosurgical patients were investigated, i.e. their screening rate and method, any changes in surgical indications, planning and activity for oncologic procedures, non-emergency surgeries, and subarachnoid hemorrhages (sahs). most question were closed-ended, multiple choice. some allowed also an open answer (q , and -see supplementary material). the primary goal was to collect data on neurosurgeons' perceptions of the health emergency, the national/regional measures undertaken for health professionals and throughout neurosurgical departments, and the changes in neurosurgical indications, planning, and activity. the secondary aim was to investigate correlations between the data collected and the epidemiological scenario in each country. the third aim was to look into differences among regions, nations and territories along with possible causes and consequences of diversities. data were initially elaborated using survey monkey ® software online; country specific historical data were extracted from the who website. for open answers, the most recurring terms were rendered as a "word cloud", in which a population of words is represented with different sizes according to their frequency. survey's responses to q were first converted into estimates in days (< week: days; > week to < month: days; > month to < month: days; > months: days). pearson's correlation was used to estimate the correlation between the number of answers in the surveys with the number of new cases in each country and the duration of the pandemic. the latter was calculated as the difference in days from the first confirmed case to the last day of the survey. where a i is the observed number of answers registered for country i. for each country, the median of the differences between each survey's entry date and perception date was calculated. statistical analysis was performed using r version . . . on april , the survey was closed and responses had been collected. the skipping rate for each question ranged from % (q ) to % (q ). most responses ( %) were filled during only days in march (saturday , sunday , and tuesday ). a total of countries worldwide responded to the survey (fig. ) . most respondents were from italy ( %), followed by india ( %) and pakistan ( %). statistical analysis did not reveal a significant correlation between the incidence of disease and number of responses by country (fig. ). for the majority of respondents ( %), the nation was facing a sars-cov- outbreak. the duration of the health emergency was between week and month for most respondents ( %), between month and months for % respondents, shorter than week for % respondents, and longer than months for % respondents. figure shows correlations between disease activity during the survey and time-length perception of respondents from some countries. regarding the special measures adopted in neurosurgical departments to face the sars-cov- outbreak, in most cases there was a reduction of surgical activity without centralization ( %), while there was a centralization of surgery in high-volume centers in % cases and full closure of neurosurgical departments in %. no special measures to face the outbreak were reported in % of centers. figure b shows the categorizations of special measures undertaken by countries in relation to the incidence of disease. the overall reported screening rate of health professionals for sars-cov- was %; % respondents reported that sars-cov- positive health professionals were asked to keep working if asymptomatic. with respect to the precautions adopted worldwide for sars-cov- positive neurosurgical patients, in most cases hospitals reserved dedicated routes for them ( %), in % cases specific operating rooms were dedicated to sars-cov- patients, and in % cases neurosurgical units were reserved for sars-cov- patients. other respondents ( %) replied with open answers and among them, no special measures were usually undertaken. the overall screening rate for sars-cov- was % for symptomatic patients and only % for patients undergoing surgery. the preferred methods for screening was nasopharyngeal swab ( %), followed by chest ct scan ( %) and chest x-ray ( %). surgical planning was globally changed in most institutions ( %): only urgent or emergency procedures were performed in % cases; urgencies/emergencies and procedures that could not be postponed were performed in % cases. oncologic procedures were preserved in % cases. the resulting reduction rate in number of surgical procedures was > % for almost half of respondents ( %). surgical indications for sars-cov- patients were modified in % cases for pathologies such as chronic subdural hematomas (cshs) and tumors, while the modus operandi in treating aneurysmal sahs did not change in % of centers. this survey, dedicated to neurosurgery and sars-cov- worldwide, demonstrated a number of interesting findings. a high number of responses (n= ) was received, suggesting a relevant global impact of covid- on the neurosurgical community, even though it is a surgical specialty that is not primarily involved in fighting the disease. italy and india were the countries with the most respondents ( fig. ). this finding is independent of the incidence of disease, as shown in figure . conversely, the us was the country with least number of respondents in relation to the incidence of disease during the study period. although it might be tempting to relate the number of answers to perception of the health emergency, we should point out that the survey circulated widely among neurosurgeons, but we cannot state that the percentage of respondents (i.e. respondents/non respondents) was the same among the different nations. the same correlation was found with regards to the medical perception of disease activity (q ) in different countries, and only few respondents ( %) claimed their country was not facing the outbreak during the time period studied: among them, neurosurgeons from germany were probably the most "wrong", since their country had between to sars-cov patients during the study period (fig. a) . notably, reactions and perceptions of covid- impact on a country may be consistently driven by government actions, as happened in india and pakistan, where most strict lockdown measures were undertaken with respect to other world countries, , possibly influencing general and health professional awareness of the health emergency. nonetheless, the differences in number of responses might be due to a heterogeneity of the survey distributions among different countries. furthermore, the perception of the emergency might be related to the health system, with germany having the highest rate of icu beds/population. regarding the time-length perception of covid- , italian and iranian respondents perceived the start of the health emergencies much earlier than the actual one (fig. ) ; chinese neurosurgeons, instead, located the start of the health emergency almost at the inflection point of decrease in incidence rate, when the sars-cov- pandemic was about to reach the plateau phase (fig. ) . the perception corresponded well to reality among the other respondents. it is tempting to interpret these data as the consequence of the strain that physicians are experiencing in countries with the longest disease involvement at the moment of the study: some might perceive that the emergency is longer than reality due to the continuous stress, or because of media pressure about other countries (i.e. china and iran) experiencing the outbreak. on the other hand, accumulating evidence shows that sars-cov- might have been circulating in italy well before february st, thus explaining the significant outbreak that took place in lombardy in northern italy. others may perceive that the emergency is shorter than reality due to epidemiology for complex reasons: chinese people outside wuhan experienced the outbreak at a later stage of the epidemic and individuals emigrating from wuhan was the main infection source for other provinces, causing a rapid increase in case load when wuhan was already in the plateau phase; the general perception in china about the national involvement might have been in reality delayed. health system organization with respect to health system organization, the most frequent action undertaken globally was reduction of surgical activity without centralization ( %, yellow bars on fig. b ). significant high rates were registered in india ( %) and pakistan ( %). centralization of surgery to high-volume centers was reported in only % cases and italy was the country with the highest number of positive respondents ( %), followed by germany ( %) and india ( %). only % of respondents report that their country did not undertake any special measure. these data show how most countries acted according to international guidelines in the management of elective procedures. india and pakistan have been reported to be the world's best respondents to the sars-cov- pandemic, - thus reflecting high rates of neurosurgical activity reorganizations. neurosurgical centers should undertake national and regional measures to meet patients' needs with logistical capabilities, as reported by guidelines. interestingly, health reorganization may vary signficantly even within the same country. more than , positive cases were confirmed in italy by april with more than , in lombardy alone. in this region, which is still at the center of the health emergency in italy, neurosurgical departments were urgently reorganized and centralization of surgery in highvolume centers was decided. [ ] [ ] [ ] other italian regions are still facing the health emergency, but at lower levels with incidences that tend to decrease from the north to the south. the same incidence disproportion between regions within a country is clearly visible in even smaller european countries such as switzerland, where the cantons of vaud and geneva account for more than , cases each, while the canton of schaffhausen has not yet reached cases. these significant variations in a single country justify the different regional reorganizations. guidelines for risk assessment and management of exposure of healthcare workers vary according to the risk of sars-cov- infection (categorized as high or low) and recommend covid- testing only for workers at a high risk of infection. in this sense, the global attitude did not deviate significantly from recommendations, , as only % of respondents reported ongoing screening for health professionals, mainly from brazil ( %), mexico ( %), and germany ( %). a minority of respondents ( %) declared that sars-cov- positive health professionals kept working if asymptomatic and a large portion of these respondents were from italy ( %). indeed, no clear national guidelines are available for sars-cov- positive health professionals, resulting in heterogeneity of recommendations throughout the country. covid- positive italian health professionals have reached more than , , with more than deaths of physicians (most of them are general practitioners) and almost nurses. at spedali civili hospital, in brescia in northern italy, sars-cov- positive health professionals are not allowed to work and daily temperature screening procedures are undertaken at the hospital entrance for both health professionals and visitors. nonetheless, there is a general perception that health professionals might have been asymptomatic carriers of the disease. regarding precautions adopted worldwide for sars-cov- positive neurosurgical patients, the most widely undertaken measure globally was to reserve dedicated routes to sars-cov- patients ( %), while specific operating room and entire neurosurgical units were created in a minority of cases. some respondents ( %, mainly from austria, germany, and uk) reported not taking any special measures for sars-cov- patients. however, guidelines clearly state that sars-cov- positive patients should be cohorted in a separate location from sars-cov- negative patients and specific hospital policy for management of known or suspected sars-cov- positive patients in the operating room should be developed. [ ] [ ] concerning the screening of neurosurgical patients, facilities should use portable radiography when chest x-rays are considered necessary, thus avoiding the need to bring patients into radiography departments; chest ct scan has been recently reported to have a high sensitivity ( %) for covid- screening, but lower specificity and accuracy. , a recently published paper in jama analyzed the sensitivity of different rt-pcr screening sources demonstrating that bronchoalveolar lavage fluid is the most sensitive specimen ( %), followed by sputum ( %), nasal swab ( %), fibrobronchoscope brush biopsy ( %), pharyngeal swabs ( %), feces ( %), and blood ( %); the authors underline that multiple testing from different sites improve sensitivity and reduces false-negative results. most guidelines at present recommend a single upper respiratory nasopharyngeal swab for suspect cases. in this survey, most respondents referred that nasopharyngeal swab was the preferred method for screening ( %), followed by ct scan ( %), and chest x-ray ( %). some respondents indicated more than one screening method, especially those from italy ( %) and india ( %), where the most common combination was the nasopharyngeal swab with chest x-ray. the covid- outbreak had a relevant impact on surgical planning, with most respondents reporting a significant change in surgical activity in their institutions ( %). the majority ( %) performed only procedures that could not be postponed (i.e. tumors with evident mass effect) and/or urgent/emergency procedures, while in a few cases ( %) the entire neurosurgical department was closed. this obviously resulted in a significant reduction of the overall number of surgical procedures: most respondents claimed more than % reduction of surgical interventions. procrastinating elective procedures has been one of the crucial indications delivered by international societies - with many important aims: a. to contain the spread of sars-cov- , by reducing visits to hospitals by people with no urgent medical issue; b. to reduce the patient load on intensive care units with non-covid- patients; c. to reduce the possibility of treating asymptomatic sars-cov- patients, who would be at high risk of deteriorating due to the surgical stress and would increase the risk of infecting health professionals. surgical indications for sars-cov- non-emergency patients (i.e. cshs and tumors) have been modified in only % cases, while % neurosurgeons worldwide referred that their institutions continued operating on elective neurosurgical patients in the same way as the pre-outbreak era; international guidelines clearly state that non-emergency procedures should be delayed. [ ] [ ] [ ] [ ] [ ] studying correlations between incidence of disease and actions undertaken by various countries (fig. c) , middle-eastern nations (i.e. turkey, egypt, saudi arabia, etc.) were the most reactive to the health emergency, followed by european countries (i.e. italy, spain, austria, etc.), and the americas (i.e. us, mexico, brazil, etc.). as for aneurysmal sahs, most respondents ( %) did not change their indications and treatment (fig. d) . even if some of these findings might seem against guidelines, the word cloud resulting from the open answers puts "patient" at the center and sums up what international societies have been suggesting: "postpone surgery and be conservative as much as possible, delay elective procedures, but, as for emergency symptomatic patients, try to operate with all recommended precautions" (fig. ) . we must indeed stress that all medical efforts, institutional plans, and health system organization would be useless without the appropriate and recommended use of personal protective equipment (ppe). , , although india is the world's second most populous country, the incidence rate of sars-cov- infections has risen less than other countries since the beginning of the outbreak. the reason might be found in the earlier government actions that india undertook while the virus was spreading out from china. , , limits of the study our study has many limits. first, it is not an epidemiological study and does not allow drawing conclusions about the actual prevalence and incidence of the variables investigated. it does allow, though, to draw conclusions regarding the perception of neurosurgeons about the covid- health emergency with respect to the actual epidemiology data. second, although this survey spread out widely among neurosurgeons, respondents were mostly from italy, india and pakistan, while the rest of the world was represented with lesser numbers. heterogeneity of the survey's percentage of respondents (i.e. respondents/non-respondents) among different countries might have biased some responses. notwithstanding, this is the first survey conducted on the impact of covid- on the neurosurgical community and we believe that data from this study can help neurosurgeons and global health organizations to tackle this health emergency. sars-cov- pandemic has consistently changed medical practice, with an enormous impact on all specialties, regardless of their contribution in facing the disease itself. neurosurgeons worldwide have changed their surgical planning and activity, in most cases following national and international guidelines. dedicated routes were put in place for sars-cov- patients in most cases and surgical activity was limited to procedures that could not be postponed, resulting in an overall reduction of surgeries by more than %. the lockdown will be soon followed by the rebuilding phase, when delayed elective procedures will need to be performed, thus opening a new challenge that to be addressed, possibly by sharing current knowledge and experience worldwide. deviation for each country of registered number of answers to the survey from the expected value. blue bars indicate an excess of answers; red bars indicate a lack of answers. covid- ) covid- in neurosurgery news, guidelines and discussion forum covid- : recommendations for management of elective surgical procedures. american college of surgeons neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) hub and spoke' lombardy neurosurgery group. may we deliver neuro-oncology in difficult times (e.g. covid- )? neurosurgery during the covid- pandemic: update from lombardy, northern italy. acta neurochir (wien) / société française de neurochirurgie world federation of neurosurgical societies telegram: join group chat the r project for statistical computing the coronavirus disease global pandemic: a neurosurgical treatment algorithm india is enforcing the harshest and most extensive covid- lockdown in the world the variability of critical care bed numbers in europe focolaio di infezione da nuovo coronavirus sars-cov- : la situazione in italia distribution of the covid- epidemic and correlation with population emigration from wuhan, china coronavirus disease (covid- pakistan's response to coronavirus among world's best, says who country head how india is responding to covid- : quarantine, travel limits and tests embed=y&:showvi zhome=no&:host_url=https% a% f% fpublic.tableau.com% f&:embed_code_version= &: tabs=no&:toolbar=yes&:animate_transition=yes&:display_static_image=no&:display_spinner= no&:display_overlay=yes&:display_count=yes&publish=yes&:loadorderid= . accessed covid- -raccomandazioni per gli operatori sanitari coronavirus in italia, morti altri sette medici: il totale sale a . la repubblica am i part of the cure or am i part of the disease? keeping coronavirus out when a doctor comes home maintaining trauma center access and care during the covid- pandemic: guidance document for trauma medical directors. american college of surgeons congress of neurological surgeons -cns.org chest ct features of covid- in correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases | radiology detection of sars-cov- in different types of clinical specimens guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed covid- guidance for health system contingency planning during widespread transmission of sars-cov- with high impact on healthcare covid- dashboard /profiles/julia-hollingsworth">julia h <a href="/profiles/brettmckeehan">brett mckeehan</a> and tara john. coronavirus live news and updates from around the world do you modify surgical indications if the patient is ncov positive for non-emergency surgery (e.g. chronic subdural hematoma, tumors?) you modify your modus operandi in treating aneurysmal subarachnoid hemorrhage? * abbreviations list sars-cov- : severe acute respiratory syndrome coronavirus wfns: world federation of neurosurgical societies who: world health organization ncov: novel coronavirus sahs: subarachnoid hemorrhages cshs: chronic subdural hematomas icu: intensive care unit rt-pcr: reverse transcription polymerase chain reaction survey administered to neurosurgeons through the wfns and the neurosurgery cocktail from march to april by web link or e-mail invitation.how have we changed our neurosurgical activity in the storm of -ncov pandemic?as neurosurgeons we might feel fairly useless during the -ncov pandemic. we think, though, that it is important to share information on the organization of the neurosurgical activity in this moment. your participation to this brief survey is highly appreciated. key: cord- -q vtrs authors: munusamy, thangaraj; karuppiah, ravindran; faizal a bahuri, nor; sockalingam, sutharshan; cham, chun yoong; waran, vicknes title: telemedicine via smart glasses in critical care of the neurosurgical patient – a covid- pandemic preparedness and response in neurosurgery date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: q vtrs objective the covid- pandemic poses major risks to healthcare workers in neurocritical care. recommendations are in place to limit medical personnel attending to the neurosurgical patient as a protective measure and to conserve personal protective equipment. however, the complexity of the neurosurgical patient proves to be a challenge and an opportunity for innovation. the goal of our study was to determine if telemedicine delivered through smart glasses was feasible and effective in an alternative method of conducting ward round on neurocritical care patients during the pandemic. methods a random pair of neurosurgery resident and specialist conducted consecutive virtual and physical ward rounds on neurocritical patients. a virtual ward round was first conducted remotely by a specialist who received real-time audiovisual information from a resident wearing smart glasses integrated with telemedicine. subsequently, a physical ward round was performed together by the resident and specialist on the same patient. the management plans of both ward rounds were compared and the intrarater reliability was measured. on study completion a qualitative survey was performed. results ten paired ward rounds were performed on neurocritical care patients with excellent overall intrarater reliability. nine out of ten showed good to excellent internal consistency and one showed acceptable internal consistency. qualitative analysis indicated wide user acceptance and high satisfaction rate with the alternative method. conclusions virtual ward rounds using telemedicine via smart glasses on neurosurgical patients in critical care were feasible, effective and widely accepted as an alternative to physical ward rounds during the covid- pandemic. the coronavirus disease (covid- ) was declared a pandemic by the world health organization (who) on march . it causes a severe respiratory disease that often culminates in fatality especially in elderly patients or those with comorbidities. its primary mode of transmission is airborne via droplets and the rate of transmission is alarmingly high. healthcare workers are at high risk of contracting the infection particularly when they are exposed to covid- positive patients during aerosol generating procedures and interventions as warned by the centers for disease control and prevention (cdc). merely being present in close proximity or in the vicinity of the patient could increase the risk significantly as the droplets can aerosolize up to metres. neurosurgery is a specialty where acute patients are often ventilated and managed in the intensive care unit (icu), hence healthcare workers who are involved in their care would be exposed to aerosols and airborne particulates. in addition, many neurosurgical patients are admitted to the hospital in a comatose or confused state and their identity and covid- risk status are initially unknown. thus, reviewing and managing an acute neurosurgical patient in the icu would predispose the healthcare worker to a higher risk of occupational transmission of covid- . in view of these risk factors, ideally all healthcare workers who are present in the same treatment room or cubicle as the acute neurosurgical patient in the icu should be made mandatory to wear the full armamentarium of personal protective equipment (ppe). this is neither practical nor cost-effective in a resource-constrained setting, especially when the global and nationwide supply of ppe is running low. one potential solution would be to reduce the number of healthcare workers who interact with the neurosurgical patient to the j o u r n a l p r e -p r o o f bare minimum as recommended by who. this may prove to be difficult as most icu ward rounds usually involve a number of doctors and nurses simultaneously. in a neurosurgical icu there may be the need for intensivists, neurosurgical specialists, residents and nurses for multidisciplinary consultation on complex problems and also training. specifically during ward rounds, multiple staff members are required both for examination and documentation purposes. however, during this difficult period, attempts have been made in many units to try and only have a single doctor and a single nurse to interact and examine the patients during ward rounds or clinical review sessions. unfortunately, this may lead to sub-optimal management as often a junior doctor would assume the role and subsequently relays the information and findings to the specialist verbally in a delayed fashion. the junior doctor may not have the necessary expertise and experience to holistically manage a neurosurgical patient who may be ridden with complex medical and surgical issues. on the other hand, the specialist may miss certain clinically relevant information when he or she is not physically present by the bedside. this limitation becomes glaring when there is a need to convey visual or graphical representation from essential bedside devices in the icu such as physiological and intracranial pressure monitors, ventilators, infusion pumps, computer and imaging terminals. thus, a safer and practical option would be to facilitate the virtual presence of key medical personnel in the icu, both routinely and when a need arises. this is possible via synchronous telemedicine which offers a real-time and contemporary solution to mitigate the shortcomings and bridge the communication gap during the covid- pandemic. , moreover, it can be applied to any clinical scenario to facilitate remote assessment and consultation with a high degree of clinical accuracy without compromising on patient care and safety. combining wearable technology such as smart glasses with telemedicine, offers the added advantage of j o u r n a l p r e -p r o o f operation with a degree of freedom and unobtrusiveness as it provides view from the examining doctor's perspective with minimal line of sight impediment. such integrated system has the potential to co-exist with and streamline current clinical workflows and their synergistic combination would no doubt be useful in the transformation of healthcare to meet the clinical demands of the pandemic. therefore, we have devised a simple yet effective solution using telemedicine via smart glasses to facilitate optimal management of neurosurgical patients in the icu. in this article, we share our method and experience in implementing and sustaining this alternative management model to safeguard neurosurgical patients and healthcare workers during the covid- pandemic. we have installed and integrated a secure mobile telemedicine system (medcom vision, centre for biomedical and technology integration, kuala lumpur, malaysia) into a commercially available smart glasses (vuzix m smart glasses, vuzix corporation, rochester, usa). the cost of a pair of the smart glasses was approximately $ , usd whereas the software was developed locally to conform to national and institutional regulations with emphasis on secure data storage and retrieval together with recognition, monitoring and control of registered users. in this study, the customised smart glasses was specifically used during the daily ward round session, all doctors attained competence and they were able to assemble, activate and start using the smart glasses and telemedicine system in less than five minutes. a copy of the sop was provided as reference which included a guide on the sequence and essential parameters for teleconsultation in neurosurgery together with an exemplary script. the smart glasses wearers were residents and they were taught how to safely disinfect the glasses after each use. on the other hand, the receiving doctors were specialists and they were taught how to participate in teleconsultation via any mobile device. once the neurosurgery team doctors were familiar and competent in teleconsultation via smart glasses, the study was commenced with institutional and ethical approval. this study used a single subject design consisting of ten virtual and ten physical ward round sessions. each ward round team consist of a random pair of resident and specialist from a pool of three residents and two specialists. the team conducted two consecutive morning ward rounds daily -starting with a virtual ward round where the resident wore smart glasses and consulted the specialist in real-time and subsequently followed by a physical ward round where both resident and specialist conducted the ward round together (video ). a log of all usage of the j o u r n a l p r e -p r o o f smart glasses was kept and the associated clinical interaction and conversation were recorded for analysis purposes. the two ward rounds were compared and analysed, particularly the problem list and management plans. if the outcome of both ward rounds differed from each other, a note was made on the reason and whether it was due to inaccuracy or inadequacy of the virtual ward round or availability of new information during the time interval. consistency and intrarater reliability for the two ward rounds were evaluated using cronbach's alpha coefficient and intraclass correlation coefficient (icc). the following scale was used for both coefficients: excellent (> . ), good (> . ), acceptable (> . ), questionable (> . ), poor (> . ) and unacceptable (< . ). a survey was sent to the users on completion of the study to assess acceptance, satisfaction, overall impact, efficacy and potential of this alternative method of teleconsultation. the team also convened regularly to discuss the difficulties and problems encountered in implementing the virtual icu ward rounds during the covid- pandemic. ten pair of ward rounds were performed in the study involving patients. the summary of each paired ward round is shown in table and the total summary of all paired ward rounds combined is shown in table . the number of changes made to decision or management plan according to reason is shown in table . nine out of the ten paired ward rounds show good to excellent internal consistency (cronbach's alpha > . ). the remaining paired ward round had an acceptable internal consistency (cronbach's alpha = . ). the overall intrarater reliability for all ten ward j o u r n a l p r e -p r o o f rounds was excellent with an icc of . . the reasons for changes to decision or plan in the physical ward rounds were either due to inadequate information in the virtual ward rounds or availability of new information in the time interval between the two ward rounds. there were no inaccuracies observed in the information relayed during the virtual ward rounds. the summary of the overall user experience in this study is shown in table . the mode score of all attributes that compose user experience were either or , thus indicating wide acceptance and high satisfaction with this alternative method of conducting ward rounds in the pandemic. furthermore, table show that majority of users recognise the potential usage and application for smart glasses in a variety of healthcare settings. the use of smart glasses in medicine was pioneered in early s and the initial specialties that adopted its use were primary care, dermatology and paediatric surgery. alas, the idea did not take off in earnest and usage was limited to a single-user setting, for example physicians used it to simultaneously access patient data by the bedside. these glasses however have been successfully utilised in business and industry to revolutionize and improve safety and productivity, especially in warehouse inventory management, high risk jobs that required safeguarding or when the supervision of more junior workers were required from a distance. , , the covid- pandemic created a situation similar to dealing with a hazardous work environment where the smart glasses have found necessity and success. thus, our team decided to adapt its usage to a critical care environment within a hospital that was gazetted as j o u r n a l p r e -p r o o f a covid- treatment centre but at the same time was continuing to manage routine neurosurgical patients. by using the smart glasses, specialists monitoring the ward rounds were able to direct residents and junior staff members through the routine daily review of patients requiring critical care. this included physical examination, review of physiological parameters (both spot values and trends over a -hour period or longer), review of medications, blood results, radiological imaging and wound management. therefore, the specialist was able to holistically and continuously "see" the exact first-hand clinical information in real-time and in a "bedside" manner to advise and guide the resident confidently and accurately. in all instances, visibility and audio-visual propagation were not a problem. the limitation during clinical examination was the inability for the specialist to observe a detailed physical examination including listening to the auscultation of chest and abdomen. , specialists were also unable to interact directly with patients who are conscious and able to communicate. in addition to the above, in the early phase of our study, we discovered that the residents may have difficulty adjusting and adapting to the smart glasses without prior training. during the first paired ward round in our study, the resident who used the smart glasses for the first time, quickly became overwhelmed with nausea and dizziness hence the study could not proceed beyond five patients. post hoc analysis revealed that the resident was continuously shifting focus between the smart glasses display screen and the environment, thus he experienced a phenomenon similar to simulator sickness experienced by users of virtual reality glasses. , additionally, constantly focusing the eyes on a display screen at close focal distances causes visual fatigue, which immensely affected the duration of optimum usage of the smart j o u r n a l p r e -p r o o f glasses. moreover, as the resident focused his central eye gaze on the display screen, his multitasking ability was significantly affected. remarkably, despite the impediments, the first paired ward round was still able to achieve an acceptable internal consistency with a cronbach's alpha score of . . to improve user adaptability to the smart glasses, we organised a training session for all the residents and specialists before the subsequent paired ward rounds. in the training session, the residents were taught strategies to minimize sickness for example by adjusting the display screen to avoid significant obstruction of their field of view and refrain from looking at the display screen unless to localize an area of interest or prompted by the specialist. in addition, the residents were also taught how to conduct the virtual ward round seamlessly and present optimally to the specialist based on the sop guidance. ingeniously, a single training session was able to facilitate user adaptability and mitigate the shortcomings encountered during the first paired ward round. the residents were able to overcome the learning curve and attain confidence in using the smart glasses independently and effectively. this was reflected in the subsequent paired ward rounds which show good to excellent internal consistency (cronbach's alpha > . ). arguably, repeated learning may have contributed to the improvement over time. the use of technology can be seen as both an essential tool and as a barrier in critical care. , , new technology is known to pose extra challenges, thus in order to be able to implement and use it as an aid rather than a hindrance or distraction, user acceptance and satisfaction are essential. facilitating factors for sustainability of any new technology are clear benefits, active end-user involvement, adequate education and training, user-j o u r n a l p r e -p r o o f friendliness, clear policies and seamless integration into existing frameworks or standards of care. , these areas were addressed in our study and played a part in its success. overall, our questionnaire findings show that there is significant potential for smart glasses in critical care of neurosurgical patients. users accept incorporation of smart glasses into their daily work to aid management and clinical decision making. in our study, the smart glasses and telemedicine system proved to be user-friendly, reliable and accurate with high quality data transmission, hence clinically effective and sustainable. some concerns were raised in the literature about reduced presence of specialists thereby potential compromise in patient safety and quality of care. however, this was not observed in our study which showed a high degree of intrarater reliability between the virtual and physical ward rounds. furthermore, no inaccuracies were observed in the communication and transfer of information via smart glasses. nevertheless, as with any technology that improves efficiency and eases workflow, the primary danger would be that medical personnel may become complacent and depend entirely on this method of teleconsultation. as such, safe usage protocols and guidelines are necessary and periodic monitoring is recommended. extrapolation for other use cases and to other specialities would require a similar approach before smart glasses can be deemed safe to be adopted as standard practice. clinical demands in the icu differs from other clinical areas due to rapid changes in patient condition and the need for immediate specialist consultation or intervention. icu telemedicine is a promising mechanism to improve outcomes for critically ill patients. j o u r n a l p r e -p r o o f moreover, with smart glasses, the ability to view the patient as a first-hand reviewer and provide accurate advice or remote guidance is highly desired and advantageous. , smart glasses can give the clinician information such as patients' data, clinical parameters or imaging studies within their field of vision so the clinician can use it simultaneously while performing other tasks or procedures. this can be very helpful as it helps to avoid looking away from the area of intervention or stepping away from the patient. in addition, smart glasses integration with a mobile communication network permits real-time consultation with another authorised clinician. this method of consultation can be used in a variety of areas and settings other than the icu. these include onboard an ambulance to facilitate communication between paramedics and receiving hospital, out-of-hours consultation by the junior doctor with the specialist who is not on-site or even in-hours consultation if the specialist is away or busy at another clinical area. from the neurosurgical perspective, this method would also support long-distance management via real-time evaluation of patients and teleconsultations between nurses or general doctors in remote facilities and centrally located specialists or qualified neurosurgeons. this capability can potentially be cost-effective in avoiding unnecessary emergency transfer of patients, as well as optimizing patient safety. additionally, smart glasses can be widely used in training and education, from telementoring to remote supervision and guidance during procedures and interventions. our study had several limitations. firstly, it was limited by the small sample size of ten paired ward rounds. however, we managed to recruit over a hundred patients, thus data analysis and interpretation of findings were reliable. to adhere to infection control guidelines during the pandemic, we used a single subject design hence measured intrarater reliability which is generally considered to be inferior to interrater reliability as decisions may be contaminated by prior knowledge and repetition. this may result in overestimation of intrarater reliabilities. , the study findings were specific to our specialty and institution, thus may be the result of existing workflow in our hospital where mobile technology is routinely used to support information sharing. furthermore, given the different needs and experiences of each responder, the subjectivity of response and recorded information are potential contributors to bias. we also have not conducted an evaluation in regard to the economic and ergonomic benefit of using smart glasses. nevertheless, our approach can be considered as the first step to improve the critical care management of neurosurgical patients during the covid- pandemic while adhering to local regulations, resource constraints and physical distancing measures. the smart glasses itself is subject to several technical limitations. the wireless connection to the mobile network occasionally exhibited brief lag, however this did not affect the conduct or flow of the virtual ward round. the smart glasses would need to be disinfected j o u r n a l p r e -p r o o f while its battery would need to be charged after each use. besides, our study was also limited to the evaluation of only one particular type of smart glasses. as the technology evolves especially in this trying time, more types of smart glasses would become available to clinicians and medical educators. therefore, head-to-head studies will be important here to explore their individual benefits, advantages and ability to revolutionize healthcare and education. with more research to come, the solution using smart glasses would only get better and popular. we have shown that virtual neurocritical care ward round using telemedicine via smart glasses is feasible, effective and acceptable as an alternative to physical ward round to circumvent manpower shortage, physical distancing measures and key shortage of ppe during the covid- pandemic. nevertheless, as with any healthcare technology, attention must be paid to certain technical details, training requirements and clinical nuances to achieve optimal outcomes. j o u r n a l p r e -p r o o f technical quality clinical accuracy reliability overall efficacy user friendliness user satisfaction *attributes scored on a -point likert scale j o u r n a l p r e -p r o o f who declares covid- a pandemic identifying airborne transmission as the dominant route for the spread of covid- aerosol and surface distribution of severe acute respiratory syndrome coronavirus in hospital wards the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study critical supply shortages -the need for ventilators and personal protective equipment during the covid- pandemic world health organization. infection prevention and control during health care when the application of temporary ark hospitals in controlling covid spread: the experiences of one temporary ark hospital telemedicine and covid- : an observational study of rapid scale up in a us academic medical system covid- : launching neurosurgery into the era of telehealth in the united states telemedicine in neurosurgery: lessons learned and transformation of care during the covid- pandemic. world neurosurg surgeon point-of-view recording: using a highdefinition head-mounted video camera in the operating room assessment of patients' acceptance of and satisfaction with teledermatology using google glass to solve communication and surgical education challenges in the operating room augmented reality "smart glasses" in the workplace: industry perspectives and challenges for worker safety and health enabling technologies for operator . : a survey augmented reality smart glasses in the smart factory: product evaluation guidelines and review of available products telemedicine for outpatient neurosurgical oncology care: lessons learned for the future during the covid- letter to the editor: the use of telemedicine by neurosurgeons during the covid era: preliminary results of a cross-sectional research virtual reality sickness and challenges behind different technology and content settings simulator sickness in augmented reality training using the microsoft hololens vergence-accommodation conflicts hinder visual performance and cause visual fatigue managing technology in the intensive care unit: the nurses' experience use of technological equipment in critical care units: nurses' perceptions in greece nursing care in a high-technological environment: experiences of critical care nurses systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals implementation of newly adopted technology in acute care settings: a qualitative analysis of clinical staff healthcare professionals' views of smart glasses in intensive care: a qualitative study telemedicine/virtual icu: where are we and where are we going? using google glass in nonsurgical medical settings: systematic review first-person point-of-view-augmented reality for central line insertion training: a usability and feasibility study smart glasses for caring situations in complex care environments: scoping review clinical and surgical applications of smart glasses telemedicine for neurotrauma prevents unnecessary transfers: an update from a nation-wide program of albania and analysis of patients biomedical visualisation. biomed vis interrater and intrarater reliability of the colloid cyst risk score statistical methodology: ii. reliability and validity assessment in study design, part a information bias in health research: definition, pitfalls, and adjustment methods lessons learned from google glass: telemedical spark or unfulfilled promise? evaluation of google glass technical limitations on their integration in medical systems we would like to thank dr tan yunrong from the department of surgery for his contribution to this study. key: cord- -nmebqrb authors: núñez-velasco, santiago; mercado-pimentel, rodrigo; plascencia, miguel ochoa; rodríguez-arias, regina; lopez-espinoza, gerardo; gonzález-gonzález, maria elena; estrella-sánchez, carlos; ramírez-huerta, carlos title: response to sars-cov- pandemic in a non-covid- designated latin-american neurosurgery department date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: nmebqrb background mexico declared the first case of novel coronavirus disease (covid- ) in february . at the time we write this article, our country is facing a community spread phase, expecting a rapid increase in the number of cases and fatalities. the fray antonio alcalde civil hospital of guadalajara has been declared a non-covid- hospital with the mission of providing care to patients already registered and also those transferred from neurosurgical departments of neighboring centers, which have been converted into covid- only hospitals. methods an organized response regarding personnel, surgical case selection, operating room behavior, and facility reorganization were designed to prevent an internal coronavirus outbreak in the neurosurgery department at the fray antonio alcalde civil hospital of guadalajara. results distancing actions by the staff and residents, including ward case discussions, neurosurgery rounds, and classes, will be carried out virtually. we classified neurosurgical patients into groups depending on whether their condition demands care in - hours, - hours, hours to days, and > days. subsequently, a questionnaire with epidemiologic, radiologic, clinical, and serologic criteria will be applied to determine the risk of covid- infection to define to which area they are going to be transferred according to the different risk zones in our facility. conclusions despite not being a covid- center, we consider all patients at the neurosurgical ward and staff members as asymptomatic carriers or infected in the preclinical period. specific measures must be taken to ensure the safety and care of neurosurgical patients and medical staff during the community spread phase. in december , an outbreak of pneumonia associated with a new coronavirus (sars cov- ), which the who calls new coronavirus disease , was reported in wuhan province of hubei, china, that quickly spread throughout the world and was declared pandemic on march , . [ ] [ ] [ ] mexico announced the first case on february . on march , the mexican government declared a health emergency, and now we are in community spread and accelerate growing face. at the time of writing this paper, , cases (an estimate of more than , cases) have been reported using a sentinel model, and , deaths have occurred. also, according to mexican officials, % of the positive cases are health-care workers, some of them not assigned to covid- areas. the state of jalisco, which up to now has presented confirmed cases and deaths, implemented a hospital reconversion strategy that of designating several hospitals of guadalajara as covid- treatment centers. the fray antonio alcalde hospital civil (faahc), where our department is located, has been designated as a non-covid- center, intended to offer treatment care for neurosurgical pathologies, not sars cov- related. this designation is especially crucial for the neurosurgery department since it would be the last public neurological surgery service for the uninsured population in the state to cede its facilities for the exclusive care of covid- and, therefore, we expect an increase in urgent cases from other centers. however, the city maintains community spread of the virus, and it is not possible to perform rt-pcr tests on every admitted patient, so preventive measures must be taken to keep our facilities, patients, and staff free of infection to keep on attending patients with neurosurgical needs under minimal risk. based on the epidemiological and biological information available in the literature on covid- , specific measures adapted to our resources were implemented to design a protocol of organized administration of human resources both assistant and administrative, optimized surgical procedures, proper handling of personal protective equipment and adaptation of the facilities of the neurosurgery department of the faahc when treating neurosurgical patients with no sars-cov- known condition. we divide our response plan into three sections: staff distribution, surgical triage classification, and operating room actions and facilities restructuration. staff distribution: all staff personnel is evaluated daily before walking in the department with a symptoms questionnaire and temperature measurement. in case of any suggestive information, they are referred to the covid- (our center has an isolated, fully equipped tower for patients with covid- and a team of experts) area to determine if they should be isolated or are eligible to return to work. residents are equally divided into three groups. each group stays for a three-days on-call round followed by a -days off period (this since the average of the preclinical infection period is five days). the members of each group are not able to have contact with another group. attending physicians follow their daily schedule, observing minimal contact between them. all on-call delivery sessions, ward rounds (one attending physician and one resident will do it in person while the rest of the staff will follow the round virtually) and, academic activities are carried out via live communications through web platforms. these activities are coordinated by the team on duty at the hospital and are followed by the rest of the medical staff at home or different hospital locations. surgical triage classification and operating room actions. we canceled the outpatient clinic and the elective surgery schedule. the only admission route for a patient is through the emergency department. every neurosurgical case is classified according to the following system: - h group, defined as those patients who present with sudden and rapidly progressive deterioration in alertness, pupillary changes, or acute signs of brainstem or spinal cord compression that demand surgery in less than hours. - h group, defined as those suffering from urgent neurosurgical pathologies who demand intrahospital care but can wait up to hours before resolution. h- d group, defined as patients with a neurosurgical pathology already diagnosed who can stay at home for up to days and will be able to return in case of progression. > d group, those with a non-urgent surgical pathology that can be resolved in days or later, with minimal chances of deterioration. once a patient is classified, a specific algorithm will be applied ( figure ). the classification of patients will be determined by a multilateral consensus of at least two attending physicians and the ward chief resident. the grouping definition is flexible and permits reclassification if a patient develops objective changes in his clinical or radiological condition. to correctly use this algorithm, we have defined a screening questionnaire ( table ) that includes the epidemiological, radiological, serum, and clinical criteria commonly described in covid- patients and that are readily available in our hospital this questionnaire allows us to classify patients at high and low risk of developing covid- ; this form must be completed by the team of on-call neurosurgery residents and reported to the attendings team on duty for verification. however, it is essential to clarify that this instrument does not diagnose covid- ; it only allows residents and attendings of our department to place patients in a group of risk. the definitive diagnosis and risk definition review, when needed, will be carried out by experts from the covid- area. for high-risk patients after being evaluated by the covid- unit, we have designed a table that indicates the surgical decisions that must be made in patients according to their rt-pcr results and the group to which they were assigned. (table ) the staff was trained in the process of donning and doffing personal protective equipment, noting that the sequence for the surgical field that requires sterile hand washing is different from that published for that personnel who perform actions that do not require sterility. therefore, we built a modified checklist from that published by the university of south carolina, , which includes not only the steps to follow, adapted to the personal protective equipment available in our hospital, but also the area of the operating room complexes in which they must be placed and removed. (table ). all patients admitted at the operating room will be considered as sars cov asymptomatic carriers until proven negative, and hence every standardized process according to this scenario will be strictly followed. [ ] [ ] [ ] facilities restructuration. offices, lecture rooms, and on-call ward rooms were signalized with visual aids on the floor and furniture surfaces to indicate the m distance demanded between every person. our department has two areas for hospitalized patients: a -beds floor for elective cases (divided in nine -beds rooms and two single bed rooms), and a trauma ward with beds distributed in two opposite rows. these areas already have barrier curtains for a physical separation of each patient. since there is not a specific area for neurosurgical intensive care patients, it is not rare to look after critically ill patients under assisted ventilation at any of these general locations at our department, when there are no beds available at the central intensive care unit. these areas are now organized in three different sections: the aerosols area is where the mechanical assisted ventilation patients are located. high risk area is designated for patients according to their covid- questionnaire rates. barrier care precautions, visit restrictions (only one family member during established hours will be allowed), and high index protective personal equipment are considered as mandatory in these two previously mentioned areas. low risk area is designated for those patients with limited likelihood of being infected, and it is located closest to the entrance. in the case of the floor cubicles, the intermediate bed will never be occupied ( figure ) and, in the case of the trauma ward rows, the beds are arranged at a two meters distance between them and will be inserted so that no patient has the opposite bed occupied. (figure ) all patients with rt-pcr positive for sars-cov- will be transferred to the corresponding covid- area. the novel coronavirus (sars-cov- ) is a beta-coronavirus associated with transmission between humans with a molecular structure similar to mers-cov and sars-cov- that previously caused outbreaks. the transmission of this pathogen occurs via person to person mainly by droplets and aerosols produced by simple conversation, sneezing, coughing and medical care procedures. - another form of transmission is through contact with surfaces contaminated with exhaled droplets that carry the virus itself, and that can survive on that surfaces for a certain time. it is clear that there is an asymptomatic carrier state and that it can transmit the disease, a preclinical incubation period of approximately five days has also been described, where the patient may not present signs or symptoms but may spread. [ ] [ ] [ ] [ ] being designated as a non-covid- hospital does not mean that we will not receive infected sars-cov- patients, since it is already in community dispersion and just as nursing homes and restaurants have been contaminated, our neurosurgery department could become contaminated too, especially if we do not have proper care. this would lead us to a catastrophic scenario because there are reports of a % of hospital-associated transmission of the virus as the mechanism of infection of patients, that in our case are weak and many of them immunosuppressed; thus, cases of contamination of health-care personnel have also been reported, especially in non-designated covid areas in which precautions might relax. [ ] [ ] [ ] [ ] [ ] ideally, we would like to offer all of our patients rt-pcr and antigen-antibody testing at the time they are admitted, given that there have been several cases of patients who underwent surgery without symptoms and who developed covid- days later and these examples can be easily reproduced in our center. , however, this is not currently possible despite the efforts of our local government. hence, it was necessary to build a screening algorithm adapted for our environment that would allow us to identify high-risk cases for timely referral to covid- experts, keeping patients who need to be hospitalized and could be a source of infection for others, isolated. we also can closely follow those patients who can be at home, so they can comply with a -day isolation (the covid- mean clinical course) and then bring them back to the hospital with the certainty that the risk is minimal. , , the main signs and symptoms of the disease are fever, headache, cough, hyposmia, respiratory distress, myalgia, arthralgia, and chest pain. these were included in our risk questionnaire, weighted according to their prevalence of presentation and following the operational definitions of our country. , , , , an important part of the questionnaire has to do with imaging studies; chest tomography has shown to be an excellent diagnostic substitute when rt-pcr is not available, , however, although it will always be preferable to have ct, the possible saturation the ct department makes us include the chest radiography to use it in cases in which it is impossible to access a ct. personal protective equipment is a great tool for the defense against the virus that health professionals have, so it is important not only to know the procedures and sequences to wear them but to adapt these to the scenarios in which we will develop; in our case, the operating room. that is why we decided to adapt our checklist to the resources we have available and also includes the spaces in which each element should be placed. hospitals designated as non-covid- centers must maintain a specific plan and sufficient precautions to avoid sars-cov- contamination within them and maintain quality care for all those patients who require urgent treatment and that this has been deferred because of the hospitals covid- resignations. fever, headache, and cough (assign points for each) dyspnea, myalgia, arthralgia, conjunctivitis, nasal congestion, sore throat, thorax pain (assign point for each) total table .-faahc neurosurgery department checklist of donning and doffing personal protective equipment, adapted to the areas in which it must be placed and removed. especially in the doffing process, every time you touch an object or surface you should sanitize your hands or internal gloves. shower is recomended but not mandatory. * in our center, the available gowns do not reach to the ankles, and we do not have full leg boots, so we propose the use of waterproof pants to ensure better protection. in case of having the supplies mentioned above, you can ignore the pants. † the external surgical mask helps to protect the n in case of reuse. ‡ in case of the absence of the full-face cap, a surgical boot can be adapted to protect the neck. a lead collar can also be used. figure .-process to be followed with neurosurgical patients assessed in the emergency room based on the maximum time in which they should be treated. * treat the patient as a confirmed case, all precautions should be taken, wear full personal protective equipment. † covid unit experts determine if rt-pcr is necessary, confirm the diagnosis and, can reassign the previously determined risk. ‡ apply the questionnaire without the radiologic criteria; this allows us to save space and time on the tomograph while the low risk patient remains isolated at home. § if a patient presents new symptoms or deterioration of the previous ones, they must be reclassified and follow the sequence assigned to the new group. preliminary estimation of the basic reproduction number of novel coronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak nicogossian a. in the news world health organization. coronavirus disease (covid- ) outbreak -mexican government covid- mexico guidance for donning and doffing personal protective equipment (ppe) during management of patients with ebola virus disease in u.s. hospitals. ebola: personal protective equipment (ppe) donning and doffing procedures key: cord- - ydvjmr authors: sekhar, laligam n.; juric-sekhar, gordana; qazi, zeeshan; patel, anoop; mcgrath, lynn b.; pridgeon, james; kalavakonda, niveditha; hannaford, blake title: the future of skull base surgery: a view through tinted glasses date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: ydvjmr abstract this article broadly outlines the potential advances in the field of skull base surgery, which may occur in the next years based on many areas of current research in biology and technology. many of these advances are also broadly applicable to other areas of neurosurgery. we ground our predictions for future developments in an exploration of what patients and surgeons most desire as outcomes for care. this leads to an examination of recent developments in the field and outlines several promising areas of future improvement in skull base surgery, per se, as well as identifying new hospital support systems needed to accommodate these changes. these include, but are not limited to advances in imaging, raman spectroscopy and microscopy, -dimensional printing and rapid prototyping, master-slave and semi-autonomous robots, artificial intelligence applications in all areas of medicine, tele-medicine, and green technologies in hospitals. in addition, we review therapeutic approaches employing nanotechnology, genetic engineering and anti-tumoral antibodies, as well as stem cell technologies to repair damage caused by traumatic injuries, tumors, and iatrogenic injuries to the brain and cranial nerves. additionally, we discuss the training requirements for future skull- base surgeons and stress the need for adaptability and change. however, the essential requirements for skull base surgeons remain unchanged, namely: knowledge, attention to details, technical skill, innovation, judgement, and compassion. our conclusion is that active involvement in these rapidly evolving technologies will enable us to shape some of the future of our discipline to address the needs of both patients and our profession. and anti-tumoral antibodies, as well as stem cell technologies to repair damage caused by traumatic injuries, tumors, and iatrogenic injuries to the brain and cranial nerves. additionally, we discuss the training requirements for future skull-base surgeons and stress the need for adaptability and change. however, the essential requirements for skull base surgeons remain unchanged, namely: knowledge, attention to details, technical skill, innovation, judgement, and compassion. our conclusion is that active involvement in these rapidly evolving technologies will enable us to shape some of the future of our discipline to address the needs of both patients and our profession. complex aneurysms and vascular lesions, and safely reconstruct the skull base to promote healing and prevent cerebrospinal fluid leakage and infections. more recent technological introductions have proceeded to revolutionize the treatment of challenging skull base pathology including the introduction of endoscopic surgery, advances in neuroimaging, radiosurgery and high energy focused radiotherapy, the perfection of vascular bypasses for replacement of major arteries and venous sinuses involved by tumors , , , and the use of skull base approaches to treat complex vascular lesions. through the establishment of organizations such as the north american skull base society, the world federation of skull base society, as well as clinical institutions focused on the refinement and teaching of skull base surgery, the knowledge and skillset necessary to properly practice this challenging subspecialty have been effectively disseminated. this long history of innovation has presently resulted in the safe and effective practice of skull base surgery. however, the discipline remains on the cutting edge of neurosurgery and many challenges have yet to be addressed. in this paper, the authors survey the many emerging technologies that appear poised to bring about the next revolution in the skull base surgery. many of the advances described in this article are generally applicable to many areas of neurosurgery. although the future is always difficult to predict, a specialist discussion of the most promising advances may help young surgeons entering the field and in turn help to shape the future. a number of techniques that may have an impact on skull base surgery are shown in table . we will focus on some but not all of these areas. patients ultimately want their surgical team to cure, control, or ideally facilitate the prevention of disease. they favor minimally invasive approaches. when possible, they want illnesses to be treated by medicines only; if further intervention is necessary, they prefer minimal surgery or radiosurgery without any tissue damage; and when it cannot be avoided, more extensive surgery without undue risk. patients rightly put a premium on minimizing morbidity, which means no damage to surrounding brain, cranial nerves or blood vessels and no cosmetic deformity. regardless of the approach, they want to minimize time away from work and family and to be treated for a reasonable cost. surgeons chose their profession to heal patients and to cure or control diseases by performing elegant operations within their limits without major complications. they want to balance this pursuit with their desire to live well and to be healthy and happy with their families. finally, they want the freedom to operate with the professional autonomy they have earned through their pursuit of highly specialized training without undue interference from the hospital administration or the government in their daily practice of medicine. the best way for surgeons to ensure that the needs of their future patients are being met is to continue to drive the innovation necessary to deliver transformative treatment options that are effective, economical and minimally disruptive. for tissue preservation and augmented diagnostic utility , . examples are shown in figure , wherein an ex-vivo skull base neoplasm has been examined by a raman fiber-optic touch probe device to determine a biochemical "fingerprint" of the specimen ( figure a and b), and by the stimulated raman scattering microscopy, in comparison with subsequent conventional tissue section stained with h&e ( figure c and d). in addition, such imaging modalities can be combined with immediate treatment. for example, laser thermal ablation is already being used in the mri suite for epileptic lesions and some brain tumors with variable results , . lasers or ultrasonic removal may also be combined with rapid intraoperative pathology for precise intraoperative tissue removal. sporadic diseases exhibit multiple mutations, unlike syndromic diseases. they require broader approaches than the treatment of syndromic diseases. immunotherapy is an approach that is being commonly used in other malignancies , using antibody-based drugs that target tumor-specific surface antigens. an example is the use of bevacizumab, an antibody that targets the the most important step in bringing novel therapeutic approaches to skull base pathology is the detailed molecular characterization of each of the pathologic entities that collectively make up "skull base tumors". such efforts are underway and will to expand as investigational techniques become more widely available and cost effective. for skull base tumors, we will need to tailor our therapeutic interventions based on disease-specific, and even patient-specific, mutational, transcriptional, or epigenetic profiles. this type of "precision medicine" will offer hope to patients for which our current treatment paradigms are inadequate. in the hospital, ai will become increasingly essential. robotics and ai will combine to influence every aspect of healthcare (see below). ai may be employed in the icu and general ward to monitor patient care in addition to providing clinical decision-making support to doctors and nurses. for instance, robotics will find increasing applications in all areas of surgery, including skull base and neurosurgery. in order to be adopted widely, a medical robot should be able to perform a task as well or better than a human, not cause any harm to the patient or the human workers, be able to adjust to the human environment, and able to be rapidly cleaned and sterilized. tasks requiring great accuracy, it is widely expected that there will be increased use of ai combined with robotics in the or in the next years. the great benefits will be for procedures which will require great precision, procedures performed through a small space, in japan, humanoid robots, specifically nurse robots and robotic assistants, are being developed due to a lack of medical personnel and caregiver resources. in the usa and other countries, such humanoid robots have also been developed for other uses. hansen robotics (hansen robotics co., hong kong, china) has created human looking and speaking humanoid robots, endowed with ai, notably those named jules and sophia. these robots have been given speech recognition skills, responses, and some other skills, but not all the elements of intelligence that are displayed by humans. humanoid robotic nursing assistants will be developed and widely used in future due to health care worker shortages, patients' desire to have x nursing assistance, and the needs created by infectious diseases wherein human-human contact must be minimized. we expect that hospitals will also use robots to replace or supplement employees such as internal delivery workers, cleaners, and other jobs inside the hospital, which require regular or rapid maintenance such as with the hospital's sewage, water, or electrical supply. cleaning of operating rooms, or other hospital rooms, which do not have patients, can be done efficiently and rapidly with ultraviolet light or other techniques, using robots , . such robots will need to be supervised by their human counterparts. but they will learn steadily with use and such knowledge can be transmitted readily to other robots like them. it is to be expected that, initially, there will be resistance to deployment of these robots, but over time, people will gradually accept them, primarily because of increased safety and lowered cost of health care. however, both of these putative benefits will need to be demonstrated scientifically. technology will transform the education of students, residents, and surgeons in the future. students will be able to study anatomy and physiology in -d, -d, and -d. the fourth dimension reflects the time-related changes in -d images (for example, carotid artery anatomy as the heart beats) along with physiology. the fifth dimension indicates three dimensional images changing in time with simulated pathology. advanced virtual reality and surgical simulations and one on one coaching by ai enabled robots will supplement traditional teacher- student learning. flexibility in adapting to quickly evolving and increasingly sophisticated systems of cognitive offloading will be critical to student success. in the future, imagination, problem solving, and the ability to work in teams with diverse members (including ai-enabled robots) will be more important than accumulation of knowledge. this is because massive knowledge storage will be available for quick recall. master ai brains will assist all of our medical work to varying degrees. this will reduce medical errors, increase work efficiency, and improve on the job learning. the educational qualifications and training for trainee neurosurgeons will be different in the next decade. mathematics, biology, physics, chemistry, and logical thinking will still form the building blocks of education in science. however, residents will also need to learn computer science, software hospitals of the next years will be very different from the hospitals today. we envision they will be smaller and closer to patients with only the most difficult cases transferred to central hospitals. all hospitals will be environmentally friendly and carbon neutral, deriving their entire energy requirements from renewable energy. this will also apply to products used in hospitals. they will be providing an enhanced and optimal healing environment for patients. for example, the patient rooms may be optimized to each patient with use of colors, plants, music, sunlight, etc. better methods of medical waste disposal will need to be developed, to avoid environmental contamination and spread of infection into communities. the future of health care workers in the age of robotics and ai in parallel with many other industries, fewer health care workers will perform manual and highly repetitive jobs and ai-enabled robots will replace some such workers. health care workers in hospitals will require greater skills and education. hospital employees will be happier, work less, and supervise robotic workers. there will be fewer radiologists, pathologists, family doctors, etc., due to robotic assistants. home visits may be made by humanoid robot (ai enhanced) exhibiting great knowledge, empathy, and no prejudice. surgeons, trainees, and other health care workers will also work collaboratively with such robots and ai since they will become commonplace. surgeons will be performing less invasive but more technically complex procedures. there will be great emphasis on master-slave robots and supervision of autonomous robots performing procedures. there will be a great role for innovators and a constant retraining for the newer procedures. with increasing use of ai and robotics, will human beings still be involved in patient care? since the patients are humans, there will always a need for human beings to care for them. however, we will see an evolutionary change in health care professionals in the next years. adaptability, cooperation in the work environment, compassion, and a special set of skills will be required of surgeons. some of these will not be obvious until the new reality emerges. the current covid- epidemic has suddenly enhanced the use of many technologies which had been developed, but not deployed on a large scale. these include tele-consultations, tele-working, different requirements for sterilization of hospitals, and home based learning. the lead author's team has also developed a low cost "home microsurgery lab" for resident trainees, and proposed this as the seventh competency in resident training in the usa . many of these changes will influence patient comfort, safety, costs of medical care, and the need for particular types of health workers. skull base surgeons and neurosurgeons of the future need to be nimble, adopting newer technologies as they become available. however, essential characteristics remain unchanged. these are knowledge, innovation, technical skill, judgement, and compassion. our active involvement in these technologies will enable us to shape some of the future. innovation will be an important requirement of future and current doctors. innovations may not be major but may be found instead in the small things impacting our day-to-day work. or they may relate to clinical surgery, basic neurosciences, workflow and efficiency, outpatient and hospital infrastructure, patient satisfaction and quality improvements. young surgeons must constantly strive to leave things better than they find them. surgeons need to be actively involved in hospital, and health care administration to guide the changes. tissue engineering to fabricate blood vessels, bone, facial tissues, etc. in conjunction with -d printing f) nanotechnology to engineer diagnostic and therapeutic particles g) rapid molecular and genetic diagnosis of tumours h) anti-tumoral antibodies, car-t cells, and checkpoint inhibitors to treat malignant tumours i) crispr cas- based genetic engineering techniques to eliminate inherited syndromes such as neurofibromatosis, von-hippel lindau's disease j) stem cell technologies to repair damage caused by traumatic injuries, tumours, and iatrogenic injuries to the brain, and cranial nerves k) master-slave, and semi-autonomous robots for use in the operating room l) humanoid robots as helpers in the operating rooms, cleaning services, food services, and nursing services in hospitals m) artificial intelligence applications for diagnosis of disease, in the hospital, and outpatient care n) re-engineered hospitals which are green, energy self-sufficient, use proper waste disposal, and adapted to the patient's needs o) new training methods for residents, and surgeons saphenous vein graft bypass of the sigmoid sinus and the jugular bulb during the removal of glomus jugulare tumors results of attempted radical cerebral revascularization for difficult skull base tumors. a contemporary series of patients. world neurosurgery shining light on neurosurgery diagnostics using raman spectroscopy raman histology and deep neural networks raman spectroscopy for medulloblastoma. childs nerv system intraoperative brain cancer detection with raman spectroscopy in humans laser ablation of newly diagnosed malignant gliomas: a meta-analysis gross magnetic resonance thermometry-guided stereotactic laser ablation of cavernous malformations in drug- resistant epilepsy: imaging and clinical results the use of a portable head ct scanner in the intensive care unit hyperfine and yale school of medicine collaborate on world's first portable mri technology schilsky rl. implementing personalized cancer care neurofibromatosis: a review of nf , nf , and schwannomatosis therapeutic genome editing: prospects and challenges crispr-edited stem cells in a patient with hiv and acute lymphocytic santagata s. an update on the cns manifestations of neurofibromatosis type a scalable platform for the development of cell-type-specific viral drivers cellular immunotherapy: a clinical state-of-the-art of a new paradigm for cancer treatment discovery and development of bevacizumab, an anti- vegf antibody for treating cancer barker fg nd , et al. hearing improvement after bevacizumab in patients with neurofibromatosis type the evolving landscape of biomarkers for checkpoint inhibitor immunotherapy genomic landscape of high-grade meningiomas cell therapy for solid tumors car t-cell therapy for glioblastoma: recent clinical advances and future challenges transplanted stem cell-secreted vegf effects post-stroke recovery, inflammation, and vascular repair the biological function of consciousness computing machinery and understanding deep learning in alzheimer's disease: diagnostic classification and prognostic prediction using neuroimaging data. front aging neurosci man against machine: diagnostic performance of a deep pupilscreen: using smartphones to assess traumatic brain injury reporting health symptoms: breaking down barriers to care with virtual human interviewers. front robotics and ai computational phenotype discovery using unsupervised feature learning over noisy, sparse, and irregular clinical scalable and accurate deep learning with electronic health records deep learning architectures for the early diagnosis of the alzheimer's disease hierarchical feature representation and multimodal fusion with deep learning for ad/mci diagnosis the current state of artificial intelligence in medical imaging and nuclear medicine current applications of robotics in spine surgery: a systematic review of the literature new perspectives on neuroengineering and neurotechnologies: nsf-dfg workshop report the use of augmented reality further enhances the experience virtual reality and simulation in neurosurgical training automated surgical approach planning for complex skull base targets: development and validation of a cost function and semantic at-las hockstein ng. transoral robotic surgery (tors) for base of the use of robotics in minimally invasive spine surgery merging machines with microsurgery: clinical experience with neuroarm microscopic micromanipulator system "neurobot" in neurosurgery: interhospital preliminary study the raven: design and validation of a telesurgery an open platform for surgical robotics research surgical cockpit comprising multisensory and multimodal interfaces for robotic surgery and autonomous neurosurgical instrument segmentation using end-to-end learning computer vision and pattern recognition (cvpr) workshops semi- autonomous simulated brain tumor ablation with ravenii surgical robot using behavior tree ieee international conference on robotics and automation (icra) tumor paint: a chlorotoxin: cy . bioconjugate for intraoperative visualization of cancer foci . begić a. application of service robots for disinfection in medical institutions developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery lab labelme: a database and web-based tool for image annotation the roboscope™ is shown with the actuator mechanism the bendable sheath presently has channels, the top two (sfe . mm)are for the two laser endoscopes, the middle two ( . mm) are for the instruments, and the bottom two ( . mm) are for suction devices. the channels can be modified to suit the surgical needs the roboscope™ with two different dimensions ( mm and mm the roboscope™ is now bent, with the tow tools in close up the karns introducer device™ for the roboscope™ is shown with a) the tulip closed, and b) the tulip open cadaveric use of roboscope™. a) shows the introduction of the roboscope™ through an opening in the skull base of a cadaver b)the remote manipulation of the controls c) the view of the structures through the laser fiber-optic endoscope (courtesy of eric seibel concept of the artificially intelligent robotic assistant, showing a) the surgeon and robotic assistant , and b) the surgeon, a human, and a robotic assistant ground truth (gt) annotation for identifying instruments in a surgical field through the neuroid dataset generated by the uw team (a) input frame (b) annotations were created using the labelme annotation tool (c) gt for distinguishing tool vs background (tissue, gauze, etc) (d) gt for locating each class of conceptualization of the android robotic nurse helper (arnh) for a patient in isolation due to an infection. the physician and the nurse are able to remotely view the patient, and all of his vitals, even sense palpation using haptic sensors, and instruct the robotic nurse helper the anrh is present with the patient continuously round the clock, and is able to sterilize itself using ultraviolet light or other methods acknowledgements: we wish to thank raja sekhar, for his review of the manuscript and the authors report no conflict of interest in this paper. key: cord- -nlk pjv authors: roberti, fabio; arsenault, katie title: minimally invasive lumbar decompression and removal of symptomatic heterotopic bone formation after spinal fusion with rhbmp- date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: nlk pjv abstract we present a case of symptomatic heterotopic bone formation following revision of posterolateral lumbar fusion/instrumentation and “off-label” use of recombinant human bone morphogenetic protein- (rhbmp- ), treated successfully with the use of a minimally invasive tubular approach. the use of recombinant human bone morphogenetic protein- (rhbmp- ) as an osteoinductive factor in spine surgery has been approved by the us food and drug administration for singlelevel anterior lumbar fusion with tapered cages in skeletally mature patients ( ) . due to its proven effectiveness in increasing postoperative fusion rates ( , ) , the "off-label" use of these proteins has gained wide spread popularity among spine surgeons dealing with various spinal conditions ( , , , , , ) and a published review of administrative data found that % of rhbmp- utilized in spinal surgery fell under the "off-label" definition ( ) . notwithstanding the proven benefits, several studies regarding complications associated with the use of rhbmp- have been so far published. increased rates of infection, postoperative seromas and hematomas, delayed wound healing, dysphagia and neck swelling, retrograde ejaculation, symptomatic radiculitis, vertebral osteolysis, cage subsidence as well as heterotopic bone formation have all been reported following the use of rhbmp- in spine surgery ( , , , , , , , ) . we report a case of symptomatic heterotopic bone formation following lumbar spinal revision surgery and posterolateral fusion with rhbmp- , successfully treated using a minimally invasive tubular approach and provide documentation of the technical aspect of the procedure. a -year-old obese female underwent an open lumbar laminectomy with instrumented allograft postero-lateral fusion using iliac bone graft, local bone, calcium phosphate augmentation and pedicle screws instrumentation at l -l at an outside institution, with clinical improvement. three years after the initial surgery, she experienced recurrent low back pain and was diagnosed with pseudo-arthrosis and hardware failure (fractured left l pedicle screw) that prompted a revision surgery with fractured hardware removal and extension of the instrumented fusion to s , bilaterally. at the time of the revision surgery rhbmp- was utilized "off-label" to promote a successful postoperative postero-lateral arthrodesis. both initial and revision procedures were performed at the same hospital and by the same surgeon. three years after the revision surgery she started experiencing recurrent episodes of severe l and s left radiculopathy and medical management and lumbar steroids injections failed to reduce the severity of the symptoms. this is when we first saw the patient. a clinical examination confirmed the presence of radicular signs and symptoms with no neurological deficits or significant back pain. lumbar x-rays and ct scan were performed and revealed the presence of new broken hardware on the left side (fractured s pedicle screws) as well as significant heterotopic bone formation mainly involving the left l -s lateral recess, leading to severe stenosis and nerve root compression (fig - - ) . despite the findings of broken hardware, there were no signs of mechanical instability at a flexion-extension x-ray and the ct documented the presence of a solid joint arthrodesis, especially on the right (fig - - a- b ). an mri was also performed which confirmed the diagnosis of severe lateral recess stenosis at l -s due to heterotopic bone formation (fig ) . clinically she had only minimal axial low back pain, no radiological signs of mechanical instability, with most of the symptoms being radicular in nature. she was severely obese with a bmi of . with history of hyperlipedimia, htn and cad. after discussing the surgical options with the patient we elected to explore the fusion, remove the broken instrumentation and decompress the involved nerve roots by removing the heterotopic bone formation using a minimally invasive tubular approach. open surgery with complete revision of instrumentation and redo arthrodesis was also discussed. in light of the absence of significant low back pain, the predominance of radicular symptoms, the absence of mechanical instability and the presence of bilateral facet arthrodesis, as well as the history of previous lumbar surgeries and associated medical comorbidities, we felt a minimally invasive approach was an appropriate option to be selected in this case and the patients concurred with this informed decision. the patient was positioned on a standard prone position on a wilson frame. metrx tubular system and antero-posterior (ap) and lateral intraoperative fluoroscopy guidance were utilized. a cm incision was made over the ap x-ray projection of the l -s broken screws on the left side and the fascia was open approx. - cm lateral to the midline, as guided by the x-rays. an xtube expandable tubular retractor was utilized to expose the l -s hardware. the rod was exposed and any surrounding newly formed bone was carefully drilled away. the rod was then cut using a carbide drill bit and removed. the lower broken screw (s ) was then utilized as landmark to start our microscopic dissection (fig ) . the borders of the previous laminectomy were the identified, epidural scarring removed and the dura and nerve roots displaced by the presence of the heterotopic bone formation identified. the traversing nerve root was decompressed below the area involved by the ectopic bone formation and the exiting nerve root was isolated and decompressed above it (fig - - ) once the nerve roots and the lateral dura were identified the heterotopic bone was removed by gentle drilling and use of kerrison rongeurs until complete decompression was achieved ( fig ) . after hemostasis was achieved and any dural leak ruled out, the remaining loosened hardware (s screw head that was kept in place as landmark) was removed. the xtube was removed and the fascia and would closed using standard techniques. the procedure lasted approx. minutes and blood loss was minimal (< cc). in light of the absence of significant low back or radiological signs of mechanical instability, the documented solid arthrodesis on the contralateral side, as well as the presence of retained fractured screws within the l and s pedicles, we elected not to place supplemental instrumentation. a postoperative ct confirmed good neural decompression (fig ) and the patient was discharged home on postoperative day . the radicular symptoms resolved and no recurrent symptoms or complications were recorded at a - and month follow up. at the most recent clinical follow up ( years after the minimally invasive surgery) the patient still remains pain free without any significant recurrent radicular symptoms or axial back pain and has been able to resume recreational sport activities. in light of the ongoing covid pandemic and following institutional protocols and policies while dealing with this event, long term follow up radiological examinations were not obtained. heterotopic (or ectopic) bone formation is a known complication associated with the of rhbmp- during spinal fusion surgery ( , , ) and due to its possible compressive nature this condition may lead to recurrent or worsening symptoms in the postoperative period. depending on size, symptoms and location of the ectopic bone formation surgical treatment may be needed, posing sometimes a technical challenge especially in patients who already underwent revision surgery of that carry multiple medical comorbidities. in such patients the use of minimally invasive decompressive techniques may be beneficial in tailoring the treatment to the symptomatic condition while minimizing possible adverse effects sometimes associated with open revision surgery. minimally invasive spine surgery (miss) techniques are nowadays utilized by many surgeons as an alternative or adjunct to open spine surgery in the treatment of various degenerative pathologies involving the cervical, thoracic and lumbosacral spine ( , , , ) as well as trauma related and tumoral conditions ( , ) . centers and surgeons familiar with these novel techniques have also expanded the use and indications of this lesser invasive techniques to deformity correction surgery and revision surgery as well ( , , ) . in our practice we too have expanded the use of miss techniques as we live in a community were many patients are seen in consultation in their th and th decade of life. spine surgery in the elderly may be at time challenging as multiple comorbidities, osteopenia/osteoporosis, as well as history of multiple previous spine surgeries need to be carefully considered while selecting the most effective and safe surgical (or non-surgical) approach. revision spine surgery may also prove challenging as several factors may contribute to render some of these procedures more complicated than others. lack or paucity of information related to previous surgeries, diagnostic limitation of radiological studies available (e.g. patients with spinal cord stimulators or non-mri compatible implanted devices) and post-surgical anatomical changes and fibrosis do in fact play an important role during the preoperative and operative decision making process in such patients. anatomical landmarks may difficult to recognize during revision surgery as post-operative changes, associated deformity and epidural fibrosis may all render the surgeon's evaluation of the operative field at times challenging. this is especially true in miss where the anatomical exposure is usually limited to the surgical area of interest and in such cases an optimal use of preoperative and intraoperative imaging plays a very important role in facilitating the surgeon during the various steps of the selected approach. miss offer many benefits in this cohort of patients (elderly, revision surgery, multiple comorbidities) as limited tissue dissection, minimal blood loss, shorter surgery time, faster and easier mobilization, lesser and shorter need for postoperative narcotics are all in favor of the use of such techniques when deemed feasible and appropriate. in the presented case it is unclear when the hardware failed/re-fractured as the patient did not complain of significant low back pain at the time of our initial evaluation. it is indeed possible that the hardware failure happened before the arthrodesis was complete and solid and before the ectopic bone formation became symptomatic. also we were unable to directly confirm what dose of rhbmp- was utilized at the time of the revision surgery, therefore cannot comment on this specific issue as cofactor for the onset of the heterotopic bone formation. review of previous operative reports revealed that the initial postero-lateral fusion was performed with the use of iliac crest and local bone autograft as well as calcium phosphate allograft augmentation. in light of the recurrence of radicular symptoms and evidence of fractured hardware at l , the patient underwent a revision surgery with "exploration of fusion, removal of l instrumentation, bilateral transverse process fusion with local bone graft and "off label" use of bmp", as well as left tlif at l -s with peek allograft and l -s bilateral pedicle screw instrumentation.". according to the operative report there was no presence of heterotopic bone formation at l -s at that time of the revision surgery and the bmp sponges were "morcellized and placed in smaller pieces, combined with the local bone graft, into both posterolateral gutters". the amount of bmp utilized was not recorded. the colleague also commented that the "fixation of the l screw on the left side was extremely good and had sustained a fatigue fracture at its base, indicating a solid anchorage in the l pedicle" therefore such fractured screw was not retrieved at that time. in light of the documented absence of heterotopic bone formation at the time of the revision surgery, the addition of calcium phosphonate to promote the arthrodesis during the initial lumbar fusion does not appear to have played a role in the genesis of the ectopic bone formation in this case, and it appears that this condition is to be associated to the use of rhbmp- , as previously described ( ) . in the presented case an open procedure of revision/decompression/lysis of adhesions could have certainly been utilized but in light of the patient's expectations, the absence of significant low back pain and radiological instability, as well as the presence of numerous medical comorbidities, we chose a minimally invasive approach, which proved to be successful in providing a long lasting relief of the preoperative symptoms. although the treatment of heterotopic bone formation associate with the use of rhbmp- may be challenging, the use of a minimally invasive tubular decompression may facilitate a tailored and safe approach to this condition and should be kept in the armamentarium of spine surgeons, as one of the many valid techniques to be considered and discussed with these patients. in the presented case we found the use of minimally invasive techniques to be of benefit for the removal of heterotopic bone formation following lumbar spine fusion with rhbmp- . this approach remains consistent with the concept that minimally invasive surgery should not equal lesser effective surgery and that final recommendation on the technique to be adopted should be tailored on a case-by-case scenario, keeping in mind patient's expectations, safety issues and goals to be achieved. anterior lumbar interbody fusion using rhbmp- with tapered interbody cages is infuse bone graft superior to autograft bone? an integrated analysis of clinical trials using the lt-cage lumbar tapered fusion device guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. part : bone graft extenders and substitutes as an adjunct for lumbar fusion fusion rates of lateral lumbar interbody fusion using recombinant human bone morphogenetic protein radiographic and ct evaluation of recombinant human bone morphogenetic protein- -assisted cervical spinal interbody fusion.clin spine surg minimally invasive reduction of thoracolumbar burst fracture using monoaxial percutaneous pedicle screws: surgical technique and report of radiological outcome the misdef algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery minimally invasive removal or revision of lumbar spinal fixation use of recombinant human bone morphogenetic protein- to achieve posterolateral lumbar spine fusion in humans: a prospective, randomized clinical pilot trial: volvo award in clinical studies off-label use of bone morphogenetic proteins in the united states using administrative data complications associated with the use of the recombinant human bone morphogenetic proteins for posterior interbody fusions of the lumbar spine fineberg sj et al clinical sequelae after rhbmp- use in a minimally invasive transforaminal lumbar interbody fusion complications with the use of bone morphogenetic protein (bmp- ) in spine surgery symptomatic ectopic bone formation after off-label use of recombinant human bone morphogenetic protein- in transforaminal lumbar interbody fusion intraoperative computed tomography navigational assistance for transforaminal endoscopic decompression of heterotopic foraminal bone formation after oblique lumbar interbody fusion bone morphogenetic protein usage in anterior lumbar interbody fusion: what else can go wrong? world neurosurg complications associated with bone morphogenetic protein in the lumbar spine promoting fusion in minimally invasive lumbar interbody stabilization with low-dose bone morphogenic protein- --but what is the cost? heterotopic ossification associated with recombinant human bone morphogenetic protein- (infuse) in posterolateral lumbar spine fusion: a case report.spine (phila pa ) ectopic bone formation in titanium mesh loaded with bone morphogenetic protein and coated with calcium phosphate pseudo-pedicle heterotopic ossification from use of recombinant human bone morphogenetic protein (rhbmp- ) in transforaminal lumbar interbody fusion cages clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation. neurosurg focus minimally invasive transforaminal lumbar interbody fusion: one surgeon's learning curve removal of ossified ligamentum flavum via a minimally invasive surgical approach the use of a "double-triple barrel" technique during minimally invasive multilevel tubular laminectomy. a technical note comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhbmp- versus autograft minimally invasive resection of spinal hemangioblastoma: feasibility and clinical results in a series of patients correction of marked sagittal deformity with circumferential minimally invasive surgery using oblique lateral interbody fusion in adult spinal deformity bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis bone morphogenetic proteins in anterior cervical fusion: a systematic review and meta-analysis. world neurosurg rhbmp- (recombinant human bone morphogenetic protein- ) fabio roberti: conceptualization, methodology, writing-original draft preparation, validation, writing-reviewing and editing. key: cord- -n jv l authors: spina, alfio; boari, nicola; gagliardi, filippo; bailo, michele; calvanese, francesco; mortini, pietro title: the management of neurosurgical patients during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: n jv l abstract the rapid spread of severe acute respiratory syndrome coronavirus (sars-cov- ) is, to date, the major challenge for healthcare systems worldwide. hospital represents one of main vector amplifying the spread of the disease among both patients and healthcare professionals. adequate department organization is pivotal to reduce hazards while still ensuring the highest quality of care. in this document we aim to share the recent experience of a neurosurgery department located in one of the first and largest coronavirus disease (covid- ) pandemic epicenters. a review of the available literature was also performed. case selection, operating room and postoperative management of neurosurgical patients were discussed. covid- pandemic has upset healthcare organizations, requiring a deep reorganization in many respects. an adequate management protocol can reduce hospital viral spread, improving safety both for patients and healthcare professionals. the entire whole world is fighting for the first time in the modern history of mankind a borderless war that has profoundly distorted the social, economic and political setting of many countries. the rapid spread of severe acute respiratory syndrome coronavirus (sars-cov- ) represents the major actual challenge of healthcare systems worldwide. in response to this spread, several conflicting actions have been taken such as social distancing, lockdowns and quarantine of suspected or less symptomatic cases. the management of an ever-increasing number of patients, particularly those suffering from coronavirus disease (covid- ) pneumonia has deeply affected the organization of healthcare facilities. furthermore, preserving financial and human resources is crucial, and a good and a preventive organization are mandatory in this phase of mass casualty. , in this scenario, healthcare providers represent the frontline in the fight against the coronavirus. covid- outbreak has upset the way to deliver medicine among different medical specialties, including neurosurgery. surely, sars-cov- infection may cause fever, pneumonia and other medical issues not pertaining to the neurosurgical practice. however, management of neurosurgical cases has been deeply affected, leading to a complicated and difficult selection of the patients to candidate for hospital admission and surgery, together with their pre and postoperative management that must take into account their potential contagiousness. . the presence of a high viral load in the nasal cavity, brain surgery and even more trans-sphenoidal surgery, make neurosurgery one of the high risk surgical specialties, along with otorhinolaryngology, anesthesiology, oral-maxillofacial surgery , - ; endoscopic procedures through the mouth and nose (such as in gastroenterology) could be considered at high risk too. ultimately, in several hospitals, neurosurgeons have been reassigned to covid- units due to the growing demand for medical personnel. sars-cov- entail a long and incompletely known incubation period, ranging from to days after first virus exposure; additionally, i significant rate of completely asymptomatic patients have been reported. the aforementioned reasons represent a noteworthy risk of accidental virus transmission for all the personnel employed in neurosurgical departments, outpatient clinics, and operating rooms . sars-cov- transmission seems to be mainly related to respiratory droplets but, covid- also showed surface stability over a long time. for healthcare professionals, both the two transmission modalities must necessarily considered to reduce the risk of accidental contagion. this requires a complete department and operating room reorganization to protect patients as well as medical staff from unnecessary and dangerous infections. data coming from the first and largest covid- eastern asian epicenters, suggest that these problems will not end soon and therefore the risk of infection will also have to be considered in the upcoming months. in a single-center chinese case series of hospitalized patients, presumed hospitalrelated infection of covid- was suspected in % of patients, with a reported mortality of . % and an intensive care unit admission rate of %. furthermore, covid- transmission rate to healthcare worker was reported up to % these data suggest that, inadequate hospital setting may represent a relevant route of sars-cov- spread both for patients and healthcare professionals. the aim of this study was to report a series of recommendations derived from our experience and from the recent pertinent literature, to prevent viral spread during neurosurgical activities. san raffaele hospital (milan, italy) is located in one of the first and largest covid- pandemic epicenters worldwide; here we described the actual organization of its neurosurgery department and current practice adopted. a literature review was also performed via pubmed, web of science and google scholar using the search terms surgery, neurosurgery, covid- , coronavirus, sars-cov- . some additional studies were selected from the references of the articles retrieved. last online research was performed on april th , . after the pandemic explosion, many hospitals have cancelled outpatients activities or reduced them only to urgent ones. , , consequently, the number of elective surgical cases have dramatically decreased, also because of the lockdown measures. , surgical treatment should be considered only in selected non-postponable cases or in emergency ones. , elective surgeries should be rescheduled to allow a correct assessment of patients' clinical condition and to give correct allocation in the ward. , the creation of covid-positive (suspected or definitive cases) and covid-free sectors, with dedicated healthcare professionals, might be desirable even inside the same department. patients' clinical evaluation must be performed by maintaining contact and droplet precautions, the social distancing has to be maintained for every patients if not for unavoidable evaluations or maneuvers such as neurological examination; adequate personal protection equipment (ppe) must always be used and have to be easily available in clinics. each patient, even if tested negative for sars-cov- infection at real-time reverse transcriptase polymerase chain reaction (rt-pcr), should be considered and approached as potentially contagious. complete information about relative's health condition, friends or history of recent travels and contacts has to be investigated. the assessment of class-risk group should be evaluated before and at hospital admission. whenever possible, elective surgery for confirmed cases (i.e. group ) should be rescheduled, because of this class of patients show higher risks of intensive care need and death. , , , , - group must undergo prompt laboratory rt-pcr or serologic testing in order to confirm covid- infection or to diagnose other viral or bacterial pneumonia. surgery for group patients should be carefully evaluated together with the anesthesiologist team, to balance the risk-benefit ratio of a surgical treatment at this time. group and patients should undergo laboratory testing and chest ct scan to exclude a developing infection. , early identification and isolation of infected patients minimize virus transmission to other patients and to healthcare professionals. patients included the three first groups must be kept in a single room, and disinfection and isolation measure have to be put in action. contact and droplet isolation precautions through gown, gloves, head cap and facial ffp (n ) mask must be taken. , also patient must wear surgical facemasks or mask without exhalation valves. , in the absence clinical information or swab test, those patients needing emergent neurosurgical procedure should be considered as group - patients and require the same perioperative management as well. a limited number of people have to be warranted in the operating room (or). confirmed cases must be treated in a negative pressure theater. for the entire anesthesiologist, neurosurgical and nurse staff, high protection ppes are recommended; personnel should not wear the same ppes inside and outside the or. ffp (n or equivalent) are suggested since ffp (n ) mask did not seem to adequately protect surgeons in china; triple layered protection gowns, eye or facial protection, single use head caps and glows are also recommended to prevent accidental transmission. , an experienced anesthesiologist should perform patient's intubation to reduce coaching and the number of attempts. video-guided laryngoscopy can be considered to attempt this goal. , surgeon should enter in the or about minutes after intubation; with the abovementioned adequate ppes to minimize aerosol transmission. the surgical team should enter the theater after min of intubation with appropriate ppe to minimize the aerosol-based transmission. all objects and instruments that come in contact with the patient included in the group - - have to be considered contaminated. viruses have been reported to survive in surgical smoke, consequently, the latter must be minimized through continuous aspiration and irrigation and minimizing the effective power of electrosurgical equipment. , , care must be taken to prevent accidental needle or scalpel injury. absorbable sutures should be considered to reduce unnecessary trip to the hospital for their removal. patients developing fever or cough after surgery have to perform chest ct scan and laboratory testing for covid- . it has to be noted that previous negative results do not preclude covid- infection, due to limitation in tests sensibility and incubation periods. confirmed coronavirus cases should be treated with oxygen delivery, medical support therapy; and a multidisciplinary management with the anesthesiologist and infectious disease specialist is also recommended. it is well known that covid- patients harbor a higher risk of thrombosis and secondary pulmonary infections, hence adequate treatment has to be warranted. , ; these covid-related risks add up to those already present in neurosurgical patients. unfortunately, in the neurosurgical setting the need for anticoagulant therapy has to be balanced with the risk of delayed postoperative bleeding, which may cause dramatic consequences. confirmed covid- cases should be discharge after clinical resolution and when the rt-pcr or antibody test is negative on two consecutive occasions (sampling interval ≥ h). those negative cases with uneventful postoperative course may go back home, complying with a -days quarantine, to prevent postoperative infections. covid- represents one of the largest and deadliest pandemic infection of the modern era. the number of positive patients is, at the current time, still growing around the world and, unfortunately, chances are that we will have to deal with this infection for many more months to come. hospital represents one of the vectors that may amplify the spread of the disease. adequate hospital and especially surgical unit organization are therefore essential to improve both patients and staff safety. careful management through a well-known protocol can minimize the risk for the neurosurgical team and for the other patients. we hope to continue providing the best possible standard of care to our patients. we wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. we confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. we further confirm that the order of authors listed in the manuscript has been approved by all of us. we confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. in so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. we understand that the corresponding author is the sole contact for the editorial process (including editorial manager and direct communications with the office). he is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. we confirm that we have provided a current, correct email address which is accessible by the corresponding author and which has been configured to accept email from spina.alfio@hsr.it. approaches to the management of patients in oral and maxillofacial surgery during covid- pandemic a commentary on safety precautions for otologic surgery during the covid- pandemic navigating the ethics of covid- in otolaryngology transmission of -ncov infection from an asymptomatic contact in germany aerosol and surface stability of sars-cov- as compared with sars-cov- protecting health care workers from sars and other respiratory pathogens: a review of the infection control literature clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan covid- : protecting health-care workers the impact of the covid- pandemic on the provision of surgical care time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid- pandemic how to risk-stratify elective surgery during the covid- pandemic? a diagnostic model for coronavirus disease (covid- ) based on radiological semantic and clinical features: a multi-center study a british society of thoracic imaging statement: considerations in designing local imaging diagnostic algorithms for the covid- pandemic coronavirus disease : what we know correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases preliminary recommendations for lung surgery during covid- epidemic period guidelines for ambulatory surgery centers for the care of surgically necessary/time-sensitive orthopaedic cases during the covid- pandemic rapid response of an academic surgical department to the covid- pandemic: implications for patients, surgeons, and the community the authors report no conflict of interest key: cord- - bq nhwm authors: borsa, stefano; pluderi, mauro; carrabba, giorgio; ampollini, antonella; pirovano, marta; lombardi, francesco; tomei, massimo; locatelli, marco title: impact of covid- outbreak on acute low back pain date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: bq nhwm nan we would like to bring our contribution from one of the most affected regions of the world by the sars-cov- on how pandemic has influenced the number of visits for low back pain and to provide food for thought for a reorganization of low back pain management in the post-covid- era. since feb th, , when the first person-to-person transmission of the sars-cov- was reported in italy, the covid- outbreak has reached the pandemic status. the italian health system had to reorganize entire hospitals to care an unprecedented number of patients who needed urgent treatments at the same time; since march th , hubs were identified for specific urgent or tumoral pathologies [ ] . what about patients who have no acute respiratory syndrome or no life-threatening or tumoral conditions? what about patients with pathologies that are usually referred to the emergency ward as acute low-back pain? low-back pain has an incidence of around % a year and up to % of the population experiences the pathology at least once in their lives; it accounts for around % of emergency ward visits in the us [ ] . although the vast majority ( - %) of patients with acute low-back pain have symptomatology that tends to regress within - weeks [ ] , there is a minority where the cause of the pain is a serious pathology: the prevalence of cancer is around % and that of vertebral fracture around % [ ] . the importance of psychological status on the pain perception and complain is clear but few reports have studied the impact of emergency settings (i.e. natural disasters, wars, pandemics) on pain management [ ] . we collected data from hospitals in milan on emergency ward (ew) and on outpatient department (od) visits for acute low back pain (albp) for the period march th , -april th , and for the same period of the previous year. last month patients came for albp, in the ews and in the ods. in the ews patients had lbp, presented sciatica, had fractures (porotics) and a tumor (prostate cancer). in the ods patients presented lbp, presented sciatica, had fractures (porotics) and a tumor (breast cancer). the patients presented during the same period in were , in the ews and in the ods. in the ews patients had lbp, presented sciatica, had fractures ( traumatics and porotics) and tumors ( breast cancers, prostate cancer). in the ods patients had lbp, presented sciatica, had fractures (porotics) and tumors ( breast cancers, prostate cancers and colorectal cancer). the data we collected showed a clear reduction (- . %) of patients presenting for albp. the decrease of visits might reflect the reduction of traumatic cases due to the lock-down that is limiting the movement of people but in most cases this is probably related to the fear of being exposed to sars-cov- in a nosocomial environment. despite the scarcity of available resources due to pandemic, the vast majority of patients with albp would have had the opportunity to access hospitals, but they decided not to. in a normal situation how many patients that we see in ew or od for albp really need an urgent nosocomial evaluation? the covid- outbreak is changing our every-day life but we could exploit this exceptional moment for a reorganization of our emergency system; we'll have to strengthen the local medicine by training and by providing guidelines and diagnostic pathways for general practitioners so to identify the cases (tumors, unstable fractures or patients with neurological deficits) who need evaluation in a hospital setting [ ] ; furthermore, we will have to deal with covid- for the months to come and it will be imperative to implement tools, such as telemedicine, that allow adequate evaluations and treatments while maintaining the necessary social distancing [ ] . the response of milan's emergency medical system to the covid- outbreak in italy evaluation and treatment of acute back pain in the emergency department united states agency for health care policy and research. acute low back pain problems in adults. clinical practice guidelines red flags presented in current low back pain guidelines: a review pain and natural disaster virtually perfect? telemedicine for covid- no funding was provided for any author on this article, and there are no known conflicts of interest for any author. author contributions: the authors would like to thank cojazzi v. and egidi m. for their contribution. declaration of interests x the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- - jg authors: field, nicholas c.; platanitis, kelsey; paul, alexandra r.; dalfino, john; adamo, matthew a.; boulos, alan s. title: decrease in neurosurgical program volume during covid- : residency programs must adapt date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: jg nan to the editor: the covid- pandemic has had wide-reaching impact on medical care across the globe, both in outpatient and inpatient settings. in the united states, it remains unknown how long and to what degree we will remain in the new status quo of "social distancing" and state-by-state lockdown. however, the short-term impact on neurosurgical resident and medical student education has begun to be realized, and the long-term implications on residency training could be vast. in order to demonstrate the degree of change, we wish to report the dramatic decrease in operative, outpatient clinic, and consult volume at our institution, albany medical center, an academic level trauma center in upstate new york. the first case of covid- in new york state was reported on march , . by march th there were confirmed cases and a state of emergency had been declared. on march th the first deaths were confirmed and were soon followed by closure of the public-school system and a statewide stay-at-home order known as "new york state on pause." elective cases were mandated to stop on march th . while our region has not suffered an overwhelming surge in covid- cases, local concern, hospital and statewide policies, and concern for departmental safety have led to a noticeable change in our practice. since the first case was reported, we have tracked our operative, clinic, and consult volume, which we report here. similar to reports by other groups, we have seen a significant decrease in outpatient clinic visits, necessitating the need for alternative methods of administering patient visits. we rapidly trialed and implemented a video conference telehealth system by the end of march and have seen a dramatic shift in our clinic practice while continuing to provide appropriate patient care ( figure ). overall, new patient visits, which are a reflection of referrals, have dropped by % and established patient visits have only dropped by %. despite reassurances about the safety of emergency room care, the public continues to avoid hospital visits and there has been widespread news coverage about the decrease in hospitalization for stroke and myocardial infarctions. at our center, this trend has held true for all neurosurgical consults except those for shunt failure and intraparenchymal hemorrhage, which have shown a minimal increase. in particular, as the highest volume trauma center in new york state, there has been a marked decrease in consults for traumatic brain ( %) and spine ( %) injuries, presumably due to decreased motor and recreational vehicle activity (figure ). despite a % reduction in large vessel occlusion stroke consults, the rate of thrombectomy has increased dramatically. overall, there has been a % reduction in all consults since the new york state stay-at-home order, compared to the same period in . the most noticeable change to the residency has been the decrease in both elective surgery volume ( %) and total surgical procedures ( %). our resident service was split into an on-call and backup team due to the decrease in case volume, and also to limit exposure to covid- , and provide coverage in the neuro icu. neuroangiography has seen a similar decline. bedside procedures, such as placement of ventricular drains, have remained stable. of note, despite the overall decline in stroke consults, thrombectomies have increased by %. operative cranial traumas have decreased by %, which is consistent with the decrease in consults. most neurosurgical residency programs are located at academic hospitals in urban or suburban centers--the areas hardest hit by covid- . our program has seen a significant reduction in consults and operations over the past three months despite being in a region with a linear case rise that has not been overwhelmed by the pandemic. while short-term fluctuations in volume are normal, the long-term consequences of a sustained decrease in volume will significantly impact resident education. if covid- persists, or future case surges occur, programs could see a reduction in patients of well over % over the course of a year. individual programs will be affected differently, and we propose consideration of the following mitigation strategies: • intern year rotations may need to shift to incorporate more neurosurgical experiences, as they will likely be exposed to fewer neurosurgical patients over the course of their year. • increase resident and medical student participation in clinic. • all non-emergent cases should require pre-operative testing. these cases could be considered relatively safe for residents to "double scrub" while still limiting possible covid- exposure. • mentorship models for junior residents may provide a means of distributing consult, clinic, operative, and neuroangiography experiences. • programs should invest in and consistently utilize dissection labs to teach, learn, and reinforce surgical approaches. • virtual conferences can be utilized for didactic sessions using platforms such as microsoft teams or zoom. these also provide an inexpensive way to invite guest lecturers from other programs to speak. • utilize online academic resources, such as the virtual visiting professor series being hosted by the cns and the resident education courses produced by the aans and nref. the covid- pandemic has led to a dramatic decline in elective neurosurgical procedures, consults, and clinic visits. the long-term implications of the outbreak are unclear, but neurosurgical residency programs must consider the long -term effects on resident education and develop an internal roadmap moving forward. new york state on pause implementation of a neurosurgery telehealth program amid the covid- crisis-challenges, lessons learned, and a way forward virtual visiting professor primary campus clinic visits key: cord- -cw xy m authors: majmundar, neil; ducruet, andrew; prakash, tannavi; nanda, anil; khandelwal, priyank title: incidence, pathophysiology, and impact of coronavirus disease (covid- ) on acute ischemic stroke date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: cw xy m nan although neurologic symptoms are rarely the initial chief complaints of patients affected by covid- , recent reports have implied that a significant percentage of patients may experience neurologic symptoms and a small percentage may even present with ais as the presenting feature. , despite the known increased risk of stroke in patients with severe infections, many recent reports suggest an increased risk of ais in patients with covid- , even in those with few risk factors for stroke. ais appears to occur in patients with covid- with little regard to cardiovascular disease risk factors or age. oxley et al. reported patients positive for covid- in a new york city hospital system who presented with strokes secondary to largevessel occlusions (lvos) over a -week period despite very few or no risk factors for stroke. a recent series from wuhan suggested that the rate of ais was % in patients with severe covid- infection. a recently published international collaboration has shown the incidence of stroke to be . % (range . %e . %) among covid hotspot centers. among patients with ais admitted in hospitals, the majority of strokes were lvos ( %) and median age of the lvos patients was years old, a significantly younger age group when compared with historical data. several other reports implying causality between covid- and stroke have also been published. there have been several mechanisms proposed to explain this increased risk of thrombotic complications, especially strokes, in patients with covid- . sars-cov- uses the angiotensinconverting enzyme ii (ace ) receptor to gain entry into human cells. the ace receptor is heavily expressed in the nasal mucosa, lungs, small intestine, myocardium, vascular smooth muscle cells, and arterial and venous endothelial cells. inflammation and damage secondary to infection of these tissues, particularly the myocardium, may result in arrhythmias and increased risk of thrombus formation leading to stroke. furthermore, covid- may result in a hypercoagulable state, possibly due to endothelial dysfunction, microthrombi formation, and the cytokine surge. as an ace -seeking virus, capillary endothelial damage likely predisposes to a thromboembolic state. a synergistic contribution to endothelial damage mediated by antiphospholipid antibodies is also emerging as a possible cause. there have also been several reports regarding elevated d-dimer levels in patients with covid- , reflecting a prothrombotic state as well as a poor prognosis ( figure ). the association of covid- and ischemic stroke is not yet fully understood. however, we are beginning to appreciate an association between the "thromboinflammation" caused by the virus and the increased risk of thrombotic/ischemic complications which can lead to strokes. , due to the high rates of nosocomial transmission as well as the potential for overwhelming hospital resources, stroke centers across the world implemented new protocols for the triaging of patients with stroke, particularly those with lvos requiring mt. covid- does not preclude patients who meet the criteria and guidelines set forth in the most recent randomized clinical trials from undergoing mt. this is a potentially lifesaving intervention that should not be withheld in eligible patients. many centers have implemented stringent protocols, especially for the intubation of patients unlikely to tolerate mt with conscious sedation (e.g., high national institutes of health stroke scale, low glasgow coma scale) to reduce the potential for aerosolization of respiratory particles in covid-positive or potential-positive patients. ultimately, the practice changes implemented (e.g., conscious sedation vs. intubation, personal protective equipment precautions and door-to-puncture times, nosocomial rates of infection) will have to be investigated further to truly understand the impact of covid- upon the delivery and practice of mt for lvos ( table ) . while younger patients may be presenting with lvos, many stroke centers across the world have anecdotally reported a decline in the total number of patients presenting with an ischemic stroke during the height of the pandemic. despite the link between covid and a hypercoagulable prothrombotic state, there appears to have been a decline in patients presenting to hospitals with stroke symptoms. this is reflected by a recent publication demonstrating a % decrease in the use of stroke imaging during the early pandemic period (march to april , ) when compared with the previous days (february e , ). the early pandemic time period coincided with the implementation of "stay at home" recommendations across most of the united states. the decrease in stroke imaging volume could reflect the apprehensiveness of patients, especially those with mild symptoms wanting to avoid visiting healthcare facilities during the height of the epidemic. in addition, patients are taking longer to present to the hospital, potentially critically impacting the time window to intervene. schirmer et al. and the endovascular neurosurgery research group published data demonstrating that patients had a significantly longer last known well to time of presentation interval during the covid-era. this finding has been corroborated by several institutions and groups across the world. a recent study from a single center in new jersey, one of the most heavily covid-impacted states in the country, corroborated the decrease in overall stroke volume but also found a greater proportion of patients with stroke presenting with lvos during the covid- period. this may suggest that while patients with milder symptoms may not be pursuing clinical care, patients who suffer from more debilitating symptoms secondary to lvos are still seeking medical attention. again, the impact of the pandemic upon patients with ischemic strokes will take some time to be understood. it will be interesting to study the trends once restrictions are lightened. although the overall incidence of ais in covid- is not clear, there is emerging evidence that the rate of lvos is increased in patients with covid- who may not have the typical stroke risk factors. , developing protocols for timely diagnosis and providing hyperacute treatment in a time sensitive manner is the key to minimize mortality and morbidity in patients with ais. we need further studies in an emergent fashion to fully understand the neuropathologic mechanism of ais in patients with covid- . in addition, we will need to study long-term trends and outcomes to fully understand the impact of this pandemic upon patients with ischemic strokes. cardiovascular considerations for patients, health care workers, and health systems during the covid- pandemic severe acute respiratory syndrome coronavirus infection and ischemic stroke neurologic manifestations of hospitalized patients with coronavirus disease in wuhan, china large-vessel stroke as a presenting feature of covid- in the young incidence, characteristics and outcomes of large vessel stroke in covid- cohort: a multicentric international study hypercoagulation and antithrombotic treatment in coronavirus : a new challenge society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid- falling stroke rates during covid- pandemic at a comprehensive stroke center: cover title: falling stroke rates during covid- collateral effect of covid- on stroke evaluation in the united states delayed presentation of acute ischemic strokes during the covid- crisis from the departments of neurological surgery and - /$ -see front matter ª published by key: cord- - q jibl authors: knopf, joshua d.; kumar, rahul; barats, michael; klimo, paul; boop, frederick a.; michael, l. madison; martin, jonathan e.; bookland, markus; hersh, david s. title: neurosurgical operative videos: an analysis of an increasingly popular educational resource date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: q jibl objective surgical education has increasingly relied upon electronic learning, and in particular, online operative videos have become a core resource within the field of neurosurgery. here, we analyze the current forums for neurosurgical operative videos. methods operative videos from sources were reviewed: ( ) the neurosurgery journal youtube channel; ( ) the aansneurosurgery youtube channel; ( ) the neurosurgical atlas operative video cases; ( ) operative neurosurgery; and ( ) neurosurgical focus: video. title, year of publication, senior author, institution, country, and subspecialty were documented for each video. results a total of , videos demonstrating , surgeries were identified. ten videos included > surgery; of those, there was a median of surgeries (interquartile range, . – . ) per video. the most frequently represented subspecialties include vascular ( . %), tumor ( . %), and skull base surgery ( . %), with almost % of videos depicting > category. videos were submitted by authors from countries, but . % of the videos originated in the united states. conclusion neurosurgical operative videos have become increasingly common through a variety of online platforms. future efforts may benefit from collecting videos from underrepresented regions and subspecialties, providing long-term follow-up data and demonstrating techniques for managing complications. surgical education has traditionally been built upon graduated "hands-on" operative experience, supplemented by textbooks, lectures, cadaver labs, and formal surgical courses. however, the rapid pace of technology has opened other educational avenues, such as online lectures and courses, virtual dissections, and simulation training. the current covid- pandemic has highlighted the importance, application, and adaptability of these electronic resources, as trainees have had less operative experience and may need to continue social distancing measures for a protracted period of time. [ ] [ ] [ ] [ ] [ ] operative videos represent another educational tool for trainees as well as for established surgeons. operative videos in neurosurgery can be traced back to gazi yasargil's early recordings of his microsurgical cases; today, videos are simpler to record, store, and transmit in high definition ( d or d). as aptly stated by robert spetzler, "it is true that watching a brilliant surgeon's video will not make you one, but recognizing what is possible and seeing it done will inspire you to be a better surgeon and to achieve that goal." to date, a number of operative video "libraries" have been collated and published. for the purpose of this analysis, we sought to include video collections that have been sponsored additionally, it includes videos from the rhoton collection, a core curriculum developed in conjunction by the aans and the society of neurosurgery, interviews of "leaders in neuroscience," and historical films. manual curation of each operative video from the aforementioned video sources was compiled in a database (microsoft excel version . ). video characteristics (subspecialty and d vs d format), source, patient demographics (age and sex), and senior author information (name, institution, and country) were compiled. videos depicting more than patient were annotated along with individual patient demographics. for subspecialty designations, each video j o u r n a l p r e -p r o o f was annotated as relating to or more core neurosurgical subspecialties: tumor, vascular, spine, pediatrics, functional, peripheral, and/or trauma. for the two youtube channels, the number of views for each video was recorded. data collection for all videos was completed by may , . all analyses were performed using r (version . . ; rstudio, https://rstudio.com) with either base stats package or rstatix (version . . ; https://cloud.r-project.org/package=rstatix). visualizations of intersecting sets were generated using upset (https://ieeexplore.ieee.org/document/ ). geocoding was performed using ggmap significance level α was set to . for all analyses except after multiple testing correction, where α was set to . . normality of continuous variables was assessed using the shapiro-wilk test. continuous variables were summarized using median and interquartile range (iqr). comparisons across groups were performed with the krukal-wallis test and post-hoc pairwise dunn's test with bh correction. count data was compared across groups using the chisquare test followed by post-hoc pairwise fisher's exact test with bh correction. analysis of the number of hits/views for each video was limited to the two youtube channels. the number of hits for each video were analyzed per subspecialty and pairwise comparisons were performed between videos that were related versus those that were unrelated j o u r n a l p r e -p r o o f to each subspecialty. the number of hits were normalized to the number of years for which each video was accessible. video, the aans youtube channel, and the neurosurgical atlas following with . %, . %, and %, respectively (fig. b) . overall, the most highly represented subspecialties included vascular ( . % of the videos), tumor ( . %), and skull base surgery ( . %) (fig. ) . spine, pediatrics, functional, peripheral, and trauma followed with . %, . %, . %, . %, and . % of the videos, respectively. additionally, videos ( . %) depicted endoscopic surgery (data not shown). (fig. ) . aside from the videos of the neurosurgical atlas, which were contributed by dr. over the last years, education at all levels has undergone radical change brought about by the digital revolution and the ever increasing access to information. increasingly, curricula have adopted elearning, which refers to an approach to teaching and training that utilizes electronic media in order to facilitate learning. - elearning may occur in either a synchronous fashion, in which the instructor and learner interact in real time, or in an asynchronous manner, in which the material has been prerecorded. in either case, elearning relies on the use of web . tools-dynamic tools and technologies that provide access to user-generated content. these tools include websites, wikis, blogs, and social networking sites, all of which can be harnessed by medical educators. [ ] [ ] [ ] [ ] within neurosurgery, numerous electronic resources, including but not limited to the surgical videos serve a number of critical roles. first and foremost, such videos are an invaluable resource for neurosurgical trainees. as stated by james rutka, "if a picture is worth a thousand words, just imagine the relative worth in words of an operative video!" it is not surprising, therefore, that many medical students and residents use online videos to supplement their traditional learning and prepare for cases. , data from the neurosurgical atlas project show that operative videos have become increasingly popular over time, with the web site logging an increased number of video sessions. , the increased web traffic has been attributed largely to an increase in "trainee engagement," with a large proportion of the visitors being in the - year age group. residents who participate in video-based training have been shown to achieve learning milestones in shorter amounts of time, presumably due to the ability to repeatedly watch a video prior to performing the procedure. conversely, videos of trainees can be used to assess their operative skills. assessment tools have been developed to confirm the competency of general surgery trainees and have been shown to be highly reliable, thereby providing an objective way to "grade" surgical competence. although used primarily by surgical trainees, operative videos can also facilitate postgraduate education. a study that used optoelectronic and video motion analyses to record kinematic data demonstrated that consistent, specific movements and tasks are performed by experienced neurosurgeons when performing microvascular anastomoses. using edited j o u r n a l p r e -p r o o f operative videos to continually review the technical steps performed by master neurosurgeons is key to refining the science, as well as the art of neurosurgery throughout our careers. indeed, a survey of neurosurgeons in india found that % of senior neurosurgeons reported that online neurosurgical videos helped improve their surgical skills. whether used by neurosurgical trainees or established attendings, web-based operative videos appear to play an important role globally, particularly in low-to-middle income countries where limited resources restrict the access of many surgeons to journals, cadaver labs, workshops, and conferences. , while there are also barriers to the utilization of web-based resources, including limited technology, limited access to the internet, limited user support, and language and cultural barriers, the free nature of many electronic resources offers an opportunity to expand neurosurgical educational efforts to the developing world. , , , a survey of neurosurgeons in india found that % of senior neurosurgeons, % of junior consultants, and % of resident trainees found online videos helpful in improving their surgical skills. the authors concluded that e-learning platforms can help provide educational opportunities to neurosurgeons across globally diverse environments-trainees, consultants, and senior surgeons in urban, semi-urban, and rural areas alike. anyone with internet access anywhere in the world can watch online videos and learn from them. this low-cost resource avoids the expenses associated with journals and textbooks, and is readily available to all neurosurgeons throughout the world. given the theoretical utility of online operative videos for facilitating global neurosurgical education, are such videos actually being used on an international scale? analytics j o u r n a l p r e -p r o o f data from the neurosurgical atlas suggest that the online resource is, in fact, being used globally. between and , while the single largest group of people accessing the site came from the united states ( % of viewers), the remainder came from brazil ( %), india ( %), and a variety of other countries. in an updated analysis between and , the overall breakdown was similar with % of viewers originating from the united states, % from india, and % from brazil, but impressively, users from individual countries accessed the website. conversely, although electronic resources are being utilized by an international audience, contributions to those very resources seem to be more consolidated. a survey of neurosurgeons in india found that although the vast majority of respondents used online videos, only % had previously uploaded videos of their own. similarly, in the current study, of the , videos that were reviewed, , ( . %) were contributed by institutions based in the united states. our study also demonstrates that in addition to geographic consolidation, the operative videos are heavily weighted toward several neurosurgical subspecialties-tumor, vascular, and skull base in particular-which account for . %, . %, and . % of the videos, respectively. overall, % of the videos in this study were related to or more of these subspecialties. at the other end of the spectrum, functional, peripheral nerve surgery, and trauma account for only . % of the overall videos. spine surgery, in particular, is notable for representing a relatively low percentage ( . %) of the overall videos, but a relatively high percentage of the overall hits, j o u r n a l p r e -p r o o f suggesting a demand for additional spine-related videos. further analyses of the number of views or hits should be used in the future to help guide calls for additional videos. the disparity in subspecialty representation is likely due, at least in part, to the technicalities of recording video during a surgery. the intraoperative microscopes and endoscopes used during tumor, vascular, and skull base cases have built-in recording features that afford the audience the same view seen by the surgeon, whereas these technologies are not typically required for many of the other subspecialties. nevertheless, website analytical data have shown that among visitors to the neurosurgical atlas site, general neurosurgical topics were viewed the most frequently, and that other subspecialty topics (tumor, vascular, pain, epilepsy, and spine) were viewed with a similar frequency. there seems to be demand for a well-rounded assortment of videos, particularly if these videos are to be used to build or supplement a neurosurgical curriculum. overhead lights with built-in cameras, miniature cameras mounted to headlights, and other emerging technologies can be used to capture surgical recordings without a microscope or endoscope. additionally, the "call for videos" format employed by neurosurgical focus: video provides a unique opportunity to guide the topics of videos that are submitted to the journal. upcoming topics include "surgery for cranio-cervical deformity and instability," "surgery for pain", and "craniosynostosis," suggesting a recognition by the editors that these are areas that have been underrepresented to date. operative videos that are accessible online, particularly those that are found on usergenerated video-sharing sites, come with an important caveat: many have not been peerreviewed, and the reliability of the content has not been verified. without academic oversight, poor-quality videos demonstrating false information and poor techniques can make their way j o u r n a l p r e -p r o o f onto the internet, particularly when there are conflict of interest issues in play-for instance, videos that highlight specific instrumentation rather than a surgical technique. calls for a more scholarly approach have resulted in the development of validated scoring scales, such as the discern instrument. , discern is a rating tool that assigns a score out of based on questions that are each rated on a scale of to . although initially designed to evaluate written consumer health information, the discern instrument has also been used to grade online videos based on critical assessments of their content. , , an analysis of the top videos on youtube related to neurosurgery used the discern instrument to evaluate each video and demonstrated that videos that were created by physicians and academic institutions were of higher quality. however, the discern tool was specifically designed to assess consumer health information-resources for patients and the lay public-rather than operative videos to be watched by other surgeons. other criteria are likely to be of value when evaluating a surgical video. the same study of neurosurgical youtube videos found that of the operative videos that were identified, only % had auditory commentary, and only % provided educational learning points, thereby lessening their educational impact. the authors called for clinicians and institutions to "hold themselves and each other to a higher standard of content creation." in contrast, the video sources that were analyzed in the current study are examples of high-quality video libraries that are endorsed by senior neurosurgical leadership, national/international neurosurgical associations, and respected neurosurgical publications. in particular, operative neurosurgery and neurosurgical focus: video are unique and forwardthinking resources that emphasize the importance of the peer-review process. indeed, a breakdown of the number of videos uploaded each year suggests that authors are increasingly turning to these journals as a destination for their videos, rather than youtube channels. videos published in these journals are indexed in pubmed, which has likely contributed to their j o u r n a l p r e -p r o o f popularity. the journals have a more formal structure for their submissions-videos are encouraged to include a brief history and physical, pertinent imaging, positioning, exposure, closure, and postoperative imaging, in addition to the "critical" aspect of the surgery. including these details, while remaining concise, is essential for ensuring that these videos maximize their educational potential. it is equally important to include sufficient follow-up information, so that the viewer may understand the impact of various surgical techniques on the patient's outcome. videos that highlight techniques for managing complications should be encouraged; viewers are otherwise at risk for developing a false sense of security by watching highly selected videos that only demonstrate the best outcomes. a modified discern instrument that takes these factors into consideration may be useful both as part of the peer review process, as well as for neurosurgeons viewing a published video. features that can be assessed include: ) a disclosure of conflicts of interest, ) audio commentary, ) a history and physical, ) preoperative imaging, ) a discussion of preoperative decision-making, ) patient positioning, ) the exposure and closure, ) annotation of the relevant anatomy with labels, and ) a discussion of the postoperative course and long-term follow-up. depending on the targeted forum for the video, a short discussion with educational learning points may follow the operative portion of the video, as well. developing such a tool may assist in maintaining high standards for neurosurgical operative videos, thereby maximizing their educational impact. there are several important limitations to this study. the current analysis is not a complete inventory of the existing operative videos, as there numerous youtube videos that are sponsored by individual surgeons and/or institutions. our goal was to provide an overview of j o u r n a l p r e -p r o o f those videos that are specifically endorsed by reputable neurosurgical organizations. we provide a snapshot of the available videos to date, but as new videos are frequently uploaded, the numbers cited in the current study may rapidly change. additionally, the video sources that were selected for analysis are based in north america, which is an important confounder when considering the analysis of geographic representation. future studies will be necessary to truly assess the global contribution to neurosurgical operative videos, which was not within the scope of the present study. future studies may also provide more detailed analyses of operative videos dealing with an individual surgical technique. operative videos are only one component of the electronic resources that are currently being used to supplement neurosurgical education. the neurosurgical atlas, for instance, contains not only operative video cases, but also "volumes" with text-based explanations of various topics, as well as "grand rounds" webinars. these other multimedia formats are important elements of building a full neurosurgical curriculum, but a full analysis of these resources was outside the scope of our study. additionally, while prior publications have used web . analytics to study web traffic data, we were unable to do so as such tools are limited to the owners of the individual website. , , however, knowing which operative videos are most frequently viewed would help identify the need for additional video topics in a dynamic manner. neurosurgical operative videos are a useful educational adjunct, both for neurosurgical trainees as well as for the continued education of neurosurgery attendings. to date, most of the operative videos that are accessible have come from surgeons in the united states and relate to tumor, vascular, and/or skull base cases. while these videos are typically of high quality, future j o u r n a l p r e -p r o o f efforts may benefit from the curation of videos highlighting underrepresented subspecialties, providing long-term follow-up data, and demonstrating techniques for managing complications. the authors wish to thank andrew j. gienapp (neuroscience institute, le bonheur children's hospital and department of neurosurgery, university of tennessee health science center, memphis, tn) for copy editing and publication assistance. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. challenges of neurosurgery education during the coronavirus disease (covid- ) pandemic: a u.s. perspective. world neurosurg impact of covid- on neurosurgery resident training and education innovations in neurosurgical education during the covid- pandemic: is it time to reexamine our neurosurgical training models? letter: maintaining neurosurgical resident education and safety during the covid- pandemic neurosurgery residency in the covid- era: experiences and insights from thomas jefferson university hospital hernesniemi's and more microsurgical videos of neurosurgery": a legacy for educational purposes neurosurgical digital teaching in low-middle income countries: beyond the frontiers of traditional education integration of elearning technologies in an interprofessional health science course elearning resources to supplement postgraduate neurosurgery training popularity of online multimedia educational resources in neurosurgery: insights from the neurosurgical atlas project what medical educators need to know about "web . studying behaviors among neurosurgery residents using web . analytic tools editorial: mastering the art of complex neurosurgical procedures: the neurosurgical atlas and the journal of neurosurgery neurosurgery videos on online video sharing sites: the next best teacher? youtube is the most frequently used educational video source for surgical preparation the neurosurgical atlas: advancing neurosurgical education in the digital age nonspecialist raters can provide reliable assessments of procedural skills evaluating competency in video-assisted thoracoscopic surgery (vats) lobectomy performance using a novel assessment tool and virtual reality simulation assessment of competence in video-assisted thoracoscopic surgery lobectomy: a danish nationwide study quantitative measures of performance in microvascular anastomoses free-access open-source e-learning in comprehensive neurosurgery skills training structured online neurosurgical education as a novel method of education delivery in the developing world discern: an instrument for judging the quality of written consumer health information on treatment choices publishing and aggregating video articles: do we need a scholarly approach? evaluation of the quality of information on the internet available to patients undergoing cervical spine surgery knopf: investigation, data curation, formal analysis, writing -review and editing rahul kumar: investigation, data curation, formal analysis, methodology, visualization, writing -review and editing michael barats: investigation, data curation, writing -review and editing supervision, writing -review and editing boop: supervision, writing -review and editing l. madison michael ii: supervision, writing -review and editing martin: supervision, writing -review and editing markus bookland: supervision, writing -review and editing conceptualization, project administration, supervision, writing -original draft preparation, writing -review and editing key: cord- -rn pkk authors: michiwaki, yuhei; tanaka, tatsuya; wakamiya, tomihiro; tabei, yusuke; samura, kazuhiro; suehiro, eiichi; kawashima, masatou title: emergent carotid artery stenting following intravenous alteplase infusion after rapid negative diagnosis for covid- by loop-mediated isothermal amplification assay: a case report date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: rn pkk background during the coronavirus disease (covid- ) pandemic, a rapid screening method for covid- detection is needed to decide the appropriate strategy to treat stroke patients. in acute ischemic stroke treatment, the efficacy and safety of emergent carotid artery stenting (ecas) for hyperacute ischemic stroke (hais) due to internal carotid artery stenosis (ics) have not been sufficiently established. case description a -year-old man with hais caused by severe ics was treated via intravenous alteplase infusion. the patient underwent screening for covid- by the loop-mediated isothermal amplification (lamp) assay shortly after arrival at our institution. the lamp result was obtained within minutes, during intravenous alteplase infusion, and turned out to be negative. the symptom of hemiplegia worsened during alteplase infusion, and he, therefore, underwent ecas after administration of aspirin ( mg). recanalization was achieved successfully by ecas, and dual antiplatelet therapy and argatroban were administrated following ecas. hemorrhagic complications or re-stenosis/occlusion of the carotid artery were not observed. he was discharged without neurological deficits days following ecas. because of the rapid negative diagnosis for covid- using the lamp method, ecas could be performed following standard procedures, along with infectious defense, without delay. conclusions this case report suggests that ecas for hais due to ics following intravenous alteplase can be an effective treatment, along with appropriate antiplatelet medication and management in select patients. during the covid- pandemic, the lamp assay for covid- detection might be a suitable diagnostic strategy preceding stroke treatment because of the rapid turnaround time. during the coronavirus disease (covid- ) pandemic, a rapid screening method for covid- detection is needed to decide the appropriate strategy to treat stroke patients. in acute ischemic stroke treatment, the efficacy and safety of emergent carotid artery stenting (ecas) for hyperacute ischemic stroke (hais) due to internal carotid artery stenosis (ics) have not been sufficiently established. a -year-old man with hais caused by severe ics was treated via intravenous alteplase infusion. the patient underwent screening for covid- by the loop-mediated isothermal amplification (lamp) assay shortly after arrival at our institution. the lamp result was obtained within minutes, during intravenous alteplase infusion, and turned out to be negative. the symptom of hemiplegia worsened during alteplase infusion, and he, therefore, underwent ecas after administration of aspirin ( mg). recanalization was achieved successfully by ecas, and dual antiplatelet therapy and argatroban were administrated following ecas. hemorrhagic complications or re-stenosis/occlusion of the carotid artery were not observed. he was discharged without neurological deficits days following ecas. because of the rapid negative diagnosis for covid- using the lamp method, ecas could be performed following standard procedures, along with infectious defense, without delay. this case report suggests that ecas for hais due to ics following intravenous alteplase can be an effective treatment, along with appropriate antiplatelet medication and management in select patients. during the covid- pandemic, the lamp assay for covid- detection might be a suitable diagnostic strategy preceding stroke treatment because of the rapid turnaround time. j o u r n a l p r e -p r o o f the coronavirus disease (covid- ) pandemic has had a significant impact on treatment paradigms of all diseases. [ ] [ ] [ ] [ ] for instance, patients with acute ischemic stroke (ais), who must be treated appropriately and promptly, should be screened for covid- simultaneously. - therefore, a rapid screening method for covid- is needed to help decide the proper treatment strategy for stroke patients. carotid artery stenting (cas) is a standard treatment procedure for internal carotid artery stenosis (ics) ; however, the efficacy and safety of emergent cas (ecas) for hyperacute ischemic stroke (hais) due to ics have not been sufficiently established. herein, we aimed to report a case of hais due to severe ics, which was successfully treated with ecas following intravenous alteplase infusion. moreover, the patient underwent screening for covid- by the loop-mediated isothermal amplification (lamp) method shortly after admission, and ecas was performed using standard procedures without any further delay because the lamp assay revealed a negative diagnosis for covid- immediately before ecas. this case report not only demonstrates the effectiveness of ecas for treatment of hais, but also shows the value of using the lamp assay for covid- screening to enable prompt treatment of hais. j o u r n a l p r e -p r o o f a -year-old man was admitted to our institution due to sudden dysarthria and slight left hemiplegia in may . he had a history of atrial fibrillation, hypertension, and diabetes mellitus, and had been receiving oral administration of dabigatran. due to the covid- pandemic, a nasopharyngeal swab specimen collected from the patient was examined using the lamp assay immediately upon arrival according to the protocol of our institution. the duration from onset to admission was minutes, and the score on the national institutes of health stroke scale (nihss) was / . computed tomography (ct) performed minutes following admission showed a slight ischemic change at the right frontal lobe (alberta stroke program early computed tomography score: ). ct angiography demonstrated severe ics and poor blood flow in the right intracranial internal carotid artery (ica) ( figure a , b). the patient was diagnosed with hais due to ics and was then treated with intravenous alteplase (time from onset to infusion: minutes; time from admission to infusion: minutes). magnetic resonance imaging (mri) performed during intravenous alteplase infusion revealed sporadic infarction in the right cerebrum ( figure c ). the symptoms of hemiplegia improved upon the initiation of intravenous alteplase infusion, but got worse again during the alteplase infusion. thereafter, we decided to perform an ecas following administration of aspirin ( mg). as the lamp assay revealed a negative diagnosis for covid- during intravenous this case report highlights two important findings. first, ecas following intravenous alteplase infusion for hais due to ics was effective and safe in this patient. second, the lamp assay was a suitable screening tool for covid- preceding stroke treatment because the results could be obtained rapidly. intravenous alteplase has been proven to improve patient outcomes following hais, , and endovascular thrombectomy has become the standard treatment for hais due to large vessel occlusion in the anterior circulation. [ ] [ ] [ ] [ ] [ ] [ ] however, the efficacy of ecas for hais due to ics has not been established. since alteplase is a thrombolytic drug, it cannot be used to treat plaque-based atherosclerotic stenosis. moreover, chronic atherosclerotic stenosis could not be removed easily by mechanical thrombectomy. therefore, it seems reasonable to assume that ecas can contribute to recanalization success in patients with hais due to ics. in the present case, we decided to perform ecas because the symptoms of hemiplegia worsened, despite intravenous alteplase infusion. while some studies have reported the efficacy and safety of ecas, , most of them performed cas within a few days to two weeks following the onset of ais, and studies demonstrating successful ecas for hais are rare. one of the reasons that the efficacy of ecas has not been sufficiently ascertained is thought to be the risk of ica occlusion caused by in-stent thrombosis due to the insufficient efficacy of antiplatelet agents administered j o u r n a l p r e -p r o o f before ecas. although administration of antiplatelet medication before elective cas has been recommended, the ideal regimen of ecas for hais has not been established. high dose antiplatelet medication could decrease the risk of in-stent thrombosis; however, it may increase the risk of intracranial hemorrhage, particularly in patients who have undergone intravenous alteplase treatment. deguchi et al. reported three cases of ecas for hais immediately after intravenous alteplase treatment. they administrated antiplatelet agents at the loading dose (cases and : mg clopidogrel + mg aspirin; case : mg clopidogrel) before ecas; case presented with an asymptomatic intracranial hemorrhage, and an ica occlusion due to in-stent thrombosis occurred in case . in the present study, the patient was administrated mg aspirin before ecas, which was less than the dose used in a previous study. the patient presented neither in-stent thrombosis nor hemorrhagic complications. therefore, the dose of antiplatelet agents used or the postoperative management performed in this case might have been appropriate. additionally, we used carotid guardwire and a carotid wallstent under pfc. one study has indicated that ecas for ais under pfc is effective and safe. this case report provides evidence that could improve the management of ecas cases following intravenous alteplase infusion. with the recent development of endovascular treatment, effective and safe therapeutic or management strategies for hais can be established. the outbreak of covid- has had a major impact on the treatment of stroke. [ ] [ ] [ ] [ ] although patients with hais should be treated rapidly, physicians have to simultaneously evaluate the patients for covid- infection. [ ] [ ] [ ] real-time polymerase chain reaction (rt-pcr) is a standard method for covid- detection; however, it takes a long time to obtain the results. therefore, the optimal time window for the treatment of stroke may be exceeded if the physicians wait until a rt-pcr result is known; conversely, stroke treatments performed without waiting for the diagnostic test results for covid- involve risks of nosocomial infections. practically, stroke treatment might have to be performed under personal protective equipment (ppe), including n respirators. , , , these clinical problems can be overcome if a rapid and simple diagnostic method for covid- screening can be developed. in the case presented here, we used the lamp assay for covid- screening. the lamp assay is a rapid, sensitive, and effective visual nucleic acid amplification method that has been widely applied for the detection of certain viruses. [ ] [ ] [ ] the results of the lamp assay can be obtained in minutes, with high sensitivity and specificity. , moreover, the lamp assay does not require expensive reagents or instruments. in this case, because the result of the lamp assay revealed a negative diagnosis for covid- during intravenous alteplase infusion, ecas could be achieved with standard equipment and procedures according to the protocol of our institute without delay. thus, the lamp assay might be suitable for covid- detection during stroke treatment because the diagnosis can be rapid. however, some uncertainty remains about whether a negative result on the lamp assay can confirm whether the patient is truly covid- -free; therefore, it is advisable to use ppe, even for patients with a negative diagnosis of covid- . , , , future clinical cohort studies evaluating the lamp assay for use in covid- screening in clinical practice will be necessary. in addition, in cases that require extremely prompt treatment for stroke when a team cannot wait even for the results of a lamp assay, it seems unavoidable that one must prioritize the stroke treatment without knowing the patient's covid- infection status while following the appropriate procedures for preventing infection. , , , rapid and accurate diagnostic methods for detecting covid- should, therefore, be developed or improved upon urgently. this case report demonstrates that ecas for ais due to ics following intravenous alteplase infusion can be an effective treatment option along with appropriate antiplatelet medication and management in select patients. during the covid- pandemic, the lamp assay for covid- detection might be a suitable diagnostic method preceding stroke treatment because the diagnosis can be made rapidly. a novel coronavirus from patients with pneumonia in china world health organization challenges and potential solutions of stroke care during the coronavirus disease (covid- ) outbreak protected code stroke: hyperacute stroke man-agement during the coronavirus disease (covid- ) pandemic letter: academic neurosurgery department response to covid- pandemic: the university of miami/ jackson memorial hospital model preparing a neurology department for sars-cov- (covid- ): early experiences at columbia university irving medical center and the new york presbyterian hospital neurosurgical impact of coronavirus disease (covid- ): practical considerations for the neuroscience community long-term results of carotid artery stenting versus endarterectomy in high-risk patients national institute of neurological disorders and stroke rt-pa stroke study group. tissue plasminogen activator for acute ischemic stroke thrombolysis with alteplase to . hours after acute ischemic stroke a randomized trial of intraarterial treatment for acute ischemic stroke randomized assessment of rapid endovascular treatment of ischemic stroke thrombectomy within hours after symptom onset in ischemic stroke stent-retriever thrombectomy after intravenous t-pa vs. t-pa alone in stroke endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials endovascular therapy for ischemic stroke with perfusion-imaging selection safety and effectiveness of emergency carotid artery stenting for a high-grade carotid stenosis with intraluminal thrombus under proximal flow control in hyperacute and acute stroke emergency carotid artery stent placement in patients with acute ischemic stroke carotid artery stenting in acute stroke carotid artery stenting for acute ischemic stroke patients after intravenous recombinant tissue plasminogen activator treatment society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid- rt-lamp for rapid diagnosis of coronavirus sars-cov- loop mediated isothermal amplification (lamp) assays as a rapid diagnostic for covid- rapid and visual detection of novel coronavirus (sars-cov- ) by a reverse transcription loop-mediated isothermal amplification assay computed tomography; ecas, emergent carotid artery stenting hyperacute ischemic stroke; ica, internal carotid artery; ics, internal carotid artery stenosis mri, magnetic resonance imaging; nihss, national institutes of health stroke scale; pfc, proximal flow control; ppe, personal protective equipment we would like to thank editage (www.editage.com) for english language editing. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. j o u r n a l p r e -p r o o f acknowledgements we would like to thank editage (www.editage.com) for english language editing. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f key: cord- -mbe dt v authors: sharif, salman; amin, faridah; hafiz, mehak; benzel, edward; peev, nikolay angelov; dahlan, rully hanafi; enchev, yavor; pereira, paulo; vaishya, sandeep title: covid -depression and neurosurgeons date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: mbe dt v nan the novel coronavirus initially originated in china and has rapidly spread globally. the growing pandemic of severe acute respiratory syndrome coronavirus diseases (covid- ) has become a significant public health liability worldwide. the covid- pandemic has grown into one of the central health crises of a generation. it has affected people irrespective of nation, race, caste, and socioeconomic groups. on th jan , the who (world health organization) announced the emergence of the novel coronavirus. it declared a pheic (public health emergency of international concern), which is the sixth pheic under the ihr (international health regulations). the rapid increase in cases and evolving guidelines regarding protection and prevention of the spread of pandemic, with no confirmed treatment or approved vaccine has caused apprehension and anxiety among health care workers. unpredictability in the biological behavior of the virus, erratic changing instructions from who, variable guidelines regarding quarantine and management of the pandemic have increased the uncertainty. as of the first week of may , , , covid positive cases with , confirmed deaths have been reported worldwide and countries are affected by the pandemic. so far, more than , health-care providers have been infected with covid- in china, and more than doctors have died in italy , . in the united states, approximately , nurses, doctors, and other frontline health care workers have been infected by the disease, and dozens have died. across western europe, nearly percent out of confirmed coronavirus cases are medical professionals which is the highest reported cases among doctors and nurses. moreover according to the report on rd april , at least doctors have died,and more than , health workers have self-isolated in countries across asia and pacific region, therefore concerns among healthcare professionals are well-founded. the pandemic is serious and disruptive , yet despite the widespread infectivity and higher mortality than the common influenza virus, not much is known regarding management of critical cases, prevention and optimal measures to reduce its spread. scarce resources and an often inadequate availability of personal protective equipment (ppe) and lack of knowledge about their optimal usage can further lead to apprehension, distress, panic and anxiety in health care workers. the covid associated health crisis has disrupted working of all medical communities around the world, including delivery of essential medical and neurosurgical services. the hasty outpouring numbers of covid positive cases, not only presents a public health challenge but also have significant medical and ethical implications for the care of neurosurgical patients. currently, there is a paucity of literature guiding neurosurgery practice. neurosurgical societies have developed and published guidelinesto promote best practices for their patients. however, implementation of these guidelines is a challenge in many parts of the world where health care systems are not well established, but adjustments during an event like the covid- pandemic have been made. it may provoke even more distress and depression within the neurosurgical fraternity. a survey was developed to assess to stressors affecting neurosurgeons as a result of the pandemic. the goal of this survey was to determine the prevalence and factors associated with anxiety and depression among neurosurgeons during the covid- pandemic. while the full impact of the pandemic remains to be seen, this survey aimed to determine the frequency of depression among neurosurgeons during the pandemic and explore any modifiable factors that could be addressed to reduce the incidence of distress and mental illness among neurosurgeons. this was a cross-sectional study design conducted through an anonymous online questionnaire with only information about the city and no contact information to address ethical implications of the survey. the study duration was weeks (until the requisite sample sizewas achieved). the questionnaire was modified based on suggestions fromworld spinal column society (wscs) executive board members. majority of the members of the world spinal column society are neurosurgeons, who also perform spinal surgery. the survey was designed on google form and sent to neurosurgeons who were members of scientific societies globally through wscs executive committee. the survey was circulated to members of wscs on their social media, whatsapp groups and emails, and through snowballing technique locally and internationally. the neurosurgeons identified through these media were asked to forward the survey to other neurosurgeons in their professional circle and so on. out of total neurosurgeons who were approached, responded. a recent chinese study showed a . % ( / ) prevalence of mild to moderate depression among physicians during the covid pandemic. depression was assessed through a world health organization validated questionnaire (selfreporting questionnaire, srq- ). a cut-off score of or more was considered as positive for depression. dependent variable: depression graded on who srq - with a cut-off score of or more for a positive case of anxiety/depression. univariate binary logistic regression was applied to determine association of each independent variable with the outcome (anxiety/depression). multivariate logistic regression was used to measure the association of multiple independent variables with the outcome (anxiety/depression) by computing adjusted odds ratios and their % confidence intervals. variables with p-value < . in univariate analysis were subsequently included in the multivariate logistic regression model. statistical significance was assumed for p-value< . in the multivariate model. consent was taken from all those who filled the online questionnaire. the participant's identity and name of the institution was not disclosed. all data were kept confidential in a password protected computer. there was no financial compensation for participation nor any penalty for not participating. a total of neurosurgery trainees and consultants from countries and continents participated in the survey (figure ). the majority of the respondents were from asia (n= , . %) (figure ). table shows the distribution of socio-demographic factors among participants. the majority of the participants were consultants ( %) from low to middle-income countries ( %). more than half were younger than . among all participants, % worked in departments with or more staff ( %), while more than half of the respondents reported having less than trainees in their departments ( . %). table shows the distribution of responses regarding the covid- pandemic. almost % reported basic to moderate knowledge about the pandemic. sources of information are depicted in figure . the most common source of information was scientific publications, while almost half of them also used social media as a source for information. the majority ( %) of the participants thought that it would take more than two months for the pandemic to end. (figure ) majority of the participants ( %) said that enough information had been provided by their institutions regarding the covid pandemic. % reported that they had not been provided ppe by their hospital, though more than half have attended training courses arranged by their institutions. among consultants and trainees, . % reported that they did not feel safe during the pandemic. the majority ( %) had severe concerns regarding the safety of their families back home. % reported that they had been exposed to a covid positive case among colleagues. of these, % had been quarantined or self-isolated themselves, . % got admitted for quarantine. surprisingly, % continued work, while . % took no action at all on being exposed. . % of the respondents reported that their primary concern during this pandemic was the inadequate provision of ppe. the majority (n= , . %) of the neurosurgeons said that as a routine, their weekly surgery volumes were more than cases. in comparison, during the pandemic, ( %) said they were doing fewer than surgeries /week (p< . ). similarly, the majority (n= , . %) reported performing more than % elective surgeries before the pandemic, while ( . %) said that the number of elective surgeries during covid- pandemic reduced to % or less (p< . ). families of % of neurosurgeons did not feel safe for them going to work. about / ( %) of the participants were redeployed to a covid affected area for work during the pandemic, and the majority ( %) thought that redeployment would not be useful considering their knowledge and expertise. a . % prevalence of anxiety/depression was found among neurosurgery trainees and consultants in this study. among all participants, % felt tensed, . % were unhappy, % experienced insomnia, almost % had headaches, were easily fatigued or tired and thought that they were unable to play a useful part in their life, % had difficulty in decision making, % cried more than usual, while, % had suicidal ideation during the pandemic (table ) . table shows the univariate and multivariate analysis for the association of different factors with anxiety and depression among neurosurgical trainees and consultants. the likelihood of depression was higher among those who didn't receive information or self-protection from their institutions to combat the situation than those who got it (or= . , % ci: . - . ). those who reported that they didn't feel safe with provided ppe were also at a higher risk of depression (or= . , % ci: . - . ). anxiety and depression were less likely among those who had minor (n= , %) and moderate concerns (n= , . %) for the health of their families as compared to participants who were more concerned for their families during the current pandemic situation (n= , . %). univariate odds ratios showed that the likelihood of depression was significantly lower in neurosurgeons who had minor concerns as compared to those with significant health concerns for their families (or = . , % ci . - . ). the prevalence of depression was also significantly higher in participants whose families considered their workplace unsafe (or= . , % ci: . - . ). in multivariate analysis (table ) , effects of the following variables were controlled; age, selfrating of covid- knowledge, information regarding protection provided by hospital, feeling safe with provided protective equipment, degree of concern for family health, presence of positive covid- colleagues and families considering the workplace safe. after controlling for the effects of other covariates, the odds of depression were significantly higher in individuals who did not feel safe with the ppes provided to them than those were satisfied with provided ppes (or= . , % ci: . - . ). participants who had moderate concerns for their families had lesser odds of anxiety and depression than those with significant concerns (or= . , % ci: . - . ). being exposed to a covid- positive colleague significantly increased the likelihood of anxiety/depression, even after adjusting for other covariates (or= . , % ci: . - . ). the covid- pandemic is spreading across the globe at an exponential rate, creating apprehension and distress among all healthcare professionals. neurosurgeons being an essential part of the healthcare community are also affected in a major way. belonging to a fundamental surgical specialty, tackling emergencies and performing complex operations requiring significant dexterity, hypothetically enable them to deal with stressful situations, making them less prone to develop anxiety and depression . this may only be an assumption as we did not find any study to determine the frequency of anxiety/depression among this specialty before the pandemic. it is for the first time that depression was found among % of neurosurgeons. it cannot be said with conviction if this frequency is higher than that before the pandemic but a study done in among surgeons, demonstrated a rise in prevalence of depression post sars outbreak with a % increase in suicide. poor mental health is a social stigma moreover, a fear of being judged may explain neurosurgeons having a lower depression score as was seen in another study assessing level of stress among surgeons. this may be one of the reasons that despite mental health problems and psychosocial issues among health-care workers, most of them do not often seek mental health care. majority of the participants were consultants ( %), and almost half of them were years of age and above. the senior neurosurgeons were less likely to be anxious and depressed, though the results were not statistically significant. in relation to this finding, a recent nhs survey also indicated that % of young physicians suffered from mental health issues, while retired physicians and surgeons were more enthusiastic to volunteer for covid duties. , there was no difference in the frequency of depression among neurosurgeons working in private or government/ university hospitals. though, a significant decrease in workload may be a potential risk factor leading to psychological distress, yet a non-differential change between workload of private and public sector explains our finding, as confirmed by a recent survey by walter jean. the covid- pandemic has a global impact, irrespective of race, caste, color or creed, with widespread xenophobia especially among the medical fraternity regarding their families' and their own health (unpublished data). despite trying times, this survey showed no difference in depression among the neurosurgeons, whether they belonged to high-income ( . %) or middle/lower-income countries ( . %), european ( . %) or non-european ( %) countries. although, a recent chinese study reported a much higher prevalence of depression ( . %), anxiety ( . %) and insomnia ( %) among frontline health care workers. this translates to the fact that more than the income, specialty or region, the area of practice influences mental health, predisposing to an increased sense of insecurity and hence psychological distress. the requirement for quarantine, social distancing, and shelter-in-place orders have lead to an abrupt change in life styles and may be leading to increased apprehension among families especially of healthcare workers. not only families of neurosurgeons felt unsafe for them to go to work but the surgeons themselves reported concerns for the safety of their families back home. therefore a feeling of self-protection with provided ppe had a significant negative association with anxiety/depression while a positive covid colleague increased the likelihood of depression among neurosurgeons. a recent survey in uk reported half of health workers suffering from stress due to inadequate availability of ppe. this pandemic has disturbed functioning of all medical and surgical specialties. selected emergency neurosurgery cases are being performed in special circumstances only such as trauma, severe acute functional impairment and tumors causing impending disability. neurosurgical approaches through the nose and sinuses are being postponed due to high risk of viral transmission and updated neurosurgical guidelines for the treatment of positive or suspected covid patients have been circulated. the covid crisis has hence led to a considerable decrease in elective cases (p< . ). walter jean also showed a drop of more than % operative volume during the present pandemic. though our study did not find a significant association between this drop in elective cases and anxiety/depression among neurosurgeons, yet if this status quo is further extended, it may lead to impending depression as one third of our participants were unhappy, felt tensed, experienced insomnia, headaches and felt fatigued and tired. moreover, one in respondents cried more than usual and had suicidal ideation. this hypothesis is confirmed by another study conducted at liaquat national hospital on frontline physicians (unpublished data) which found that there was more depression in physicians who were working < hours a week compared to those who are working > hours during the pandemic. although the potential shortage of ventilators and icu beds necessary to care for the surge of critically ill patients has been well described, additional supplies and beds will not be helpful unless there is an adequate workforce. according to our data, about % of the participants were redeployed to a covid affected area, during the pandemic. nevertheless, % of neurosurgeons believed that their knowledge and expertise in an unknown environment would not be useful, and their work will not be meaningful if redeployed out of their specialty. to our knowledge, this is the first study ever to determine the frequency and factors associated with anxiety and depression among neurosurgeons from countries. the prevalence of depression and anxiety among neurosurgeons was found to be lower than the frequency reported among other frontline workers during the covid pandemic. yet, it is difficult to conclude the magnitude of the problem attributable to the pandemic, as there is a paucity of data regarding mental illness among neurosurgeons before the catastrophe. in a recent survey among neurosurgery residents, the risk of burnout was found to be . % and higher working hours was one of the drivers for burnout ( ) while another survey found a . % burnout among neurosurgeons ( ) . as both these surveys did not explore depression or anxiety, results of our study are not comparable, yet, as the working hours during the pandemic have considerably reduced, it can be extrapolated that the frequency of burn out would be consequentially less. , mental illness is a social stigma around the globe and this may be more of an issue among fraternities who are considered as the "resilient lot" such as the neurosurgical specialty, hence leading to an underreporting of symptoms. only one scale (srq- ) was used to screen for anxiety /depression, as asking too many questions on an online survey was inconvenient and would have lead to missing data. moreover in online surveys, there is always a high probability of participation bias because the participants, based on their state of mind at the time of the study, may or may not choose to participate in the study. though, it may lead to non-differential participation bias. with the evolving pandemic, the situation is still dynamic in various countries around the globe. circumstances have varied from day to day, and hence the response of participants may be different according to their changing situation. therefore, the survey being filled readily by participants having more concerns regarding the ongoing pandemic may have introduced a bias. although we tried to control for confounders during recruitment as well as analysis stage through multivariate analysis, yet there is a possibility that we may have missed potential confounders which may have exaggerated or masked the associations. yet, the factors associated with anxiety/depression among neurosurgeons in the multivariate analysis are all biologically plausible. the world is going through an unprecedented crisis, which caused turmoil in all the countries in the world. the health system in decades has not dealt with such a disaster. neurosurgeons, like all other specialties, are affected and experiencing challenges in their work and daily living. colleagues getting infected, feeling of being unprotected and concerns for the health of their families were factors found to be associated with anxiety/depression. we therefore recommended that the safety of the health-care workers be ensured by providing standard ppe and having optimum safety measures for them to regain confidence and hence reduce the incidence of mental ailments. less than weeks to weeks to months more than months don't know never death from covid- of health care workers in china doctors and healthcare workers at frontline of covid epidemic: admiration, a pat on the back, and need for extreme caution factors associated with mental health outcomes among health care workers exposed to coronavirus disease validation of the who self-reporting questionnaire srq- ) item in primary health care settings in eritrea stress in surgeons. the british journal of surgery uk military doctors; stigma, mental health and help-seeking: a comparative cohort study mental health and a novel coronavirus ( -ncov) in china clinical depression: surgeons and mental illness the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study factors associated with career satisfaction and burnout among us neurosurgeons: results of a nationwide survey we thank ms. noureen durrani for statistical analysis of the data and mr. imad ullah for helping throughout the study. key: cord- -zki ac g authors: pena, robert c.f.; khatri, deepak; kwan, kevin; d'amico, randy s. title: in reply to the letter to the editor regarding “coronavirus neurosurgical/head and neck drape to prevent aerosolization of coronavirus disease (covid- ): the lenox hill hospital/northwell health solution” date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: zki ac g nan t he authors offer a simple method for reducing aerosol dissemination of the sars-cov- during high-speed drilling neurosurgical procedures. a thin, transparent plastic sheath, originally supplied with the disposable draping set, was utilized in this technique to cover the operative site and contain the aerosol particles generated by the drilling. the authors demonstrated the applicability of their technique in the transcranial resection of a pituitary macroadenoma via pterional craniotomy and a petrotentorial meningioma via retromastoid suboccipital craniotomy. both cases resulted in aggregation of small aerosol clusters on the inner surface of the drape with the removal of larger particles via continuous suctioning underneath it. this idea focuses on procedures with posterior fossa involvement, and builds on recently published methods to reduce aerosolization of airborne sars-cov- from the oropharynx during intubation and extubation and during the entirety of neurosurgical procedures. this simple, cost-effective method can be easily assembled and is flexible with minimal disruption of the surgery being performed, while offering the ability to shield essential personnel in the operating room during procedures involving drilling of air-cells potentially harboring sars-cov- virions. these drapes are also adaptable across multiple surgical protocols and specialties. further optimization and validation of these methods is critical as our understanding of aerosolization and airborne transmission of sars-cov- in and out of the operating room evolves. the research surrounding sars-cov- aerosolization has become well established since the outbreak of the pandemic, and several medical techniques have been found to be culprits of aerosol generation and airborne spread of the virus, including endotracheal intubation, airway suctioning, bag mask ventilation, cardiopulmonary resuscitation, , electrocautery with subsequent formation of "surgical smoke", as well as occurrences as mundane as surgeons breathing and speaking to one another during cases. , for neurosurgery and related specialties, highspeed drills have been shown to generate and spread aerosols across a radius . feet from the source. in addition, these tools are responsible for the production of aerosols with high-viral loads during the disturbance of nasal mucosa (e.g., transsphenoidal pituitary tumor excision). , one simulation study regarding extremely high-risk endonasal procedures, for example, determined a covid- -laden aerosol spread to a radius cm, with maximal particle distribution measured at cm. the inherent risk of endonasal procedures was even determined to be severe enough to prompt the american association of otolaryngology-head and neck surgery (aao-hns) to recommended cancellation of all nonemergent procedures of this subtype during the pandemic. even more so, drills can produce blood and hemoglobin-laden aerosols, which in turn disperses hiv- , hepatitis b virus, and hepatitis c virus particles from seropositive patients, and perhaps sars-cov- as well, as it is known to have some small component of blood-bound transmission. more specific to neurosurgery, the disruption of the blood and meninges of nasally colonized covid- patients may result in additional exposure of surgeons to cerebrospinal fluide bound aerosols, although further research is still necessary. , the benefits of this simple and cost-effective technique are therefore multifaceted. first, it offers protection at high drill settings ( , rpm in this study), thus preserving the integrity and efficiency of drill use without sacrificing speed and mechanical power. hiv- aerosolization, for example, has been shown to occur at slower drill speeds ( , rpm), meaning a precautionary reduction in rotational speed likely does not protect against viral aerosol transmission. , this draping method may therefore provide additional protection to surgeons against multiple viruses aerosolized by a wide range of drill settings, although further research should be conducted regarding covid- aerosol generation in relation to drill speed in neurosurgical and otolaryngology-based procedures. in addition, the high risk of covid- transmission during endonasal procedures is addressed in this and prior draping methods developed and tested by surgical staff. this should result in increased protection of neurosurgeons during emergent endonasal and other cases, while also accelerating the resumption of elective procedures currently being suspended. finally, whereas other researchers have proposed various methods of mask modification or alternate materials to provide barrier protection against covid- aerosol transmission, this and prior draping techniques may offer additional simple, easy to assemble, and cost-effective intraoperative protection. as a result, a nonspecific, affordable, and easily disposable protective sheath, such as the one described here, show great promise in assisting surgical fields in their struggle to perform procedures during the covid- pandemic. one area of concern with regard to this barrier, however, is its composition. plastics and stainless steel, materials ubiquitous throughout operating rooms, have been shown to be favorable fomites for sars-cov- with increased duration of aerosol stability for up to hours after initial contamination. importantly, however, viral load on these materials significantly decreases in comparison to the initial inoculum. because this plastic barrier is disposable, any fears with regard to the use of this new device as a potential fomite can be easily assuaged. regardless, great care with the removal and disposal, as with all surgical and personal protective equipment, must be ensured. to fully appreciate the capabilities and pitfalls of this method, further research into its use should be encouraged. objective parameters assessing its efficiency in collecting and preventing transmission of aerosolized sars-cov- particles should be implemented, including postoperative testing of both the inner and outer surfaces of the drape, personal protective equipment of all practitioners involved, et cetera, with quantitative analysis of viral load per gold standard rt-qpcr. various forms of plastics should also be compared to other transparent materials to determine rate of fomite generation as well. additionally, any combination of this technique with others that address different aspects of a surgical procedure (i.e. intubation/extubation, world neurosurgery : - , november www.journals.elsevier.com/world-neurosurgery posterior fossa involvement, endonasal approach) could merit further benefit to patient and practitioner and should thus be investigated. finally, intraoperative transmission to patients and the operative staff should be critically monitored as a component of local contact tracing protocols. overall, the method proposed by the authors stems from the simple idea of repurposing available resources of a standard operating room to provide an effective barrier against airborne covid- transmission. the drape is universally available, requires no additional cost, and seems easy to implement. specifically, this method provides protection to neurosurgical staff during high-speed drilling in the posterior fossa, whereas previously described drapes focus more on the restricted dissemination of covid- -laden aerosols during intubation, extubation, positive pressure ventilation, and endonasal endoscopic procedures. although the implementation of social distancing, the cancelling of elective procedures and substantial reduction in operative caseload, and profound alterations to the practicing norms of neurosurgeons around the globe have proven effective thus far, the high-acuity nature of neurosurgery demands a more sustainable approach in dealing with a pandemic without a clear end in sight. even more, the cancellation of elective surgical procedures may protect surgical staff to a point, but they still incur substantial risk in the performance of emergent, nondelayable care. as a result, methods of protecting surgeons and staff are critical to safe postpandemic recovery. finally, such devices will allow the resumed provision of timely patient care and hopefully mitigate further losses to hospital financial stability incurred by the cancellation of hundreds of neurosurgical cases per institution per week at a revenue cost of millions of dollars in that same short span of time. these technological advancements will thus help revive a sense of normalcy in the medical community, ensure provision of medical care, allow surgical departments to potentially avoid financial ruin, and promote the health and safety of medical professionals and the public they serve. amico department of neurological surgery, lenox hill hospital/northwell health, donald and barbara zucker school of medicine at hofstra/northwell coronavirus neurosurgical/head and neck drape to prevent aerosolization of coronavirus disease (covid- ): the lenox hill hospital/northwell health solution aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review aerosol-mediated transmission of sars-cov- or covid- in the cardiac surgical operating room surgical smoke: a review of the literature. is this just a lot of hot air? characterization of expiration air jets and droplet size distributions immediately at the mouth opening airflow dynamics of human jets: sneezing and breathing-potential sources of infectious aerosols mastoidectomy and transcorneal viral transmission letter: rongeurs, neurosurgeons, and covid- : how do we protect health care personnel during neurosurgical operations in the midst of aerosol-generation from high-speed drills? endonasal instrumentation and aerosolization risk in the era of covid- : simulation, literature review, and proposed mitigation strategies evaluation of contamination by blood aerosols produced during the various healthcare procedures detection of sars-cov- in different types of clinical specimens status of sars-cov- in cerebrospinal fluid of patients with covid- and stroke validation of sars-cov- detection across multiple specimen types aerosol and surface stability of sars-cov- as compared with sars-cov- rapid point-of-care testing for sars-cov- in a community screening setting shows low sensitivity tracking the volume of neurosurgical care during the coronavirus disease pandemic neurosurgical practice during the severe acute respiratory syndrome coronavirus (sars-cov- ) pandemic: a worldwide survey impact of covid- on an academic neurosurgery department: the conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- -tul fr authors: zaed, ismail; tinterri, benedetta title: how is covid- going to affect education in neurosurgery? a step toward a new era of educational training date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: tul fr nan despite being underestimated during the isolation of the first cases in wuhan, china, back in december , severe acute respiratory syndrome coronavirus (sars-cov- ) has dramatically changed the world from that moment. nowadays approximately half of the world's population is or has been in some form of lockdown with almost all countries imposing travel restrictions in an attempt to retard the spread . the medical staff has always been at higher risk of contagious diseases compared to the general population. knowing that covid- can be transmitted even from asymptomatic individuals, the risk is multiplied , evaluated to be about % higher . as a consequence, this pandemic has necessitated a dramatic paradigm shift in terms of interaction among health care professionals. many medical offices have either made the transition to telemedicine or greatly reduced their patient volumes to accommodate the widely accepted "social distancing" recommendation by the world health organization (who) and the united states covid- has forced us to rapidly adapt, integrate, and use technology to help us survive during these challenging times. to avoid an interruption of residency and fellowship training programs in neurosurgery, it has been imperative to find a strong integration among the different technologies and tools now available. here we briefly discuss the emerging educational delivery methods and the utilization of technology platforms, some that already exist, some that must be developed further in response to covid-pandemic. because of the full schedules of residents in neurosurgery, it very difficult for them to attend daily or weekly educational activities or even multiple conferences under normal circumstances. in fact, trainees have variable timetables, often making attendance of educational activities, such as grand rounds and journal clubs difficult and stressful. virtual attendance using web-based services may be helpful to overcome these issues. virtual meetings allow us to connect and educate the future class of neurosurgeons from the safety of their own homes. in such a difficult moment, it should be asked how we could improve the use of virtual meetings up to the point of allowing conferences at national and international scales. another point of discussion should be the real possibility of these new types of meetings to become the new standards, somehow offering the same benefits of physical encounters, such as case-based panels with questions and answers and the possibility of networking for the younger doctors . some of the possible flaws could include the risk of losing passion live question and answer sessions, due to broadcasting delays, and the decision of some presenters to answer to selected questions, which may be found frustrating to the public. all virtual meetings will be considerably different from the traditional ones where there are the chances to see live surgeries in the job's duties and focus in a rigorous way in the training session. even if the assumptions of these technologies are great, there are still a lot of questions that are waiting for an answer, such as if the same feeling of involvement could be achieved, if the environment could be a strong source of distraction, if there will be any technological malfunction that will take away from the educational experience and if the responsibility to report to work will take over. as a profession, we must critically evaluate the value of face-to-face interaction and whether virtual meetings can serve as a substitute, particularly in a field that is dependent on human interaction and technical skills? additionally, we must ask ourselves if these technology platforms afford the same networking opportunities as an in-person event. because of the pandemic, all the universities in countries where lockdown has been established had to include distance learning as part of the curriculum. many neurosurgical societies and associations have also already added educational materials on their websites . e-learning is based on using technologies to educate a certain class of people outside the traditional spaces. one of the potential advantages of this form of learning is that the teachings can be live or can be pre-recorded, allowing participants to both see the lectures at their own pace and even provide the opportunity to go back and review what they have already learned. also, this modality can claim the advantage of having already several programs that are commonly used, such as blackboard, moodle, vista, or angle. these programs allow some forms of interaction since they present features such as chat and messaging . e-learning opportunities are not limited to these procedures; in fact, webinars and podcasts can be added to this list of educational tools for participants. obviously, the attendance of these sessions can be recorded, allowing also to provide continuing medical education (cme) credits. also, in this case, this type of technology allows overcoming problems related to locations and scheduling constraints, reducing also in a significant way the associated costs. e-learning platforms could be also used to try to provide a more heterogeneous formation among the different programs, which could also rely on national and international experts. technology is a powerful tool that will likely emerge to enhance educational experiences but should not serve to be the sole replacement. boost the surgeon's confidence and reduce the steepness of her/his learning curve, especially with technically-demanding procedures . these simulations are not resident-dependent; in fact, they need to be supervised by experts who should be able to evaluate the performance of residents and suggest to them how to improve their skills. residents' performance should be also recorded, not only for the supervisors' evaluation, but also to be able to track signs of progress over time. despite being a very promising technology able to influence neurosurgical training, several barriers still need to be defeated, such as the expensiveness of the acquisition, the significant amount of space that many hospitals and programs do not have for its installation and the fact that even the most modern simulators allow the performance of only a few specific procedures. even if it is a well-established area, there is still the need to study to better understand if the skills learned on the simulators could be transferred in the operating rooms , . other concerns arise about the use of surgical simulators, such as the fear that they can compromise the learning of nontechnical skills essential to patient care and the need to find the right balance between the simulation-based, cadaveric skills training, and live surgical cases. even if they started to be appreciated in medical fields only in the most recent years, virtual reality (vr) technologies have been widely used in other fields, such as entertainment industries, for some time already, with great results. vr aims to make the subject visualize a realistic three-dimensional environment, able to provide feedback from the subject's actions . in more recent times, vr technologies started to be used also in surgical fields, allowing an enhanced training of surgical skills. it is possible to imagine that in a near future, virtual meeting platforms can be combined with vr technology to provide participants with a real-time feel compared to watching a screen, improving different aspects of the meetings, such as watching live surgeries, being able to interact with the surgical team. nowadays, it is widely accepted that mobile-based apps are to be considered an important source of learning the future of neurosurgical training is rapidly evolving. this evolution is partially due to the increasing integration with technologies and its strong innovations abilities. the modern society puts an increasing pressure on surgical staff to deliver high-quality patient care and, to do so, it is important to find new ways to acquisition of data: all authors. analysis and interpretation of data: all authors. drafting the article: all authors. critically revising the article: all authors consent: no consent was needed for publication of this study severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges clinical characteristics of hospitalized patients with coronavirus-infected pneumonia in wuhan, china public health recommendations after travel-associated covid- exposure coronavirus disease (covid- ) advice for the public. world health organization coronavirus disease the changing face of orthopedic education: searching for the new reality after covid- innovations in neurosurgical education during the covid- pandemic: is it time to reexamine our neurosurgical training models? zaed i. covid- consequences on medical students interested in neurosurgery: an italian perspective abbreviations: three-dimensional ( d); virtual reality (vr) covid- ); centers for world health organization (who) key: cord- -raubqnko authors: murlimanju, bukkambudhi v.; shrivastava, adesh; moscote-salazar, luis rafael; rahman, md moshiur; agrawal, amit title: letter to editor regarding: “decrease in neurosurgical program volume during covid- : residency programs must adapt” date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: raubqnko nan letter to editor regarding: "decrease in neurosurgical program volume during covid- : residency programs must adapt" c oronavirus disease has undoubtedly placed many unprecedented restrictions on the life of current generations globally. the closure of educational institutions and the new normal of social distancing have reduced the number of people leaving their home and engaging in personal interactions. this has led to another unique challenge to medical teaching and training programs the world over. it is important to note that most neurosurgical residency programs are provided in academic hospitals, which are mainly based in urban centers. for obvious reasons and because of the displacement of immigrant populations, these urban and suburban areas have been maximally affected by the covid- pandemic. apparently, this has also resulted in a decrease in trauma admissions in the hospital. we agree with field et al. that the decrease in neurosurgical consultations for traumatic brain and spine injuries has resulted from the sudden reduction in the usage of motor vehicles. almost all hospitals and clinics globally have reported significant reductions in the attendance at outpatient clinics and inpatient admissions, and this phenomenon can largely be attributed to the phobia regarding the covid- pandemic, in addition to the restrictions imposed on the mobility of people. reported data have shown that patients have not been seeking advice even for emergency situations, with an % reduction in visits, this decrease in the clinical specialty workloads has affected the postgraduate teaching programs in medical schools worldwide. the effects have been adverse in several aspects, including the decreased number of clinical cases per specialty, staff reductions, cancellation of academic conferences, and the difficulty in conducting training and licensing examinations. this has also led to uncertainty regarding the completion of mandatory clinical research projects and dissertations, which are often required in residency programs. we share the concerns raised by field et al. that to address the decrease in learning resources during neurosurgery residency training and, as the authors have rightly suggested, that the residency program must be able to adapt such unforeseen circumstances. it will be very useful if the interns could be given more number of days in neurosurgical training because they might have been exposed to a very small number of neurosurgical patients owing to the covid- pandemic. patients undergoing elective cases can be tested for the covid- infection, and residents could be offered to "double scrub" and perform the surgery for these cases, as described by field et al. neurosurgical simulation laboratories could be established, which could lead to learning and reinforcement of surgical approaches. advanced and userfriendly virtual reality simulators with simplified imaging technology could provide the new options for neurosurgical training. we agree with field et al. that online meetings can serve as virtual conferences and can be performed using the many video conferencing platforms available. field et al. have shared an excellent framework in which they started a video conference telehealth system to initiate appropriate patient care. their efforts have shown positive effects, and in may , personals visit to their clinic had increased compared with those in april . in these challenging times, residents, trainees, program directors, and licensing bodies have been facing difficult situations and have been constantly striving to find unique solutions. the global leaders in academia should take this covid- pandemic as an opportunity to formulate long-term policies and appropriate pathways to address the new challenges faced by resident training programs. decrease in neurosurgical program volume during covid- : residency programs must adapt decrease in trauma admissions with covid- pandemic impact of the covid- pandemic on emergency department visits-united states postgraduate medical training and covid- pandemic: should we stop, freeze, or continue? simulation training in neurosurgery: advances in education and practice conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- -tmk c eh authors: alhaj, ahmad kh.; al-saadi, tariq; mohammad, fadil; alabri, said title: neurosurgery residents perspective on the covid- : knowledge, readiness, and impact of this pandemic. date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: tmk c eh abstract background the novel coronavirus disease (covid- ) is a life-threatening illness, which represents a challenge to all the health-care workers. neurosurgeons around the world are being affected in different ways. objectives this is the first study regarding the readiness of neurosurgery residents towards the covid- pandemic and its impact. the aim is to identify the level of knowledge, readiness, and the impact of this virus among neurosurgery residents in different programs. methods a cross-sectional analysis in which neurosurgery residents from different centers were selected to complete a questionnaire-based survey. the questionnaire comprised of three sections and questions that ranged from knowledge to impact of the current pandemic on various features. results the median knowledge score was out of . the proportion of participants with satisfactory knowledge level was %. there was a statistically significant difference between the knowledge score and location of the program. around % of the neurosurgery residents dealt directly with covid- patients. receiving a session about personal protective equipment (ppe) was reported by . %. the neurosurgery training at the hospital was affected. about % believed that this pandemic influenced their mental health. conclusion neurosurgery residents have a relatively good knowledge about covid- . the location of the program was associated with knowledge level. most of the participants did not receive a sufficient training about ppe. almost all responders agree that their training at the hospital was affected. further studies are needed to study the impact of this pandemic on neurosurgery residents. the novel coronavirus disease (covid- ) is a respiratory tract viral infection, caused by the newly emergent, severe acute respiratory syndrome coronavirus (sars-cov- ). , it is a life-threatening viral illness, which represents a challenge to all health-care workers over the globe. the world health organization (who) reports that this viral infection confers a % to % crude mortality rate. this pandemic has affected everyone in all aspects of daily life, especially in the healthcare. the quality of residency training is negatively influenced as a result of the recent pandemic. as the number of individuals infected with this virus rapidly increases, neurosurgeons from different nations are significantly affected in multiple ways. , , , neurosurgery residents are now facing a major challenge, especially for those who work in hospitals with a high number of covid- patients. in addition, some residents are fully responsible for patients with this infection. the strategies to increase the regional intensive care unit (icu) allowance included the reduction of all surgical activities, starting with elective, to ultimately, also, include some urgent cases. currently, most of the neurosurgical centers postponed their elective surgeries due the burden of this infection. , , furthermore, several programs have reduced the number of residents by % of normal, thus keeping the remainder of the residents at home. almost all neurosurgery programs around the world have changed their academic meetings to online communication in an attempt to reduce physical contact. to our best knowledge, this is the first study regarding the readiness of neurosurgery residents towards the covid- pandemic and the impact it has on their training. the aim of this study is to identify the level of knowledge, readiness, practices, as well as the impact of this virus among neurosurgery residents in various neurosurgical programs. this cross-sectional study involves the assessment of neurosurgery residents through a questionnaire-based survey. the study was conducted during the pandemic, from the th until the th of april . the sample size "n" is represented by a total of respondents from different neurosurgical programs. they completed the survey (appendix a) on the awareness, knowledge, practices, and safety measures about covid- . the questionnaire was mainly adapted from the current interim guidance and information for healthcare workers, published by the us centers for disease control and prevention (cdc). several editorial studies published recently about the impact of the virus on neurosurgery residents was also utilized to create the questionnaire. , , the target population consists roughly of around residents, comprised of neurosurgery residents from various neurosurgical centers that we chose. a representative sample from canada, united stated of america (u.s.a.), kuwait, saudi arabia, serbia and italy were selected. we divided the regions into north america, which includes canada and u.s.a. in addition, saudi arabia and kuwait represent the programs in the arabian gulf cooperation council (gcc) countries. regarding the european programs, we reached out to residents from serbia and italy. residents from different centers where selected from three different regions, with the number of participants from each region being close to one another. moreover, we communicated with senior neurosurgeons from these regions, and they provided us with lists of residents with their contacts, which we selected randomly from. therefore, our sampling procedure comprised of random selection of the participants. in addition, each resident was reached in person via a direct phone call or a text message in order to restrict the data to our inclusion criteria, which involved only neurosurgical residents. moreover, this method of direct contact facilitated a very high response rate. all neurosurgeons who finished their training or were above the sixth year of the program were excluded from our data. an informed consent was obtained from each subject. the study objectives were explained to the residents. they were also assured regarding confidentiality of the collected information, and that they were free to decline participation in the study. one participant who refused to complete the survey was excluded. the questionnaire consisted of three sections and questions. the first section ( items) involves the baseline information: gender, age, location of the program, year of training, and current health condition. the next section ( items) contains inquiries about basic biological and microbiological knowledge of this virus , , hand hygiene, as well as personal protective equipment (ppe). additionally, we evaluated whether the subjects received any formal training in hand hygiene, ppe, and n- mask handling. the final section ( items) focuses on the impact of this pandemic on the resident in terms of neurosurgical training, studying, mental health, as well as whether their social life was affected or not. , , convenient sampling method was used for data collection, and the distribution of qualitative responses was presented as frequency and percentages. sub-groups were classified on the basis of gender, age, location of the program, and year of residency training. the statistical package for social sciences (ibm spss statistics , ibm corporation, armonk, ny, usa, ) was used for data entry and analysis. first, univariate analysis was conducted, and qualitative variables were described by frequency and percentage. the quantitative variable (total knowledge score) was calculated by adding the points for the five knowledge items (each item equals one point). this variable, with a non-normal frequency distribution, was summarized by a median and inter-quartile range. we determined that the cut-off of the satisfactory knowledge level is a total knowledge score ≥ median. also, a logistic regression model was used to identify the determinants of low knowledge level. at that point, p-value ≤ . was used as the cut-off level for statistical significance. pearson's chi-square test was utilized to assess the association between the qualitative variables. mann-whitney u test was used to compare two groups with a non-normal frequency distribution, while kruskal-wallis one-way analysis of variance test was used to compare more than two groups. we tested the association of our questions in relation to age, gender, location of the program, and year of residency training. in the present cross-sectional sample survey, neurosurgery residents attending different centers around the world were contacted directly from the six countries mentioned earlier. out of this number, participants returned a completed self-administered questionnaire, and hence, the analysis was based on this number (response rate = . %). table depicts the descriptive analysis of self-reported baseline information and the current health status of the residents with regard to covid- virus. the majority of the participants were male ( . %). concerning the age, . % were below year old, and . % were year-old or above. regarding the location of the neurosurgery program, the percentage of residents representing each country in our sample were as follow: canada . %, u.s.a. . %, kuwait . %, saudi arabia . %, and from the european countries (italy and serbia) . %. the frequency of participants from each year of the residency (r) training were: (r ) . %, (r ) . %, (r ) . %, (r ) . %, (r ) . % and (r ) . %. besides, table , also shows the current situation of residents in terms of this pandemic: . % were under stay home order by their institution or the government; however, . % are resuming their work at the hospital. in addition, according to our results, . % of the neurosurgery residents were under quarantine or isolation. from our sample, only one resident from europe tested positive for covid- . furthermore, about . % were negative, the rest, which represent the majority, . %, were not tested for the infection. almost half of the responders, . %, dealt directly with covid- patients, while the rest did not. table a shows the frequency of correct responses to the five items of the knowledge score about the virus and the safety measures in relation to the location of the program. the number of residents who answered the questions correctly were as follows: . % knew that the virus type, . % knew the main mode of transmission, and . % recognized the most common symptoms. the most accurate estimation of the incubation period of this virus was answered by only . % of participants. concerning the preferred hand hygiene method in the healthcare settings; unexpectedly, only . % knew the correct answer. the first section of the table also displays the responses according to each location of the program in details, and some of the items showed statistically significant results. in table b, we recorded the responses about the training of safety measures, the safe practices, and the strategies of infection control. as expected, receiving a formal hand hygiene training was reported by . %. in addition, receiving formal session of the correct sequence of ppe donning and doffing was stated by . %. only % of our sample knew their correct size of n- mask prior to this pandemic. likewise, only % knew how to correctly obtain a nasopharyngeal swab sample. most of the results in the previously mentioned items were significantly associated with the location of the program. the distribution of the total knowledge score was shifted to the right with left skewness (figure ). the maximum total knowledge score was five, and the median knowledge score of our participants was four out of five, representing a good knowledge level. table demonstrates the association of this score about the virus with gender, age, year of residency training, location of the neurosurgery program. the table also depicts the association between the knowledge score and whether the participant was taking care of covid- patients. the median for male residents was four, compared to three in females. there was neither a difference in medians nor statistical significant association of the knowledge score with regard to age and year of residency training. the median in each location was as follow: four, four, and three in north america, gcc countries, and europe region, respectively. the difference in medians was statistically significant between europe and north america, as well as between europe and gcc countries (p-value = . ). figure shows the boxplot of the knowledge score based on the region of the program. the cut-off of the satisfactory knowledge level was four, which is the median. in our results, . % had satisfactory knowledge about the virus, while . % had a non-satisfactory level. the impact of this pandemic among neurosurgery residents is shown in table . almost all of the residents found that their training at the hospital was affected. when asked about their opinion regarding the neurosurgical procedures during this pandemic, roughly % desired to resume their elective surgical procedures. additionally, the daily studying hours was affected by about %, while the remaining did not face a change in the studying hours per day. the social life of all residents in our sample was influenced by the current situation. shockingly, this pandemic affected the mental health of % of the participants. in table , the association of the impact on mental health of covid- and year of training revealed that the mental health of all residents in the first, third, and sixth year of training was affected. although the percentage of fifth year residents was also high ( . %), they were the lowest group in this aspect. this association was significant (p-value . ), but other confounders' effect could not be eliminated. our study is the first regarding the readiness of neurosurgery residents towards the covid- pandemic and the impact it has on their training. this pandemic is evolving rapidly worldwide, disrupting personal and professional life, including that of neurosurgeons and neurosurgical residents. most programs have seen a significant drop in elective or nonessential surgical volume, impacting the functional neurosurgery cases foremost. regarding surgeries, around . % in our study agreed that elective neurosurgical procedures should not be resumed during this pandemic ( figure -a) . in another editorial, authors stated the following "we have halted all elective cases, but will continue to schedule urgent and emergent cases, involving head and spine trauma, cauda equina syndrome, embolic stroke, ruptured aneurysms, and acute hydrocephalus are relatively noncontroversial; however, urgent cases such as malignant brain tumors and progressive cervical spondylotic myelopathy may require a more nuanced discussion." responses from our analysis disclosed that only % think that brain tumor or compressive spinal cord tumor surgeries should be postponed. in terms of skillset, a trustworthy neurosurgical team should have the ability to treat patients with infectious diseases who also require emergency operations. at the same time, in our survey, most of the residents (≈ %) will only do emergency surgery on a confirmed covid- patient if there are appropriate ppe, while a minority (≈ %) will perform it regardless the presence or absence of ppe; none of the participants refused to perform this surgery in either way ( figure -c) . access to and training on proper ppe use are critical to the safety of workers. when asked about the residents' opinion, if neurosurgical programs should involve a session about ppe every year, around % agreed that this session is essential ( figure -b) . overall, programs report a significant decrease in the volume of cases. clinic visits have transitioned to telemedicine where possible, decreasing resident exposure to outpatient encounters. similarly, all in-person conferences such as grand rounds, resident education conferences, and multidisciplinary meetings have been replaced by video teleconferences. in concordance with our expectations, almost all of the residents found that their training at the hospital was affected. certainly, once this pandemic has concluded, careful retrospective analysis of its impact on resident case volume will be necessary to ensure we are prepared for any future event. the american board of neurological surgery has postponed both primary and oral examinations. , the royal college of physicians and surgeons of canada has also decided to postpone the written exam, while the oral component will no longer be required. in our sample, the daily studying hours was affected in about %. nonetheless, the studying hours might be affected positively or negatively. a study, about involving physicians in patients' care during epidemics, advised of possible alternatives to real patient-physician interaction as to avoid placing trainees at risk. less than half of the neurosurgery residents ( . %) feel competent in taking care of covid- patient, most of those who feel capable have already dealt with covid - patients (figure ) . due to increasing number of covid- patients who require hospitalization, some radiology residents have been reassigned to internal medicine and icu as to care for the high influx of patients. similarly, almost half of the neurosurgery residents in our sample, . %, dealt directly with covid- patients in the previously mentioned settings. on the other hand, some neurosurgery residents might gain intensive care skills. in the end, working temporarily in the icu or internal medicine department will benefit any physcians in one way or another. "social distancing measures have circumvented the traditional trainee-faculty member workstation teaching, which is especially disadvantageous for residents who may be rotating on a service for the first or second time in their training." our survey revealed that . % of the sample followed social distancing in a daily manner, while only two of the participants found it difficult to stick to this practice. "work-related stress is a potential cause of concern for health professionals. it has been associated with anxiety including multiple clinical activities, depression in the face of the coexistence of countless deaths, long work shifts with the most diverse unknowns and demands in the treatment with patients with covid- ." in our data, this pandemic negatively affected the mental health of % of the participants. however, this influence is not specific, and might affect the residents mental health either positive or negative way. the median knowledge score about covid- pandemic and infection control measures was four out of five ( %) with a range from one to five. the correct answers to the knowledge questions were the following: . % knew that the virus type is an rna virus single-stranded and . % knew that the main mode of transmission is via respiratory droplets. moreover, the most common two symptoms of the virus are fever and cough , which . % got correct. the most accurate estimation of the incubation period of this virus is days , and it was answered by only . % of participants. concerning the preferred hand hygiene method in the healthcare settings, which is hand rub for at least seconds with % ethanol ; unexpectedly, only . % knew the correct answer. on the other hand, . % think that hand rub for at least seconds with soap and water is the preferred method. only % of the residents knew their correct n- mask size, as it is required to safely manage any suspected or confirmed cases. this study has some limitations. temporal association of the knowledge score with the aspects discussed above cannot be definitely established due to the nature of the cross-sectional study design. besides, the pandemic has affected the whole world in diverse degrees at different times. we have reached the neurosurgery residents in only six countries with different academic settings and resources. therefore, the ability to generalize the results of this study to all neurosurgery programs may be limited. our study suggested that neurosurgery residents have as a relatively good level of knowledge about covid- pandemic, despite that a significant number of the participants did not reach the satisfactory level of the knowledge score. the location of the program was independently and significantly associated with knowledge score after adjusting for confounding between variables. concerning the infection control, most of the neurosurgery residents received a formal hand hygiene training prior to the pandemic. however, receiving a formal training of the correct sequence of ppe donning and doffing was not sufficient. most of the responders agree that their training at the hospital was affected. larger retrospective studies that include a representative sample of neurosurgical residents with a wide range of regions is essential in order to generalize the results to the target population. it is recommended that health authorities provide infection control sessions to prepare the residents for any future events. neurosurgery program directors may consider sharing experiences with other programs to enhance education and decrease the infection rate among surgeons. regarding surgery, delay of elective procedures but proceeding with semi-elective, urgent, and emergency surgeries is advised. that being said, surgeons should also be provided with sufficient quantities of ppe so as procedures can be performed safely. due to increased stress and decrease studying hours, we urge to provide the residents with adequate time to prepare for any upcoming evaluation. according to the reviewed editorials about this pandemic, we also encourage that the academic training should be continued with social distancing measures with a minimal number of attendees, or even online communication. furthermore, ease of access of residents to mental health professional to prevent any psychological traumatic event, and provide them with stress-management sessions is also suggested. • % = column % • p-values were generated using pearson's chi-square test (≤ . is statistical significant) figure . frequency distribution of the total knowledge score among the neurosurgery residents in our sample. coronavirus disease (covid- ) situation report- the outbreak of covid- : an overview coronavirus disease (covid- ) situation report- letter: academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model neurosurgical priority setting during a pandemic: covid- neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) impact of covid- on neurosurgery resident training and education response to covid- in chinese neurosurgery and beyond and chiocca ea. editorial. covid- and academic neurosurgery information for healthcare professionals coronaviruses post-sars: update on replication and pathogenesis q&a on coronaviruses (covid- ) covid- awareness among healthcare atudents and professionals in mumbai metropolitan region: a questionnairebased survey the impact of covid- on radiology trainees the american board of neurological surgery the royal college of physicians and surgeons of canada involving physicians-in-training in the care of patients during epidemics supporting the health care workforce during the covid-• gcc: arabian gulf cooperation council (gcc) countries • p-values were generated using the mann-whitney u test for comparing two groups, and *kruskal-wallis one-way analysis of variance test for comparing more than two groups & canada gcc: arabian gulf cooperation council countries (kuwait & saudi arabia). european country: data selection from italy & serbia we thank all the participants in this project for their time and effort. we also thank dr. dragan savic and dr. jacquelyn corley, for providing us the contacts of some neurosurgery residents. in addition, we would like to thank all the health-care workers in the front lines against covid- pandemic. this is the first study regarding the readiness of neurosurgery residents towards the covid- pandemic and its impact. the aim is to identify:• the level of knowledge about the novel coronavirus among neurosurgery residents in different programs. • we also studied and discussed the readiness of the neurosurgery residents.• the impact of this virus on the neurosurgery was illustrated in order to give a general picture of the effect of this pandemic on the training in the hospitals, studying, and the general well-being of the residents. • neurosurgery residents have a relatively good knowledge about covid- .• the location of the program was associated with knowledge level.• most of the participants did not receive a sufficient training about personal protective equipment (ppe).• almost all responders agree that their training at the hospital was affected.• about % believed that this pandemic influenced their mental health.• further studies are needed to study the impact of this pandemic on neurosurgery residents. key: cord- -zzhsrytw authors: rispoli, rossella; diamond, mathew e.; balsano, massimo; cappelletto, barbara title: spine surgery in italy in the covid- era: proposal for assessing and responding to the regional state of emergency date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: zzhsrytw abstract in december , coronavirus disease (covid- ) was discovered in wuhan, hubei province, from where it spread rapidly across the globe. covid- characteristics – elevated infectivity, rapid spread, and general population susceptibility – pose a great challenge to hospitals. infectious disease, pulmonology, and intensive care units have been strengthened and expanded. all other specialties have been compelled to suspend or reduce clinical and elective surgical activities. the profound effects on spine surgery call for systematic approaches to optimizing the diagnosis and treatment of spinal diseases. here, based on the experience of one italian region, we draw an archetype for assessing the current and predicted level of stress in the health care system, with the aim of enabling hospitals to make better decisions during the pandemic. further, we provide a framework that may help guide strategies for adapting surgical spine care to the conditions of epidemic surge. can cause the severe acute respiratory syndrome coronavirus (sars-cov- ) and represents a potentially fatal disease of enormous public health importance. by the time of the world health organization (who) classification of the novel coronavirus as a global pandemic ( ) , many hospitals in northern italy were already overcrowded by covid- patients, especially intensive care units, where about % of all available icu beds were occupied by covid- patients ( ) . physicians from specialties beyond infectious or respiratory diseases, including neurosurgery, were reassigned to the new covid-wards to rationalize the use of resources ( ) . the covid- pandemic has forced hospitals to progressively reduce surgical volume, both to minimize disease transmission within the hospital and to preserve human resources and personal j o u r n a l p r e -p r o o f protective equipment (ppe) and other resources needed to care for covid- patients ( ) . as the covid- burden on hospitals increased, italian healthcare services responded with new procedures. these include postponing elective surgical procedures until a more appropriate time, putting in place strategies to ensure urgent/emergency operations during the pandemic, defining type of hospital and the assistance pathways, designating covid- operating rooms for urgent procedures with guidance information posted conspicuously to all the professionals, ensuring systematic and correct use of appropriate ppe, controlling and limiting the number of patients' visitors, developing support strategies for healthcare professionals, and treating outpatients through telemedicine (teleorientation, telemonitoring, and teleinterconsultation) ( ) . while the sars-cov- virus and its expression as covid- do not appear to affect the spinal cord or peripheral nerves, except in rare cases ( , ) , the disease impacts spine surgeons and their patients as a consequence of the overall reorganization of health care outlined above. therefore, it is essential to formulate initiatives to help patients and healthcare professionals face this challenging situation. in the context of the pandemic, it is important to underline that most surgical spine procedures do not require intensive care ( ) and the suspension of elective surgeries appears to have a relatively minor impact on icu capacity ( ) . due to uncertainty in the future severity of the outbreak, there is no reliable timeline for the normalization of elective surgical scheduling; estimates range from several weeks to months or longer ( ) . the lombardy regional council, situated at the core of the italian covid- pandemic, decided to reshape the health care system by concentrating all neurosurgical activities that could not be postponed into neurosurgical "hub" hospitals. three hub hospitals guarantee / acceptance of emergency cases. the three hospitals were chosen on geographical bases; all of the other departments have been assigned to one of the three hubs as a "spoke". the fourth "hub" hospital, the regional neuro oncological center, has been re-allocated for urgent oncological patients coming from all the other departments of the region ( ) . this is an example of how one regional health system, overwhelmed by the epidemic wave, reorganized the totality of its hospitals. hospitals in friuli venezia giulia (fvg) responded to the covid- pandemic quickly. on march , the prime minister of italy emanated the rules of a strict lockdown for all regions without j o u r n a l p r e -p r o o f distinction. to increase hospital capacity for future covid- patients, the fvg health system director on march limited elective surgery in general; in particular, elective spine surgery was completely suspended. outpatient access was also reduced: thereafter, only urgent and priority b outpatients could access the medical practice. self-sufficient patients were required to come unaccompanied. our unit was permitted to perform only urgent spine surgical procedures such as spinal trauma and emergency spinal oncological pathology with rapidly evolving spinal cord or roots compression ( ) . in the remainder of this report, we assess trends in the spread of the infection and the pressure it generates on the healthcare system, proposing a modus agendi for optimizing surgical activity. specifically, we build a program to adapt surgical spine care to the ongoing, objectively measured stage of epidemic surge. the university hospital of udine is located in the immediate outskirts of udine and is a hub our approach is to create a scheme in which the health care authorities can rapidly assess the state of the system and provide indications to the surgery clinics in real time. we define three alert levels of the health care system -green, yellow, and red -and identify the surgical procedures appropriate to be undertaken at each level. our view is that two readily available parameters, intensive care occupancy and the estimated doubling time of the number of infected persons, offer the means to compute the stress level of the health care system. these are plotted in figure , along with boundaries which are proposed to divide the space into green, yellow, and red alert levels. first, intensive care occupancy -the number of covid- patients currently in icu divided by the number of beds available in icu under normal conditions -is a proxy for the current level of resources dedicated to covid- patients. as the occupancy increases, from left to right along the green to yellow to red gradient, the health care system is under increasing stress and is less able to allot resources to non-covid- functions. we employed icu occupancy in the index because it is a readily accessible measure that correlates closely with overall health system stress, due to the enormous demand on personnel and materials resources associated with each single icu patient. figure , as the doubling time decreases, from bottom to top along the green to yellow to red gradient, the health care system can expect increasing future stress and is therefore less able to allot resources to non-covid- functions. to illustrate the case of the fvg region, the number of new positive cases was acquired daily from the data released by the protezione civile ( ) . doubling time, t d , in units of days, is where r is daily growth in percent of patients. analyses can be easily carried out in any statistics software; for figure , we used excel. the doubling time measure will be largely independent of regional differences in the policy or availability of covid- testing. two service areas with different testing regimes will each detect some percentage of the true carriers in their respective regions. doubling time within both service areas will be sensitive to changes in the regional daily number of detected positives, and will accurately chart the projected spread of the virus notwithstanding differences in testing across regions. a change in testing policy or capacity within one service area will not affect the derived j o u r n a l p r e -p r o o f doubling time provided the change is effected at a slower timescale than the day-to-day count that yields the doubling time. due to the large orders-of-magnitude ranges covered by the data, it is convenient to assess the health care system status using logarithmic scales. the alert level boundaries intersect at occupancy levels of . (green/yellow), and . (yellow/red). on the ordinate, the green/yellow alert level boundary intersects at doubling time of day. the data used for each point are averaged across the previous days (current date included) to smooth away daily fluctuations and to make temporal trends more reliable. in the fvg region, the baseline count of icu beds is ( ) . occupancy of icu beds was acquired from https://covstat.it/analisi-regioni/#trasmissione-varie-regioni ( ) . note that our scheme allows occupancy to surpass . . this seemingly paradoxical situation occurs when the health system builds new icu facilities in response to epidemic conditions, as occurred in lombardy. when occupancy of icu beds by covid- patients is equal to or greater than . , the alert level is, by definition, red. the proposed decision making grid for spine surgery, shown in table the alert level data points relative to the fvg region of northeast italy are shown in white points in the proposal for prioritizing surgical activities in relation to health care system alert levels is given in all these patients were admitted urgently due to the onset with neurological deficits and, in one case, for early signs of infection. as an example, we report the case of one patient with a facial and cervical trauma, with a facet fracture, on february . we prescribed an x-ray and re-evaluation after weeks. during that period, all the non-urgent radiological exams were suspended. the patient began to experience neck pain and paresthesia. he then started to lose strength in his hands and notwithstanding the lockdown, he went to the emergency room. after a clinical examination, we detected signs of cord compression. x-rays and mri showed a c -c dislocation with cord compression. we operated on the young patient with a double approach. after surgery all the symptoms were resolved. during the first and second yellow alert level pandemic ( - march and april to may ) we performed emergency surgical procedures and programmed with a priority (spinal cord and\or roots impending or chronic but progressive compression, intractable pain, impending deformity). they were subdivided by etiology as follows: oncologic, trauma, acute and subacute with mechanical intractable pain, and degenerative. after the return to green alert level (may to ), we performed surgical procedure programmed, all with a priority. since may we have been allotted hours/week to perform programmed surgery with clinical priority. in our hospital ppe (gloves, gowns, masks, etc), ventilators, ventilator filters, and medications were never lacking. the main factor that led to the reduction or cancellation of elective surgery was the availability of or staff, who were focused on covid- treatment. clinical decisions were made and acted on prior to the formulations represented by figure and table . retrospectively, we can observe that patients operated on during the three alert levels fell into the appropriate categories. for this reason, we can treat the -level decision making grid as the formalization and systematization of practices that had emerged in ipsa hora in "the heat of the battle." the ongoing covid- global pandemic is unprecedented in the last years. it has led to the upheaval of the health care system at all levels and in all specializations. spine surgery triage has its own unique set of challenges and the acuity of cases may be higher than in many other surgical specialties. the spine surgeon has a crucial role to play as provider, conserver of health care resources, and public health advocate. ( ) . recently, the north american spine society (nass) developed a guidance document and the authors' current recommendations for triaging surgical spine cases are largely based on this document ( ) . in lombardy the regional council reorganized the hospitals as described in the introduction. oncological pathology priority has been defined as: patients requiring immediate treatment (class a++: rapidly evolving intracranial hypertension with deteriorating state of consciousness, acute hydrocephalus, spinal cord compression with rapid tetra-or paraparesis), patients requiring treatment within a maximum of - days (class a+: tumors with mass effect or with progressive neurological deficit, without deterioration of consciousness), patients requiring treatment within a month (class a: oncological pathology that appears malignant and determines a neurological j o u r n a l p r e -p r o o f deficit) ( ) . this was made possible with the active collaboration of the expert surgeons who developed protocols for evaluating which operations had to be done urgently and which could be delayed. in this perspective, we propose to incorporate three variables (surge level, etiology of spinal pathologies and clinical presentation) in order to create a dynamic scheme that prioritizes spine surgery. every surgeon can apply this algorithm to any clinical scenario and place the patient in the correct box, as exemplified in table "after this pandemic, nothing will ever be the same" -this oft-heard statement is especially true for healthcare providers and surgeons. in this report have highlighted opportunities to maximize the benefit and minimize the risk of spine surgery during this pandemic and potentially, any future waves. the alert levels of figure allow us to make decisions rapidly and with a solid data base, using infection doubling time to predict the situation in the coming week. one of the benefits of the covid- crisis has been the robust implementation of telemedicine and virtual visits. although it is not meant to replace in-person medical care, telehealth allows for mitigation of patient and avoids exposure to potential contagions by facilitating compliance with home quarantine. in spine surgery, there is the potential to miss a significant neurologic deficit in the course of a telemedicine consultation; spine surgeons must increase the time spent on history acquisition and must be sensitive to descriptors suggestive of a neurological deficit. we think that at the moment telemedicine could be useful for already established patients and long-term postoperative surveillance patients. in conclusion, although there is no single universally agreed plan for recalibrating health systems in the face of the covid- pandemic, we have presented a balanced and succinct description of j o u r n a l p r e -p r o o f rational, safe approaches to all surgical/clinical procedures in case of emergencies that we may encounter in the future. this dramatic, unprecedented experience teaches us to reason in terms of the scarce availability of human and material resources (beds, ventilators gloves, gowns, masks, etc.). faced with limited resources, we are motivated to set priorities that offer the best possible care to patients with spine disease, seeking to preserve their quality of life. when we emerge from the other side of this pandemic, our hope is look back and feel confident that no patient suffered due to the unwise use of health care resources. j o u r n a l p r e -p r o o f table . spine surgery across red/yellow/green alert levels. relationship between clinical presentation, etiology, and alert level to guide spine surgery during covid- pandemic and similar emergencies. the description of the spinal pathology is intended as an example only. a new coronavirus associated with human respiratory disease in china effects of the covid- outbreak in northern italy: perspectives from the bergamo neurosurgery department a novel coronavirus from patients with pneumonia in china current status of epidemiology, diagnosis, therapeutics, and vaccines for novel coronavirus disease (covid- ) acute myelitis after sars-cov- infection: a case report covid infection presenting as motor peripheral neuropathy spinal emergencies in primary care practice cancellation of elective surgery and intensive care unit capacity in new york state: a retrospective cohort analysis when will hospitals recover from covid- ? questions answered neurosurgery in the storm of covid- : suggestions from the lombardy region impact of covid- mitigation measures on patients with spine disease in friuli venezia giulia triaging spine surgery in the covid- era north american spine society. coronavirus nass guidance document neurosurgery during the covid- pandemic: update from lombardy, northern italy cappelletto have made substantial contributions to all of the following: ( ) the conception and design of the study, or acquisition of data, or analysis and interpretation of data sars-cov- : severe acute respiratory syndrome coronavirus who: world health organization icu: intensive care units ppe: personal protective equipment fvg: friuli venezia giulia acs: american college of surgeons cdc: united states centers for disease control and prevention ota: orthopedic trauma association rcs key: cord- -mqxwwwcd authors: raj, sumit; chouksey, pradeep; mishra, rakesh; shrivastava, adesh; agrawal, amit title: letter to the editor regarding: “case volumes and perioperative covid- incidence in neurosurgical patients during a pandemic: experiences at two tertiary care centers in washington, dc” date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: mqxwwwcd nan letter to the editor regarding: "case volumes and perioperative covid- incidence in neurosurgical patients during a pandemic: experiences at two tertiary care centers in washington, dc" w e read the article by dowlati et al., in which the authors shared their thought-provoking observations to determine the risk of a neurosurgical patient becoming infected with coronavirus disease in the perioperative period and the effect of covid- on the neurosurgical case volumes. this is an important topic to study because resumption of neurosurgical services has begun after the initial periods of lockdown. dowlati et al. reported a low . % positive covid- rate among the patients in the perioperative period. the finding must be interpreted with caution because all the patients were not tested for covid- preoperatively. thus, the reported positive covid- rate could not reveal the true incidence of perioperative infection. the greatest challenge has been (and continues to be) that patients infected with covid- can be asymptomatic. also, because of logistics and many other issues, testing asymptomatic persons for covid- has continued to be an issue of debate. , although some attempts have been made to address perioperative covid- transmission, its true incidence is not known. many other studies have shown a similar reduction in neurosurgical operative case volumes. - dowlati et al. reported a . % decrease in operative cases and a . % decrease in neurointerventional cases during the peak period of lockdown at tertiary neurosurgical centers in the united states. the significant decrease in spine and functional neurosurgical cases is consistent with the findings reported by other studies. , , the findings of an increased length of hospital stay and increased complication rates in covid- epositive patients suggest that a higher complication rate is associated with perioperative covid- transmission. this finding is consistent with those from other studies reporting increased complications in patients with covid- postoperatively. , it was interesting to note that an increase had occurred in nonelective cranial neuro-oncological cases. this might have been because intracranial spaceoccupying lesions have more potential to expand and result in clinical deterioration. a maximum decline had occurred in the number of diagnostic neurointerventional cases in the absence of any significant decline in elective, urgent, or emergent cases. to understand this, we need to further explore elective versus emergency (acute deterioration) indications for diagnostic neurointerventional investigations in periods before covid- . this is an interesting finding that requires further investigation because it might have resulted from patient-related factors or from unique policies that restricted the movement of people and, thus, limited the number of patients seeking healthcare access for minor stroke-related symptoms. their study defined emergent cases as those for which intervention was required within hours and urgent cases, those for which intervention was required within week. this categorization was probably determined by the underlying pathology, duration of onset of acute symptoms, and the expected rate of progression when the patient presented to the hospital. if so, the cases of the patients in whom covid- had been detected before the procedure, with a subsequent delay in intervention should not be grouped as emergent or urgent. the results and findings from their study have shown that a real risk of perioperative transmission exists and have summarized how the current covid- pandemic has been changing the neurosurgical caseload patterns. the neurosurgical case volumes had decreased by > % in the study period; hence, the positive covid- rate they reported might only represent the tip of the iceberg. it will be helpful if such information will be reported from the later part of the pandemic when covid- cases have increased significantly and restrictions have been lifted. a greater positive covid- rate in the perioperative period is likely to occur during the later phases of the pandemic. to summarize, the study by dowlati et al. represents an important study owing to the resumption of neurosurgical services after the initial periods of lockdown. their findings have provided an idea of how covid- has been changing neurosurgical caseloads and the transmission risk to patients. their study can be extended, and future work, therefore, should seek to address these shortcomings. case volumes and perioperative covid- incidence in neurosurgical patients during a pandemic: experiences at two tertiary care centers in covid- transmission through asymptomatic carriers is a challenge to containment. influenza other respir viruses covid- mass testing facilities could end the epidemic rapidly perioperative presentation of covid- disease in a liver transplant recipient neurosurgical practice during coronavirus disease (covid- ) pandemic by the numbers analysis of covid- 's effect on a neurosurgical residency at the epicenter impact of the covid- pandemic on neurosurgical practice at an academic tertiary referral center: a comparative study impact of the covid- pandemic on neurosurgical practice in india: results of an anonymized national survey covid- in post-operative patients: imaging findings increased mortality and major complications in hip fracture care during the covid- pandemic: a new york city perspective the baffling case of ischemic stroke disappearance from the casualty department in the covid- era key: cord- -s do cb authors: lara-reyna, jacques; yaeger, kurt a.; rossitto, christina p.; camara, divaldo; wedderburn, raymond; ghatan, saadi; bederson, joshua b.; margetis, konstantinos title: “staying home” - early changes in patterns of neurotrauma in new york city during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: s do cb abstract objective new york city is the epicenter of the novel coronavirus disease (covid- ) pandemic in the united states. traumatic brain injury accounts for a significant proportion of admissions to our trauma center. we sought to characterize the effect of the pandemic on neurotraumas, given the cancellation of non-essential activities during the crisis. methods retrospective and prospective review were performed from november to april . general demographics, clinical status, mechanism of trauma, diagnosis, and treatment instituted were recorded. we dichotomized the data between pre-covid- (before march st) and covid- periods and compared the differences between the two groups. we present the timeline of events since the beginning of crisis in relation to the number of neurotraumas. results a total of patients composed our cohort with a mean age of . years (sd+/-: . ), and % male. more males sustained neurotrauma in the covid- period compared with the pre-covid- ( . % vs . %, p= . ). the most common mechanism of trauma was mechanical fall, but it was observed less frequently compared to the pre-covid- period ( . % vs . ; p= . ). subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for the most common pathologies in both periods. non-operative management was selected for most patients ( . vs . %, p= . ) in both periods. conclusions a decrease in the frequency of neurotraumas was observed during the covid- crisis concomitant with the increase in covid- patients in the city. this trend began after the cancellation of non-essential activities and the implementation of social distancing recommendations. on march of , the world health organization declared the infection with the novel coronavirus disease (covid- ) as a pandemic, after the initial outbreak in wuhan, china in december . - , by february , the first cases in the united states (u.s) were confirmed. since then, there has been an exponential growth in disease incidence, and the u.s. became the world's epicenter. , new york city (nyc), in particular, saw the most significant impact, reaching an overwhelming number of , new cases diagnosed in a single day, on april th. since the outbreak began in the city on march rd, there have been , confirmed cases, and , confirmed deaths by april th. . as a result, healthcare systems throughout the city had to divert significant resources and staff to newly created covid-specialized units. in an attempt to slow the progression of covid- pandemic, new york state and city governments enacted strict social distancing policies starting on march th, which included a progressive restriction and cancellation of non-fundamental activities, like the closure of schools, restaurants, bars, and business; as well as the cancellation of all elective surgical procedures. . according to the last new york state trauma registry report, for discharges between and , there was an average of , trauma incidents with a . % case fatality rate, with falls accounting for % of the total leading cause of trauma followed by motor vehicle accidents (mva) in . % of the cases. . we hypothesize that the social distancing and restrictive policies have changed the typical neurotrauma patterns throughout the city, given that fewer people were working, less transportation, and less interpersonal contact. to assess these possible changes, we reviewed all neurotrauma admissions to our trauma center during the early covid- period, and assessed changes in frequency, demographics, and mechanisms, in order to highlight any changes due to social distancing policies. mount sinai morningside is located in the upper west side of manhattan, is a level- trauma center accredited by the american college of surgeons, and is the centralized trauma facility in our system. institutional data on neurotrauma admissions were queried between november st, (one month prior to the disease outbreak in china) until april , . the start date for our query was selected based on the first confirmed cluster of pneumonia associated with the novel coronavirus (sars-cov- ), which was documented in china on december , . data analysis was done both retrospectively and prospectively, after institutional review board approval [irb # - ] was obtained. the data were dichotomized in pre-covid (before march , when the first case in new york city was confirmed) and covid groups (after march st). general demographics (age, sex), date of the encounter, mechanism of the trauma, injury severity score (iss), glasgow coma scale (gcs), radiological diagnosis, length of stay (los) in the intensive care unit (icu), days intubated (if applicable), total in-hospital los, and treatment instituted were obtained. additionally, we recorded specific information during the pandemic, such as covid- status (reported positive or negative by nasopharyngeal swab polymerase chain reaction (pcr), and unknown cases -if no test was obtained), presence of respiratory symptoms, known close contact with covid- patients, and radiological signs suggestive of active infection. we excluded patients who presented with neurosurgical conditions other than related to trauma (i.e spontaneous intracerebral hemorrhage, stroke, aneurysmal subarachnoid hemorrhage, central nervous system tumor). descriptive and comparative analyses of data were performed using chi-square, fisher's exact test, or a -sample t-test, depending on the variable type and observed values of the variables. the significance was set to alpha = . . we used r version . . in rstudio interface (rstudio integrated development for rstudio, inc, boston, ma). during the study period, patients with neurotraumas with a mean age of . years (sd+/- . ) and male prevalence of % presented to our institution, in the pre-covid- era and in the covid- period. figure shows the monthly frequency of neurotrauma cases during the study period. an average of . cases was observed in the pre-covid- period, and . cases in the covid- time. an average of case/day was observed in march and a decrease to . patients/day in april. figure shows a timeline of events during the covid- crisis. an inverse relationship was noticed between the number of positive cases and the frequency of neurotraumas since march st. by the third week of march, a drop in the frequency of neurotraumas was noticed, especially since the cancellation of non-essential activities (march th). an increase in the frequency of cases was noticeable in the second week of april, which was observed concomitant with the decrease in the number of new covid- cases in the city. during the covid- crisis, patients with a mean age of . years (sd+/-: . years) and . % male distribution were evaluated by our service. the most common neurotrauma was caused by mechanical fall ( . %), unknown mechanism ( . %), and mva/transit-related injuries ( . %). the most common diagnoses were subdural hematoma (sdh), traumatic subarachnoid hemorrhage (tsah), and intracerebral contusion in . %, . %, . % respectively. medical management accounted for . % of treatment instituted, and . % required surgical intervention. from this cohort, patients ( . %) were tested positive for covid- , ( . %) negative, and ( %) with unknown status at the time of evaluation. two patients ( . %) had a recognized contact with a positive person, and ( . %) unknown contact. five patients ( . %) had positive clinical symptoms on arrival (cough, dyspnea, fever) and ( . %) patients had positive radiological findings consistent with covid- pneumonia. table summarizes the comparative findings between pre-covid- and covid- groups. no significant difference between the groups regarding age was noticed ( . vs . years, p= . ). in both groups, most of the traumas were observed in males, with an increased male gender predominance in the covid- period ( . % vs . %, p= . ). the most frequent mechanism of trauma in both cohorts was mechanical fall, with a higher frequency in the pre-covid- period ( . % vs . %, p= . ). unknown mechanism ( . % vs . %), mva/transit-related ( % vs . %), and violence-related/inflicted traumas ( . % vs . %) increased in frequency in the covid- period with significant difference (p= . ). subdural hematomas were the most frequent diagnosis between both groups, with a decrease in numbers of cases in the covid- period ( . % vs . %). traumatic subarachnoid hemorrhage ( . % vs . %), intracerebral contusion ( . vs . %), and epidural hematoma ( % vs . %) experienced a relative increase in frequency during the covid crisis with a non-significant difference (p= . ). medical management was the most common treatment modality in both groups, ( . % vs . %, p= . ). among the non-surgical interventions, the frequency of conversion to dni/dnr status, and poor surgical candidacy increased in the covid- period from . % to . % (p= . ). overall, neurotraumas requiring surgical management decreased during covid- ( . % vs . %) but the difference did not reach statistical significance (p= . ). healthcare institutions in nyc witnessed an exponential growth of covid- cases since march , with the highest peak of , diagnoses on april th, and a peak of deaths on april th. during this time period, we observed a decrease in the frequency of neurotrauma at the early phase after the strict limitation of non-essential activities in the city, compared to the pre-covid- period. overall, we noticed a significant increase in males who sustained neurotrauma, with a nonsignificant tendency to be younger in the covid- period. mechanical fall accounted for the majority of cases in both periods, but the frequency decreased during the covid- crisis. interestingly, transit-related neurotrauma, as well as tbis related to violence (direct head trauma with an object) increased in frequency in the covid- period showing significant difference. subdural hematomas were the most frequent pathologies in both periods, and surgical management was observed less frequently in the covid- period, but these differences did not reach significance. in the past, several classic public health strategies have been implemented in a pandemic crisis. these include isolation, quarantine, social distancing, or community containment. . in order to decrease the spread of the virus, social distancing is defined by spacing ft away between individuals. other related activities include avoiding public transportation, working remotely to decrease the number of possible contacts, and staying home as much as possible. by encouraging all these measures, the expectation is to decrease the community transmission of the disease and ensure the separation between healthy and infected people. ahmed et al found a reduction of % of the influenza attack rate and a delay in the peak of the influenza rate with the institution of social distancing strategies. . we hypothesized that under these unique circumstances in which social interaction is expected to be limited, the frequency of traumas will decrease accordingly. overall, the incidence of tbi has been reported to be per . persons, as well as . cases per million in case of spinal cord injury (sci) in the u.s. , , , . we found that a significant increase of males sustained neurotrauma compared to the pre-covid- era ( . vs . %, p= . ). as previously reported, males are more likely to incur in tbi compared to females, especially between the age range of to years ( . cases per , persons for females and . per . for males), but this tendency disappears by the age of ( . per , for females, . per , for males). the increased incidence of tbis in males could be attributed to the increased risk-taking behavior and high-risk activities, most commonly engaged by men. . in the setting of a pandemic and "lockdown", we can presume that males are more prone to be involved in activities that increase the risk of trauma even while social distancing policies are in place, such as exposure to violencerelated/inflicted trauma, mva, falls associated with alcohol use. we noticed that the frequency of neurotraumas decreased the same week the social distancing and cancellation of non-essential activities were instituted (figure ). this trend was observed until the fourth week after the first case was reported and the second week after the executive order was implemented. the weekly maximum peak of covid- cases was observed between march th and march st, three weeks after the first case was reported in nyc, and one week after the executive order started. this progressive increase in the incidence of new covid- cases was observed inversely with the frequency of neurotraumas. this trend may be explained by the mandatory restriction of non-essential activities and the recommended social distancing policies that require avoidance of people crowding and limitation in public transportation in the city. experiences from italy, one of the most impacted countries, reported a preliminary impression that public "lockdown" during the pandemic has diminished the number of traumatic cases, which eased the number of surgical cases. similarly, christey et al reported an overall reduction of % of all-injury related admission in new zealand during a short period of lockdown due to covid- . . fall-related brain injury comprises % of all tbis in the elderly. . it is believed that this is due to increases in falls-related arrhythmias and the high intake of medication for chronic diseases. we noticed the same tendency in our cohort, having mechanical fall in . % of the cases overall. once dichotomized, we found that this mechanism was evident in . % of the cases in the pre-covid- period and . % of the neurotrauma cases in the covid- crisis. although we observed a significant decrease in the frequency of this mechanism compared to the pre-covid- period, it remained the most frequent etiology. this may be explained by the fact that falls can still happen irrespective of the location of the patient and can not necessarily be modified by the policies about the restriction in mobilization, especially in the elderly. following mechanical falls, the reported remaining leading causes of tbi are struck by an object ( . per . persons), mva ( . per . persons), and those related to assaults ( . per . ). we were expecting that the frequency of the aforementioned mechanism may be more common in an environment in which social interaction and personal mobilization are not limited. interestingly, in our cohort, we noticed a significant increase in mva/transit-related accidents and those related to violence. this tendency would not be expected during quarantine or lockdown, due to the theoretical restriction of interpersonal relationships and mobilization. recent reports mentioned an increase in the frequency of traffic-related fatalities during the pandemic, probably related to the decrease in transit that allows drivers to exceed speed limits and the fact that more people choose to walk or bike while there is a limitation in public transportation. [ ] [ ] [ ] . on the other hand, several reports have mentioned the increased risk and vulnerability to suffering domestic violence, specifically associated with the isolation requirements during the pandemic. - the possible factors that may lead to domestic violence in these circumstances have been associated with economic stress, exposure to previous exploitative relationships, disaster-related instability, and reduced support. , medical management accounted for the majority of treatment modalities implemented in both time periods, with a decrease in numbers of surgical cases between the pre-covid- and covid- period, which was not statistically significant. even though it did not reach statistical significance, it is worthy to note that the tendency to convert neurosurgical patients to a dni/dnr status increased in the covid- period from . % to . %. dnr decisions are made after a conjoined evaluation between trauma and neurosurgery. if both teams agree that aggressive care is not warranted based on the severity of injury and prognosis, a goal of care discussion is scheduled with the health care proxy or an appropriate surrogate. palliative care is often but not always involved in these discussions. the role of palliative care was definitely expanded during the covid- crisis. in our institution, the dnr form must be signed by an attending physician (trauma surgeon, intensivist or neurosurgeon depending on the primary service). the second physician can be a fellow or resident. in the case of a patient without capacity and surrogate, two attending physicians must agree that dnr is appropriate and complete the required dnr forms. during this crisis, it was of utmost importance to discuss advance care planning for adult patients. overall, the reported rate of advance directive completion is less than % in adults of years-old. several factors may influence this decision during the covid- crisis, especially the predicted life expectancy. by the moment this report is been written on may th, the national death count due covid- was , and , if limited to nyc; with an overall estimate of by august. , , interestingly, just . % of our cohort tested positive, and % had an unknown status at the time of evaluation. we may infer that the decision to change the status was based on the overall assessment and prognosis of the trauma, and not exclusively limited to the covid- status. this pandemic is affecting almost all levels of care in a health system. the relocation of staff, including neurosurgeons and neurointensivists to cover covid- units has been necessary during this crisis to ensure proper coverage to the infected patient population. under normal circumstances, neurosurgery responds to and evaluates all trauma codes. the "trauma code" is the hospital's designation for the highest-level activation for a trauma patient who is brought to the ed. for lower level trauma activations (trauma alerts), neurosurgery consults are obtained if there are positive findings on clinical assessment or imaging. in addition, all injured patients with positive ct findings are evaluated by neurosurgery, regardless of activation level. all neurotrauma patients are initially admitted under the trauma service for a minimum of hours. in isolated neurotrauma cases, the patient is then transferred to neurosurgery no sooner than hours after admission. this allows the trauma team to complete a tertiary survey and safely transition of the patient to care of a single service. regarding sci, the spine call schedule is shared by neurosurgery and orthopedics. there were no changes in the schedule during the covid crisis, so this shared call does not interfere with the reported results. we have modified our triaging process and admitting steps. as reported in other institutions worldwide, all transfers within our system and from outside hospitals (osh) are being restricted to life-rescue surgical cases and/or impending irreversible neurological deficits. , , each consult is evaluated by the on-call attending neurosurgeon. in case a transfer is indicated, the attending then discusses and obtains approval from a designated neurosurgeon that oversees all transfers, admissions, and surgical cases within the entire system. when the patient is not transferred, we provide a direct line to our neurosurgery service, this allows direct communication between services for the further management of the same patient. we are recommending the covid- test for all patients before initiating the transfer. in case the patient was not tested or the result is not yet available, we treat the patient as a person under investigation (pui). the pui policy includes the implementation of contact, droplets, respiratory precautions, isolation of the patient, and the use of proper personal protective equipment (ppe), as well as radiographic and clinical screening for covid- infection. one of the biggest limitations that we encountered is the single-center nature of the data, which may limit the generalizability of the results. the relatively small size of the cohort may lead to observational bias. we only explored the results of neurotrauma and not the total number of traumas, which may vary during the installment of social distancing policies. the type of trauma may vary between institutions, with some other hospitals having more inflicted traumas compared to ours due to the location in areas in which violence can be more prevalent. the total number of spine traumas may be underestimated due to the possible overlapping of more severe conditions because we used the primary diagnosis for the analysis. the true incidence of mild cases of neurotraumas may be underestimated, because patients may have preferred to stay at home and avoid hospitals due to the fear of getting the infection. also, the system triage policy table : comparison groups between the pre-covid and covid period. iss: injury severity score, tbi: traumatic brain injury, mva: motor vehicle accident update: public health response to the coronavirus disease outbreak -united states the lancet infectious diseases. covid- , a pandemic or not? the covid- epidemic the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak -an update on the status the who just declared coronavirus covid- a pandemic who declares covid- a pandemic johns hopkins coronavirus resource center covid- : data -nyc health new york state trauma registry -statistical wilder-smith a, freedman do. isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus ( -ncov) outbreak epidemiology of traumatic brain injury blue book) | concussion | traumatic brain injury | cdc injury center global prevalence and incidence of traumatic spinal cord injury people with spinal cord injury in the united states the epidemiology of traumatic brain injury variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level lockdown for covid- in new zealand motor vehicle fatality rates up percent in march, despite covid- --occupational health & safety the roads are quieter due to coronavirus, but there are more fatal car crashes family violence and covid- : increased vulnerability and reduced options for support ; : . . pandemics and violence against women and children covid- era and beyond: ethical considerations regarding older adults covid- : projections of mortality in the us rise as states open up letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of coronavirus infection protein chain reaction tbi: traumatic brain injury sci: spinal cord injury mva: motor vehicle accident dni/dnr: do not intubate/do not resuscitate pui: person under investigation ppe: personal protective equipment osh: outside hospital disclosures and conflict of interest disclosures: none conflict of interest: lara-reyna: none yaeger: none rossitto: none camara: none wedderburn: none bederson: contractual relationship and has received financial compensation from brainlab conceptualization, methodology, formal analysis, investigation, data curation, writing -original draft, writing -review & editing, supervision, project administration yaeger: investigation, data curation, writing -review & editing rossitto: investigation, data curation, writing -review & editing camara: writing -review & editing wedderburn: writing -review & editing ghatan: writing -review & editing bederson: writing -review & editing margetis: methodology, formal analysis, data curation, writing -review & editing, supervision acknowledgments: we appreciate the contribution of gina maria arena, ma (regulatory approval), lindsey heacook, cstr and deborah travis, rn (data acquisition).this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord- -v by dnp authors: kessler, remi a.; oermann, eric k.; dangayach, neha s.; bederson, joshua; mocco, j.; shrivastava, raj k. title: changes in neurosurgery resident education during the covid- pandemic: an institutional experience from a global epicenter date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: v by dnp nan to the editor: the first case of the severe acute respiratory syndrome coronavirus (sars-cov- ) and its associated coronavirus disease in new york state was diagnosed on march , . it was declared a global pandemic by the world health organization (who) shortly thereafter on march , . as it rapidly spread across new york city (nyc), the city's major teaching hospitals underwent unprecedented changes to re-organize resources, make space for the massive surge in covid- positive patients who would require hospitalization and ventilatory support, and to re-deploy physicians of all specialties to aid in the effort. given that ny is leading the nation in the number of patients diagnosed with covid- ( , cases as of april , ), coupled with the cancellation of all elective surgeries, the comprehensive redeployment of attending neurosurgeons and residents to assist in covering a covid- intensive care unit (icu) became a necessity. here we present our detailed institutional experience -from an , -bed, tertiary care academic center and six other affiliate hospitals of the mount sinai health system in nyc-on how the re-organization efforts changed our neurosurgical graduate medical education program from the heart of the pandemic. on march , , the department of neurosurgery at mount sinai issued its first version of changes to resident practice. the inciting event for this was the conversion of the new neurosurgical icu (nsicu) into a dedicated -bed covid-icu, requiring full-time staffing from all four of our faculty neuro-intensivist physicians. at this juncture, neurosurgery departmental leadership re-deployed residents and attendings to provide / neuro-critical care coverage, and mid-level providers were assigned to coverage in the emergency department and covid-icu. the old neurosurgical icu was re-activated, and all neurosurgical patients were resident education from the pandemic epicenter transferred there. one of the first changes made was expanded resident coverage to staffing this older neurosurgical icu and junior residents responsible for call every third night. the four chief residents (pgy- s and pgy- s) rotated on a weekly basis between the nsicu, the standard icu and two neurosurgery operating rooms (ors). the nsicu chief supervised the neurosurgical service, neurosurgery floor patients, nsicu patients, oversaw neurosurgery consults, and rounded with the icu team in the morning to build expertise in critical care. they were also responsible for preparing the biweekly radiology conference. the icu chief neurosurgery resident worked closely with the icu physician and rounded in the icu on all patients, supervised icu management day-to-day, and was in-house during the day with home call at night. the first or chief had primary or responsibility, and the second or chief was to remain home unless the second or was running. both pgy- residents were exclusively assigned to the cerebrovascular neurosurgery service and functioned at the fellow level. this change was in response to the seven-fold increase in stroke admissions related to covid- seen at mount sinai within recent weeks. all junior residents were re-assigned to a minimum of six weeks of neurocritical care and six weeks of neurosurgery. the neurocritical care junior residents were scheduled for -hour in-house call every third day. the juniors assigned to the neurosurgery service were scheduled for -hour call every fourth day. their responsibilities include prepping patients for the or, preparing the radiology list, and covering the surgical cases. one other junior resident was considered backup for covering cases, otherwise was to stay at home. interns were assigned to the nsicu through july . the same principles applied to the residents covering the other mount sinai affiliate hospitals. all resident weekly teaching conferences and grand rounds were held virtually via video conferencing. on april , , changes were made to this aforementioned version of the department staffing by introducing a dedicated senior and resident education from the pandemic epicenter junior resident to staffing the covid- icu, due to increased need. the chiefs were also reassigned to four, one-week rotations consisting of the nsicu, the icu, the or, and the hospital floor/neurosurgical consults. the reason for this change was that the low volume of surgical cases did not require a second chief resident and that physician staffing was better utilized in other areas of the hospital dedicated to covid- . the changes to neurosurgery resident education at mount sinai were borne out of a necessity for re-deployment of our physicians to assist in the fight against covid- , given the sheer abundance of positive patients in nyc. the emory university department of neurosurgery reported similar changes for residents covering their neurosurgical service and each resident is to spend one week during the month of april caring for covid- patients. a number of programs have reported reducing resident staffing by % with teams rotating one week at a time, while the rest of the residents remain at home. cases that ultimately go to the or are typically limited to a single resident to both reduce exposure and preserve ppe. the massachusetts general hospital/brigham and women's programs has re-deployed attendings and residents on a voluntary basis. the shutting down of research facilities for residents completing their research years has also led to delays in scientific productivity for those involved in wet bench research. emory, along with many other programs, have similarly used videoconferencing for live-streaming grand rounds, educational didactic sessions, and case conferences. the covid- pandemic has dramatically transformed the clinical neurosurgery residency training program at mount sinai due to the need to treat the unprecedented high numbers of > , covid- positive patients currently admitted to our hospital. the covid- pandemic has required our department to change resident education to an exceptional degree, but we are continuing neurosurgical learning in innovative ways while heeding the call to care for nyc's sickest patients. keywords: resident education, neurosurgery, pandemic, virus who director-general's opening remarks at the media briefing on covid- - cases in u.s. centers for disease control mount sinai neurosurgeon warns of covid- causing sudden strokes in younger patients letter: maintaining neurosurgical resident education and safety during the covid- pandemic impact of covid- on neurosurgery resident training and education covid- and academic neurosurgery impact of covid- on neurosurgery resident research training a neurosurgery resident's response to covid- : anything but routine key: cord- -pini eqw authors: al saiegh, fadi; ghosh, ritam; stefanelli, anthony; khanna, omaditya; hattar-medina, ellina; hoffman, michelle; hafazalla, karim; sabourin, victor; farrell, christopher; tjoumakaris, stavropoula; jabbour, pascal; sharan, ashwini d.; rosenwasser, robert h. title: virtual residency training interviews in the age of covid- and beyond date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: pini eqw nan virtual residency training interviews in the age of covid- and beyond t he traditional application process for specialty residency training in the united states has involved a series of on-site interviews to which selected applicants are invited at various cities across the country. during this period, residency applicants would travel for a median of days and spend a median of $ . , however, with the coronavirus disease (covid- ), the medical community is facing a challenge because the necessary travel for on-site interviews has the potential to increase the spread of the disease. therefore, the association of american medical colleges and the society of neurological surgeons have recommended the suspension of all on-site interviews and the use of virtual assessments in the selection process. because this is not a practice the medical community is accustomed to, we simulated virtual residency training interviews and compared models to assess the feasibility and uncover the technical challenges in preparation for the upcoming interview season. using interviewers and interviewees consisting of senior neurosurgery residents and fourth-year medical students, respectively, we authors devised models using the zoom platform (zoom inc., san jose, california, usa) to simulate the interviews ( figure ). the "static model" followed the traditional on-site interview structure, in which the interviewees rotate through several rooms meeting with different interviewers for w minutes each. using zoom, the physical rooms were replaced with meeting identifications (ids). each interviewer was assigned an individual "static" meeting id and was joined by the interviewee at a given time for minutes. in the "dynamic model," meeting was joined by all study participants (interviewers and interviewees) and a meeting administrator. after a brief overview, the administrator paired each interviewer with interviewee in a submeeting to start a -minute interview. at the end of each interview, the interviewees were dynamically moved to the next submeeting. those who were on a break were kept in a "breakout room," where they could communicate with each other using video and audio. brief notifications were sent by the administrator to all participants when the end of an interview was approaching. at the conclusion of the simulation, a web-based survey was conducted to assess the strengths and weaknesses of both models. the survey response rate was %. in most cases ( . %), the participants had experienced no technical issues with video or audio in either model ( figure ). any technical issues encountered were transient and were related to the audio. of the participants, % reported that the dynamic model ran more seamlessly and was more time efficient. also, the dynamic model was preferred by two thirds of the participants. the participants reported that both models allowed them to connect with each other during the interviews. however, the dynamic model allowed the interviewees to feel more natural and comfortable. interviews are an integral part of residency applications, allowing both applicants and programs to get to know one another to ensure the best fit. applicants are able to gauge the character and city of the program, and the programs rank applicants according to their views of the best fit. however, because of the covid- pandemic, this opportunity is no longer possible. thus, it is imperative that an alternative method is developed and used to simulate the normal interview process to the greatest extent. the goal of our simulation was to find a model that would give applicants the most natural feel and allowing interviewers an adequate opportunity to assess their prospective residents. most of our participants (applicants and interviewers) favored the dynamic model. they reported that the dynamic model provided smoother transitions, allowed the applicants to be more comfortable, and gave participants a more natural feel. the dynamic model also removed the onus of the interview away from the applicants and placed more emphasis on a third party, which was our residency coordinator. this allowed the already nervous applicants to focus more on their interview, rather than worry about the logistics of it. in the static model, the participants were required to keep track of separate meeting ids, which can be overwhelming for applicants during the interview process. one of the understated aspects of the interview trail is the ability to connect and form bonds with other medical students across the united states through travel. in the covid- era, this experience has been removed. however, the use of the "breakout room" in the dynamic model might allow for some semblance of this experience. when planning virtual interviews, one challenge will be scheduling applicants from different time zones. both models can be used to accommodate applicants by offering multiple interview sessions at different times. in large specialties such as internal medicine, often interviews will occur per season, and smaller specialties such as neurosurgery will have as few as or interviews. because virtual interviews obviate the need to travel, more interviews can be planned to group the applicants from the same time zone. finally, because of the cost-saving potential of virtual interviews, this practice might extend beyond the covid- era as an alternative to on-site interviews. virtual interviews are a necessary alternative to residency applications in the wake of covid- . our simulation has shown that they can be performed seamlessly and efficiently using the models we have provided, which can be adopted by other programs to assess applicants. fadi al saiegh: conceptualization, methodology, data acquisition, data analysis, figure creation, current interview trail metrics in the otolaryngology match financial and educational costs of the residency interview process for urology applicants conducting interviews during the coronavirus pandemic key: cord- -gn mwun authors: kanmounye, ulrick sidney; ammar, adam; esene, ignatius; el ouahabi, abdessamad; park, kee title: letter to the editor: covid- & neurosurgical training in low- and middle-income countries date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: gn mwun nan letter to the editor: covid- & neurosurgical training in low-and middle-income countries o n june , , the world federation of neurosurgical societies (wfns)' global neurosurgery committee (gnc) and young neurosurgeons forum (ynf) discussed the effects of coronavirus disease (covid- ) on training in low-and middle-income countries (lmics). during this event, the leadership of the wfns and stakeholders of global neurosurgery identified challenges and proposed solutions to the issues faced by trainees during the pandemic. we recount the problems and action items that were identified during the meeting. each year, million patients develop neurosurgical conditions, and % of them live in lmics. lmics have < % of the specialist neurosurgical workforce and require an additional , neurosurgeons to meet local neurosurgical demands. , few lmics have sufficient capacity to make up for the local workforce deficit; thus, neurosurgeons from all over the world are working to find sustainable solutions. this movement has given birth to the field of global neurosurgery-"an area for study, research, practice, and advocacy that places a priority on improving health outcomes and achieving health equity for all people worldwide who are affected by neurosurgical conditions or need neurosurgical care." to coordinate the efforts of global neurosurgeons, the wfns has created an ad-hoc committee: the wfns gnc. in addition to the difficulties already faced in providing neurosurgical care in lmics, the current covid- pandemic has further strained healthcare resources, especially for those in lowresource settings. to understand the effects of the pandemic on training and propose solutions to the issues identified, the wfns gnc and the wfns ynf co-hosted a webinar. the following are key messages from the presentations: . covid- has had a significant effect on medical education and surgical training and is likely to do so for the foreseeable future owing to restrictions on gatherings, restrictions to local movement, and the reduction in overseas travel. . we must ensure that our graduates in lmics are supported with equipment and continuing education to allow them to establish successful practice within their healthcare system. . education in neurosurgery is a bidirectional exchange of knowledge, which is essential for success. and continuing professional development, which has been accelerated by the pandemic. collaboration is the key to successfully improving education in global neurosurgery. . it is the responsibility of neurosurgeons to lead the process to ensure an adequate neurosurgical workforce in their respective countries. more than attendees registered on zoom, and an additional followed the live streams on facebook and youtube. additionally, the audience followed and commented about the webinar on twitter with the hashtag #globalneuroandcovid ( , impressions and , reaches; figure ) . notably, . % of participants were women, from southeast asia and africa ( . %), and either neurosurgeons or residents ( . %; figure ). most ( . %) had reported a significant change in their training as a result of the pandemic. the participants reported that the wfns could help them train better in the postecovid- era if it sponsored online courses ( %), virtual dissection laboratories . harmonization of the present "several randomly organized webinars by various wfns committees" to create a coherent and essential curriculum suitable for lmic trainees and accepted by national accreditation authorities. in that regard, the wfns might consider issuing certificates that could be recognized by local authorities. www.journals.elsevier.com/world-neurosurgery . reinforcement of twinning programs with more organized collaborations between high-income countries and lmics, . the development and validation of novel educational and training tools such as virtual meetings, virtual laboratories, and surgical simulation using augmented reality. although the current covid- pandemic has had a sudden and negative effect on the ability to train neurosurgeons, especially in lmics, the increased use of social media and virtual platforms (in our case, zoom) is markedly improving the interactions between the leadership of the wfns and neurosurgeons around the globe. the feedback from the audience will serve as a reliable driver of how the wfns will respond to the pandemic vis-a-vis training. the wfns leadership has been quick to adapt to the pandemic and has proactively encouraged the use of virtual platforms for its activities. we clearly see untapped potential in these platforms and look forward to maximizing the potential for the benefit of all who need neurosurgical care. neurosurgery unit, department of surgical and medico-surgical sciences, faculty of medicine and pharmacy global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. executive summary of the global neurosurgery initiative at the program in global surgery and social change operative and consultative proportions of neurosurgical disease worldwide: estimation from the surgeon perspective global neurosurgery: innovators, strategies, and the way forward: jnspg th anniversary invited review article global neurosurgery: the unmet need covid- .jns conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- -qs g fz authors: jella, tarun k.; desai, ansh; jella, taral; steinmetz, michael; kimmell, kristopher; wright, james; wright, christina huang title: geospatial distribution of neurosurgeons age and above relative to the spread of covid- date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: qs g fz objective to perform an ecological study in order to analyze the geospatial distribution of neurosurgeons ≥ years old and compare these data with the spread of covid- across the; u.s. methods data regarding the distribution of covid- cases was collected from the environmental systems research institute and demographic statistics from the american association of medical colleges state workforce reports. these figures were analyzed using geospatial mapping software. results as of july , , the states with the highest number of covid- cases showed older neurosurgical workforce proportions (the proportion of active surgeons aged years or older) ranging from . % to . %. among states with the highest number of covid- deaths, the older workforce proportion ranged from . % to . %. connecticut demonstrated the highest with . % of neurosurgeons years or older. conclusions regional covid- hotspots may coincide with areas where a substantial proportion of the neurosurgical workforce is ≥ years of age. continuous evaluation and adjustment of local and national clinical practice guidelines are warranted throughout the; pandemic era. despite local and national attempts to contain the novel coronavirus (covid- ), it has continued to spread, with states reporting re-opening related surges throughout the united states as of july , . the continued prevalence of the disease and wide fluctuations in hospital resources have forced many healthcare institutions, including neurosurgical departments, to repeatedly amend departmental practices. , the pandemic has disrupted and reconfigured supply chains on local and international levels. most notable and most publicized was the unreliability in available personal protective equipment (ppe) for the healthcare workforce. the fluctuations in both covid case numbers and ppe availability could prove dangerous especially as states enter into various phases of reopening. it is important to conscientiously assess the risks faced by the neurosurgical workforce and identify the most vulnerable populations within the specialty. numerous risk factors have been found to contribute to covid- disease severity and mortality. however, age independently has been reported as one of the most significant risk factors for death due to covid- . - characterization of the geospatial patterns between covid- and the most at-risk neurosurgeons will help to determine regions that must optimize resources and commit to safety precautions in order to safeguard the neurosurgical workforce. as a result, this study was performed in order to establish first the geographical distribution of neurosurgeons aged years or older and, secondly, to compare this data to the distribution of covid- cases across the country. recent publications have analyzed similar distributions with respect to orthopedic surgeons and otolaryngologists, but a specific focus on the neurosurgical workforce is vital because it would allow for protective precautions to be taken more strategically. , data collected included the total number of neurosurgeons in each state, the number and proportion of neurosurgeons aged years or older per state, and the total state population. next, geospatial data describing the spread and severity of covid- were gathered from the environmental systems research institute (esri). to compile and display all of this data, the qgis geospatial analysis software (version . . ) was used, creating a map of all states that displayed the coordinates of active covid- cases and deaths as of july , . based on the distribution of the neurosurgeon ages, states were grouped into quintiles and a graduated color scheme was established to visualize and compare with regional covid- statistics. finally, temporal data regarding the daily and cumulative incidence of confirmed covid- cases were extracted from the new york times online data repository and graphed in order to visualize the national trajectory of the pandemic over the past six months. in the five states with the highest number of active covid- cases as of july , , the percentage of neurosurgeons years or older ranged from . % to . % (figure , table ). similarly, in the five states with the largest number of covid- related deaths as of july , the percentage of neurosurgeons years or older was as high as % (figure , table (table , table ). overall, the states in the highest quintile of neurosurgical workforce age showed between % and . % of actively practicing neurosurgeons to be aged years or above (table ) . additionally, of this quintile, florida, alabama, and montana are in the top five for the oldest average physician workforce (figure ) . it is also important to note that, when comparing state workforce age proportions across specialties, neurosurgery has a higher proportion of the workforce years or older than only vascular surgery, obstetrics & gynecology, and emergency medicine (figure ) . downtrend in covid-deaths occurred in mid-april, which simultaneously marked the return to elective surgeries authorized by the american college of surgeons (acs) on april th . the number of daily covid- deaths has continued to decrease from this original peak of over , deaths per day. a second peak occurred in mid july at , daily confirmed cases followed by a valley that leveled off at , cases daily as of september , and now again appears to be increasing. this study performed an overlay of cross-sectional data to understand more intimately the risks to the neurosurgical workforce by geographical region and age. this study found that, as of july , , certain states, specifically florida, massachusetts, georgia, alabama and connecticut, have been significantly affected by covid- , have some of the highest average physician workforce ages, and report the largest proportion of neurosurgeons aged years or above. as suggested in this paper and by most news sources across the country, the number of covid- cases in the united states continues to increase, but, as emergent, urgent, and even elective neurosurgical procedures are cleared to proceed, it is important that local entities, such as state neurosurgical societies, encourage hospitals, particularly those in states with the highest proportion of practicing neurosurgeons aged years and above, to take proper steps to guarantee the safety and security of the neurosurgical workforce. age is a known independent risk factor for poor outcomes and higher rates of mortality in both the general and the physician populations infected with covid- . one study reported a google search of physician deaths as of april , , and found physicians worldwide had died from covid- and their average and median age was . and years respectively. additionally, as of june nd , neurosurgeons across the world have died from covid- , with the average and median age at death being and , respectively. the case fatality rate in italy, as of march , for individuals years or older was nearly three times higher than that of individuals younger than years of age. given that this analysis is performed with state-level data, we cannot distinguish age distributions or covid- cases by urban or rural regions, academic or private hospitals, or hospital networks. furthermore, states where less than neurosurgeons are above years old did not report data for this metric due to privacy reasons and were thus excluded from our study. a total of states states (ak, az, me, ne, nd, nh, sd, vt, wy) did not provide data on age of neurosurgeons. our data also could not distinguish whether providers were practicing full- time or part-time and/or the age distribution of neurosurgeons by subspecialty. also, the data provided regarding the neurosurgeon workforce is also from december and more recent data is not available, so recent changes in the workforce demographics are not reflected. this is a cross-sectional evaluation that is unable to accurately capture the rapid undulation in covid- rates, and it furthermore does not report this data as a true rate. in other words, the data presented provides a relatively broad overview that will continue to change as time passes. the data that is provided with regards to the number of covid- cases or deaths by state is relatively general information that is likely not novel for many readers. since this study's data was acquired on july , the daily surge in cases has peaked at , , rather than , , as reported above. further, determining an accurate point estimate of covid- incidence has proven to be an national epidemiological challenge. it is undermined by the significant variance in proportion of state populations that actually receive testing, the range of sensitivity of tests spread, hospitals have strengthened their policies with regards to ppe usage and testing, which has both mitigated the risk that providers faced early on during the pandemic and also minimized the spread of covid- in hospitals. in addition to the importance of ppe availability, numerous covid- related guidelines and consensus recommendations already have been published for a host of neurosurgical subspecialties. , - armed with this increased awareness of regional hotspots in the united states, it is our hope that state associations, hospitals, neurosurgery departments, and neurosurgeons, will apply and improve these guidelines in order to ensure that the most at-risk esri: gis mapping software, location intelligence & spatial analytics technology github. nytimes/covid- -data: an ongoing repository of data on coronavirus cases and deaths in the u accessed new cases of covid- memoriam: a memoir for our fallen "heroes case-fatality rate and characteristics of patients dying in relation to covid- in italy workforce in the usa during the coronavirus disease- pandemic licensed physicians in the united states survey of covid- disease among orthopaedic surgeons in wuhan, people's republic of china key: cord- -bh qbn q authors: bajracharya, aliza; gurung, suja; munakomi, sunil title: scoping the perplexing effect of the covid pandemic in nepal, and the appraisal for precautionary measures from its lurking aftermath date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: bh qbn q nan scoping the perplexing effect of the covid pandemic in nepal, and the appraisal for precautionary measures from its lurking aftermath the coronavirus (covid- ) pandemic has led to the global health crisis. [ ] it is not only challenging the health aspect of the world but is draining the global economy along with the social and political sectors. [ ] in the context of nepal, our country is in the community transmission phase at the moment. our there is also a lack of adequate medical professionals, staff, and medical supplies such as ot gowns, medicines, spinal instruments, that need to be transferred from the capital city thereby hampering their timely interventions. amidst the current surge of the disease with this paradoxical lack of resources, currently, we are only able to screen only a few cases each day. this places the whole center at a very high risk of inadvertent transmission of the disease while we focus on the accountability of managing such emergency cases. putting patient care as our primary focus and also maintaining covid protocols, we have segregated the rounds among each neurosurgeon, so as to limit the exposure. we are mostly taking the help from the telemedicine and social network applications to enquire about the neurological status of the patients and their radiological imaging prior to their referral from the peripheral centers, for preparatory knowledge, counseling, and needful preparations. nepal has been on the state of lockdown since the last days, which has outturned obvious decrement in the incidence of road traffic accidents. however, but there has been an uprise in fall incidents, physical assaults, sub-acute to chronic subdural hematomas, oncological emergencies with herniation syndrome, and the incidents of hemorrhagic strokes. covid also has concurrent risks of strokes, encephalitis, and disseminated intravascular coagulation (dic). it can also complicate post-operative events in our patients. similarly, this pandemic has caused collateral damage from a panic state fearing covid. this pandemic has also eclipsed other health issues that shouldn't be neglected. in the midst of the crisis, the other aspect of concern is the lack of adequate training among staff working in isolation and icu pertaining to covid . there is also a lack of adequate knowledge in proper donning and doffing methods of the ppe's and the proper methods of waste disposal. this might cause more harm and can be paradoxically disastrous for the whole hospital. along with this, precautionary measures taken are also dismal. though tests for patients are done, visitors aren't tested due to the lack of testing kits. similarly, no measures are taken for handling patients and safeguarding the health workers in outpatient clinics. likewise, the ambulances that carry patients from the neighboring district are not timely disinfected. this will endanger all the medical teams and other staff involved. so, there is just a thin line between the selfprotection issues and the accountability towards our patients amidst such pandemic. by far to contain this infection, the government has ensured isolation facilities, quarantined the suspected cases, and contact tracing of the exposed patient, increased the screening tests, but all these steps are at a snail's pace. the isolation facilities provided are not up to the mark, the care standard is unsatisfactory and the quarantine facilities are inadequate. as a result, some of the patients have even started eloping from these centers, endangering the risk of community exposure. the government has started to seal the hospitals after identification of the positive cases, and all the exposed health team members are kept in quarantine for days. although it may appear a rational step to contain the spread, it is not a permanent solution, especially in our context, wherein the shortage of manpower is already a major health issue. to at least make a start, there needs to be a provision of rapid testing of every high-risk emergency case so as to safeguard the health workers. the referral cases need to have the facility of conducting the test prior to the referral to the center so that it avoids unnecessary delay and the environment of fearful uncertainty while managing them. in this period of shortage of protective gear, only minimal indispensable personals required in the management need to be employed for the care. the precaution needs to be there for the backup health personnel workforce in cases of accidental exposure and their absenteeism during isolation or treatment. there is certainly going to be an exponential growth in cases as the influx of migrants is rising every day. the only solution is to ramp up pcr testing and employing strict contact tracing. but we are still crippling on managing ppe, test kits, quarantine, and isolation facilities. the management algorithm is still not well structured. a road map for tackling the issue in a battlefield upfront and in the current environment with limited resources is pivotal. hub and spoke model can be ideal to run the health care system in this time of crisis. this can magnify efficiencies, effectiveness, and enhance the quality of health services. the government has been building their plans in moving sand although there is a mammoth task ahead of us in combating the covid. this is a war with no smoke and we the soldiers with no ammo. there is still no silver lining in the control of this pandemic, and but there needs to some methodology to unravel this health crisis in a justifiable manner. there is a need for some calmness amidst the chaos. the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study spillover of covid- : impact on the global economy key: cord- - qmgjdc authors: goyal, anshit; kerezoudis, panagiotis; yolcu, yagiz u.; chaichana, kaisorn l.; abode-iyamah, kingsley; quiñones-hinojosa, alfredo; bendok, bernard r.; krauss, william; parney, ian f.; spinner, robert j.; van gompel, jamie j.; bydon, mohamad title: survey of academic us programs regarding the impact of the covid- pandemic on clinical practice, education and research in neurosurgery date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: qmgjdc nan to the editor: the covid pandemic has had a drastic global impact on clinical practice across multiple surgical specialties, with neurosurgery being no exception. with attention diverted to providing appropriate care to covid patients, practices have had to adapt in order to create sufficient reserves and prepare to bear the brunt of case surges in their respective geographical locations. a precise understanding of spread and prevention has been ever evolving, therefore, a consistent response across different neurosurgery practices may not be expected. the surgeon-general of the united states recommended cancellation of all elective surgeries on march , . however, a few weeks following this directive, multiple state administrations lifted the embargo on elective procedures after ongoing evaluation of case numbers and considering the potential adverse impact of persistent cancellation on other non-covid patients and financial risk to hospitals. given that the surge of cases in the pandemic is expected to be changing, a consistent response devoid of confusion and variable compliance would be paramount to restrict spread and protect the public in the event of a repeat peak in cases in the future. apart from disruption to patients as well as to practice, there have been concerns raised about the impact of the situation on resident education and research initiatives across neurosurgery. , with resident conferences, staff and research meetings cancelled, it is as also unclear if most programs were able to successfully incorporate the virtual online mode of teaching and research into their workflow. since it is also unknown if the worst is over, a coherent response strategy will be crucial in a post-shutdown world due to the possibility of multiple outbreaks sustained across following years. to understand how different academic neurosurgery departments across the us responded to this devastating covid pandemic, we conducted a national survey of program leaders to determine the measures taken for ensuring patient and personnel safety and adapting to teaching and research needs. the goal was to assess the degree of variability in response, and highlight any potential shortcomings (anonymously) to facilitate discussions about the right path forward. in this report, we summarize the findings of this survey. the survey was collected practice: most respondents ( %) reported that they cancelled non-urgent surgeries, while % reported that while non-urgent surgeries were cancelled, they were planning to resume those procedures in the next - weeks. two respondents reported that they employed a "volume-limiting" approach based on the level of community transmission. a minority of respondents ( %) said that their institution did not put in place a specific triage mechanism for patients who may require neurosurgical intervention based on a nuanced discussion. for patients with brain and spine tumors, a few respondents said they preferred a paneled case review with leaning towards non-surgical intervention ( . %) while % said that a panel review was performed with no specific leaning towards non-surgical intervention. the majority ( . %) of respondents reported that for patients with newly diagnosed high-grade gliomas, surgery was offered within - weeks of diagnosis. about % of respondents said that, for non-enhancing lesions presumed to be low-grade gliomas, close outpatient monitoring was preferred with surgery deferred until the covid situation would improve. only a minority of respondents ( . %) preferred hypofractionation in case radiation was administered to limit patient exposure to the hospital. also, a very small number of respondents completely deferred surgery for patients over age ( . %). a minority of respondents ( %) reported that routine covid testing was not offered to patients undergoing neurosurgery (with the exception of true neurosurgical emergencies). regarding airway management in the or, while the majority of respondents said that high-level personal protective equipment (ppe) is worn by a clinician performing intubation and extubation ( %) and the number of personnel in the or was limited at that time ( %), a minority of groups used a powered air-purifying respirator (papr) ( %) at the time of airway management. with regards to endonasal procedures: approximately % of respondents suggested that additional levels of ppe such as face shields, n masks and papr were used in case surgery could not be postponed in a known covid positive patient. about % of respondents reported that all endonasal surgeries were suspended temporarily. a small ( %) of respondents also reported issues with shortage of ppe for neurosurgical procedures. interestingly, all ( %) of respondents suggested that outpatient services were delivered remotely via a telemedicine health portal. education: for personnel/resident safety, most respondents ( %) suggested that a minimal number of residents and/or fellows were allowed in the hospital while % also suggested that a designated alternate pool of providers and residents were available as a substitute in case those on service demonstrated covid- symptoms. about % also reported that residents seeing consults had sufficient ppe available while only % reported use of virtual hand-offs between care teams to minimize transmission. nearly % of respondents also reported that residents were redeployed to provide coverage for covid- units. for resident education, a small number ( %) reported cancellation of all didactic sessions within the department while the remaining suggested successful use of a video-conference based format. research: for research activities, the following was observed: % reported additional efforts/attention directed towards resident driven research; % reported that all research/staff meetings were being held virtually; % reported that efforts were made to support remote online access for research staff to work from home; % reported that patient enrollment into ongoing non-covid related studies was suspended; % reported that for animal studies related to non covid research, breeding activities requiring increase in cage counts were suspended while % reported that animal survival surgeries were also stopped to preserve ppe. ensuring seamless care delivery and maintaining the same standards of resident education and research are obvious challenges in a pandemic, in the face of preserving patient and personnel safety. certainly, there are limitations to this survey given the low response rate (~ %).while most departments pursued important policies such as cancellation of non-urgent surgeries and performed covid testing preoperatively, we did find a small number of respondents who reported not offering preoperative testing routinely. the aans/cns tumor section recently published guidelines to provide neuro-oncologic care in the covid era. according to these guidelines, patients with newly diagnosed high-grade gliomas should preferably receive surgery within - weeks of diagnosis and close outpatient monitoring is recommended for non-enhancing lesions presumed to be low-grade gliomas in order to stratify those who require more urgent surgical intervention versus those in whom the treatment may be safely postponed. while we found that majority of respondents seemed to follow this recommendation for high-grade tumors, only half reported following the corresponding recommendation for presumed low-grade lesions. the small number of respondents completely deferring tumor surgery for patients over the age of years was also interesting to noteespecially in cases where one considers a case where the patient would be most definitely while the present survey highlighted a general regard towards following best practices, we found some inconsistencies in response. while these inconsistencies may simply be a function of the ground reality of practicing neurosurgery in different settings in such unprecedented times, it brings forward the fact that a comprehensive and well-debated set of guidelines that address each of these issues may need to be already in place in case of a sudden resurgence of the situation. they may not necessarily be "one size fits all" due to the inherent diversity of training programs, but could certainly supplement each department's local coping strategy by highlighting general best practices towards some common goals: maintaining patient safety, protecting personnel on the frontlines, delivering complex neurosurgical care to patients who would still need it had there not been a pandemic and maintaining existing standards of education and research for the next generation of trainees who would still be practicing when the pandemic is over. the repercussions of these changes in clinical practice and surgeon adaptation in the covid- era on patient outcomes remains to be determined. surgeon general advises hospitals to cancel elective surgeries states lifting bans on elective procedures impact of covid- on neurosurgery resident training and education innovations in neurosurgical education during the covid- pandemic: is it time to reexamine our neurosurgical training models? inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the covid- pandemic: general guidance for neuro-oncology practitioners from the aans/cns tumor section and society for neuro-oncology key: cord- - io xux authors: kanmounye, ulrick sidney; esene, ignatius n. title: covid- and neurosurgical education in africa: making lemonade from lemons date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: io xux abstract never in history has the fabric of african neurosurgery been challenged as it is today with the advent of covid- . even the most robust and resilient neurosurgical educational systems in the continent have been brought to their knees with neurosurgical trainees and young neurosurgeons bearing the brunt. in the face of this new reality, and in order to limit the impact of the current covid- pandemic, multiple programs have implemented physical distancing which reduces in-person interactions. in some cases, residents have been asked to stay home at least till they are instructed otherwise. this unfortunate event presents an innovative opportunity for neurosurgical education in africa. herein, we detail the framework of an online neurosurgical education initiative to advance the education of african residents and young neurosurgeons during and after the covid- pandemic. initiative to advance the education of african residents and young neurosurgeons during and after the covid- pandemic. seventeen of the african countries do not have the recommended specialist neurosurgeon workforce density principally due to a lack of training programs ( ) . also, few african training programs offer a wide range of neurosurgical subspecialty experience to their trainees. yet, some of the most respected neurosurgeons in the world are african neurosurgeons who have either trained on the continent or are training the future generation of neurosurgeons in their countries. these neurosurgeons are an estimable resource that we have underused. to reach greater heights, we must choose to stand on the shoulders of these giants. however, educational exchanges between our training centers are limited and pale in the face of the partnerships our training centers have with high-income country institutions. perhaps owing to the fact that it is generally cheaper and easier to travel outside of our continent than it is inside ( ) . we hope therefore that the african continental free trade area will facilitate the transfer of knowledge. in the meantime, however we must find alternative ways to share the skills and experiences of our senior neurosurgeons with the younger generation. african residents and young neurosurgeons are already learning from and about world renowned neurosurgeons via online medical education platforms ( ). it is clear from this that we can do a better job of integrating online medical education and our experts into our training programs. in order to limit the impact of the current covid- pandemic, multiple programs have implemented physical distancing which reduces in-person interactions. in some cases, residents have been asked to stay home at least till they are instructed otherwise ( ). this unfortunate event presents an opportunity for neurosurgical postgraduate medical education in africa. herein, we detail the framework of an online neurosurgical education initiative to advance the education of african residents during and after the covid- pandemic. led by the professional societies, senior faculty from all neurosurgical subspecialties and from all the regions will be invited to host continental neurosurgery grand rounds. with permission from program directors, residents will be recruited and will be asked to register online (google some speak of the return to pre-covid "normalcy" after the pandemic but it is more likely that the post-covid period will define a new "normalcy". one in which some things that were considered impossible before will not no longer be impossible. successful organizations adapt promptly in the face of adversity. while the post-covid surprised and tested our health systems, post-covid african neurosurgical education must reinvent itself and transform its potential into achievements. resilience in this situation lies in recognizing the value of learning from those who walked the path we wish walk and using technology to our advantage. we cannot let the current crisis stifle our progression and we should not aim to return to the pre-covid "normalcy". for when life gives you lemon, make lemonade! the neurosurgical atlas: advancing neurosurgical education in the digital age impact of covid- on neurosurgery resident training and education the authors declare no competing interest. usk and ie contributed equally to the conceptualization, writing, review and editing of the manuscript. the authors declare no competing interest. key: cord- -gkvd fol authors: yang, xiaoyu; chen, fan title: asymptomatic carrier transmission of covid- and the multi-point aerosol sampling to assess risks in or during pandemic period date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: gkvd fol nan the novel coronavirus disease (covid- ) causing acute infectious pneumonia has widely spread in china and other countries in the world. globally, as of : pm cest, july , there have been , , confirmed cases of covid- , including , deaths, reported to who . studies have documented that novel coronavirus spread through human-to-human transmission in hospital and family setting , . nevertheless, the transmission of the novel coronavirus from an asymptomatic carrier should be considered as a source of the infection of covid- as well . it has been demonstrated that viral load detected in the asymptomatic patients was comparable to that in the symptomatic patients, suggesting the transmission potential of asymptomatic or minimally symptomatic patients . therefore, it is of significance to identify and isolate asymptomatic carriers as well as patients with mild symptoms to prevent the spread of the virus. to achieve this, asymptomatic patients has been comprised in the daily report and released by the government of the people's republic of china from april . but attention was paid insufficiently to this aspect in other regions including the us and europe. currently, china has lifted coronavirus restrictions, and some of the european countries have also started to ease lockdown from the mid-may . we should be alert for a potential second wave of infections from the massive movement after lockdowns ease owing to the certain level of infectivity of asymptomatic carriers. since the resurgence in contagion could be possible as late as and potentially detect or discover new pathogens with pandemic potential. we believe that when used in combination with molecular diagnostic technology, aerosol sampling is expected to serve as a non-invasive tool to monitor sars-cov- in operating room(or). and in the stage of pandemic period, the availability of aerosol sampling in or is important to encourage analytical efforts by independent teams and provide robust evidence to guide interventions. clinical characteristics of coronavirus disease in china clinical features of patients infected with novel coronavirus in wuhan, china clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing sars-cov- viral load in upper respiratory specimens of infected patients projecting the transmission dynamics of sars-cov- through the postpandemic period evidence of airborne transmission of the severe acute respiratory syndrome virus systematic comparison of two animal-to-human transmitted human coronaviruses: sars-cov- and sars-cov practical recommendations for critical care and anesthesiology teams caring for novel coronavirus ( -ncov) patients bioaerosol sampling for respiratory viruses in singapore's mass rapid transit key: cord- - mcdk authors: sweid, ahmad; jabbour, pascal; tjoumakaris, stavropoula title: incidence of acute ischemic stroke and rate of mechanical thrombectomy during the covid- pandemic in a large tertiary care telemedicine network date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: mcdk nan ahmad sweid, md, pascal jabbour, md, stavropoula tjoumakaris, md. funding statement: this research received no specific grant from any funding agency in public, commercial, or not-for-profit sectors. our outcomes (table ) demonstrate a significant decline in ais admissions by % (p= . ) and telestroke consults by % (p= . ) compared to similar months in previous years. contrary, mt procedures increased by % (p= . ) during the same period. notably, of all thrombectomy cases ( ), six were covid- positive, constituting % of all thrombectomy patients, which is significantly higher than the expected frequency (incidence of covid- is . %). lastly, there was no significant delay in diagnosis to intervention ( mins vs. mins, p= . ). the precipitous decrease in ais admissions and telestroke consults may be a consequence of patients not reporting neurological manifestations due to the fear of contracting the virus by visiting the emergency room. also, social distancing may have contributed to lack of detection of neurological changes by family, especially in the elderly population. such outcomes are consistent with previous reports by the world stroke organization ( %- % decline in ais admission) and the cardiology experience from the usa ( % decrease in cardiac catheterization lab stemi activations). , the higher incidence of covid- patients in the overall stroke group can be supported by recent theories that systemic covid- may contribute to a hyper-thrombotic state and increase the risk of ais. , this is additionally supported by the fact that the thrombus burden observed during the mt, is significantly higher than historical controls. of the covid- patients, had tandem occlusions or multiple arterial occlusions ( %) compared to historic controls in our stroke series of %. nation and worldwide efforts to increase preparedness and hospital efficiency during the pandemic are reflected on the overall lack of significant change in diagnosis to treatment time. therefore, based on the undying efforts of frontline medical personnel, patients suffering from ais may still be able to receive standard of care for medical and interventional treatment. in our series, despite the need for extra precautions, including covid- rapid testing and personal protective equipment, and the decrease in number of health care staff, we did not observe a significant delay to intervention compared to prior years. stroke care and the covid pandemic words from our president. www.worldstroke.org/news-and-blog/news/stroke-care-and-the-covid -pandemic accessed cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease (covid- ) pandemic thromboinflammation and the hypercoagulability of covid- coagulopathy and antiphospholipid antibodies in patients with covid- temporary emergency guidance to us stroke centers during the covid- pandemic society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid- the authors have no conflict of interest to report. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.author agreement: all authors have seen and approved the final version of the manuscript being submitted. the abstract of this study has been accepted at the annual meeting of the aans april , san diego, ca. key: cord- -ots qks authors: molliqaj, granit; schaller, karl title: how neurosurgeons are coping with covid- and how it impacts our neurosurgical practice: report from geneva university medical center date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: ots qks nan how neurosurgeons are coping with covid- and how it impacts our neurosurgical practice: report from geneva university medical center q q q q q granit molliqaj and karl schaller background who could have imagined that a virus in the st century could so quickly destabilize the world? an economic, health, and social catastrophe spread worldwide in a manner of a few weeks. starting from a small outbreak in the middle of china, the sars-cov- coronavirus is hitting the world hard with , , confirmed cases and , deaths worldwide as of april q , and the global curve still seems to be on an exponential upward slope. nonetheless, on january in geneva, switzerland, the director-general of the world health organization made public that the outbreak of the new coronavirus met the criteria of a public health emergency of international concern. in spite of this, more than month later, neither in europe nor in the united states, no clear and coherent response from experts or political leaders on how to deal with this exceptional situation had been reported. in march , the region of lombardy, italy, found itself overwhelmed by the rapid spread of the epidemic. , the disaster reported in northern italy seemed to have awakened the other european countries, each taking similar but nevertheless different measures. switzerland has a population of . million, with zurich and geneva as its economic capitals. with its agglomeration, geneva has a population of almost , and . million for the lake geneva q region. geneva is the center of international organizations including the european headquarters of the united nations, international committee of the red cross, world trade organization, and world health organization. on march , the federal council declared switzerland to be in an "extraordinary situation" until april; in the context of art. of the epidemics act, the cantons must comply with federal regulations. restaurants, bars, nonessential shops, and places of leisure and entertainment will thus remain closed until at least april. border controls with germany, france, and austria will be introduced. the federal council is providing up to military personnel for the health, logistics, and security system until the end of june. to date, easter monday ( april ), more than , covid- Àpositive cases have been confirmed in laboratories and deaths have been recorded for covid- according to the federal office of public health (figures and ) , and these numbers are steadily increasing. at its peak, geneva's university hospitals (in french "hopitaux universitaires de genève" or hug), had to deal with patients hospitalized for covid- , of which comprised intubated patients on the same day. hug has also taken drastic measures with the aim of increasing their capacity to deal with the epidemic. entire surgical units and other departments have been completely modified to accommodate covid- patients only. this also implies a reassignment of medical and nursing staff; for example, % of our neurosurgical residents were trained in hours in intensive care management of acute respiratory distress syndrome and then permanently assigned to the crisis unit managing the distribution of physicians for covid units. furthermore, the elective operating rooms are completely locked down and general management has imposed the cancellation of all vacations for hug employees (i.e., , of them). the neurosurgery department with its high-tech platform is maximally concerned by these institutional efforts (i.e., by the closure of its hybrid vascular operating rooms and of its intraoperative high-field magnetic resonance suite). collaboration between private clinics and public hospitals has been established, notably to operate on spinal pathologies. urgent pathologies that are not covid positive are redirected to the various private clinics in the canton of geneva. however, as the technical platform in private clinics does not allow for complex cranial surgery, some of our complex surgeries, such as ruptured arteriovenous cerebral malformations or ruptured aneurysms, had to be transferred to other swiss university hospitals, which were and are less impacted by the covid- situation. good morale rhymes with good team spirit. the fact that we have assigned % of our residents to covid- units does not prevent us from ensuring that they maintain a minimum level of training. to counter this, we have introduced daily microsurgery courses in our training rooms at the swiss foundation for innovation and training in surgery. of course, this is done in a hygienic way, with resident per table with > m distance from each other (figures and ) . a pool of multiple-choice questions has been created to allow the residents to test their knowledge and to guide their reading and learning during this slowed period on their gaps. we have often heard it, "the remedy worse than the devil," especially from economists and politicians: a deep recession in the coming years could lead to a catastrophe more serious and deadlier than the virus itself. is the remedy applied in some countries and hospitals likely to prove worse than the disease itself? all elective surgical activity has been stopped in many centers affected by the epidemic, as in hug in geneva. even worse, although sometimes necessary, patients are afraid to go to the hospital and cancel their visit. this same observation has also been relayed by the neurosurgical clinics in bergamo in italy and other internationally renowned centers around the world. , , , would it have been a valid alternative to, for example, mount a fully equipped modular covid- center outside the campus of the university medical center, as it is currently done in other cities such as zagreb or moscow, to keep free access to the high-quality technical and operating room platform? there are so many speculations around this topic, and we will get answers to those questions long after the current crisis, only when all this has been worked up in detail. print & web c=fpo coronavirus covid- ( -ncov). available at the-secondmeeting-of-the-international-health-regulations-( )-emergency-committee-regarding-the-out break-of-novel-coronavirus-( -ncov) neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum effects of the covid- outbreak in northern italy: perspectives from the bergamo neurosurgery department switzerland's population continued to grow and age in -population change in : provisional results press release. federal statistical office facts and figures about international geneva rs . . ordinance of april on the fight against communicable diseases in humans introduction hub and spoke q q q department of neurosurgery key: cord- -vnazexhj authors: pelargos, panayiotis e.; chakraborty, arpan r.; adogwa, owoicho; swartz, karin; zhao, yan d.; smith, zachary a.; dunn, ian f.; bauer, andrew m. title: an evaluation of neurosurgical practices during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: vnazexhj objective to understand how the covid- pandemic has affected the neurosurgical workforce. methods a survey consisting of twenty-two questions assessing 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 was distributed electronically to neurosurgeons throughout the united states and puerto rico. results there were respondents throughout the united states and puerto rico representing all practices types and subspecialties. nearly all respondents reported hospital restrictions on elective surgeries. most reported a decline in clinic and operative volume. nearly % of respondents saw a decrease in the work hours of their ancillary providers, and almost half ( . %) of respondents had to downsize their practice staff, office assistants, nurses, schedulers, etc. overall, . % of survey responders had experienced a decline in income, while . % 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 as compared to their colleagues. conclusion the covid pandemic will likely have a lasting effect on the practice of medicine. our survey results describe the early impact on the neurosurgical workforce. nearly all neurosurgeons experienced a significant decline in clinical volume which leads 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. 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. procedures, triaging of urgent cases, deploying telemedicine for office visits, and altering the traditional workflow of every day practice. for many, productivity has decreased, and neurosurgeons' practices and income have been affected. to better understand the ways the covid- pandemic has affected the neurosurgical workforce, we conducted an electronic survey of practicing neurosurgeons in various settings. specifically, we sought to understand how the pandemic has impacted case and clinic volume, compensation, changes in clinic structure, employment of support staff, and attitudes towards these changes. categorical variables were summarized using counts and proportions and were compared among grouping variables such as subspecialty and geographic region (high volume vs low volume) using the fisher's exact test. cochran-armitage trend test was used to assess the relationship between number of years in practice and the reduction in income during the covid- pandemic. high volume regions were defined as those states, districts, or territories with greater than , cases of covid- and low volume regions were defined as those with less than or equal to , cases, as reported by the united states centers for disease control and prevention on may , . all tests were two-sided, and a p value less than . was considered statistically significant. statistical analysis was performed using sas (version . , sas institute, cary, nc) . demographics the first email was opened by , aans and csns members with opening the survey link. the second email was opened by , members with opening the survey link. in total, there were respondents from all states as well as from the district of columbia and puerto rico. the overall response rate was . %. all practice types and subspecialties were represented ( figure ). there were survey responders from low volume regions and from high volume regions; survey responders declined to give the location of their practice. most respondents were in practice for greater than twenty years ( . %), while the remainder were evenly distributed in terms of years of practice: - years ( . %), - years ( that care was not negatively affected and . % were unsure ( figure ). there was no significant difference between effects to neurosurgery care when comparing respondents by their years in practice, type of practice, or sub-specialty. most respondents ( . %) reported a decline in their clinical volume: . % experienced - % decline, . % experienced - % decline, . % experienced - % decline, and . % experienced - % decline. twenty-four respondents ( . %) closed their practice completely during the pandemic, while . % of respondents experienced no change in clinic volume and . % reported an increase in their clinic volume ( figure ). neurosurgeons in practice greater than years ( . % vs. . % for all others, p=. ), those in solo private practice ( . % vs. . % for all others, p=. ), and those whose primary sub-specialty is spine ( . % vs. . % for all others, p= . ) were significantly more likely than their counterparts to completely close their outpatient clinics during the pandemic (figure ). of those who continued to see patients in clinic, most continued to do so remotely, as . % increased their use of telemedicine. similarly, most respondents ( . %) reported a decline in their operative volume: . % experienced - % decline, . % experienced - % decline, . % experienced - % j o u r n a l p r e -p r o o f decline, and . % experienced - % decline. thirty-three respondents ( . %) stopped operating completely during the pandemic, while . % reported no change in their operative volume and . % reported an increase in their operative volume ( figure ). several groups were found to be more likely than their counterparts to stop operating completely during the pandemic period. those in practice greater than years were more likely to stop operating during the pandemic than those in practice less than or equal to years ( . % vs. . %, p<. ). neurosurgeons in solo private practice were more likely to stop operating than their peers in other practice types ( . % vs. . %, p=. ). spine surgeons were more likely to stop operating than colleagues in other sub-specialties ( . % vs. . %, p<. ) ( figure ). further, the reduction in operative volume differed significantly (p=. ) between regions with high volumes of covid- cases compared to regions with low volumes of cases (table ) . while there were generally fewer restrictions placed on outpatient surgery centers, . % of respondents decreased their use of the outpatient surgery center, while nearly one-tenth ( . %) continued to operate at the same or greater volume. most respondents ( . %) did not perform surgeries at outpatient surgery centers prior to or during the pandemic. slightly more than half of respondents ( %) reported working with residents or fellows. of those, . % felt that the education of their residents and/or fellows has suffered as a result of the pandemic, and . % felt that adequate adjustments were made to the educational program so that their education would not suffer. just over sixty percent of respondents noted a decrease in resident and fellow clinical work hours during this period. j o u r n a l p r e -p r o o f similarly, nearly % of respondents saw a decrease in the work hours of their ancillary providers. only . % of respondents reported increasing the work hours of their ancillary providers to make up for the decrease in clinical hours worked by residents and fellows. almost half ( . %) of respondents had to downsize their practice staff, office assistants, nurses, schedulers, etc., due to the pandemic, while . % did not have to make any changes to their staff. the pandemic has also had an effect on the academic pursuits of neurosurgeons. of the respondents who participate in research, nearly half ( %) stated that they were unable to enroll patients into clinical trials during the pandemic period. many respondents also had to downsize or close their research laboratories ( %) or were unable to hire laboratory staff ( . %). further, many experienced delays in publication of scholarly papers ( . %), and . % were unable to obtain or experienced delay in obtaining grant funding. a small group applied for emergency grant funding to study covid- associated neurosurgical issues ( . %) (figure ) . exposure to covid- only . % of respondents reported their practice being affected due to themselves or a partner being exposed to or contracting covid- resulting in quarantine. further, only . % of respondents were asked by their hospital to provide non-neurosurgical medical services to covid- patients. just over % said they would be willing to provide non-neurosurgical medical care to covid- patients on a voluntary basis if needed, while . % said they would not be willing to provide non-neurosurgical medical care, and another . % stated they were j o u r n a l p r e -p r o o f not comfortable or qualified to provide these services. neurosurgeons in practice less than years were significantly more likely to be willing to provide non-neurosurgical care to covid- patients than those in practice greater than years ( . % vs. . %, p=. ). neurosurgeons, and % of peripheral nerve neurosurgeons experienced or expected to experience a decline in income. these differences across subspecialties were statistically significant (p=. ). overall, there was no statistical difference found in income changes between responders practicing in high volume versus low volume states (p=. ) ( table ) . nonetheless, nearly two-thirds of participating neurosurgeons felt that care for their patients suffered during this period and these effects were similar for all neurosurgeons regardless of their seniority, type of practice, sub-specialty, or practice location. overall, nearly three-fourths of neurosurgeons experienced greater than % decline in outpatient clinic volume with just over % of respondents closing their outpatient clinics during the pandemic. these changes in clinic volume were similar in all states and regions regardless of the volume of covid- cases. this decline in clinic volume creates a major access problem for our patients and an ethical dilemma in deciding which patients are "emergent" enough to be seen or to have surgery. those in solo private practices were disproportionately affected as nearly % closed their outpatient clinics in response to the pandemic, a statistically significant percentage compared to other practice types. given that many solo practices are located in areas which are already underserved, this may serve to perpetuate the patient access problem. while this survey did not specifically address the types of patients or cases that were delayed, it may be worth further study to determine which elective or semi-elective cases are universally considered "urgent" or "emergent". for example, should surgery for a patient with newly diagnosed glioblastoma be delayed for a number of weeks based on the fact that it is not truly emergent? the pandemic has also brought out new ways in which we practice neurosurgery. nearly % of those that responded to our survey said that they increased their use of telemedicine. j o u r n a l p r e -p r o o f the reduction in operative volume was higher than previously reported during the early pandemic period. nearly three-fourths of respondents had experienced a decline of greater than % in operative volume with . % stopping surgery completely. while the reduction in operative volume was not significantly different across neurosurgeons with different experience or type of practice, there was a statistically significant decline in operative volume in regions with higher cases of covid- . further, spine surgeons were more likely to stop operating completely during the pandemic period. this decrease in inpatient operative volume did not translate to a proportional increase in outpatient surgery center use as only . % of respondents continued to operate at the same or greater pace at the outpatient surgery center, while more than double that decreased their use of the outpatient surgery center during the same period ( . %). the pandemic not only affected neurosurgeons and their patients, but it had similar effect on neurosurgery trainees and ancillary providers. over sixty percent of respondents noted a decrease in resident and fellow clinical work hours, and nearly % expressed concern that their education suffered as a result. the shortfall in work by residents was not compensated for by increased use of ancillary providers as less than % reported an increase in their ancillary providers' work hours. rather, . % of survey responders saw a decrease in their ancillary providers work hours and almost half had to decrease their practice staff. these limitations in residents and ancillary providers may have led to a larger role for the staff neurosurgeon in call coverage and inpatient hospital work which may have further limited patient access. given the decline in clinic and operative volumes, it can be expected that most neurosurgeons would experience a decline in income during the pandemic. overall, % of respondents experienced or expected a decline in income during the pandemic while the remaining % did not. neurosurgeons who practiced in a private practice setting were more j o u r n a l p r e -p r o o f likely to experience a decline in income than those who were hospital-employed (p<. ). those who were hospital-employed were more likely to experience a decline in income than those in an academic setting (p<. ). this may be reflective of the fact that there are often other non-clinical components of the compensation plan of the academic neurosurgeon which were less likely to be affected by covid- (i.e. research, teaching, etc.). there was a greater decline in income of more senior neurosurgeons during the pandemic period. this likely reflects the fact that senior neurosurgeons have well-developed elective referral bases and mature practices that are more likely to be strongly affected by any limitation in elective work. it is also possible that the more senior neurosurgeons were more vigilant about practicing social distance measures. it is also important to consider that while the incoming revenues significantly declined, practice expenses (payroll, insurance, office expenses, etc.) continue unchanged, which led . % of the respondents in our study to downsize their practice in an effort to limit these expenses. this, in turn, may lead to issues for patient access in the future. overall, about two-third ( . %) of respondents were willing to assist in the non- neurosurgical care of covd- patients if needed. neurosurgeons that have been in practice more than years stated they were less willing to provide non-neurosurgical medical care than their counterparts in practice fewer than twenty years. most neurosurgeons, however, were not asked by their hospital to assist in the non-neurosurgical care of these patients, as only . % of respondents reported being asked by their hospital to do so. was also sent to non-board-certified neurosurgeons; therefore, it reasonable to expect that the survey was sent to the majority of practicing neurosurgeons in the united states and puerto rico. as with any survey, there is the opportunity for response bias. our selected population was not random, and it is quite possible that neurosurgeons most affected by the pandemic were non- responders due to their increased responsibilities working on the front lines caring for covid patients. additionally, due to the rapid progression of the pandemic, the survey could not be validated as a psychometric analysis tool prior to distribution. therefore, the results should be interpreted more in a descriptive fashion. the covid pandemic will likely have lasting effects on many aspects of the practice of medicine. our survey sheds light on the particular vulnerabilities of different practice types and subspecialties to disasters of this nature. nearly all neurosurgeons have seen a significant decrease in clinical volume. this was most pronounced for more senior surgeons who have well established elective practices and more likely for those who subspecialize in spine. as expected, this decrease in volume has led to decreased income for neurosurgeons and their practices which in many cases has led to restructuring of the practice itself. in the future, this may lead to j o u r n a l p r e -p r o o f reduced patient access. there is little doubt that the lessons learned will shape our clinical practice patterns, compensation models, and preparedness for future pandemics or disasters. there are no conflicts of interest to report as pertained to this work. the authors would like to acknowledge the support and collaboration from the csns workforce committee. without their assistance in survey distribution, this work would not have been possible and certainly would not have been as complete. finally, the authors appreciate and acknowledge the willing participation of survey respondents nationally in this difficult time. most respondents experienced a greater than % decline in their clinic volume, while over % of respondents closed their clinic altogether during the pandemic. figure . change in clinic volume by years in practice, type of practice, and subspecialty during the covid- pandemic. those in practice greater than years were significantly more likely to close their clinic than the remainder of their colleagues ( . % vs. . %, p=. ). those in solo private practice were significantly more likely to close their clinic than those in other practice types ( . % vs. . %, p=. ). those whose primary sub-specialty was spine were significantly more likely to close their clinic than those in other sub-specialties ( . % vs. . %, p=. ). most respondents experienced a greater than % decline in their operative volume, while over % of respondents stopped operating altogether during the pandemic. j o u r n a l p r e -p r o o f figure . change in operative volume by years in practice, type of practice, and subspecialty during the covid- pandemic. those in practice greater than years were significantly more likely to completely stop operating than the remainder of their colleagues ( . % vs. . %, p<. ). those in solo private practice were significantly more likely to completely stop operating than those in other practice types ( . % vs. . %, p=. ). those whose primary sub-specialty is spine were significantly more likely to completely stop operating than those in other sub-specialties ( . % vs. . %, p <. ). j o u r n a l p r e -p r o o f ( ) q has the covid epidemic affected your academic and research pursuits? select all that apply. have not been able to enroll patients in clinical research trials ( ) downsized or closed research lab ( ) unable or delayed in obtaining grant funding ( ) i have applied for emergency covid grant funding for study of covid associated neurosurgical issues ( ) delay in publication of scholarly papers ( ) unable to hire laboratory staff ( ) i do not participate in any clinical or laboratory research ( ) j o u r n a l p r e -p r o o f q has your practice been negatively affected because you or one of your partners was exposed to or contracted covid resulting in quarantine? o yes ( ) o no ( ) q have you been asked by your hospital to provide non-neurosurgical medical services to assist with covid patients (i.e. critical care, medical care, ventilator management, er triage, etc.)? s. -investigation, data curation, writing (original draft and revisions), visualization bs -writing (original draft and revisions) owoicho adogwa m.d.-data curation, writing (review and editing) zhao ph.d. -validation and formal analysis, visualization smith m.d. -writing (original draft and revisions), writing (review mba -conceptualization, methodology, investigation, data curation, writing (original draft and revisions), writing (review and editing), project administration and supervision key: cord- -onr ue authors: sciubba, daniel m.; ehresman, jeff; pennington, zach; lubelski, daniel; feghali, james; bydon, ali; chou, dean; elder, benjamin d.; elsamadicy, aladine a.; goodwin, c. rory; goodwin, matthew l.; harrop, james; klineberg, eric o.; laufer, ilya; lo, sheng-fu l.; neuman, brian j.; passias, peter g.; protopsaltis, themistocles; shin, john h.; theodore, nicholas; witham, timothy f.; benzel, edward c. title: scoring system to triage patients for spine surgery in the setting of limited resources: application to the covid- pandemic and beyond date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: onr ue abstract background as of may , , the covid- pandemic has affected over . million people and touched every inhabited continent. accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. it is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients. methods using a modified delphi technique, a cohort of fellowship-trained spine surgeons from academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling. results the devised scoring system included independent components: neurological status, underlying spine stability, presentation of a high-risk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. the resultant calculator was deployed as a freely-available web-based calculator (https://jhuspine .shinyapps.io/spineurgencycalculator/). conclusion here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. we believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the covid pandemic and post-covid period. every inhabited continent. accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. it is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients. methods using a modified delphi technique, a cohort of fellowship-trained spine surgeons from academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high- priority elective, or low-priority elective scheduling. results the devised scoring system included independent components: neurological status, underlying spine stability, presentation of a high-risk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. the resultant calculator was deployed as a freely-available web-based calculator (https://jhuspine .shinyapps.io/spineurgencycalculator/). conclusion here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. we believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the covid pandemic and post-covid period. in acute respiratory distress syndrome (ards) and/or death. , since that time it has spread rapidly to affect nearly every country, placing significant stresses on the global healthcare system. in order to mobilize resources to combat this pandemic, the centers for medicare and medicaid services (cms), the centers for disease control and prevention (cdc), and multiple professional organizations , recommended the cancellation of elective surgical procedures. in spite of this, it was recognized that there were cases, many of them neurosurgical, which required urgent or emergent intervention to minimize patient morbidity and maximize the chances of an optimal outcome. in response, several centers have presented frameworks for the management of neurosurgical patients presenting during the covid- pandemic. [ ] [ ] [ ] [ ] additionally, a triage scoring system has been previously developed in an attempt to guide spine surgery consults. , however, to date, there has not been a systematic, multi-institutional scoring system that includes resource availability and disease burden to aid in triaging spine surgery patients during this crisis. though certain symptoms referable to chronic spinal conditions may not necessarily be life threatening, these can cause significant pain and disability prompting the challenge of determining who and when to operate in times of crises. it is recognized that effective triaging of these cases in the post-covid era will be essential to prevent the healthcare system from being overwhelmed by the backlog of elective spinal cases that have been deferred because of the covid- pandemic. [ ] [ ] [ ] recently, a scoring system aimed at triaging such cases has been published in the general surgery literature, however no comparable system has been described for spine patients. here we present an applicable example of such a system assembled based upon input by a multi-institutional collaboration. this scoring system is designed to assist in two ways. first, it may assist spine surgeons and administrators with triaging surgical patients during the covid- pandemic. second, the scoring system may help health systems triage elective cases in the post-covid crisis, which is likely to also see a relative shortage of surgical resources and has been described by some as a potential collateral pandemic. methods scoring system development to generate this scoring system, the first author proposed an a priori scale highlighting those elements thought to be pertinent to the triaging of an operative spine patient in the setting of limited resources. the elements applicable to the spine patient included the patient's current neurological status (rapidity of progressive, severity), the presence of underlying spinal instability, and radiographic evidence of neural element compression. several general elements were added that could be used to triage any surgical patient, including general patient health/comorbidities, expected resource utilization, current resource availability, and local disease burden. medical comorbidities were pulled from the charlson comorbidity index and from previously published series describing comorbidities associated with increased symptom severity in patients infected with the sars-cov- virus. , [ ] [ ] [ ] [ ] [ ] after identifying these elements, weights were initially assigned based on input from surgeons at the lead institution using a modified delphi approach that included both neurosurgical and orthopaedic spine surgeons. component weighting of the preliminary scale was tested using ten example spine patients, testing the assessed urgency of the patient as determined by the scoring system against the consensus opinion of the group of surgeons. after identifying a preliminary scoring system, a multi-institutional group was convened, including neurosurgical and orthopaedic spine surgeons from multiple institutions with varying levels of experience. a modified delphi approach was again used to alter the weights assigned to the categories to refine the preliminary score. three rounds of written communication, polling, and electronic teleconferencing sessions were used to solicit input. example cases were again devised to test the degree of agreement between the scoring system and the consensus opinions regarding the urgency of the hypothetical patient's issue (supplemental data). the final scoring system was then deployed as a freely available, web-based calculator (figure ; https://jhuspine .shinyapps.io/spineurgencycalculator/). details of the multi-institutional panel the study group was comprised of spine surgeons representing the degree of impairment that their deficit causes in ambulation or the ability to perform activities of daily living (adl). the scoring system runs from - (lowest priority elective case) to (highest priority emergent case) and classifies cases as "emergent," "urgent," "high-priority elective," or "low-priority elective" as identified in table . additionally, in they have not provided an algorithm for the prioritization of such cases in the setting of potential resource shortages. here we present a scoring system devised by a multi-institutional collaboration that aims to assist with these triage issues. the ability to assist with both populations is a strength of this scoring system, which we feel may be a useful tool for health systems both during the covid pandemic and in the post-crisis period, as they struggle to accommodate the large volume of non-emergent surgical cases. additionally, though we hope such a need does not arise, the present scoring system could also have value in the triaging of patients if a "second wave" of the coronavirus pandemic occurs, which may lead to further resource limitations. such a wave occurred during the spanish influenza pandemic and many experts have speculated that a similar phenomenon could occur during the present pandemic. , furthermore, the framework of the proposed scoring system could apply to future pandemics where healthcare resources are similarly stretched as the current covid- pandemic. prior examinations of triaging in neurosurgery there have been several broad descriptions of triage strategies presented in the neurosurgical literature, , and guidelines from the american college of surgeons (acs) currently divide surgeries into five levels based upon apparent acuity. however a large proportion of spinal cases require emergent or urgent addressal in addition to a perceived lack of granularity, neurosurgical triage systems published in the pre- covid era have predominately focused on emergent surgical issues. triage amongst non- emergent cases has been largely overlooked. one exception to this is the "accountability for reasonableness (a r)" framework described by ibrahim and colleagues to emphasize scheduling fairness and minimize operating room downtime at an academic center seeing a mixture of emergent and elective cases. unlike the present scoring system however, their framework was purely qualitative -triaging was performed by a single stakeholder without an obvious means by which surgical cases were ranked. another exception is the calgary spine severity score proposed by lwu et al. that assessed spine referrals based on the clinical, pathological, and radiological aspects. similar to the a r framework, however, this score was not intended for implementation in the setting of a crisis or the acute resource shortages that are expected in the post-covid era. constituted an urgent case, namely a surgical issue requiring treatment within weeks that was not identified in the emergency list. elective cases were similarly identified as all cases that did not fall into the above two categories. unlike the system presented here, however, no formalized system was identified for the prioritization of cases within the urgent or elective categories. neuro-oncology (sno) made recommendations to prioritize adjuvant therapies (e.g. chemotherapy and radiotherapy) over earlier surgical intervention for spinal and intracranial malignancies, as this will decrease the risks posed by hospitalizing oncologic patients in the same facility as covid- -positive patients. however, the groups acknowledge that this is not always possible, and that care deferral may cause some elective cases to progress to the point of requiring urgent operative management. the european association for neurosurgical societies has attempted to address the question of how to prioritize elective neurosurgical cases through an "adapted elective surgery acuity scale." unfortunately, while this scale provides some guidance, the three tiers it employs are quite broad and there are no guidelines for prioritizing cases within a category or a given diagnosis (e.g. "degenerative spinal pathology"). consequently, we feel the need for a means of triaging both emergent and elective spine cases remains unmet. while there have been several general frameworks highlighting those cranial pathologies requiring emergent management, , , there has only been one description of a framework for triaging emergent spine surgeries. derived from the experiences at a single italian center tasked with treating cord compression and spinal instability, the framework of giorgi and colleagues is a care pathway intended to expedite the identification, treatment, and safe discharge of patients with spine emergencies. priority within the system was based upon american spinal injury association (asia) grade and radiographic evidence of instability. though good results were described for the patients treated under the framework, the pathway is non-quantitative and seemingly lacks the granularity to prioritize between two or more emergent patients. similarly, it is not equipped to triage non-emergent cases. a more quantitative approach was described by jean and colleagues based upon nearly respondents to an internet survey, asking respondents to assign an urgency score to each of nine hypothetical cases. the authors found mild-to-moderate agreement regarding the extent of surgical urgency for each case (range . - . %), however, their "acuity index" was simplistic in that it was based solely upon the perceived case risk and case urgency assigned to it by respondents. case risk was graded on a to scale ("no risk" and "cannot postpone") and case urgency on a to scale ("leave until after the end of the pandemic" and "case already done"). the scale itself did not incorporate neurological status, patient comorbidities, or local resource limitations, all of which are likely to influence the timing of operative management. because of this lack of granularity, it is unclear that this "acuity index" can be generalized to other case scenarios, thus limiting its potential utility relative to the multidimensional scoring system described here. limitations as with scoring systems published in other domains of neurosurgery, the present scoring system is not intended to be prescriptive in its guidance. rather, we present it as a potential tool to aid surgeons and healthcare systems when triaging patients in times of national crisis or global resource shortages. as with the triage frameworks presented to date, the present scoring system is derived from expert opinions. consequently, the scoring system is limited by the biases of the surgeons recruited and their respective institutions. we attempted to address this by recruiting surgeons at multiple levels of training, at academic centers spread across a large geographic region subjected to varying covid- burdens. furthermore, by only including surgeons into the decision-making process of the urgency of spine patients, there is potential that additional points from the non-surgical and administrative personnel could have altered the final scoring system. additionally, in an effort to maximize the usability of the scoring system, it was necessarily simplified and is consequently not all encompassing. for example, the broad term of "new neurologic deficit" was included under the "high-risk postoperative complication" category, however, this leaves it up to the treating surgeon whether this new deficit is "high- risk". therefore, while it can assist in determining surgical priority, final disposition should be based upon the clinical judgment of the treating surgeon and institution. nevertheless, we believe that it can be an effective tool for informing clinical stakeholders as to how each patient's case may be triaged at peer institutions. our scoring system is also limited by the fact that it operates on the assumption that the patient desires surgery at the same time recommended by the treating surgeon. this is not always the case and the ultimate timing of surgery must therefore rely on an in-depth discussion between provider and patient. finally, the present scoring system was devised with the covid- pandemic in mind. consequently, it could be argued that it may not be applicable to other resource challenging situations, and future pandemics may limit resources in a manner not assessed in the current work. however, we feel that the modular structure employed could easily be adapted to other crises that cause a shortage of medical resources. therefore, the present system may have utility beyond the present crisis and any "second wave" that may arise. conclusion here we present a scoring system for the triaging of spine surgery patients during times of crisis and severe resource scarcity. our system was developed by a multi-institutional panel using a modified delphi technique and has the potential to assist surgeons, hospital administrators, and other clinical stakeholders in assigning priority to both emergent and non-emergent spine surgery patients. while not intended to be prescriptive, this scoring system may prove useful as a guide during both the covid crisis and the post-covid period to help prioritize patients with the greatest surgical needs, though determining the urgency of an individual procedure should be left to the operating surgeon. additionally, we believe the modular structure of the scoring system implies that it may potentially be adapted to other crises resulting in an acute shortage of medical resources. tables table : spine surgery urgency scoring system table : proposed timeframes for surgical treatment based upon urgency score figure . screenshot of web-based calculator deployed based upon scoring system identified (https://jhuspine .shinyapps.io/spineurgencycalculator/) key: adl -activity of daily living; asc -ambulatory surgery center; d -day; hrhour; mo -month; snf -skilled nursing facility; wk -week †whether the complication requires surgical intervention or can be treated with nonoperative management is made at the discretion of the attending surgeon ‡vital structures include spinal cord, esophagus, trachea, aorta, lung, §medical comorbidities included: active malignancy, age > , congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, current cigarette or vape use, diabetes mellitus, history of myocardial infarction, interstitial lung disease, moderate-to-severe liver disease. urgent (e.g. within weeks) - high-priority elective (e.g. within weeks) < low-priority elective (e.g. delay until after covid- crisis) key: covid- -coronavirus disease a novel coronavirus from patients with pneumonia in china clinical characteristics of coronavirus disease in china fair allocation of scarce medical resources in the time of covid- coronavirus disease (covid- ): healthcare facility guidance covid- : recommendations for management of elective surgical procedures. acs: covid- and surgery. published . accessed nass guidance document on elective, emergent, and urgent procedures letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic a scoring system for elective triage of referrals: spine severity score validation of the calgary spine severity score how to risk-stratify elective surgery during the covid- pandemic? letter: collateral pandemic in face of the present covid- pandemic: a neurosurgical perspective editorial. covid- and its impact on neurosurgery: our early experience in singapore medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid- pandemic a new method of classifying prognostic comorbidity in longitudinal studies: development and validation covid- in critically ill patients in the seattle region -case series clinical characteristics of covid- in new york city clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study covid- and neurosurgical practice: an interim report the management of emergency spinal surgery during the covid- pandemic in italy beware of the second wave of covid- a year of terror and a century of reflection: perspectives on the great influenza pandemic of - first-wave covid- transmissibility and severity in china outside hubei after control measures, and second-wave scenario planning: a modelling impact assessment assessment of a triage protocol for emergent neurosurgical cases at a single institution protocol for urgent and emergent cases at a large academic level trauma center is case triaging a useful tool for emergency surgeries? a review of trauma surgery cases at a level trauma center in south africa priority setting in neurosurgery as exemplified by an everyday challenge inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the covid- pandemic: general guidance for neuro-oncology practitioners from the aans/cns tumor section and society for neuro-oncology triaging non-emergent neurosurgical procedures during the covid- outbreak the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study key: cord- -i a si k authors: lozada-martínez, ivan; bolaño-romero, maría; moscote-salazar, luis; torres-llinas, daniela title: letter to the editor: ”role of the neurosurgeon in times of coronavirus disease (covid- ): the importance of focus in critical care” date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: i a si k nan these modifications caused the neurosurgeons to exceed within their activities, having as the main objective to help their colleagues in the emergency and the critical care departments to mitigate the impact of this disease on local and regional health systems. some authors who have reported the execution of similar changes point out that these transformations have implied real challenges, since they have needed to be rapidly trained in critical care to be able to establish and provide quality support treatment. relocation of neurosurgery personnel, priority in the implementation of treatment, decision-making within the matter of ethics, risk of generating moral damage, medicolegal risks, financial difficulties, complications in carrying out the training within short periods, barriers to complete research work, and limits to carry out selective surgeries are some of the drawbacks of this major challenge. in response to these types of issues, experts have published various consensus, such as that of wang et al., where the main emphasis is on the critical neurologic care of patients with covid- . this consensus in particular sets a road map for the diagnosis and treatment of patients with covid- in a didactic way, as well as a protocol to be followed in intensive care units to facilitate the patient admission process, triage establishment, isolation management, disinfection of the medical equipment and the environment, waste disposal, highly specialized personal protective equipment use, airway management, and ventilatory support, and finally evaluation of neurologic diseases such as stroke, epileptic status, and neuroimmune and neuromuscular diseases, among others. these events indicate the need for the neurosurgeon to focus on critical care, not only from the neurologic sphere but also at the systemic level. a remarkable experience in which the participation and benefit that has resulted from integrating into the management of critical patients may be observed was published by caridi et al., where they manifest their role played linked with other services such as infectiology and nephrology, which have also remained in distinct performing areas during this pandemic. an important aspect mentioned is their role played as communicators with the patient's relatives, since relatives are not allowed to visit any patient as a preventive measure. finally, it shall be emphasized that this initiative should be taught from the academy starting with the undergraduate students. even when their focus is on primary health care, it is not out of place to train them in topics that are vital when covering the frontline in emergencies under circumstances similar to the ones in which we currently live. letter to the editor "service and training during the covid- pandemic: perspectives from a how neurosurgeons are coping with covid- and how it impacts our neurosurgical practice: report from geneva university medical center challenges to neurosurgery during the coronavirus disease (covid- ) pandemic expert consensus on prevention and control of covid- in the neurological intensive care unit letter: news from the covid- front lines: how neurosurgeons are contributing conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- - mwv f authors: miranda, stephen p.; glauser, gregory; wathen, connor; blue, rachel; dimentberg, ryan; welch, william c.; grady, m. sean; schuster, james m.; malhotra, neil r. title: incorporating telehealth to improve neurosurgical training during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: mwv f • telehealth clinic provides learning for residents. • resident education achievable during covid- . • learning model adaptable based on local viral burden. training in neurological surgery has evolved significantly since its formalization in . training is highly regulated, both by the accreditation council for graduate medical education (acgme) and the american board of neurological surgeons (abns), and curricular structure has evolved over the years to accommodate changes in healthcare and ensure proficiency upon graduation. in , the acgme mandated that all residents must work no more than hours per shift, hours per week, and required day per week without patient care responsibilities . at the time, residents and faculty believed this mandate would make it difficult for residents to be adequately trained, similar to the acgme work hour restrictions in , the covid- outbreak presents a significant challenge to residency training in neurosurgery. as an initial response to the covid- pandemic in the united states, the american college of surgeons (acs) recommended suspension of all elective surgical procedures . further, in an attempt to manage both healthcare provider personal protective equipment (ppe) and human-to-human contact, outpatient clinics at many institutions have been substantially reduced, or pivoted to telehealth. these measures have almost immediately eliminated the traditional educational experiences available to neurosurgical residents. this communication aims to outline how one academic department has adapted to meet the highest standards of neurosurgical education possible given the unique circumstances of the covid- pandemic. at present, education in neurosurgery is based primarily upon the neurological surgery milestones, a document created by the acgme to guide evaluation of resident performance . the milestones are multi-faceted, focusing on attitudes, skills, knowledge and other attributes included within the acgme developmental framework (table ) . each milestone is arranged in levels, from to , which signify movement from novice to expert in the given sub-competency. these milestones do not necessarily correlate with post-graduate year, and residents can potentially advance early or even regress in their milestones based on their performance. level is considered a goal for resident graduation, while level is considered an expert resident or fellow level, above the expectation for graduation in a given sub-competency . although operative training is the main focus of most patient care sub-competencies, with specific procedures detailed by subspecialty, many of the other educational objectives can be met despite the limitations dictated by the covid- crisis. with limited operative time available for trainees, it is exceedingly important for residency programs to optimize all available learning opportunities. at our institution, we have leveraged telehealth to focus on clinical experiences that are traditionally underrepresented in residency training, using educational theory as the underpinning for our activities. a number of educational theories are relevant to training in surgical sub-specialties, and these remain applicable during the covid- era, despite limited in-person patient interaction. for example, surgical educators are well aware that trainees develop expertise through deliberate practice and regular reinforcement (ericsson's theory), with guidance from more experienced experts (vygotsky's theory), and by sharing their knowledge within communities of practice (lave and wenger's theory) , . as time in the operating room has grown scarce, we have found that these ideas can easily be applied to education outside of the operating room as well. it is easiest to conceptualize educational models by grouping them either into explicit "mastery" models of instruction that lead to expertise, and implicit "constructivist" models that consider the cognitive and social perspectives of the learner . mastery models are readily apparent in surgical training, in which skills acquisition and technical proficiency are primary goals. for instance, ericsson's theory outlines that deliberate practice is a key factor in achieving expertise, with the specific intention and motivation to improve, as opposed to rote repetition. however, it is often underappreciated that this approach is most effective when coupled with constructivist strategies, including experiential learning methods that include targeted feedback from instructors. experiential learning theory involves learning through direct encounter, reflecting on experiences to develop concepts, and receiving feedback, so that behaviors can be modified for application to new situations. vygotsky's theory identifies a "zone of proximal development" (zpd), in which learning tasks that are outside of learner's current abilities are achievable with guidance from a more knowledgeable teacher, who provides observation and feedback that serves as a "scaffold" for progression through the zpd, before deliberately "fading" when no longer needed , . these concepts are beginning to be utilized more formally by neurosurgery programs for procedural training: duke neurosurgery has recently implemented a surgical autonomy program that applies the zpd concept to the development of operative skills among their residents . this type of learning can be enhanced further within communities of practice, which allow for shared repertoire, joint enterprise and mutual engagement among peers. as lave and wenger described, learning is not a process of individual experience, rather it is an integral aspect of social practice, achieved through increased knowledge, competency and involvement in the surrounding community . finally, during instruction, it is also important to consider individual learning styles of each student. there is precedent in general surgery and other disciplines for using the kolb learning style index, a -item questionnaire developed by david kolb, to characterize individual learning styles into groups: accommodating, assimilating, converging, and diverging . emotional and interpersonal relationships are the main features of the accommodating learning style, whereas assimilating learners thrive with abstract logic. individuals categorized as converging learners work best by actively solving problems, whereas diverging learners excel through observation . prior work has shown that optimal learning styles tend to be generalized across professional groups, and can predict success in surgical residency . while general surgery trainees have been characterized by accommodating and converging learning styles, early work in taiwan has shown that neurosurgical residents typically exhibit diverging learning styles and progress toward an assimilating learning style as training progresses . further study of learning styles in neurosurgical training is required for educators to generalize these findings to other settings. at our institution, we have found that involving residents in telehealth clinic and supplementing this time with virtual, case-based conferences have already enhanced resident education, by taking learning models classically used in surgical skills training and applying them to surgical decision-making and management instead. it is well understood that some of these "softer" skills in residency training, just like surgical skills, are not necessarily natural abilities. however, these skills can also be taught, learned and practiced in a structured fashion . traditional neurosurgical training heavily emphasizes hands-on operative experience and associated inpatient care, limiting curricular space for outpatient clinical experience. as a result, neurosurgeons anecdotally report that one of the more difficult aspects of transitioning to independent practice is learning how to develop their "style" in clinic: identifying appropriate candidates for surgery, engaging in shared decision-making, managing patient expectations, developing longitudinal patient relationships, managing complications in the short and long term, and so forth. the skills learned during inpatient care are not directly transferable to this setting, because of the fragmented way in which care is delivered by residents coming on and off service, and the hierarchical nature of decision-making in the hospital. clinic experience in residency is highly variable from program to program, and depends on attending availability and program logistics, including work hours, as most residents are primarily responsible for managing the inpatient service. nevertheless, outpatient clinical experience provides a critical opportunity for trainees to develop the non-operative skills emphasized by the acgme milestones, including information gathering and interpretation, evidence-based practice, critical thinking for diagnosis and therapy, and awareness of healthcare systems (table ) . these skills are necessary to become certified as an attending neurosurgeon, as evidenced by the fact that the oral board examination itself requires candidates to apply their medical knowledge to sample case scenarios, and to review their own decision-making for patients they have taken care of, instead of asking candidates to perform surgical tasks. while operative training is certainly required to become a neurosurgeon, these additional skills are necessary for a successful practice. in response to the covid- outbreak, our department has pivoted quickly to develop a robust clinical pathway for outpatient evaluation using telehealth . the telehealth format is optimal for seamlessly incorporating residents into clinic. with operative volume limited to emergencies at each of our clinical sites, residents have been reassigned to virtual clinics across a number of disciplines, from peripheral nerve and spine to brain tumor and vascular neurosurgery. prior to covid- , the curriculum only allowed space for two required outpatient clinic rotations for all residents, both in spine. under the current telehealth system, residents are assigned a clinic day for one faculty member at a time. after patients are screened by medical assistants and all of the relevant clinical data is collected by the outpatient coordinator, the resident is able to review the information and conduct telehealth appointments with each patient. residents are asked to complete documentation in the electronic medical record using a standardized template that automatically incorporates the relevant clinical information and allows the learner to focus on recording their history, virtual physical examination, clinical assessment, and plan. each case is then discussed one by one with the attending using these templates for efficient review of all clinical data, including imaging findings. the resident can then observe how the attending conducts each encounter with the patient by video conference. senior residents have the option to take a more central role in the second encounter, depending on the resident's skill level and relationship with the patient. the format of gradually elevated responsibility used in our telehealth clinic is modeled after the acgme milestones. residents are provided with the opportunity to go from novice level observation to expert level autonomy, in line with the training guidelines ( figure a ). in this format, telehealth outpatient clinic manifests many of the principles offered by educational theory for the development of expertise. residents have the autonomy to conduct clinical encounters and deliberately practice their approach (ericsson's theory, mastery learning model). they then can receive direct feedback from faculty members and reflect on their performance, after either observing the attending conduct the same encounter, and or having the attending observe their performance in a follow-up encounter (vygotsky's theory, experiential learning model). further, telehealth can easily be adapted to all four of kolb's learning styles, affording observation for divergent learners, active problem-solving for convergent learners, logical clinical reasoning for assimilating learners, and relationship building--with both patients and faculty mentors--for accommodating learners. because telehealth is likely going to remain an integral part of care even after the covid- crisis subsides, this format is flexible for adaptation as surgical volume grows, and can even serve as the blueprint for a resident-run clinic (with attending oversight), which is typically difficult to arrange within most health systems. lastly, we have augmented our traditional radiology case conference while operative case volume remains low. prior to covid- , at our weekly case conference with all residents and faculty present, patients from each clinical site are presented and residents have the opportunity to simulate an oral boards examination, practicing surgical decision-making with each case scenario. using videoconferencing, residents now conduct their own case-based conferences three times per week, with an introductory didactic to review a specific topic followed by case presentations, each moderated by a senior resident and a faculty member with relevant subspecialty expertise. so far, this approach has created a community of practice for social learning (lave and wenger's theory) that is primarily resident-driven, not only strengthening relationships between co-residents, but also allowing residents to develop their individual teaching styles while reviewing essential neurosurgical content together. in a manner similar to the telehealth learning structure, the alternative resident learning opportunities provide a means for gradual increasing responsibility, modeling the acgme milestones ( figure b ). of note, the alternative education structure is designed with the capacity to expand as the pandemic deepens and regress as elective practices return to normalcy. ultimately, this makes it possible for our department to maintain the standard of residency education while flexibly adapting to the ebb and flow of the current pandemic. neurosurgical training is complex and constantly evolving. the covid- outbreak so far has posed a significant challenge to resident education by limiting the number of operative procedures and in-person encounters available for resident involvement. however, at our institution, efficient adoption of telehealth clinic and virtual technology has presented a unique opportunity to enhance resident training despite these constraints, by leveraging traditional educational theories. accreditation and approval of residency positions in neurological surgery in the united states: an overview resident duty hours in american neurosurgery results of a national neurosurgery resident survey on duty hour regulations trends in united states neurosurgery residency education and training over the last decade covid- : recommendations for management of elective surgical procedures neurological surgery milestones applying educational theory to simulation-based training and assessment in surgery practical skills teaching in contemporary surgical education: how can educational theory be applied to promote effective learning? how educational theory can inform the training and practice of plastic surgeons simulation in paediatric urology and surgery. part : an overview of educational theory innovation and opportunity: expanding horizons for the duke neurosurgery residency program optimal education techniques for basic surgical trainees: lessons from education theory learning styles vary among general surgery residents: analysis of years of data how residents learn predicts success in surgical residency the preferred learning styles of neurosurgeons communication--the most challenging procedure telemedicine in the era of covid- : a neurosurgical perspective highlights:• telehealth clinic provides learning for residents.• resident education achievable during covid- .• learning model adaptable based on local viral burden. key: cord- -fobek ak authors: bond, jacob d.; zhang, ming title: clinical anatomy of the extradural neural axis compartment: a literature review date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: fobek ak abstract objective the extradural neural axis compartment (ednac) is an adipovenous zone located between the meningeal and endosteal layers of dura and has been minimally investigated. it runs along the neuraxis from the orbits down to the coccyx and contains fat, valveless veins, arteries and nerves. this review aims to outline the current knowledge regarding the structural and functional significance of the ednac. methods a narrative review of ednac literature was conducted. results the ednac can be organised into four regional enlargements along its length. these are the orbital, lateral sellar, clival and spinal segments with a lateral sellar orbital junction linking the orbital and lateral sellar segments. the orbital ednac facilitates movement of the eyeball, while elsewhere it allows limited motility for the meningeal dura. major nerves and vessels are cushioned and supported by the ednac. raised intraabdominal pressure (iap) is also conveyed along the spinal ednac causing increased venous pressure in the spine and cranium. from a pathological perspective, the ednac functions as a low-resistance, extradural passageway that might facilitate tumour encroachment and expansion. conclusions clinicians should be aware of the extent and significance of the ednac which may impact on skull base/spine surgery and present understanding of tumour spread pathways and growth patterns. comparatively little research has focussed on the ednac since its initial description therefore future investigations will provide more information on this underappreciated component of neuraxial anatomy. was the first to formally describe the extradural neural axis compartment (ednac) in his seminal account of this region wherein he portrayed it as an elongated, slender, adipovenous compartment in the neuraxis that is extradural in nature, being interposed between the meningeal and endosteal layers of the dura mater. , this compartment spans from the orbital fossa, back into the cavernous sinus, along the clivus, through the foramen magnum and into the spine before terminating at the coccyx. [ ] [ ] [ ] [ ] the ednac has aptly been referred to as an 'anatomic continuum', and is perhaps the longest single anatomical compartment known to date. [ ] [ ] [ ] epidural fat is the characteristic and major component of the ednac and contained within this fatty matrix are plexuses of small valveless, epidural veins allowing bidirectional flow of blood. , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] this epidural adipovenous tissue is irregularly distributed and varies in amount throughout the length of the ednac. in certain locations, the ednac also transmits nerves, in addition to arteries and larger veins before they continue on their extracranial or extraspinal course. while it is asserted that the ednac is recognised by skull base surgeons, there is a relative paucity of ednac literature, and only a small number of papers have investigated this compartment specifically or made reference to it. comprehensively reviewed the history of the ednac which revealed that past anatomists and physicians, while likely aware of the nature of the ednac, never explicitly reported it in their writings. he further proposed organising the ednac into four distinct segments. this review aims to summarise the current research pertaining to the anatomy and function of the ednac and comment on relevant aspects of clinical significance. a comprehensive review of the literature in the narrative style was conducted to identify key papers and supporting literature regarding the ednac. all papers were from the english body of literature save for one seminal paper which was in french. the ednac was illustrated on paramedian and median sagittal plastinated slices from a -year-old male cadaver and four anterior-to-posterior coronal plastinated slices from an -year old female cadaver (figures and respectively). overview: the cavernous sinus within the skull was first recognised by taptas ( ) as an extradural zone which he incorporated into his 'interperiosteodural concept' that also included all intracranial dural sinuses. , this notion laid the groundwork for parkinson ( a) to propose and promote the concept of an 'extradural neural axis compartment' or ednac. , , in essence, the ednac is a development of the interperiosteodural concept, and comprises a lengthy, multifarious, anatomical complex with four segmental enlargements containing fat and neurovascular elements that extends throughout the axial skeleton from the orbit to the coccyx. , , - , , a fatty matrix and small valveness venous plexuses are the characteristic and major components of the ednac. , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] therefore, excepting those in the skull base, most intracranial dural sinuses, e.g. the superior and inferior sagittal, straight, transverse and sigmoid sinuses, reside in the interperiosteodural space but may not be in the ednac as they are not imbedded in a fatty matrix. , methodologies utilised by researchers to investigate aspects of the ednac have included anatomical microdissection, vascular injections/casting, epoxy sheet plastination, histology and even electron microscopy. the ednac is intimately associated with the dura mater, or pachymeninx, and runs between the endosteal layer adherent to the bone which forms the 'floor', and the meningeal layer forming the 'roof' of the compartment. thus, the ednac is effectively cocooned and for the most part, limited by these two dural sheets within which the adipovenous contents are packed. the ednac can be subdivided into four segments based on the differences in regional anatomy along its length. the most rostral segment of the ednac is located in the orbital fossa ( figure a , figure a ). this segment resides between the periosteum of the orbit (known as periorbita) and the optic nerve sheath and contains abundant orbital fat that supports the eyeball, large valveless ophthalmic veins, ocular muscles and other smaller vessels and nerves. , , , , , lateral sellar orbital junction: froelich et al. ( ) conceived the term 'lateral sellar orbital junction' (lsoj) to describe the transitional zone between the orbit and the lateral sellar compartment. the lsoj is located within the wide, medial portion of the superior orbital fissure (sof) ( figure a , figure a ) . this intermediate region of the ednac represents an adipose corridor between the meningeal and periorbital dura which transmits the lacrimal and frontal branches of the ophthalmic nerve (cn v ), the trochlear nerve (cn iv), the superior ophthalmic vein as well as fat and orbital veins from the orbit to the lateral sellar compartment. , , , the central structure of the lsoj is the annular tendon of zinn onto which the four rectus muscles originate. liugan et al. ( ) also provide evidence that an adipose space surrounds the ophthalmic artery within the optic canal but how this fat is related to the lsoj is unclear as the optic canal is separate from and medial to the sof. communication between this sleeve of adipose tissue and the orbital ednac may also be reduced as meningeal dural fibres from the optic nerve sheath blend with the periosteum in the optic canal. at this rostral region of the ednac, it is important to mention the pterygoplatine fossa which is located deep to the lsoj ( figure a , figure a ). while this compartment possesses a significant mass of fat, and contains a number of neurovascular structures, it is roofed by the orbital muscle of müller and communicates with the cavernous sinus via the foramen rotundum, but is not considered an anteroinferior extension of the ednac. , lateral sellar segment: passing back through the sof, the ednac opens out into its second segment: the cavernous sinus or lateral sellar compartment (lsc). , , , this region contains a rich meshwork of discrete, very delicate veins imbedded within a fatty matrix which also transmits cns iii, iv, vi, the v and v divisions of cn v and the internal carotid artery ( figure a , figure b ). , , , , , , the venous anastomoses between the orbital veins, superior petrosal sinus and petroclival venous confluence are also embedded in the lsc. , inspired by the quantity and variety of structures contained within the lsc, parkinson quaintly describes this region as 'an extradural, anatomical jewel box'. , parkinson also makes a case against the use of the traditional, yet anatomically inaccurate label 'cavernous sinus' noting that there exists no single venous cavern, but rather a plexus of separate, discrete veins and appealed that the term 'lateral sellar compartment' (lsc) be used instead. , as it is truer to the anatomy of the region, this name has gained support in the literature and will be used henceforth to describe the 'cavernous sinus'. , , , at the posterior margin of the lsc resides meckel's cave; an evagination of the meningeal dura which envelops the trigeminal ganglion and the proximal divisions of cranial nerve v. this protruding dural pouch is associated with the ednac but is not strictly an ednac component. , françois et al. ( ) additionally note that the lsc contains less adipose tissue compared to other regions of the ednac such as the orbit or spine. using novel epoxy sheet plastination technology (similar to figure ), zhang's team revealed the fine architecture of the matrix, and medial and lateral walls of the lsc. , within the lsc, a trabecular dural framework deriving from the meningeal dura of the middle cranial fossa and meckel's cave acts to suspend the traversing cranial nerves and vessels. this meshwork then fans out to continue with the adipose matrix. the fat deposition in the lsc is mainly concentrated medial to the traversing nerves, and exhibits a dumbbell-shaped morphology on a transverse orientation. the ednac may even communicate with the potential space between intracranial nerves and their surrounding sheaths. it has been demonstrated that within the lsc, meningeal dural fibres surround the traversing cranial nerves, forming the epineurium of the nerve, and then gradually fan out to continue with the adipose tissue of the ednac. the comparative anatomy of the lsc in different primate species has been explored in several studies. found that in the olive baboon (papio anubis), the overall architecture of the parasellar region, including the interperiosteodural arrangement, is similar to that of humans. the authors describe the parasellar space as being occupied by large anastomosed sinuses, as opposed to a fine venous meshwork, and also that the baboon has a deposition of fat in the anterior lsc, similar to what is observed in man. utilising histology and electron microscopy to investigate the lsc anatomy of the crab-eating macaque (macaca fascicularis), rajendran and ling ( ) instead describe a single main venous channel running in the lsc. they concluded that the simian lsc is for the most part similar to the human lsc. in another early study by eyster ( ) on rhesus macaques (macaca mulatta), the venous component of the lsc was also reported to comprise one venous sinus which was minimally interrupted by trabeculae located medial to the internal carotid artery. clival segment: moving posteroinferiorly along the skull base, the ednac extends down the length of the clivus -a shallow intracranial depression on the basilar process of the occipital bone ( figure b , figure c ). the ednac thins out markedly in this segment, being reduced to scant patches of adipose tissue bestrewn amongst plentiful veins. these veins include breschet's veins which are continuations of the venous channels in the lsc, , , this clival segment also contains the basilar venous plexus, the anterior condylar veins, and the inferior petrosal sinus plus their anastomotic connections. spinal segment: after it exits the foramen magnum, the ednac once again broadens out and fatty tissue amply fills the epidural space along the length of the spinal canal ( figure b , figure d ). , this caudal spinal portion is the fourth segment of the ednac and transmits the epidural veins of batson which anastomose extensively with breschet's veins in the suboccipital region. , , , this fourth segment is also the interface between the neuraxial, epidural veins and their drainage out into the extra-axial venous systems. these interconnected, valveless epidural veins within the ednac have been grouped into what is called the cerebrospinal venous system (csvs): a continuum of venous plexuses and anastomoses entailing the orbital ophthalmic veins, lsc veins, breschet's veins and surrounding networks, petroclival veins, batson's veins, the internal vertebral venous system and the terminal coccygeal veins. , , , the spinal ednac may have four partitions demarked by the lateral margins of the thecal sac: the central anterior and posterior parts and the two lateral parts. the lateral spinal canal portion of ednac also extends out into the intervertebral foramen ( figure d ). the ednac may follow the neurovascular structures and extend peripherally into the spaces in the skull base and between the vertebrae. the intervertebral foramen is a well-known example illustrating the peripheral extension of the ednac ( figure d ). , in the skull base region, a report by bernard et al. ( ) verified the presence of the ednac within the jugular foramen (jf) following a cadaveric dissection study. indeed, the foraminal ednac is so significant, that it was incorporated as a feature of their new tripartite compartmental model of the jugular foramen. , they claimed that the vicinal sigmoid and inferior petrosal sinuses appeared to course within the ednac before entering the foramen. it is likely that there is an ednac presence in these foramina considering ) their proximity to an ednac expansion in the lsc, and ) that the foramen ovale transmits both neural and vascular structures which are supported by an adipose matrix ( figure a) . taptas ( ) attests that the two first divisions (v and v ) of the trigeminal nerve run within the ednac of the lsc but whether the ednac terminates before reaching these two foramina is yet to be seen. it is highly likely that the hypoglossal canal (transmitting cn xii, the posterior meningeal artery and anterior condylar vein) may also contain an extension of ednac seeing that it is immediately adjacent to a significant deposition of fat in the spinal epidural space. defining the margins and limits of the ednac can be difficult in places because this compartment resides between two dural layers which have varying configuration. the 'interior' ednac boundary is relatively straightforward as it is demarcated by the inner, meningeal dura. the 'exterior' limits of the ednac are defined by the endosteal dura, and when the ednac extends into a foramen, by the extracranial foraminal margins. within the orbit, the ednac boundaries are well defined by the orbital bony margins and eyeball/optic nerve coverings. at the lsc, an encasement of meningeal dura forms the roof, lateral wall and anterosuperior medial wall of the lsc to limit the ednac. , , conversely, the posteroinferior medial lsc wall is composed of a meshwork of loose fibres from the lsc that attach to the pituitary capsule, while the floor of the lsc comprises endosteal dura. at the clival segment, the ednac is contained by a roof of meningeal dura and an endosteal dural floor. it is unclear, however, as to how far the ednac extends laterally in this region; it may extend with the inferior petrosal sinus along the petro-occipital fissure. the spine has a welldefined ednac component which is limited interiorly by the meningeal dura surrounding the spinal cord. endosteal dura forms the exterior border intraspinally. however, exteriorly, the ednac opens into the paravertebral adipose space via the intervertebral foramen ( figure d ). the fat in the orbital enlargement of the ednac contributes to eye function, specifically, by facilitating triaxial movement. , in the spine, this fat is thought to facilitate movement of the meningeal dura during flexion/extension of the vertebral column. in the skull base, the filling of adipose tissue apparently acts to enhance minute movement between the two opposing sheets of dura. elsewhere, such as those foramina and channels in the skull base and the intervertebral foramina, the main function of the ednac is to cushion the neurovascular structures as dural fibres contribute to their coverings. considering the ednac's distribution, it is evident that it tends to be more substantial and enlarged in areas transmitting major neurovascular elements which is exemplified by the expansions in the orbit, the lsc, and the spine. as previously described, the ednac also sends a prolongation into the jf and a fatty pocket is a noticeably significant feature that surrounds the nerves and inferior petrosal sinus within the anterior foramen. insufflation of the abdomen during laparoscopic surgery is another means by which iap can be elevated which in turn raises itp, intraspinal pressure and icp as outlined previously. perioperative visual disturbance or loss has been reported as an uncommon side-effect following such a procedure [ ] [ ] [ ] [ ] [ ] . this is presumably brought about by the transmission of iap along the spine into the skull base ednac segments and then through into the orbit which causes those diagnosed with covid- and a number of recent papers emphasise utilising the prone position for operations on this patient group which will minimally alter iap and iop. [ ] [ ] [ ] [ ] nonetheless, some anaesthetic medications, particularly propofol, have been reported to mitigate iop and its sequelae during operations even in the presence of iap and steep patient positioning. [ ] [ ] [ ] [ ] [ ] controversy: it has been claimed that all of the cranial sinuses lie in the 'interperiosteodural space'. , while there are some general features that characterise periosteal and meningeal dural layers, there is not a distinct border between them. the walls of the dural venous sinuses are only composed of dural fibers lined with endothelium. therefore, the interperiodural space may not be equivalent to the ednac which has been defined as an adipovenous space. , , there are also several points of disagreement regarding the ednac in the literature. angiolipomas are particularly rare types of neuraxial tumours that arise directly from the ednac adipose tissue. they are contained by the two dural layers and therefore illustrate the ednac concept rather well. , , these fatty lesions are much more prevalent in the spine, compared to the skull base because there exists a significant, stabilising fatty matrix. the valveless csvs in the ednac can also be utilised for dissemination by metastatic cancers. rao et al. ( ) reported a cervical carcinoma that infiltrated the clival ednac via the haematogenous csvs route. in another instance, gasco et al. ( ) described the spread of a prostate adenocarcinoma up through the csvs into the skull base forming a tumour within meckel's cave, lateral to the lsc. the jugular foramen (jf), with its significant anterior pocket of fat represents a typical example for invasive growth of extrinsic tumours or expansion of intrinsic tumours into the ednac. jf tumours like paragangliomas and schwannomas frequently exploit the soft adipose matrix of the ednac as a conduit for infiltration, following the paths of least resistance. , paragangliomas are the commonest jf tumours and are unencumbered by a capsule, allowing for aggressive invasion of ednac pockets to produce extensive, irregular lesions. [ ] [ ] [ ] direct expansion of tumours within the ednac will be influenced by a number of elements, including ednac arrangement, dural fibrous network configuration, restrictive bony walls and mechanical barriers formed by crossing neurovascular structures. another pathology associated with the ednac is epidural haemorrhage of the occupying blood vessels leading to bleeding between the dural layers. , known as a spinal epidural haematoma, it involves a rupture of the epidural vessels (batson's veins) in the spinal segment of the ednac along the thoracocervical or thoracolumbar spine. , this condition is thought to be brought about by trauma, vascular malformations and anticoagulants among others, and results in haematoma formation within the epidural space causing compression of the spinal cord and concomitant neurological symptoms. [ ] [ ] [ ] [ ] [ ] this narrative review of the literature has shown that the ednac is a relatively obscure compartment with a multitude of roles and functions. the ednac is an intricate, extradural, neuraxial continuum consisting of adipovenous tissue, epidural veins, and traversing neurovascular structures. it can be subdivided into four segments (orbital, lateral sellar, clival and spinal) and one transitional zone (lateral sellar orbital junction) (figure ). peripherally, it extends into the intervertebral foramina the ednac is responsible for eyeball movement, facilitating movement between the two dural layers and supporting major nerves and vessels. the spinal segment of this compartment also has a noteworthy role as a venous pressure conduit that transfers iap through into the spinal and intracranial compartments. perhaps the most pertinent function of the ednac from a clinical perspective is that it represents a soft-tissue corridor throughout the neuroaxis that cushions the neurovascular dural sheathes while they traverse the skull base and vertebrae and can function pathologically as a conduit for tumour expansion. the ednac also plays a role in perineural tumour spread (pns) which is a recognised pattern of tumour dissemination occurring along the potential space between the nerve and its coverings, and is associated with risk of tumour recurrence and higher morbidity and mortality. it is therefore vitally important for the clinician to be aware of ednac in terms of both its anatomical arrangement and functional roles. this understanding may influence surgical plans for regions with a significant ednac presence and will help with appreciating patterns of extradural tumour expansion and optimising surgical approaches. this review has also shown that there are many facets to the ednac's anatomy and function that remain to be unveiled and clarified by future investigations. the extradural neural axis compartment history of the extradural neural axis compartment venous anatomy of the lateral sellar compartment. cavernous sinus the interperiosteodural concept applied to the jugular foramen and its compartmentalization dissemination of prostate adenocarcinoma to the skull base mimicking giant trigeminal schwannoma: anatomic relevance of the extradural neural axis component the transition between the cavernous sinus and orbit. cavernous sinus the interperiosteo-dural concept applied to the perisellar compartment: a microanatomical and electron microscopic study morphology of the human internal vertebral venous plexus: a cadaver study after intravenous araldite cy injection. the anatomical record: an official publication of the american association of anatomists venous collateral circulation of the extracranial cerebrospinal outflow routes the dural sheath of the optic nerve: descriptive anatomy and surgical applications anatomy of the spinal meninges carcinoma cervix presenting with clivus metastasis the significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal la loge du sinus caverneux, sa constitution et les rapports des éléments vasculaires et nerveux qui la traversent comparative microanatomy of the lateral wall of the 'cavernous sinus' in humans and the olive baboon lateral sellar angiolipoma: a tumor illustrative of the extradural compartment of the neural axis: case report dural entrance of the bridging vein in the middle cranial fossa: a novel classification of the cerebral veins for preoperative planning the dural entrance of cerebral bridging veins into the superior sagittal sinus: an anatomical comparison between cadavers and digital subtraction angiography lateral sellar compartment ot (cavernous sinus): history, anatomy, terminology. the anatomical record: an official publication of the american association of anatomists endoscopic endonasal anatomy of superior orbital fissure and orbital apex regions: critical considerations for clinical applications in vivo d analysis of the adipose tissue in the orbital apex and the compartments of the parasellar region dural venous system in the cavernous sinus: a literature review and embryological, functional, and endovascular clinical considerations reduced free communication of the subarachnoid space within the optic canal in the human the pterygopalatine fossa: imaging anatomy, communications, and pathology revisited anatomy and embryology of the trigeminal nerve and its branches in the parasellar area extradural approach to the lateral sellar compartment must we still call cavernous sinus the parasellar vascular and nervous crossroads? the necessity of a definite topographical description of the region. the cavernous sinus a new concept in dorello's canal microanatomy: the petroclival venous confluence carotid cavernous fistula. history and anatomy. the cavernous sinus advice and hints on imaging the lateral sellar compartments. diagnostic and interventional imaging dural relationships of meckel cave and lateral wall of the cavernous sinus meckel's cave. world neurosurgery configuration of fibrous and adipose tissues in the cavernous sinus is there an identifiable intact medial wall of the cavernous sinus? macro-and microscopic anatomical study using sheet plastination light and scanning electron microscopical study of the cavernous sinus of the monkey, macaca fascicularis the cavernous sinus in a macacus rhesus monkey. the anatomical record three-dimensional architecture of the neurovascular and adipose zones of the upper and lower lumbar intervertebral foramina: an epoxy sheet plastination study lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression compartmental subdivisions of the jugular foramen: a review of the current models meningeal architecture of the jugular foramen: an anatomic study using plastinated histologic sections surgical anatomy of the dural walls of the cavernous sinus the prevalence of perioperative visual loss in the united states: a -year study from to of spinal, orthopedic, cardiac, and general surgery perioperative visual loss in spine fusion surgeryischemic optic neuropathy in the united states from to in the nationwide inpatient sample raised intraocular pressure (iop) and perioperative visual loss in laparoscopic colorectal surgery: a catastrophe waiting to happen? a systematic review of evidence from other surgical specialities intraocular pressure changes with positioning during laparoscopy the increase of intraabdominal pressure can affect intraocular pressure iop variations from sitting to supine postures determined by rebound tonometer changes in intraocular pressure and optic nerve sheath diameter in patients undergoing robotic-assisted laparoscopic prostatectomy in steep trendelenburg position systematic review and meta-analysis of prone position on intraocular pressure in adults undergoing surgery minimally invasive surgery and the novel coronavirus outbreak: lessons learned in china and italy. annals of surgery use of prone positioning in nonintubated patients with covid- and hypoxemic acute respiratory failure respiratory parameters in patients with covid- after using noninvasive ventilation in the prone position outside the intensive care unit awake prone positioning for non-intubated oxygen dependent covid- pneumonia patients intraocular pressure changes during laparoscopy in patients anesthetized with propofol total intravenous anesthesia versus isoflurane inhaled anesthesia does intraocular pressure increase during laparoscopic surgeries? it depends on anesthetic drugs and the surgical position increase in intraocular pressure is less with propofol than with sevoflurane during laparoscopic surgery in the steep trendelenburg position intraocular pressure changes during laparoscopic surgery in trendelenburg position in patients anesthetized with propofolbased total intravenous anesthesia compared to sevoflurane anesthesia: a comparative study. anesthesia, essays and researches attenuation of increased intraocular pressure with propofol anesthesia: a systematic review with meta-analysis and trial sequential analysis on the question of a subdural space ectopic (extradural) meningioma of the orbit: a report of two cases in children extensive epidural extension growth of a glioblastoma: a case report and literature review tumors of the lateral wall of the cavernous sinus review of surgical anatomy of the tumors involving cavernous sinus the endoscopic endonasal approach for extradural and intradural clivus lesions intradural spinal tumours and their mimics: a review of radiographic features. postgraduate medical journal spheno-orbital meningiomas surgery: multicenter management study for complex extensive tumors intracranial angiolipoma spinal extradural angiolipoma: report of two cases and review of the literature differential diagnosis of jugular foramen lesions the jugular foramen: a review of anatomy, masses, and imaging characteristics jugular foramen tumors: diagnosis and treatment spontaneous spinal epidural hematoma: a study of cases focused on the etiology and treatment strategy spontaneous spinal epidural hematoma management: a case series and literature review. spinal cord series and cases spinal epidural hematoma spontaneous spinal epidural hematoma spontaneous spinal epidural hematoma in a patient on rivaroxaban: case report and literature review. the journal of emergency medicine rapid recovery of spontaneous spinal epidural hematoma without surgical treatment: case report and literature review spinal epidural hematoma: rare, but potentially devastating acute spinal epidural hematoma after acupuncture: personal case and literature review spontaneous spinal epidural hematoma: literature review imaging of perineural spread in head and neck cancer the authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. ednac: extradural neural axis compartment lsoj: lateral sellar orbital junction sof: superior orbital fissure lsc: lateral sellar compartment csvs: cerebrospinal venous system cn: cranial nerve jf: jugular foramen iap: intraabdominal pressure icp: intracranial pressure itp: intrathoracic pressure ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.the authors j.d. bond and m. zhang certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- -nk mbwdj authors: o'kelly, cian; rempel, jeremy l.; diestro, jose danilo b.; marotta, thomas r. title: letter to the editor: pandemic (covid- ) proctoring for eclips neurointervention date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: nk mbwdj nan letter to the editor: pandemic (covid- ) proctoring for eclips neurointervention letter: w ithout question, the covid- pandemic has impacted the practice of medicine in numerous ways. with rapid introduction of novel technology in the field of neurointervention, in-person case proctoring has traditionally been used for the effective and safe dissemination of the use of new endovascular devices. unfortunately, in-person case proctoring poses numerous challenges in the covid- pandemic environment with proctors needing to travel to treatment centers and work in close proximity with the local neurointerventionalists. telemedicine has been proposed as a means of ensuring continuity of patient care without risking virus transmission to either the patient or the health care provider. online videoconferencing apps have become key to performing our tasks as physicians while maintaining proper social distancing. as a proof of concept, we present a recent endovascular repair of an aneurysm using a novel device that was proctored virtually using a videoconferencing app. we present a case of a -year-old patient presenting with an incidental unruptured wide-necked carotid termination aneurysm ( figure ). we thought conventional treatment options, such as balloon-assisted coiling or y-stenting, would result in suboptimal coil filling and later recurrence. we decided to repair the aneurysm endovascularly using an eclips device (evasc medical systems corp., vancouver, british columbia, canada) that serves as a neck bridging device to ensure adequate aneurysm coiling and as a flow diverter to prevent recurrence. the treatment center (university of alberta hospital, edmonton, alberta, canada) had experience with an earlier iteration of this device, but had only completed cases using the current model. it was thought that proctoring was indicated for the safe deployment of the device. the encrypted version of the zoom (san jose, california, usa) platform was used for this case. a meeting was created with invites sent to the proctor located in toronto (ontario, canada), company representatives in vancouver (british columbia, canada), and to the devices for use in the angiography suite at the treatment center. at the treatment center, one device was setup to face the control room monitors allowing remote participants to world neurosurgery : - , october www.journals.elsevier.com/world-neurosurgery view the live fluoroscopic images. a second device was used in the suite itself, allowing remote participants to see and interact with the local neurointerventionalists. this second device could also be used to view the devices and setup on the operative and side tables ( figure ) . only the device in the suite had active audio to prevent reverberation and feedback. the procedure progressed uneventfully with successful deployment of the device to assist coiling of the aneurysm (figure ) . the proctor was able to provide real-time advice during access to the aneurysm, delivery and deployment of the eclips device, crossing of the device for coiling, and detachment of the device. image transmission was adequate to view the device and radiopaque markers, assisted by toggling between road map fluoroscopy and live fluoroscopy images. audio communication was clear and without delays. we present a case of successful virtual proctoring of a neuroendovascular case, thereby circumventing the challenges posed by pandemic-related restrictions on travel and physical distancing. no special equipment was required; however, an encrypted version of the videoconferencing application was used to ensure patient confidentiality. the quality of the transmitted images was sufficient for the case performed. a proctor can also be given multiple image displays and views of the procedure tables by inviting more devices to the meeting. telemedicine has also been previously used to support a variety of surgical paradigms such as telerobotics, telementoring, teleeducation, and teleconsultations. the analyzed systems used wearable cameras and microphones and required teleconferencing equipment, limiting ease of use and generalizability. more recently, bechstein et al. assessed the feasibility of remote proctoring for acute stroke intervention by connecting to an endovascular simulator for training purposes. similarly, remote proctoring for the eclips device has been done before, but with the device specialist still present in-person. we have demonstrated successful virtual proctoring of a remote endovascular procedure without the need for specialized videoconferencing equipment. this approach allows proctoring to continue during current pandemic restrictions, but also has implications for supporting training and cases in remote and disadvantaged environments. virtually perfect? telemedicine for covid- the second-generation eclips endovascular clip system: initial experience telemedicine and telementoring in the surgical specialties: a narrative review training and supervision of thrombectomy by remote live streaming support (ress) [e-pub ahead of print a training paradigm to enhance performance and safe use of an innovative neuroendovascular device setup of zoom-connected devices in the control room (a and b) and angiosuite (c and d) conflict of interest statement: t. r. marotta is a principal of evasc neurovascular, manufacturer of the eclips device.https://doi.org/ . /j.wneu. . . . key: cord- -sa eyzq authors: ramos-fresnedo, andres; domingo, ricardo a.; refaey, karim; gassie, kelly; clifton, william; grewal, sanjeet s.; chen, selby g.; chaichana, kaisorn l.; quiñones-hinojosa, alfredo title: neurosurgical interactive teaching series: a multidisciplinary educational approach date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: sa eyzq objective the goal of this manuscript is to investigate the effects of a multidisciplinary multinational web-based teaching conference on trainee education, research and patient care. methods we present the structure, case selection and presentation of our educational lectures. we retrospectively reviewed our database to gather data on the number of presentations, type of presentation, and the pathology diagnosis from november , until february , . to investigate attendee satisfaction, we analyzed our yearly cme evaluation survey results to report the impact that this series may have had on our attendees. we assigned a numeric value to the answers and the mean overall scores where compared through an anova. further analysis on specific questions was performed with a fisher’s exact test. results we have hosted lectures, in which we have presented neurosurgical cases corresponding to general session, pituitary, and spine cases, as well as distinct lectures by guest speakers from institutions across the globe. we received responses to our yearly cme evaluations over the course of three years. on these evaluations, we have maintained an excellent overall rating from - (two-sided p> . ) and received significantly less suggestions to improve the series comparing with (two-sided, p= . ). conclusion as the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript. the impact that this series may have had on our attendees. we assigned a numeric value to the answers and the mean overall scores where compared through an anova. further analysis on specific questions was performed with a fisher's exact test. results: we have hosted lectures, in which we have presented neurosurgical cases corresponding to general session, pituitary, and spine cases, as well as distinct lectures by guest speakers from institutions across the globe. we received responses to our yearly cme evaluations over the course of three years. on these evaluations, we have maintained an excellent overall rating from - (two-sided p> . ) and received significantly less suggestions to improve the series comparing with (two-sided, p= . ). conclusion: as the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript. in , alfred w. adson founded the neurosurgery department at the mayo clinic. however, his expertise was mostly related to general surgery. despite being appointed to treat neurosurgical patients, he is noted to describe neurosurgery as a "hopeless field" due to the high mortality and morbidity associated with these procedures at that time. just a few years prior to the work of dr. adson, ( ) , harvey cushing was establishing neurosurgery as its own separate discipline. - neurosurgery has since evolved from general surgeons taking care of neurosurgical patients, to a completely separate entity with multiple sub-specializations; including vascular, functional, spine, pediatrics, and skull-base. as we advance medical knowledge, we strive towards the need to process an impressive amount of information limited to a single topic, leading to a sub-specialization across all medical fields, including neurosurgery. - furthermore, certain pathological entities require multiple medical sub-specialties to achieve the best patient care possible. it has been repeatedly shown that multidisciplinary approach to patient care maximizes patient outcomes in multiple disciplines, and this holds true for neuro- oncology as well. [ ] [ ] [ ] similarly, in skull-base surgery, resection of these tumors is an essential component of treatment, but a multispecialty team, including neurosurgery, radiation oncology, neuro-oncology, neuro-pathology and neuro-radiology is needed to appropriately manage these patients. institutions have established weekly multidisciplinary meetings where complex cases are discussed to reach a consensus on how that specific case should be approached. , based on the multidisciplinary approach, we created a separate weekly lecture format, that is broadcast internationally, where trainees are encouraged to critically prepare (with the help of multiple experts) and review surgical cases for educational purposes. in this multimedia format, the trainee is encouraged to use intraoperative videos to be able to tell a story where multiple groups get to comment and learn from, including the junior and senior colleagues. technological advances over the recent years has had an impact on the way physicians are trained, shifting from practicing directly on the patient towards the use of indirect and simulated experiences to avoid harming the patient during their learning. [ ] [ ] [ ] in this manuscript we present the structure of a new integrative, interactive, international, and multidisciplinary educational approach to neurosurgical cases (accredited by the accreditation council for continuing medical education (accme)) of patients who underwent care in our institution, as well as data from our experience since the series was established in november of . the neurosurgical teaching series lecture is held on a weekly basis. it is scheduled to last one hour, where two interactive cases are presented. the cases are led by our neurosurgery resident physicians, fellows, and trainees, who present at least once a month. the lecture is structured in a way that the presenter talks about the case as if he was the lead physician, promoting third order thinking skills. the physicians and surgeons who are involved in the care of the case are present for guidance and surgical rationale. the physicians who were not involved in the care of the presented case are also in the audience for questions and discussions. to develop a multidisciplinary approach, members from the following specialties are present to enrich our discussion from different perspectives: neurosurgery, neurology, medical neuro- oncology, radiation-oncology, neuroradiology, neuropathology, otorhinolaryngology, neuropsychology, and endocrinology. after the cases are presented, the audience engages in a discussion on the rationale that will be beneficial in the education of trainees. this is a real-time peer-reviewed discussion using scientific evidence from the literature, as well as experience from our institution. the structure of the case presentations is based on recommendations by the american board of neurological surgery (abns) for case studies. cases are selected with two weeks in advance, so the presenter can properly prepare the case, have a thorough understanding, and review the presentation with the corresponding neurosurgery supervisor, and all other physicians involved in care. additionally, the neuro-pathology team prepares representative images of the histology studies performed on the tissue, and the neuro-radiology team selects representative images from the diagnostic workup to make a comment on how the diagnosis was guided. these cases are selected to either have a high complexity or include surgical pearls and nuances to maintain our trainees up to date. the presentations begin with the history of present illness and chief complaint, including the evolution of the disease and symptomatology. initial workup is then presented including laboratory values, imaging studies (e.g. magnetic resonance imaging (mri), computerized j o u r n a l p r e -p r o o f tomography (ct) scans, and conventional angiography) that are representative of the decision- making process during surgical assessment based on case-specific characteristics. presenters are encouraged to recognize important anatomical landmarks in these images. after the history, symptomatology, and diagnostic workup is presented, differential diagnoses are discussed with the audience, enlisting the most probable to the least probable. the final diagnosis is not disclosed with the audience to encourage third order thinking. to enhance surgical education, a brief operative procedural video is presented. this video is three to five minutes long, and includes: positioning, surgical approach, surgical pearls, reconstruction, and closure. post- operative hospital care and evolution is presented to evaluate acute complications related to the procedure. post-operative follow-up with relevant laboratory values and imaging studies is also presented. this is followed by conclusions, where the presenter is encouraged to engage in critical thinking and comment on the obstacles that had to be overcome during patient care. to finalize the case, a brief review of the literature with the latest data is presented. the audience and the presenter are then encouraged to engage in an active discussion about the nuances of the case ( fig. ) . every four weeks our multidisciplinary neuro-oncology team holds a special pituitary section where the endocrinology team leads the discussion about complex pituitary cases. these are co- presented by both endocrinology and neurosurgery to provide a more thorough understanding of the hypothalamic-pituitary-end organ axes disrupted by these lesions. j o u r n a l p r e -p r o o f although rare, spinal and medullary tumors arise and also need a multidisciplinary approach to their care. , every eight weeks, we hold a special spine section to discuss two challenging cases on spinal oncology. we retrospectively analyzed our records of the multidisciplinary teaching series, including the yearly report done to comply with the regulations for continuing medical education (cme). we analyzed previous presentations to review their diagnosis, which are presented in this paper. presentations that were not available for retrospective review were not included in the analysis. to ensure patient confidentiality, the presentations are stored in a password protected and encrypted drive for educational and research purposes, within the mayo clinic server. informed consent for research and education was obtained for each case prior to presentation. no patient information, identity or identifiers are disclosed during the presentations. after the end of every calendar year, our group surveys our audience members from the different disciplines to provide feedback about this academic activity. to obtain objective suggestions these responses are anonymized. we reviewed the feedback reports for the years , , and . to assess whether there has been a change overall in the survey results over the course of our series, a one-way anova with tukey's multiple comparisons was performed. to obtain the mean score of the survey we assigned a numerical value to the answers of every question as follows: answers to questions , , and included: very deficient, deficient, good, very good, and excellent; and values from - were assigned, respectively. answers to questions , , and included: unmet, partially met, and met; and values from - were signed, respectively. answers to questions , , , and included: no or yes; and values from - were assigned, respectively. for question , we assigned a value of for the answer "no changes needed" and no score for any other answer. to evaluate the changes for each specific question, a fisher's exact test was performed. only questions and were analyzed as they were the only questions with variation of the responses. statistical analysis was carried our using graphpad prism (version for mac, graphpad software, san diego, california usa, www.graphpad.com). the questions and answers to the close-end questions are summarized in table . results we analyzed our records from november , to february , . over this period, we have hosted a total of meetings. there has been a total of cases presented; out of which were general session cases, were pituitary cases, and were spine cases. we have also over . % of the total survey answers for question rated the lectures overall as "excellent" (maximum rating) while the rest . % rated it as "very good"; no answers were recorded for the rest of the categories (good, bad, very bad). objectives and were recorded as "met" on the % of the survey results; while % recorded objective as "met" with only one response as j o u r n a l p r e -p r o o f "partially met"; no responses were recorded as "unmet". for presenter skills in , . % of the responses recorded them as "excellent" while the rest classified them as "very good"; in we saw an increase in this ratings to a recorded . % rating them as "excellent"; we had no year (two-sided, . % and . % vs. . % and . %, p= . ) or year to year (two-sided, . % and . % vs. . % and . %, p= . ) (fig. ) . even though the topics discussed in the lectures are focused on neurosurgical topics, the format of the presentations allows for any healthcare professional, ranging from technicians to fully trained faculty. this is due to the recurring specific structure that can be applied to any medical field or specialty, allowing any-level health professional to develop an ordered rationale and third order thinking. by directing to any type of health worker, we allow the lectures to have a larger audience. there have been results on the variability of attention span in humans, and its relationship with different types of stimulus. our group has tried to account for these factors by including multimedia elements, such as imaging and short surgical videos into the presentations; as well as frequent interaction between attendees. in this manuscript we present a cme accredited, recurring and international lecture series for medical trainees from all levels of education that has been shown to have a direct impact in patientcare. a multidisciplinary approach towards patient care is essential to achieve optimal outcomes in neuro-oncologic patients. , , [ ] [ ] [ ] [ ] many institutions, including our own, have implement a weekly multidisciplinary conference, commonly known as a multidisciplinary tumor board (mtb), where complex cases from the practice are discussed to reach an integrative approach towards treatment. , , recent studies have surged about the importance and benefits of these multidisciplinary meetings, further highlighting the importance of this approach to patient care. [ ] [ ] [ ] due to the growing evidence, our group decided to establish a weekly educational series for our young surgeons. we believe that a multidisciplinary form of care must be integrated to the education of every surgical trainee, as early understanding of its benefits will be beneficial to the care delivered by them. to the best of our knowledge, this is the first manuscript to describe an established multidisciplinary interactive lecture series, organized and presented by medical trainees that is held on a weekly basis. we present how a structured meeting can be effectively held in the benefit of residents and attendings. we also present data on the type of lesions that are chosen for presentation, which are mostly skull base tumors. this is probably due to the tenacity of the cases that are chosen for presentation as they require a multispecialty team. [ ] [ ] [ ] we believe that this educational tool will have a positive impact in the career of our young residents, and as such we are enthusiastic to share our methods with other training programs. the overall satisfaction level has been maintained as "excellent" throughout the past three years as reflected in our analysis. even though in the year we obtained less "excellent" responses than the previous two years, the difference was non-significant. we believe that this is possibly due to the responses consistently falling within the maximal values throughout the study period, therefore any small variation within the responses will not affect the significance. the decrease in these responses may be due to the variability of the attendees answering the survey as they may be different between the years, as well as a minimal difference in the definition between "very good" and excellent". moreover, on analysis of question we see a significant improvement in the feedback, with a significant increasing number of answers recommending no further changes to the format, suggesting that our attendees are satisfied with how the meeting is carried out. by creating a case review within a multidisciplinary setting, like the one we present in this paper, we take medical education one step further by allowing our trainees to develop a framework of how to critically think through complex cases, and receive real time feedback from international experts as they present. this is a study representing the data that we have collected from our weekly multidisciplinary lecture series. it was done at a single institution with a single multidisciplinary team within a single residency program. studies within our institution, as well as multicenter studies are needed to validate our data, as well as the efficacy and impact that these meetings have in the education of young physicians. there are inherited limitations in this study as it is retrospective and survey-based in nature. these include sampling error and recall bias. as the survey results are anonymous and blinded, it gives us the opportunity for future feedback. even though this study has its strengths and limitations, it can provide a baseline for future manuscripts in order to improve medical education. as the world of neurosurgery is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians-in-training, such as the implementation of structured, multi-disciplinary, case-based lectures as presented in this manuscript. we encourage the community to share their experience institution. this process is based on the recommendations by the abns for case studies. following these steps allows for a structured format that can be replicated on a weekly basis. n/a -data was unavailable for this section. the answers that were not recorded in the survey results were not included in the summarized table. answers to questions , , and included: excellent, very good, good, bad, very bad. answers to questions , , and included: met, multidisciplinary management of brain metastases communication in and clinician satisfaction with multidisciplinary team meetings in neuro-oncology the role of tumor board conferences in neuro-oncology: a nationwide provider survey new requirements for resident duty hours simulation-based surgical education effectiveness of continuing medical education: updated synthesis of systematic reviews pituitary hormonal loss and recovery after transsphenoidal adenoma removal an integrated multidisciplinary algorithm for the management of spinal metastases: an international spine oncology consortium report multidisciplinary management of primary tumors of the vertebral column outbreak of a novel coronavirus letter: the impact of the coronavirus (covid- ) pandemic on neurosurgeons worldwide letter: approaches to mitigate impact of covid- pandemic on neurosurgical residency application cycle impact of covid- on neurosurgery resident research training the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study. acta neurochir (wien) impact of covid- on neurosurgery resident training and education on pandemics: the impact of covid- on the practice of neurosurgery path to reopening surgery in the covid- pandemic: neurosurgery experience ensuring an adequate neurosurgical workforce for the st century follow-up on a national survey: american neurosurgery resident opinions on the accreditation council for graduate medical education-implemented duty hours. world neurosurg impact of the accreditation council for graduate medical education work-hour regulations on neurosurgical resident education and productivity understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery more learning in less time: optimizing the resident educational experience with limited clinical and educational work hours. world neurosurg the importance of teaching clinical anatomy in surgical skills education: spare the patient, use a sim! clin anat the future of biomechanical spine research: conception and design of a dynamic d printed cervical myelography phantom. cureus development of a novel d printed phantom for teaching neurosurgical trainees the freehand technique of c laminar screw placement biomimetic -dimensional- printed posterior cervical laminectomy and fusion simulation: advancements in education tools for trainee instruction. world neurosurg attention span during lectures: seconds, minutes, or more? multidisciplinary management of colorectal brain metastases: a retrospective study the management of pineal tumors as a model for a multidisciplinary approach in neuro-oncology improvements in quality of care resulting from a formal multidisciplinary tumour clinic in the management of high-grade glioma neuro-oncology: continuing multidisciplinary progress tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer practice and impact of multidisciplinary tumor boards on patient management: a prospective study a single-institution prospective evaluation of a neuro-oncology multidisciplinary team meeting a prospective study of the clinical impact of a multidisciplinary head and neck tumor board. otolaryngol head neck surg case-based learning and its application in medical and health-care fields: a review of worldwide literature key: cord- -zsbisk b authors: bohórquez-rivero, josé; garcía-ballestas, ezequiel; moscote-salazar, luis rafael title: letter to the editor: humanization of neurosurgery: incorporation of a new concept in times of covid- date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: zsbisk b nan letter to the editor: humanization of neurosurgery: incorporation of a new concept in times of covid- letter: t he practice of medicine has changed nowadays. the increasingly and progressive fragmentation of medical practice, increases in administrative processes, and decrease in physicianpatient communication have immersed physicians in an environment of insensitivity and indifference with regard to the human being. professionals prefer not to have a patient of their own, but rather to strictly comply with a part of the diagnosis or treatment as specialists, without getting involved or committing to a relationship with the human patient. , thus, the patient has been divided into parts: the carrier of the disease (who receives more attention) and the individual (who represents little interest to science). in other words, the perception of a patient as an individual has been set aside. for example, a neurosurgeon sees a brain tumor, and it would be clear to the neurosurgeon that it would have to be removed, but he or she does not think about the person (the individual carrying the tumor), their perception of the disease, their goals, their dreams, their purpose in life, and so forth. this attitude on the part of physicians can produce despair and provoke an emotional crisis in patients. it is a problem that needs a deep restructuring, where a change in ethical values and the establishment of new humanist connections are needed. in particular, the concept of humanizing includes the relationship with the other, sharing a community and empathetic, kindly contact. humanization in health care is characterized by a set of practices aimed at better care of the person. , in this order of ideas, a physician with humanization approaches his or her patient from an integral perspective of the human and scientific knowledge. the process of humanizing medical practice contributes to improving the physician-patient relationship, improving patient safety, and avoiding medical errors. each historical period has had events to humanize medicine. neurosurgeons are currently working in difficult circumstances caused by the novel coronavirus disease (covid- ) pandemic. challenges neurosurgeons are facing include, among others, the advent of new technologies, an increasingly impersonal physician-patient relationship, loss of interest in the emotional aspects of the patient, differences in public versus private care, loss of autonomy to make decisions about patients, loss of interest in performing an adequate physical examination, and hospitals becoming increasingly less humanized. as a result, in daily neurosurgical practice and during the process of training new neurosurgeons, humanistic principles receive little attention, and scientific and technical aspects dominate. this situation has led to the incorporation of a new concept during the covid- pandemic: the humanization of neurosurgery. the neurosurgeon has immediate contact with the physical material that constitutes an individual (the brain), and brain manipulation demands well-intentioned actions with beneficial objectives. however, in addition to the fact that such surgical manipulation implies the possibility of a cure, it also includes the possibility of changing the personal characteristics of an individual. therefore, knowledge and technical skills must be accompanied or surpassed by attitudes of compassion and empathy. the work of a neurosurgeon during this pandemic must be based on fundamental principles, humanism, clinical, and technical, which are closely related. these require a high level of professionalism from specialists and neurosurgery teachers. the greater the professionalism, the more effective humanism will be. it is believed that prioritization of human values and moral norms at each stage of education, capacitation, and neurosurgical practice can prevent the dehumanization of neurosurgery. therefore, the humanization of the neurosurgeon must begin from the first years of residency, medical school, and even high school, as the development of the ability to communicate and interact with patients and their family members requires time and preparation. , other measures must be implemented in these times to avoid dehumanization and encourage humanization in neurosurgery. art and literature are powerful sources for humanization and to inspire a sense of wonder and justice in a physician (e.g., studying fine arts, reading sci-fi, listening to music). similarly, maintaining the quality of hospital treatment and additional rehabilitation therapy to achieve the optimal level of adaptation to daily life and work as well as the treatment of behavioral and emotional disorders caused by a disease is a social duty of the neurosurgeon. moreover, neurosurgical centers should advocate for the design of models of humanization, including an environment for neurosurgeons, patients, and families that allows informal physician-patient contacts not related to the disease (e.g., conversations on current topics, humanistic use of patient consciousness, and spheres of subconsciousness). based on the foundation of the project for the humanization of intensive care units (proyecto hu-ci), in madrid, spain, we consider that some aspects of this excellent approach can be incorporated into neurosurgical practice. optimal communication must occur in interactions of neurosurgeons and the medical team with patients and their families. the physician should understand the emotional state of the patient's relatives and try to help, using all available tools. medical practice should be perceived as human; thus human science and the patient cannot be reduced to diseases. , the first priority is promoting the patient's well-being, and the second priority is the preservation of the physical and mental status of the neurosurgeon in accompanying the patient to the end of postoperative and palliative care. the implementation of humanization programs must be mandatory in all neurosurgical services. neurosurgery residents must develop humanization skills. the neurosurgery associations of each country should institutionalize the humanization of our specialty. humanization is necessary in these difficult times. we extrapolate to the current covid- era a statement expressed by likhterman: "[the] neurosurgeon must not only be homo sapiens, but also homo moralis. humanization: a conceptual and attitudinal problem the humanization of medicine ethics and factors of humanization of modern neurosurgery the role of humanities and arts in medical education with special reference to neurosurgery care ¼ organisation þ physical labour þ emotional labour humanizing intensive care: toward a human-centered care icu model conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- -zxh u eg authors: patel, pious d.; kelly, katherine a.; reynolds, rebecca a.; turer, robert w.; salwi, sanjana; rosenbloom, s. trent; bonfield, christopher m.; naftel, robert p. title: tracking the volume of neurosurgical care during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: zxh u eg abstract objective this study quantifies the impact of covid- on the volume of adult and pediatric neurosurgical procedures, inpatient consults, and clinic visits at an academic medical center. methods neurosurgical procedures, inpatient consults, and outpatient appointments at vanderbilt university medical center were identified in the time periods of march , through may , ("during covid- ") and march , through may , ("before covid- "). neurosurgical volume was compared between these periods. results a % reduction in weekly procedural volume was demonstrated during covid- (median [iqr - ] to [ - ], p< . ). there was a % reduction for weekly adult procedures ( [ - ] to [ - ], p< . ), and % reduction for weekly pediatric procedures ( [ - ] to [ - ], p= . ). among adult procedures, the most significant decreases were seen for spine (p< . ), endovascular (p< . ), and cranioplasty (p< . ). there was not a significant change for adult open vascular (p= . ), functional (p= . ), cranial tumor (p= . ), or hydrocephalus (p= . ) procedural volume. weekly inpatient consults to neurosurgery decreased by % ( [ - ] to [ - ], p= . ) for adults. weekly in-person adult and pediatric outpatient clinic visits witnessed a % decrease ( [ - ] to [ - ], p< . ). weekly telehealth encounters increased from [ - ] to [ - ] (p< . ). conclusion there were significant reductions in neurosurgical operations, clinic visits, and inpatient consults during covid- . telehealth was increasingly used for assessment. the long-term impacts of reduced neurosurgical volume and increased telehealth utilization on patient outcomes should be explored. the sars-cov- novel coronavirus and associated disease, covid- , was initially identified rapidly evolving guidelines emphasized social distancing as a necessary strategy to reduce viral spread. , subsequently, a series of federal recommendations and executive orders from states recommended the cancellation of elective scheduled medical procedures. [ ] [ ] [ ] [ ] however, the dichotomization of elective versus non-elective procedures has been criticized for inadequately risk-stratifying patients. within neurological surgery, concerns exist about potential harms created by delays in care. potential adverse effects due to delayed elective procedures vary by neurosurgical subspecialty, be it vascular, oncology, functional, spine, or pediatrics. patients with tumors amenable to endoscopic endonasal resection may be particularly at risk, as many institutions have followed guidelines to indefinitely cancel these cases due to the aerosolizing nature of this approach. - the impact of covid- on neurosurgical case volume has been anecdotally reported through social networks, news media, and editorial pieces. , , a survey study assessing global neurosurgical volume changes during covid- found that roughly half of the respondents reported greater than % decrease in total operative volume. however, these estimates and reports have yet to be quantified in the scientific literature. in addition to procedures, inpatient consultations and outpatient encounters have been affected by covid- . to limit viral exposure, hospital administrators have adopted new protocols for in-hospital telehealth consults to the emergency department (ed) in addition to telehealth consultation for outpatient clinics. , patient volume is also decreased as adult and pediatric eds experience declines in non-covid-related patients. the federal government has may , were collected and categorized into the "during covid- " period. this was the - week time period immediately following the signing of a tennessee gubernatorial executive order preventing "non-essential procedures." patient records from an analogous -week period from march , through may , were collected and categorized as "before covid- ." in addition to these time periods, data were collected from the week period spanning hydrocephalus was defined as ventriculoperitoneal shunt insertion or revision or endoscopic third ventriculostomy. other procedure was defined as any procedure that did not fall into the above categories. procedure subcategories that have lower clinical likelihood of being categorized into the "high acuity" tiers a or b, defined by the acs guidelines, are marked with an asterisk in table ( , adult, pediatric), and , outpatient clinic encounters ( , adult and pediatric) met inclusion criteria during the "before covid- " and "during covid- " periods. the median age of our cohort for adults and pediatrics was consults, and clinic visits by %, %, and %, respectively (figures - ) . the impact on procedures and clinic visits was noted across both pediatric and adult practices, although less marked for children. in adults, the most impacted subspecialty services were elective spine and endovascular cases, but significant reduction was also seen for cranioplasties. when for adults or children. this trend could be attributed to the many "essential workers" who continue to commute to work as well as the unchanged rate of firearm-related crimes in the nashville area, trends also witnessed in other major cities such as chicago and philadelphia. - the reinstatement of normal societal operations in the post-pandemic period may increase inpatient consultations once more, but the extent remains to be seen. while this study examines many important neurosurgical practice changes in response to the covid- pandemic, it is important to note the study limitations. as a single center study, there was insufficient statistical power to analyze results for many individual surgical procedures; therefore, most procedures were grouped together within their parent neurosurgical subspecialty. a more in-depth analysis could be completed with data from multiple institutions. a multi- institutional study would also help account for regional variability in the us due to covid- local disease burden, state and local ordinances, and unique hospital-driven regulations in response to the pandemic. this study's focus on a large, tertiary, level trauma center limits its generalizability to smaller hospitals that treat fewer traumas or transfer patients. while an attempt was made to analyze the pandemic's effect on satellite, largely-elective neurosurgical practices in the vumc system, this investigation was limited by low sample size. secondly, this report only includes data through the first weeks after the gubernatorial order to cease elective surgery, which is a short period of time. since one aim of this article was to help institutions understand the disease's immediate impact on their neurosurgical volume, expediency was deemed key. as more data from the pandemic and post-pandemic period become available, a more robust analysis of procedural changes may be performed. similarly, the "before covid- " period was defined using a period of weeks from that were analogous to the "during covid- " period. while this reduces the effects of seasonal variation, the resultant decrease in sample size increases the likelihood of type ii error. thirdly, this analysis was unable to differentiate return or follow-up outpatient visits from new patient visits due to a limitation in the electronic medical record's categorization of encounter type after implementing telehealth visits. the covid- pandemic led to significant, measurable decreases in neurosurgical caseload, inpatient consults, and outpatient clinic visits. all subspecialties were affected, but spine incurred the largest impact in both inpatient and outpatient settings. these results may be generalizable to similarly large, level trauma centers, and may also inform the design of multi- institutional analyses aimed at measuring the nationwide effect of the pandemic. as elective procedures and in-person clinical encounters resume, the effects of reduced volume during covid- on long-term patient outcomes warrants further investigation. despite the decline of in-person neurosurgical clinic visits, telehealth visits witnessed a marked increase over the study period, which is indicative of quick practice adaptability to a rapidly changing situation. the cpt codes spine , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ao, t, tl, gr, c, t, c, m, m, c , pbonspine endovascular , , , , , , , , , , , , , , , , , , , , , , , t, p, p, p, p, t, stroke open vascular , , , , , , , , , , , , , functional , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , a, - , - , , , , , , , j , j craniotomy for deep brain stimulation , , , , - , - cranial tumor , , , , , , , , , , , , , , , , , , , , , , , a, a hydrocephalus , , , , , , , and treatment recommendations current practice and the future of deep brain stimulation therapy in parkinson's disease unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. the lancet management of unruptured intracranial aneurysms defining the value of neurosurgery in the new healthcare era nepogodiev d, bhangu a. elective surgery cancellations due to the covid- pandemic: global predictive modelling to inform surgical recovery plans they are terrified': fearing coronavirus, people with potentially fatal conditions avoid emergency care see which states and cities have told residents to stay at home not all mechanisms are created equal: a single-center experience with the national guidelines for field triage of injured patients. the journal of trauma and acute care surgery accessed report: ohio has seen a decrease in traffic accidents due to the new coronavirus pandemic special report (update): impact of covid mitigation on numbers and costs of california traffic crashes collision analysis tool tennessee bureau of investigation. tbi releases crime drops around the world as covid- keeps people inside; . accessed we need the beds telehealth and patient satisfaction: a systematic review and narrative analysis telemedicine and its role in revolutionizing healthcare delivery. the key adoption factors, barriers, and opportunities ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: key: cord- -auq msc authors: deora, harsh; mishra, shashwat; tripathi, manjul; garg, kanwaljeet; tandon, vivek; borkar, sachin; varshney, nagesh; raut, rupesh; chaurasia, bipin; chandra, p sarat; kale, s. s. title: adapting neurosurgery practice during the covid- pandemic in the indian subcontinent date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: auq msc abstract background the covid- pandemic has changed the practice of neurosurgery. significant resources have been dedicated to it. the pandemic in the indian subcontinent, when compared to the rest of the world, is relatively delayed. the neurosurgical practice cannot remain unaffected by hugely disruptive measures such as a lockdown. the inevitable rise in covid infections with its gradual relaxation continues to pose a risk for health care providers. therefore, it is imperative to evaluate whether the pandemic has had a discernible effect on the same especially in terms of practice modifications in private establishments and publicly funded hospitals, the emotional impact on the surgeon, and the influence of social media on the psyche of the surgeon. material and methods an online questionnaire-based survey was prepared, with questions related to the covid specific themes of precautions taken in outpatient services and operation theaters, the influence of social media, the economic loss incurred, and the perceptible impact of telemedicine and webinars. the links to the survey were mailed to neurosurgeons in private and public practice all over the country. the responses were anonymized to ensure free and unbiased answers to the survey questions. results a total of responses were received from all over the indian sub-continent. the median age of respondents was years (range - yrs) and the post-residency experience was years (range - yrs). respondents were an equitable mix of public and private practitioners. % of the respondents were practicing restricted outpatient services, more in public institutions (p= . ) which also had a higher incidence of tele-outpatient services( % vs %). wearing surgical masks, n- masks, and gloves were the most commonly practised precautionary measures in outpatient services(> %). while private practitioners were continuing elective cases( %), public institutes were more cautious with only emergencies being operated( %). the greatest fear among all practitioners was passing the infection to the family ( %). social media was helpful for brainstorming queries and updating practice modifications, but some surgeons admitted to receiving threats upon social media platforms( . %). depression and economic losses were palpable for approximately % neurosurgeons. conclusion the survey highlights the perception of the neurosurgeons towards the pandemic and the difference in public-private practice. suspension of elective procedures, severe curtailment of the regular outpatient appointments, drastic modifications of the normal opd/or practices and apprehensions related to inadequacy of safety provided by ppe usage and financial losses of private establishments were some of the visible themes in our survey results. though telemedicine has not been as widely adopted as expected, yet online education has been favourably received. the covid- pandemic has changed the practice of neurosurgery. significant resources have been dedicated to it. the pandemic in the indian subcontinent, when compared to the rest of the world, is relatively delayed. the neurosurgical practice cannot remain unaffected by hugely disruptive measures such as a lockdown. the inevitable rise in covid infections with its gradual relaxation continues to pose a risk for health care providers. therefore, it is imperative to evaluate whether the pandemic has had a discernible effect on the same especially in terms of practice modifications in private establishments and publicly funded hospitals, the emotional impact on the surgeon, and the influence of social media on the psyche of the surgeon. an online questionnaire-based survey was prepared, with questions related to the covid specific themes of precautions taken in outpatient services and operation theaters, the influence of social media, the economic loss incurred, and the perceptible impact of telemedicine and webinars. the links to the survey were mailed to neurosurgeons in private and public practice all over the country. the responses were anonymized to ensure free and unbiased answers to the survey questions. a total of responses were received from all over the indian sub-continent. the median age of respondents was years (range - yrs) and the post-residency experience was years (range - yrs). respondents were an equitable mix of public and private practitioners. % of the respondents were practicing restricted outpatient services, more in public institutions (p= . ) which also had a higher incidence of tele-outpatient services( % vs %). wearing surgical masks, n- masks, and gloves were the most commonly practised precautionary measures in outpatient services(> %). while private practitioners were continuing elective cases( %), public institutes were more cautious with only emergencies being operated( %). the greatest fear among all practitioners was passing the infection to the family ( %). social media was helpful for brainstorming queries and updating practice modifications, but some surgeons admitted to receiving threats upon social media platforms( . %). depression and economic losses were palpable for approximately % neurosurgeons. the survey highlights the perception of the neurosurgeons towards the pandemic and the difference in public-private practice. suspension of elective procedures, severe curtailment of the regular outpatient appointments, drastic modifications of the normal opd/or practices and apprehensions related to inadequacy of safety provided by ppe usage and financial losses of private establishments were some of the visible themes in our survey results. though introduction "i understand that it's hard for everyone, but one cannot give in to emotions... we'll have to draw lessons from the current crisis and now we'll have to work on overcoming it." the covid- pandemic has irrevocably challenged the traditional perspectives and practices of neurosurgery. medical services have been heavily scaled down during the lockdown as a huge amount of resources were deployed to face the emerging epidemic. hospitals rapidly reduced scheduled clinical and surgical activities and were forced to postpone non-emergent procedures. during this period, a significant shrinkage in access to the emergency department for both minor and major pathologies has been observed, together with the precipitous decline in outpatient appointments . perhaps the fear of contagion prevented patients, even with severe symptoms, from seeking care. alternatively, patients may also have experienced difficulties in accessing medical services given the extraordinary commitment to treat the new disease and curbs on mobility of people . the lockdown imposed to contain the contagion had some unavoidable adverse consequences for healthcare delivery . in this context, the effect of the disease and its influence on the health care system continues to be felt daily , . the neurosurgical practice is not untouched by the current situation. there are reports from various parts of the world including europe and north america regarding the change in the neurosurgical practice during covid pandemic [ ] [ ] [ ] [ ] . neurosurgical patients needing intensive care may have suffered as most of the resources like icu beds, ventilators and intensivists were diverted to the care of covid patients . however, there are some major differences in the developed and developing world (e.g. indian subcontinent); a large and dense population, limited resources, and already strained health infrastructure , . recently, there are a few publications from the developing world describing the perception of neurosurgeons about pandemic and changes in the neurosurgical practice in the pandemic but there is none from indian subcontinent [ ] [ ] [ ] [ ] [ ] . hence, there was a need felt to understand the effect of the covid epidemic on neurosurgical practice in the indian subcontinent. moreover, there is a fear of an alarming rise in the number of cases of violence against medical personnel owing to a fear of contagion or frustration with the increasingly hamstrung healthcare system in the indian subcontinent. we surveyed the practicing neurosurgeons in the indian subcontinent about the changes in the neurosurgical practice during this pandemic. we also discuss unconventional issues like the loss of economic remuneration, mental health worries, the impact of social media, and the surge of surveys and webinars. our primary intent here was to explore the disparity, if any, between private and publicly funded institutions, concerning the patterns of clinical neurosurgical practice and the use of personal protective equipment (ppe) during direct patient exposure. we also discuss the use of telemedicine in indian subcontinent. we prepared a comprehensive online questionnaire with questions with multiple choice answers and circulated the same in various social media groups, focused email lists, and direct messaging platforms consisting of neurosurgeons from the indian subcontinent (india, pakistan, bhutan, bangladesh, nepal, sri lanka). the total number of recipients of the survey was approximately . the respondents were anonymized concerning name, place of practice, sex, and country of origin in order to have an unbiased opinion. data was collected using google forms® software online. questions were divided into three broad areas: . the pattern of neurosurgical practice during covid- pandemic . influence of social media and electronic learning platforms on neurosurgeons and their mental health . the financial and emotional impact of the epidemic on neurosurgeons the statistical analysis was primarily descriptive. data compiled on the online google spreadsheet was analysed with the "r" language. the categorical variables were examined using chi-square statistics and the continuous variables were compared using welch's t test. the responses collected on likert scale patterns were studied using the non-parametric tests (wilcox rank sum test and kruskal-wallis test). statistically significant differences have been reported. we received a total of responses from a total of potential recipients ( . % response rate) from the survey which received responses between from st may to th may . the respondents were equally distributed among government and private institutions ( vs respondents) ( table ) and were of varying duration of experience following residency ( figure ). the median age of the respondents was years (range - yrs) and the median post-residency experience was years ((range - yrs). most of the neurosurgeons had approximately a median of beds (interquartile range = ) to manage per head ( figure ) with private neurosurgeons having more beds to manage per head than those in public institutions. there was a noticeable change in the outdoor patient department (opd) practices of neurosurgeons with most of them either restricting opd ( . %) or opting for tele-opd ( . %). some stopped the opd services completely ( . %) . at the other end of spectrum were a similar number of surgeons who continued their regular opd practices( . %) ( table ) . interestingly, the practice varied with the number of neurosurgeons in a group. whereas single/sole practicing neurosurgeons opted for restriction of opd numbers or follow-up cases or continued unchanged, groups with > neurosurgeons either stopped opd completely or relied completely on tele-opd. this can be attributed to the fact that most of the large neurosurgical practice groups belonged to public institutions and were obligated to close outpatient departments following government directives. this is corroborated by observations when the opd practices of private and public institutions were compared. twenty six percent of the government/public practitioners had stopped opd completely and the same proportion had opted for tele-opd services. in contrast only % of private practitioners had found it feasible to suspend their opds; . % had started tele-opd (table ). these differences in the changing patterns of outpatient services were significant (p< . ) when compared across groups. this needs to be interpreted in the context that most respondents ( . %) worked in smaller (< surgeons) groups. it is reflective of the type of neurosurgery practice in our subcontinent which is still considerably individualized in the private sector. while government institutions had an almost equitable distribution of the number of neurosurgeons between > and < groups ( vs ), private practice was dominated by teams comprising - neurosurgeons per team ( figure d , table ). in outpatient clinics, ordinary surgical masks were being used primarily, although the respondents believed that ideally n masks with gown/gloves and prior screening of cases need to be adopted ( figure ). many neurosurgeons even expected glass barriers to be erected between patients and themselves or even the use of full ppe kits in opd for maximal protection. however, these protective measures were being implemented sparingly when examined against the expectation of the clinicians ( figure , table ). surprisingly face shields were not popular either in usage or expectations in opd probably because their prolonged use was considered to be cumbersome. this is even though face shields made with surgical sterilization wraps also made to meet fda criteria report a bfe (bacterial filtration efficacy) of . %- . %. apart from this, practice more or less matched expectations both in public and private practice. in operation theatres (ot) too, the operative strategy had shifted from elective and emergencies to doing mainly emergencies and occasional elective cases during the pandemic ( figure , table ). here too, while government hospitals did either only emergencies or emergencies with covid testing, non-government organizations continued to do occasional electives or had their practice unchanged i.e. continued to do electives too (table ) . there was no difference in terms of the expectation of ot precautions with donning/doffing area, full ppe usage, and face shields/goggles being expected by both private and government institutions ( figure , table ). in terms of practice, however, the private practitioner was more careful and had higher usage of donning/doffing area ( . %vs . %), full ppe usage ( . % vs %) and face shields/goggles( . % vs . %) when compared to government institutions. one of the biggest concerns among practitioners during this time was passing the infection to family members with > % of all respondents wanting to prevent the same ( figure ). this was way higher than the fear of getting infected and financial losses (table ). regarding their outlook towards the resumption of clinical practice many felt the same would be restricted for the foreseeable future ( . %) while a substantial number of them were uncertain ( . %). in the absence of government regulations most wanted to continue semielective and elective cases with testing for covid ( . %) or do only very restricted practice like only emergency cases ( %) ( table ) . about a quarter of the respondents were mentally depressed during the past six weeks of the lockdown period following the declaration of the covid pandemic measures. social media was rife with fake news claiming false treatments and more than % of respondents seem to have encountered such news daily (table ). however, ppes and prophylactic medications like hydroxychloroquine were also discussed frequently by neurosurgeons on social media as the pandemic struck the subcontinent. most respondents (> %) found social media to be useful in deciding workflow and planning during the pandemic (table ). most respondents denied facing any threats from the community during the covid pandemic, in contrast to the social media stories. however, % of the respondents admitted that they felt discriminated against or encountered hostility on social media during the pandemic with % never reporting the same and % choosing not to respond to the same . an overwhelming majority of respondents ( . %) felt that an 'infodemic' of papers and surveys on covid- had accompanied the pandemic, perhaps more than can be humanly absorbed. about two-thirds of the respondents expected a greater role in telemedicine in the post covid era. most of the respondents were aware of the neurological manifestations of covid- ( . %) and recounted names of reputed journals (nejm, lancet, jama, nature) as their popular sources of scientific information on the pandemic. almost . % of the respondents remarked that webinars were a good source of learning during this phase of social distancing (table ) . most of the neurosurgeons reported economic losses during this period with only . % reporting no loss. the salaried surgeons face a deduction in the salary ranging from - % while private practitioners face setbacks as they need to meet the running cost of the infrastructure. the estimated losses ranged from usd to usd (inr , to , , rupees per month. average monthly salary of a neurosurgeon in india has been estimated to be usd (range from usd to usd) . this should be interpreted carefully as the losses not only meant salaries but erosion of savings and investment valuations. covid- has infected almost , , people worldwide as of this writing and has spread to more than countries across the globe , . as of now, india has more than , cases and is just behind the us, brazil and russia in terms of caseload. the surge of cases in india has been delayed perhaps due to the strict lockdown implemented by the government in the initial period which was inevitably lifted due to socio-economic compulsions. this was important to collect and streamline the resources and increase public awareness necessary to counter the epidemic. the relaxation of the lockdown and increased covid testing has led to an expected recent rise in the number of cases in india. the experience from most countries including india, brazil and russia shows that the pandemic has been disproportionately severe in densely populated metropolitan centres. high population density is one of the most important factors responsible for the uncontrolled spread of the virus with a maximum number of cases seen in metropolitan cities with population more than million (mumbai and new delhi). similarly, st. petersburg in russia and rio de janeiro and sao paulo in brazil have borne the brunt of disease.this is probably attributable to the prolonged and close contact between the infected and susceptible population, occasioned by the crowded nature of these urban centres. thus, a short term dispersion of the population outside crowded urban centres may be a useful middle path strategy vis a vis an absolute lockdown. while most of the developed nations in europe and scores of us states have seen enough progress in their fight against the virus to focus on how best to reopen their economies, the developing nations of brazil india and russia have seen a surge in cases and now place - th in the list of cases overall. however, the response in all these nations has been different. while india initiated an early lockdown and had a spike of cases later, brazil had a partial lockdown and later lifted the same. russia on the other hand had a partial economic shutdown imposed in late march helped slow the outbreak and prevent the nation's health care system from being overwhelmed. the nationwide lockdown was later needed and encouraged provincial governors to consider reopening industries and construction sites. one of the common factors in all these nations is the incapability to sustain long periods of lockdown due to economic factors which has led to a late increase in cases. developed nations on the other hand have had resources to sustain a lockdown and thus have been able to contain the spread and reopen early (usa, italy and spain). given the serious public health risk, medical practice has changed remarkably during this pandemic. although the virus primarily affects the respiratory system, the neurological manifestations of the covid are now well recognised . though, neurosurgery is not at the forefront of the medical battle against this pandemic, neurosurgical practice and training is not insulated from this epidemic. many organizations have advocated against operating elective cases during this time , , as more and more resources are being claimed by the response to the pandemic. we sought to highlight a seldom explored disparity between the response of private establishments and public hospitals offering neurosurgical services as they grapple with this pandemic. we also intended to examine the effect of social media, the economic losses incurred and the most effective sources of information for a neurosurgeon in the indian subcontinent during this pandemic. all the neurosurgical societies worldover including indian society have responded to this pandemic by making changes in the existing protocols and reorganizing the neurosurgical activities , , . focus has been shifted to triaging patients on the basis of pathology into those needing emergent or elective care , though not many pathologies are amenable to elective management in neurosurgery. scoring system for triaging patients for spine surgery in the setting of limited resources has also been developed . our survey similarly reflected the global trend towards postponing non emergent surgeries. there was a noticeable difference between the outpatient practices being followed at private and government institutions. quite unexpectedly, neurosurgeons in larger practice groups (> neurosurgeons) saw a much sterner closure of normal outpatient services. this may be because most of such large practice groups belonged to public institutions and were obligated to close outpatient departments following government directives. many government hospitals were declared covid centers by the government and even the specialists were kept ready to take care of the patients admitted with a diagnosis of covid. this policy resulted from the strategy of 'preserving' the 'manpower' for the worst. operative strategy in government hospitals was adapted to the directions issued by the neurological society of india and other organizations , . private practitioners too scaled down their operation to occasional electives with very few continuing unchanged. these policy decisions are not insulated from the financial implications being faced by the respondents. private practitioners needed to continue the practice to remain financially viable and government institutions needed to balance the risk of operating emergencies with the high risk of iatrogenic transmission, given the larger caseload and active covid- cases being treated at most of the public hospitals. it was interesting to note that neurosurgeons were most anxious about passing the infection to their families. however, this does not mean that the neurosurgeons were not worried about their safety. even in the immediate future most of them envisage doing only emergencies and semi-elective with covid testing implying their commitment towards preventing transmission of the virus and keeping themselves safe (table ). these concerns were also reflected when we enquired about practice outside the regulation umbrella. eight hundred million indians have limited access to secondary and tertiary care, having to travel mostly to metropolitan centres for superspecialty care . telemedicine provides a potential solution to mitigate this deficiency, more so, during the mobility restrictions due to the covid pandemic. telemedicine has been the predominant mode of patient follow up and has significantly replaced outdoor visits to neurosurgery departments in most of the developed world . one major centre from the us reported that % of visits to neurosurgery departments were deferred to a later date and more than % of the remaining visits were successfully converted to virtual . another centre reported a -fold increase in the use of telemedicine after the shelter-in-place measures were initiated with a significant increase in the mean number of patients evaluated via telemedicine per week across all divisions of neurosurgery ( . to . patients/week) . they reported that both the established patient visits and new patient visits increased significantly. however telemedicine services were offered by only . % of neurosurgeons in our survey, which is quite low. there are many reasons responsible for this low figure. first, not many indian patients have access to the internet at home except for smartphones, and are uncomfortable with various platforms like zoom Ⓡ and webex Ⓡ etc for telemedicine are concerned. secondly, telemedicine facilities were practically nonexistent in india before covid pandemic began and it is difficult to ensure rapid adoption of a relatively new service both for the patients and doctors. third, most of the patients do not have any medical insurance and few of those who have it are covered under various schemes run by the government. in both the scenarios there is no remuneration for the physician that leads to low initiative on the part of the neurosurgeons to offer teleopd services. the increased risk of malpractice suits with teleopd and undefined regulations further discourage remote consultations. use of ppe has been recommended during interaction and transfer of patients presenting with neurosurgical emergencies as well as during neurosurgical surgeries and procedures for confirmed and suspected patients with covid- . most of the respondents across different set ups felt the need to use ppe during patient encounters in opd as well as during surgery in operation theatre. however, there was a difference in the felt need and practice regarding the use of ppe found amongst the respondents of our survey ( tables , ) . there might be several reasons for this observation. the supply of ppe was initially erratic due to disruption of the global supply chains. the ordinary ppe suits often become very uncomfortable for the surgeon during involved and prolonged neurosurgical procedures, discouraging its use. private practitioners were more punctilious in terms of ppe usage. these observations may be attributed to diversion of ppes in large public hospitals to other departments that were facing higher caseloads of covid patients or suspects. mental health has been an often-neglected issue among neurosurgeons. physicians and medical students had higher rates of burnout and depression than the general population . before the covid pandemic, physicians were able to mitigate their stress levels with social and familial interactions. currently, the stress extends outside of the realm of healthcare facilities. physicians worrying about infecting their families and contaminating their homes may choose to self-isolate or face the guilt of potentially infecting a family member . this was reflected in our survey too with the primary concern being not spreading the infection to families and around % neurosurgeons feeling depressed during this time. a recent survey involving respondents from countries found that % of the respondents felt tense, . % were unhappy, % experienced insomnia, almost % had headaches, and % had suicidal ideation during the pandemic . fourteen percent of the respondents were found to have scores consistent with depression on self-reporting questionnaire- . various factors identified by this study to be associated with higher risk of depression included those who did not receive guidance about self-protection, those who did not feel safe with provided personal protective equipment, and those whose families considered their workplace unsafe. a recent report from china has highlighted a welcome response that there was no ripple effect or violence against doctors when they started resuming their routine neurosurgical outpatient clinics after lockdown of three months. in contrast, at least % of the respondents in our survey admitted to receiving unwelcome and intimidatory messages via social media during this pandemic, though it is difficult to ascribe all this to covid pandemic. majority of these threats specific to covid pandemic resulted from misplaced apprehension of the general public that healthcare workers could carry the infection into the neighbourhood . the other reasons for hostility could be the delay in the treatment of patients who require neurosurgical attention due to the difficulties posed by suspension of regular services, any survey suffers from many limitations with the foremost being selection bias. this was not an epidemiological study and does not allow concluding the actual prevalence and incidence of the variables investigated. it does allow, though, to conclude the perception of neurosurgeons about the covid- health emergency concerning the actual epidemiology data. another shortcoming is that the perceptions are likely to change over time as the pandemic is evolving and no survey can possibly surmount this limitation. however, we do not expect major changes in the perception and practices of the surgeons as the risk of catching the disease remains high till we pass the pandemic. in an area with more than neurosurgeons we were able to generate only respondents. despite this, we are the first survey to analyze seldom asked questions on mental health, social media impact, and differences among private and public centers which has somehow lost in this pandemic. neurosurgical fraternity in developing countries cannot insulate itself from the implications of the covid pandemic and must adapt rapidly to the changed scenario in healthcare delivery. suspension of elective procedures, severe curtailment of the regular outpatient appointments, drastic modifications of the normal opd/or practices and apprehensions related to inadequacy of safety provided by ppe usage and financial losses of private establishments were some of the visible themes in our survey results. though telemedicine has not been as widely adopted as expected, yet online education has been favourably received. ) names of each author who received specific funding ) specific material support given: nil neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malo bonum) are we forgetting non-covid- -related diseases during lockdown? projecting the transmission dynamics of sars-cov- through the postpandemic period neurosurgical practice during the severe acute respiratory syndrome coronavirus (sars-cov- ) pandemic: a worldwide survey. world neurosurg impact of covid lockdown on orthopaedic surgeons in india: a survey neurosurgeon salary in india | payscale neurosurgery and neurology practices during the novel covid- pandemic: a consensus statement from india letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic letter to the editor: neurosurgical practice in covid- pandemic: from the view of academic departments in india, japan and china letter: maintaining neurosurgical resident education and safety during the covid- pandemic scoring system to triage patients for spine surgery in the setting of limited resources: application to the coronavirus disease (covid- ) pandemic and beyond. world neurosurg information for laboratories about coronavirus (covid- ) telemedicine in the indian context: an overview. stud health technol inform telehealth and telemedicine in the covid- era: a world of opportunities for the neurosurgeons telemedicine in neurosurgery: lessons learned and transformation of care during the covid- pandemic. world neurosurg burnout among u.s. medical students, residents, and early career physicians relative to the general u.s. population covid -depression and neurosurgeons. world neurosurg clinical findings in a group of patients infected with the novel coronavirus (sars-cov- ) outside of wuhan, china: retrospective case series telemedicine has not been as widely adopted as expected, yet online education has been favourably received. nil key: cord- - dup sr authors: lu, victor m.; menendez, ingrid; levi, allan d.; komotar, ricardo j. title: letter to the editor: lessons to learn from the coronavirus disease (covid- ) pandemic for international medical graduate applicants and united states neurosurgery residency programs date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: dup sr nan t he opportunity to participate in a neurosurgery residency program within the united states is highly sought after by both american and international medical graduates (imgs). estimates suggest %e % of all residents in u.s. neurosurgery residency programs are indeed imgs, , typically supported by either a j- (exchange) or h -b (work) visa. in light of the current covid- pandemic, a number of changes affecting the visa process in the united states has revealed particular immigration policies that are subject to change without notice. sudden changes can affect when an incoming img resident can expect to start and therefore when a u.s. neurosurgery program can expect to have its full complement of residents. we highlight herein the key lessons learned from the current pandemic for potential img neurosurgery applicants and programs to consider. these will ensure both applicants and programs are better equipped to withstand any sudden changes to immigration conditions in the future. . applicants should plan to be in the united states before match day. in the early stages of the covid- pandemic, multiple countries, including the united states, installed travel bans both in and out of the country. the number of possible flights to the united states decreased, including from lebanon and india, the largest contributors of img residents to u.s. neurosurgery programs. in this scenario, all successful img applicants would not have been able to physically reach their program were they not in the united states before these changes, impacting their application for various licenses and completion of scheduled orientations needed to legally commence residency. therefore, being present in the united states before match day is recommended to ensure that if an img candidate is successful, changes in travel policies and plans will not impact their ability to start residency on time. . programs should not solely rely on premium processing for h -b visas. as lockdowns in the united states began, the u.s. citizenship and immigration services suspended premium processing of h -b visas, which would have greatly impacted incoming img residents. this is because the time between match day and the start of the residency program is typically months, and the time for h -b petitions preecovid- required months on average to be approved. premium processing was the sole avenue in which these petitions could have been approved within the -month turnaround, as it expedites the process. yet, with the suspension of h -b processing, incoming img residents and programs would have had no choice but to delay their start date for an uncertain period of time waiting for their h -b to be approved. . applicants and programs should always have immigration and visa support. the most recent presidential executive order in response to covid- suspended the entry of all j- and h -b visa holders from overseas entirely until the end of . although this occurred in june , if it had occurred earlier, then any new img resident residing outside the united states would not have been eligible to enter the united states until , and perhaps even apply for visa support then. it is difficult for a lay person to interpret if neurosurgery would have satisfied the sole exception to this order that those "involved with the provision of medical care to individuals who have contracted covid- and are currently hospitalized" would be allowed entry at the discretion of the customs officer. this is why accessible and contemporary immigration and visa support is crucial for any incoming img resident and program to properly interpret these caveats. . applicants and programs should start preparing as soon as possible. an inevitable consequence of this covid- pandemic is the backlog of visa petitions that have accumulated in the time of lockdown. this will likely lead to longer processing times for months once all the executive orders are completed. if the order is extended further beyond into , who is to say new incoming img residents will need to apply for visas even earlier to ensure maximum time is given for their visa support to be approved. moving forward, the impact of the backlog could even last up until the time img neurosurgery residents need to renew their visas, as neither the j- nor h -b lasts for years. early preparation will allow imgs and programs the best chance to ensure any possible delays in processing do not impact the start or continuation of training for img residents. the current covid- pandemic has shed light on how difficult the immigration process can be for prospective img applicants and u.s. neurosurgery programs, as well as how unpredictable it can be. given both the short turnaround from match day to the start of residency, as well as the -year duration of neurosurgery residency, there are multiple considerations future img applicants, current img residents, and programs should prepare for to ensure that their application, training, and service are not compromised. informed preparation will serve all involved well to be better equipped to withstand any sudden changes to immigration circumstances in the future, even after the pandemic has abated. the path to u.s. neurosurgical residency for foreign medical graduates: trends from a decade geographic distribution of international medical graduate residents in u.s. neurosurgery training programs citizens: beirut international airport closure embassy and consulates in india. status of repatriation flights to the united states uscis announces temporary suspension of premium processing for all i- and i- petitions due to the coronavirus pandemic proclamation suspending entry of aliens who present a risk to the u.s. labor market following the coronavirus outbreak conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- -gecu ksa authors: rahman, md moshiur; azam, md gaousul; garcia-ballestas, ezequiel; agrawal, amit; moscote-salazar, luis rafael; khan, robert ahmed title: letter to the editor: pain management strategy in neurosurgical patients during the coronavirus pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: gecu ksa nan m anagement of pain has evolved significantly in the last decades. not only neurosurgeons, but also various specialists, provide both invasive or noninvasive methods to control or relieve pain. it plays a significant role in the patients who do not respond to conservative methods of pain management. , pain management includes gabapentin, oxcarbamazepine, zonisamide, amitriptyline, nortriptyline capsaicin, and lidocaine patches. there are many well-accepted procedures including diskectomy, microvascular decompression, deep brain stimulation, spinal cord stimulation, and direct drug administration into the central nervous system through different routes, such as cingulotomy, medial thalamotomy, stereotactic mesencephalotomy, cordotomy, cordotectomy, rhizotomy, commissural myelotomy, and so forth. the current coronavirus disease epidemic has changed our way to deliver neurosurgical care to patients. we also have been encouraged to contain the spread of infection; therefore, neurosurgeons must avoid every kind of close contact. neurosurgeons need to anticipate that because the coronavirus disease pandemic continues growing, the increasing literature will also attempt to characterize the neurologic manifestations. , because many of the nonurgent neurosurgical procedures have been deferred during this pandemic, there is a need to develop guidelines for the management of painful syndromes (these conditions may not be life-threatening but can be quite disabling). evidence suggesting the relative efficacy of several therapeutic alternatives might be pretty helpful for patients with disabling pain. these patients may get priority for one of these alternative treatments as reported in the literature. [ ] [ ] [ ] [ ] additional noninvasive methods (radiosurgery, physiotherapy) of pain control can be further explored. there is enough available evidence; therefore, the scope can be extended with consensus. cancer pain syndromes multisociety letter to the agency for healthcare research and quality: serious methodological flaws plague technology assessment on pain management injection therapies for low back pain inhibition of il- signaling: a novel therapeutic approach to treating spinal cord injury pain' by covid infection presenting as motor peripheral neuropathy covid : neuromuscular manifestations coronavirus disease (covid- ) outbreak: single-center experience in neurosurgical and neuroradiologic emergency network tailoring intravenous acetaminophen (paracetamol) for post-craniotomy pain; systematic review and meta-analysis of randomized clinical trials letter: a survey of chronic pain due to spinal dural arteriovenous fistulae intravenous acetaminophen (paracetamol) for postcraniotomy pain: systematic review and meta-analysis of randomized controlled trials non-drug non-invasive treatment in the management of low back pain conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. key: cord- -nkkmzymu authors: cabrera, juan p.; yurac, ratko; guiroy, alfredo; carazzo, charles a.; joaquim, andrei f.; zamorano, juan j.; valacco, marcelo title: letter to the editor: is covid- the cause of delayed surgical treatment of spine trauma in latin america? date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: nkkmzymu nan letter to the editor: is covid- the cause of delayed surgical treatment of spine trauma in latin america? letter: w e have been reading with great interest the growing information regarding the catastrophic novel coronavirus disease (covid- ) pandemic. covid- , caused by severe acute respiratory syndrome coronavirus (sars-cov- ), has strongly affected almost every country across the globe, leading to > , deaths. as such, latin american countries such as mexico, brazil, ecuador, peru, chile, and argentina, among others, are deeply impacted. in many latin american countries, the government has mandated total quarantine to minimize virus exposure in the population in an attempt to flatten the epidemiologic curve of the disease. health care workers are split into work groups to improve working conditions and to try to guarantee coverage of any necessary medical disease. in addition, substantial undocumented infection is enormously facilitating transmission, and latin american countries have limited resources for screening all asymptomatic patients. before sars-cov- arrived in latin america, the ideal timing for surgical treatment of spine trauma cases was highly influenced by local conditions with great heterogeneity, including differences in access to health care between public and private systems. in fact, this motivated the ao spine latin america trauma study group to conduct an ongoing survey in this region to evaluate the delay in the treatment of spine trauma requiring surgery: "surgical delay in thoracolumbar fractures in latin america. how long does it take?" the impact of timing on surgical intervention in spine trauma cases has been demonstrated in previous studies for cervical and thoracolumbar spine trauma. notably, cases with incomplete deficit are generally more urgently treated compared with cases with complete spinal cord injury. the impact of early surgery on the outcome of complete cervical traumatic spinal cord injury was demonstrated: to promote neurologic recovery, surgical decompression of the spinal cord within hours seems particularly beneficial. with regard to spine surgery during the covid- pandemic, there are some recommendations to perform emergency or confined surgery for patients with severe nerve root compression, spinal cord injury, progressive aggravation of nerve dysfunction, or spinal fracture with obvious displacement or compression. however, many of these high-risk surgeries performed in high-risk patients require care in the intensive care unit, especially in cases in which a polytrauma needs to be properly managed. many intensive care units are completely occupied or, when they are not, availability for patients who do not have covid- is not considered a priority owing to the estimated projection of the virus spreading based on information obtained from outside of latin america and influenced by the beginning of the disease in a specific country. in addition, while working at any kind of hospital, spine surgery is not the biggest concern for administrators and is not a priority of the government during the time of a pandemic. however, spine surgeons need to offer the earliest and the best treatment possible to these patients in the community. patients with spine trauma are usually healthy, having unexpectedly sustained a significant injury of the spine, resulting in some cases in vertebral instability and/or new neurologic deficit, and in these patients social distancing is not possible. when these patients present with spine trauma, there is no knowledge regarding sars-cov- status, including in low-risk or asymptomatic patients, thereby impacting the final outcome if the patient treated has covid- , and sometimes the surgery is already performed, having the potential to spread the infection to health care workers. a potential side effect of the covid- pandemic for patients with spinal trauma is a delay in surgical treatment in patients with less severe injuries, who may develop late deformities or neurologic deterioration, owing to limited health care resources. in latin america, even without a pandemic, limitations of resources already exist, such as adequate spinal implants, intensive care unit beds, operating room availability, and a good spine team. this reality is likely to become worse. finally, a longer waiting list of patients with other spine pathologies for elective surgeries is expected, especially in the poorest locations. we conclude that the unprecedented covid- pandemic will deeply impact the care of the whole spectrum of spinal diseases, particularly trauma cases in locations with deficient structural resources and limited health care support. therefore, spine surgeons in latin america must try to anticipate these problems with hospital administrators in an attempt to minimize suffering of patients and improve outcomes in a scenario of adverse conditions. substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (stascis) neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization timing of surgery in traumatic spinal cord injury: a national, multidisciplinary survey complete traumatic spinal cord injury: current insights regarding timing of surgery and level of injury advice on standardized diagnosis and treatment for spinal diseases during the coronavirus disease pandemic projecting demand for critical care beds during covid- outbreaks in canada clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid- infection conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . . key: cord- -zynnr authors: agrawal, amit; rafael moscote-salazar, luis; mishra, rakesh; shrivastava, adesh; rahman, moshiur title: letter to the editor– “staying home - early changes in patterns of neurotrauma in new york city during the covid- pandemic date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: zynnr nan we congratulate lara-reyna et al. for their timely shared experience with neurotrauma between pre covid- and during covid- . there is a colossal shift in the pattern of practices for neurotrauma management during this covid- pandemic. additionally, our apparent impression is that there is decrease in the number cases who are requiring neurosurgical interventions for neurotrauma related conditions. this is well supported by the findings of lara-reyna et al . we would like to mention that road traffic accidents (rta) comprises more tbi cases in low and middle-income countries (lmic). , it is likely that epidemiology in these places will change correspondingly. according to one systematic review, rta accounted for over % of the neurotrauma cases and double than of falls. as the authors have observed, experience from other trauma centres also identifies fall at home as the most common mechanism and thus strategies to prevent falls in the elderly should be devised and implemented. spinal injury is a more dynamic event than traumatic brain injury and it will be further interesting to explore the paradigm shift in the epidemiology of spinal cord injury (if any). overall reduction in numbers can be attributed to the restricted outdoor mobility due to government guidelines. , furthermore, comparative reduction in the number of surgeries may be due to overall decrease in neurotrauma cases and also due to dnr (do not resuscitate) strategies in terminally sick patients. , the interesting finding from the present study is that the conversion rate to neurosurgical intervention was low and there was an increase in the dni/dnr status ( . % from non-covid to . % in present covid era). it leaves us with many open questions including whether we were doing over interventions before covid epidemic or we are doing under intervention during this covid epidemic. the answer to this question is only possible by injury severity comparison and overall outcome (including mortality and functional outcome). observations suggest that a significant number of neurotrauma cases are potentially preventable and thus we can save and optimize the use of much needed resources. we also observe that probably the reduction in the incidence in neurotrauma cases (needs more studies and objective to support) is due to restriction of nonessential activities, social distancing, less crowding and restricted public as well as private transportation. in spite of the limitations, the present article provides a thought-provoking overview of the unique epidemiology of neurotrauma and rendered acute care in an epidemic outbreak. this can be good opportunity for all of us to identify possible interventions to continue to reduce the occurrence of neurotrauma at large in the society. references: staying home an epidemiological study of traumatic brain injury cases in a trauma centre of new delhi (india) estimating the global incidence of traumatic brain injury a systematic review of quantitative research on traumatic brain injury in india variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level lockdown for covid- in new zealand impact of the covid- pandemic on orthopedic trauma workload in a london level trauma center: the "golden month lessons learnt from covid : an italian multicentric epidemiological study of orthopaedic and trauma services covid- -impact on dnr orders in the largest cancer center in jordan the importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus (covid- ) staying home" -early changes in patterns of neurotrauma in new york city during the covid- pandemic key: cord- -vx lub s authors: lubansu, alphonse; hadwe, salim el. title: reply to the letter to the editor regarding " covid- impact on neurosurgical practice: lockdown attitude and experience of a european academic center ". date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: vx lub s nan we appreciate goyal et al. for their interest and valuable questions regarding our recently published paper "covid- impact on neurosurgical practice: lockdown attitude and experience of a european academic center". we noted and appreciated that the protocol and workflow for the management of neurosurgical patients that we applied at the early onset of the covid pandemic, at our institute, seems to be also effectively applied in larger and different countries such as india. as in belgium and many other countries including usa , china , or italy , they implement in their current daily practice measures of social-distancing including the use of telemedicine and replacement of meetings and physical classes with videoconferences. they anticipate any potential health care congestion according to the national and institutional forecasts by suspending non-urgent elective surgeries and outpatient activities and re-deployed wards, resources, and teams. on pandemics: the impact of covid- on the practice of neurosurgery preliminary recommendations for surgical practice of neurosurgery department in the central epidemic area of coronavirus infection critical care utilization for the covid- outbreak in lombardy, italy: early experience and forecast during an emergency response countries where coronavirus has spread -worldometer deployment of neurosurgeons at the warfront against coronavirus disease of (covid- ) false-negative results of initial rt-pcr assays for covid- : a systematic review. medrxiv j o u r n a l p r e -p r o o f key: cord- -hdy va e authors: lubansu, alphonse; assamadi, mouhssine; barrit, sami; dembour, victoria; yao, gedeon; hadwe, salim el.; witte, olivier de. title: covid- impact on neurosurgical practice: lockdown attitude and experience of a european academic center. date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: hdy va e introduction the coronavirus disease (covid- ) pandemic is an unprecedented challenge. different models of reorganization have been described aiming to preserve resources while ensuring optimal medical care. limited clinical neurosurgical experience including covid- patients have been reported. we share organizational experience, attitudes, and preliminary data of patients treated at our institution. methods institutional guidelines and patient workflow are described and visualized. a cohort of all neurosurgical patients managed during the lockdown period is presented and analyzed assessing suspected nosocomial infection risk factors. a comparative surgical subcohort from the previous year was used to investigate the impact on surgical activity. results a total of patients were admitted in days, twenty tested positive for covid- . patients initially admitted to the neurosurgical ward were less likely to be suspected for a covid- infection when compared to patients admitted for critical emergencies, particularly with neurovascular and stroke-related pathologies. the mortality rate of covid- patients was remarkably high ( %), and even higher in patients that underwent surgical intervention ( %). in addition to the expected drop in surgical activity (- %), a decrease in traumatic emergencies was noted. conclusion by applying infection prevention and resource-sparing logistics measures shared by the international medical community, we were able to maintain essential neurosurgical care in a pandemic with controlled nosocomial infection risk. special consideration should be given to medical management and surgical indications in patients infected with the sars-cov- virus, as they seem to exhibit a problematic hemostatic profile that might result in an unfavorable clinical and surgical outcome. a total of patients were admitted in days, twenty tested positive for covid- . patients initially admitted to the neurosurgical ward were less likely to be suspected for a covid- infection when compared to patients admitted for critical emergencies, particularly with neurovascular and stroke-related pathologies. the mortality rate of covid- patients was remarkably high ( %), and even higher in patients that underwent surgical intervention ( %). in addition to the expected drop in surgical activity (- %), a decrease in traumatic emergencies was noted. despite being a developed country, the country is not able to acquire nor produce enough personal protective equipment (ppe) to ensure the healthcare providers' optimal safety, in addition to the lack of reagents and logistical resources to proceed with mass testing. accordingly, the health ministry guidelines reserved biochemical tests of nasopharyngeal samples only for suspected covid- patients requiring hospital admission, and no targeted screening strategy was defined for healthcare providers. since march , , all medical activities of our academic hospital have been reorganized. non-urgent elective surgeries and outpatient activities were suspended. wards, resources, and teams were redeployed to anticipate any potential congestion according to the latest national and institutional forecasts . to our knowledge, no specific neurosurgical practice recommendations anticipating such situations were available at the onset of the outbreak in our country, and there are still only limited clinical experiences reported to support recently published ones , , . we, therefore, share our lockdown experience, attitude, and taken measures from the frontlines, substantiated by preliminary data of treated patients, outlining some features of covid- patients. all descriptive statistics and statistical analyses were performed using "r" version . . within the rstudio software version . . . chi-square test was used to investigate independence for categorical data; fisher's exact test was applied when sample size consisted of occurrences less than five, welch's t-test, was used as a location test when applicable. the pre-defined statistical significance level was assumed when p-value was inferior to . . (table ) . the retrospective review resulted in a crisis cohort of inpatients ( table ). the mean age moreover, concern about a potentially delayed aftermath due to postponed surgeries and the • patient transportation on a closed circuit to a small size negative pressure suction room. • respect airway management protocols for intubation/extubation (minimal personnel in the room, using contained air purifying respirators, out-of-room waiting time). • limit unnecessary personnel. • avoid endonasal surgeries. • decrease speed of bone drilling to reduce spread of bone dust. • optimize surgical team to shorten duration of surgeries. • disposable ffp /n mask, water-resistant gown, gloves, goggles, cap, and full-face visor shield. • for covid- positive patients, ffp mask and/or powered air purifying respirators (paprs). • endonasal surgery: manage patient as suspected case -nasal irrigation with povidone-iodine (pvp-i) solution, caution with dural handling, minimize drilling and prefer osteotomes. • spine surgery: favor prone position, minimally invasive approach, reduce suction and splatter. • brain surgery: avoid awake strategies and biopsy rather than surgical resection if possible. intensive care unit • manage positive covid- patients to a separated covid icu unit. • postoperative care for uncomplicated surgery includes craniotomies cases in a medium care unit rather than icu. • emphasize rapid discharge with close telemedicine follow-up. • follow universal precautions and personal protection equipment (ppe) guidelines. • social distancing for all group-based activities. • reduce the number of healthcare staff on clinical duty. • clinical team-bases rotations to reduce virus exposure. • social distancing for all group-based activities. • all in-person conferences were canceled and replaced by seminars or webinars through video teleconferences. covid- situation reports epistat -covid monitoring covid- outbreak: a single- centersingle center experience in neurosurgical and neuroradiological emergency network tailoring. world neurosurg response to covid- in chinese neurosurgery and beyond. j neurosurg the management of emergency spinal surgery during the covid- pandemic in italy covid- and neurosurgical practice: an interim report academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital maintaining stereotactic radiosurgical treatments during covid- outbreak: the case of the gamma knife unit in brescia -italy coagulation disorders in coronavirus infected patients: covid- , sars-cov- , mers-cov, and lessons from the past incidence of thrombotic complications in critically ill icu patients with covid- neurologic manifestations of hospitalized patients with coronavirus disease bleeding in covid- severe pneumonia: the other side of abnormal coagulation pattern? acute hemorrhagic necrotizing encephalopathy: ct and mri features covid- and intracerebral hemorrhage: causative or coincidental? new microbes and new infections three unsuspected ct diagnoses of covid- letter: covid- infection affects surgical outcome of chronic subdural hematoma fisher's exact test or student's t-test, chd: coronary heart disease ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒the authors declare the following financial interests/personal relationships which may be considered as potential competing interests:j o u r n a l p r e -p r o o f key: cord- -t tv lxs authors: pressman, elliot; noureldine, mohammad hassan a.; kumar, jay i.; krafft, paul r.; mantei, braden; greenberg, mark s.; agazzi, siviero; van loveren, harry; alikhani, puya title: the return back to typical practice from the ‘battle plan’ of the covid- pandemic: a comparative study date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: t tv lxs abstract background every aspect of the medical field has been heavily affected by the covid- pandemic and neurosurgical services are no exception. several departments have reported their experiences and protocols to provide insights for others impacted. the goals of this study are to report the load and variety of neurosurgical cases and clinic visits after discontinuing the covid- battle plan at an academic tertiary care referral center too provide insights for other departments going through the same transition. methods the clinical data of all patients who underwent a neurosurgical intervention between may , and june , was obtained from a prospectively maintained database. data of the control group was retrospectively collected from the medical records to compare the types of surgeries/interventions and clinic visits performed by the same neurosurgical service before the covid- pandemic started. results one-hundred sixty-one patients underwent neurosurgical interventions, and seven-hundred one patients were seen in clinic appointments, in the four-week period following easing back from our covid- ‘battle plan’. discontinuing the ‘battle plan’ resulted in increases in case load to above average practice after a week but a continued decrease in clinic appointments throughout the four weeks compared to average practice. conclusions as policy-shaping crises like pandemics abate, easing back to ‘typical’ practice can be completed effectively by appropriately allocating resources. this can be accomplished by anticipating increases in neurosurgical volume, specifically in the functional/epilepsy and brain tumor subspecialties, as well as continued decreases in neurosurgical clinic volume, specifically in elective spine. in december , a novel coronavirus (covid- ) was detected in patients presenting with acute respiratory illness in wuhan, china. it quickly spread globally resulting in a pandemic affecting every fabric of society. in the perspective of healthcare systems, it was initially estimated that approximately % of patient suffering from covid- required hospitalization and % required intensive care unit level care. in response, hospitals began improvising and continuously revising protocols to maintain efficient functioning despite significant shortages in facilities and equipment. [ ] [ ] [ ] every aspect of the medical field has been heavily affected by the covid- pandemic and neurosurgical services are no exception. several departments have reported their experiences and protocols to provide insights for others impacted. [ ] [ ] [ ] [ ] [ ] [ ] [ ] we recently published our response, the 'battle plan', from the university of south florida department of neurosurgery as well as how the neurosurgical case load had changed during covid- and this plan's implementationo. , the 'battle plan' was designed to divide the pool of attending physicians and residents into three teams, where each team provided comprehensive coverage of the neurosurgical service for one week, followed by a two-week self-quarantine at home in accordance with the united states centers for disease control and prevention (cdc) recommendations for exposed individuals. since in emergent cases our personnel on the neurosurgery service could be potentially exposed, in this way they were always able to quarantine for two weeks after one week of service coverage. as regulations are relaxed both nationally and locally due to the curtail of covid- spread, it remains unclear how the post-covid- world will look, especially as it pertains to healthcare. the goals of this study are to report the load and variety of neurosurgical cases and clinic visits after discontinuing the covid- 'battle plan' at an academic tertiary care referral center to provide insights for other departments planning to go through a similar transition. our hypothesis is that neurosurgical volume and clinic volume will remain below pre-covid levels. specifically, we believe that elective spine procedures and functional procedures will be proportionately lower. we believe that the subspecialty clinic findings will be analogous. this study was approved by our institutional review board with a waiver of patient consent. clinical data of all consecutive patients who were seen in our neurosurgical clinic or who underwent a neurosurgical intervention between may , and june , were obtained from a prospectively maintained database. these were the first four weeks of clinical practice after discontinuing the 'battle plan'. urgency of cases was defined as emergent, requiring immediate transfer to the operating room (or); urgent -within one day or urgentwithin one week, where the intervention should be performed within one day or one week, respectively, to preserve neurological function; and elective, where the intervention was scheduled from a clinic appointment to be performed at a pre-arranged time. data of patients who underwent neurosurgical interventions over a six-month period (january -june , ), was retrospectively collected from the medical records as a control group for the same neurosurgical service before the covid- pandemic began and averaged to four weeks for proper comparison of the four-week data collected after discontinuing the 'battle plan'. clinical visits were defined as nonoperative -a visit where further workup or conservative management was advised; preoperative -the visit that the physician and patient agreed to neurosurgical intervention; postoperative -any visit after a neurosurgical intervention; surgical consult -a visit with an advanced practitioner days prior to surgery to ensure preoperative workup was complete and administrative documents were appropriately filled out; procedural -in-office electromyography (emg) or lumbar puncture (lp). the control group for this cohort was retrospectively obtained from our practice's records of clinic visits over a threemonth period (april -june ) which was then averaged to weeks for proper comparison. the demographic and clinical data of patients who underwent neurosurgical interventions over the four weeks after discontinuing the 'battle plan' are summarized in table . the mean age at surgery was years (range - ). one-hundred two patients ( %) were admitted for elective surgery from clinic, ( %) presented through the emergency department (ed), ( . %) were transfers from outside hospitals, and ( . %) presented to our service from an in-hospital consult. one-hundred two patients ( %) underwent elective interventions, ( %) required an urgent intervention ( within one day, within one week), and ( %) required an emergent intervention. this delay in urgent cases to within one week was a result of conditions in which such a delay was deemed appropriate (carotid endarterectomies following strokes; cord decompression and spinal fusion following central cord syndrome; etc) in combination with a limitation in or availability. the average length of operative time was . hours in the patients undergoing non-endovascular interventions. in discharged patients (n= of ), mean length of stay was . days. of those discharged, ( %) returned home, ( %) were discharged to inpatient rehabilitation, one patient was discharged to an outside hospital, and one to a skilled nursing facility. one patient ( . %) expired during their hospital stay; no patients were found to be expired on follow-up. eight patients required emergent or urgent return trips to the or during their hospitalization (due to ventriculoperitoneal shunt surgeries, hematomas, wound washouts, etc.). sixty-two of sixty-four patients who were recommended to follow-up within the data collection window attended their follow-up appointments- of which were in-person, were through telemedicine. the demographic and clinical data of patients who visited the neurosurgical clinic over these four weeks are summarized in table . patients were seen by one of attending physicians or advanced practitioners within the neurosurgery department. the mean age at clinic visit was year (range - ). of these visits, ( %) occurred in person; ( %) occurred via telemedicine. of the types of appointments, ( . %) were pre-operative in nature, ( %) were post-operative, ( %) were non-operative, ( . %) were surgical consults, and ( %) were procedural ( emgs, lps). as seen in table , each visit was assigned to a neurosurgical subspecialty. the three most common categories were degenerative spine ( %), intracranial tumors ( %), and miscellaneous: csf ( . %; this category includes vps, arnold-chiari malformations, idiopathic intracranial hypertension, etc). for preoperative and postoperative visits, type of intervention was recorded using the same categories as the neurosurgical interventions in the preceding section. regulations. comparison of clinic visits in each neurosurgical subspecialty between these two time periods was not possible within our database. four patients ( . %) recommended surgery preferred to postpone it due to covid- fears. eight telemedicine visits ( . %) concluded with providers noting they would likely recommend surgery but would need to see the patient inperson first. this study highlights our center's experience in the period immediately following the discontinuation of our covid- 'battle plan' and its differences with 'typical' practice. one week after resuming non-'battle plan' practice, neurosurgical interventions reached and then exceeded the 'typical' volume seen at our center. of neurosurgical interventions, the subcategories of "adult functional and epilepsy", and "adult brain tumor" were more prevalent in the four weeks after covid- than in 'typical' practice whereas "adult spine" and "endovascular" procedures were less prevalent than in 'typical' practice. clinic volume on the other hand remained less busy than in average 'typical' practice for each of the four weeks evaluated. in clinics, in the four weeks following covid- 'battle plan' relaxation, degenerative spine and intracranial tumors were the two most common neurosurgical subspecialties for which patients came to see a physician. plan' remained below 'typical' volume before increasing to above 'typical' volume for the next three weeks. this week-delay in volume can be attributed to new administrative barriers and infrastructure associated with operative cases in our institution. for example, all patients are required to have covid- testing hours before surgery. as well, it took some time at our institution for ancillary staff to be available to staff more operative suites-for the first week, our service only had access to two ors for non-addon procedures in addition to two angiography suites. for the remaining three weeks reported, our service typically had three ors for elective cases (plus two angiography suites), identical to the pre-covid period. the increase to above 'typical' volume for the latter three weeks studied was a result of permitting elective cases after having canceled all elective cases from march until may , reducing our volume by more than half. this correlates with the increase in adult functional/epilepsy surgery volume seen during these four weeks post-'battle plan' as it was the subspecialty most affected by the cancelling of elective cases during implementation of the 'battle plan'. , adult brain tumor surgeries were also increased post-'battle plan' era ( . % versus %) as providers could not continue holding patients from elective tumor resection. we expect that neurosurgical volume will remain at a higher level for some months. adult spine procedures were greatly decreased in the post-'battle plan' era ( % versus %). this can likely be attributed to the pandemic causing many patients to lose their medical insurance, paid time off, and savings combined with the elective nature of these surgeries. endovascular procedures witnessed a decline compared to 'typical' practice ( % versus %) which is likely a result of regressing towards the mean in light of an increase in procedures during the month prior, however it could also be due to patients postponing treatment/monitoring due to lack of medical insurance, paid time off, and savings. it does not appear that fears of covid- were major detractors of surgical intervention in our practice. clinic appointments, though featuring an increase in volume in the fourth week after discontinuing the 'battle plan' , continued to lag behind 'typical' clinical volume. first, appointments are now required to be at-minimum thirty minutes apart. this is because clinic space is shared between practitioners of the same and different departments and all patients must remain at least six-feet apart at all times per cdc recommendations. as well, because many patients now lack financial security and paid time off, some are forgoing clinic visits. though degenerative spine remains the most common neurosurgical problem for which clinic appointments are made, providers feel that there are significantly less appointments than before. while telemedicine appointments have continued to be important throughout this post-covid period, and could help improve this decrease in clinic volume, our center has had to restrict interposing telemedicine appointments with regular appointments because of staff constraints, so telemedicine can only be used for an entire half-or full-clinic day. however, telemedicine has remained a viable and productive way to talk with and evaluate patients-especially those with travel concerns. while we have discontinued the 'battle plan' in clinical practice, it is important to note that educational conferences continue to occur virtually as specified in the original plan. this aspect was continued so as to restrict the number of people assembling in one location at a given the patient population is relatively small due to the short period ( weeks) after discontinuing the 'battle plan' , which reduces the power of this study as well as limits its generalizability. also, our experiences with the post-covid era is limited, and self-appraisal is an ongoing process. during pandemics, implementation of crisis protocols is essential to continue delivery of optimal care and safe practice. as these events abate, retreat to 'typical' practice can be completed effectively by appropriately allocating resources. to accomplish this, departments can anticipate increases in neurosurgical volume, specifically in the functional/epilepsy and brain tumor subspecialties, as well as continued decreases in neurosurgical clinic volume, specifically in elective spine. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. a novel coronavirus from patients with pneumonia in china clinical characteristics of coronavirus disease in china how to balance acute myocardial infarction and covid- : the protocols from sichuan provincial people's hospital. intensive care medicine proposed protocol to keep covid- out of hospitals covid- pneumonia: infection control protocol inside computed tomography suites. japanese journal of radiology academic neurosurgery department response to covid- pandemic: the university of miami/jackson memorial hospital model letter: emergency response plan during the covid- pandemic: the university of alabama at birmingham experience. neurosurgery neurosurgery during the covid- pandemic: update from lombardy, northern italy. acta neurochirurgica covid- and academic neurosurgery letter: adaptation under fire: two harvard neurosurgical services during the covid- pandemic impact of covid- on an academic neurosurgery department: the johns hopkins experience. world neurosurgery letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm impact of the covid- pandemic on neurosurgical practice at an academic tertiary referral center: a comparative study florida's covid- data and surveillance dashboard. internet. florida department of health, division of disease control and health protection the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this articlethe authors received no financial support for the research, authorship, and/or publication of this article key: cord- -gkzebyda authors: hoz, samer s.; al-sharshahi, zahraa f.; dolachee, ali a.; matti, wamedh e. title: letter to the editor: “beyond containment: tracking the impact of coronavirus disease (covid- ) on neurosurgery services in iraq” date: - - journal: world neurosurg doi: . /j.wneu. . . sha: doc_id: cord_uid: gkzebyda nan letter to the editor: "beyond containment: tracking the impact of coronavirus disease (covid- ) on neurosurgery services in iraq" letter: t he coronavirus disease (covid- ) pandemic is one of the greatest threats to humankind. the contagion is rising at an alarming pace and is testing the limits of the health care systems worldwide. despite stringent containment measures to stem the spread of the virus, the situation has deteriorated rapidly; the virus has now swept across the globe, with a total of , fatalities and . million confirmed cases worldwide. in iraq, a nation that has been through cycles of ongoing violence for decades, the situation is rather peculiar. the crippled state of the health care system, the socioeconomic disparities, the lack of social security, and health insurance systems, along with the volatile political context and the absence of a stable political leadership all create a precarious and high-risk environment for a full-fledged covid- outbreak. ironically, in the first few months of the pandemic, the virus seemed to be sparing our fragile communities, with just deaths and confirmed cases as of march , . however, around mid-may, and coinciding with the end of ramadhan (eid al-fitr holidays), the number of confirmed cases increased -fold, from fewer than cases on may to , on june . , since then, the country has witnessed enormous daily jumps in the number of cases that quickly overwhelmed our already-strained health care system. currently, there are , confirmed cases and deaths; the population in iraq is million (data as of the world health organization situation report on august , ). hospitals across the nation have been hit hard, particularly after the drop in oil prices and the resultant cuts in government funding. while all efforts are being made to adhere to best practice guidelines, deviations are inevitable, given the country's exceptional circumstances. [ ] [ ] [ ] in this letter, we track the impact of the pandemic on neurosurgery services at the nation's largest tertiary neurosurgery center, focus on our efforts to survive the pandemic, and on potential steps to mitigate the risk of an impending catastrophe. the neurosurgery teaching hospital (nth) in baghdad, iraq, provides neurosurgical care for . million people-approximately % of the population in baghdad, with a total capacity of beds, neurosurgical intensive care unit (nicu) beds, and operating rooms. the hospital hosts neurosurgeons and residents. as part of the response plan that we have introduced over the past few months, the hospital capacity has been expanded with the addition of nicu beds. a new covid- unit, comprising beds, was also set up in the hospital. however, these measures are far from adequate and the hospital remains a full-house at all times, with at least patients per hospital room, challenging the proper implementation of social distancing guidelines. the admission rate decreased to % of that before the covid- era. two admission pathways have been established; emergency and urgent. time-dependent cases are directly admitted to the hospital. cases requiring less immediate care are only admitted if the condition is deemed to be "urgent." this decision is the responsibility of a newly assembled local hospital committee, composed of senior neurosurgeons. all admitted patients are screened for fever and exposure status. symptomatic patients undergo polymerase chain reaction swap testing. full personal protective equipment is only provided to workers in the nicu and those employed at the covid- facility. for the majority of the hospital personnel, only basic surgical masks are available. remarkably, in the absence of a structured ambulance network in the country, almost all trauma and other emergency cases are brought on by relatives, who seldom comply with the reception staff orders for personal protection. all this, along with the extreme shortage of terminal cleaning supplies in the hospital, dispels any efforts to curb the rate of cross-contamination in the hospital. in patients who are found to be positive for covid- , efforts are usually made to postpone surgery if the condition permits. reducing intraoperative exposure risk is also attempted by a range of steps, including avoiding bone drilling during craniotomy; limiting the use of microscopes, endoscopes, and surgical chairs; reducing the number of theater personnel on duty; and ensuring that only senior neurosurgeons who are beyond their learning curve handle the operation. the room is then sterilized, ventilated, and isolated for the ensuing e hours. patients are discharged early and followed up through regular, scheduled phone calls. in general, postoperative stays are now shortened to days for patients requiring a craniotomy (previously was e days) and day for spine cases (previously was e days). on january , , the nth declared a delay in all elective and semielective cases until further notice to curb the spread of the virus. from january to july , a total of operations were performed, as compared with operations over this same period in , a net decrease of . %. elective spinal and peripheral nerve surgeries were mostly affected, with a total decrease of . % (from to operations). the number of elective cranial operations went from to , a total decrease of . %. trauma and other emergency operations were reduced to a lesser extent, from to , a decrease of . %. this reduction in trauma cases may be attributed to the nationwide curfew that has been imposed by the government and the reduction in referral rates from the other governates. world neurosurgery : - , november www.journals.elsevier.com/world-neurosurgery the outpatient department since january , , hospital outpatient department visits have been limited to cases referred from regional hospitals and primary care centers, resulting in a total % reduction in the monthly inperson visits department visits, as compared to the pre-covid- era. however, the number of referred patients surged again in july, coinciding with the nationwide closure of private health clinics. certain presentations, primarily lower back pain and headache, showed the most remarkable decline; % (p < . ). to date, % of hospital staff, or of , have tested positive for the virus. as for patients, a total of acute trauma cases have been confirmed to be positive by immediate postoperative polymerase chain reaction. such situations are hazardous and require urgent legislative change that determines the covid- status of all admitted patients to be positive unless proven otherwise. nevertheless, given the existing constraints of national and institutional capital, additional measures, including greater-level strategic planning, are urgently required. in addition, national public education plans for the de-stigmatization of the disease are needed, since many reports of transmission to hospital personnel have been traced back to patients who have denied their symptoms or exposure status. here, at the nth in baghdad, the conditions are indicative of the country-wide situation. given the regional, system, and resource limitations, our response has been far from ideal, which necessitates sharing this experience with the world to draw the attention of international societies and initiate collaborative plans of countries with a similar set of circumstances, which may provide a gateway from the crisis with the least-possible loss. iraq to whom correspondence should be addressed coronavirus disease (covid- ): situation report e coronavirus disease (covid- ): situation report e coronavirus disease (covid- ): situation report e coronavirus disease (covid- ): situation report e covid- : recommendations for management of elective surgical procedures elective medical services, and treatment recommendations coronavirus disease (covid- ) and neurosurgery: literature and neurosurgical societies recommendations update conflict of interest statement: the authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/ . /j.wneu. . . .