SARS-CoV-2-Related Acute Necrotizing Encephalopathy of Childhood With Good Response to Tocilizumab in an Adolescent.

BACKGROUND: Acute necrotizing encephalopathy of childhood (ANEC) is a rare parainfectious neurological disorder. ANEC is associated with a high mortality rate and poor neurological outcomes. ANEC is postulated to arise from immune-mediated or metabolic processes driven by viral infections. Although there have been some case reports of acute necrotizing encephalopathy with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coinfection in adults, paediatric cases are rare. METHODS: A single case report of SARS-CoV-2-related ANEC in an 11-year-old boy is presented through retrospective chart review. Literature search was performed using PubMed, Embase, Cochrane database, and Google Scholar to compare and analyze similar cases of parainfectious immune-mediated encephalopathies related to SARS-CoV-2 in children. RESULTS: An 11-year-old boy with acute SARS-CoV-2 infection presented with ophthalmoplegia, ataxia, and aphasia. Neuroimaging findings demonstrated significant swelling and signal changes in bilateral thalami, brainstem, and cerebellar hemispheres, consistent with ANEC. His high ANEC Severity Score indicated poor neurological prognosis. Treatment with a combination of early steroid therapy, intravenous immunoglobulin therapy, and targeted interleukin 6 (IL-6) blockade yielded good neurological improvements. Literature search identified 19 parainfectious immune-mediated neurological disorders related to SARS-CoV-2 in children. The only other pediatric ANEC case identified was postinfectious and thus not included. CONCLUSIONS: This is the first report of a pediatric case of SARS-CoV-2-related ANEC, which responded well to early immunotherapy, including IL-6 blockade. Early immunotherapy with IL-6 blockade can be considered as an adjunct in managing severe ANEC.

Protected elective surgery unit: a single centre experience

Objectives: To assess service provision in the COVID-free 'green zone' in response to COVID-19 pandemic. Design: Prospective single centre study. Methods: Between July 2020 and July 2021 data were prospectively gathered including demographics, number and type of operation, service provision activity (e.g. cancellations), COVID-related morbidity and surgical outcomes. Results: 314 Operations listed for 260 patients with an average age of 52.7. 154 (59%) were female. 54 (17%) of cases were cancelled due to patient factors (n=26) and service factors (n=28). 13% of patients required transfer to amber zone. Average length of stay was 5 days. 35% of patients suffered an adverse event postoperatively - 38 (14.6%) were surgical complications. Of these 15 (5.7%) were surgical site infections - double the rate pre-COVID. There were no COVID-related morbidities. Conclusions: The opportunity for operationalised green zones limit the spread of COVID-19, potentially at the cost of an increase in surgical site infections.1.

Making every operation count - using an instructional design model to maximise the learning experience in neurosurgery

Objectives: Recent reforms to postgraduate medical education, the 'Shape of Training (SoT)' and 'Excellence by Design: standard for postgraduate curricula' mandate a re-evaluation of the way in which surgical education is delivered, particularly in the teaching of surgical techniques. More so, as we continue to train with the restrictions imposed by the COVID pandemic, emphasis must be placed on maximising every training opportunity. Design: In this article, we demonstrate the utility of an instructional design method to enhance the teaching of neurosurgical procedures. Specifically, we utilise the instructional design method of teaching first described by Robert Gagne in the 1960s. Subjects: The framework we provide can be used to equip all neurosurgical trainees with the necessary capabilities to achieve the high-level outcomes expected from the new curriculum. Methods: We design a lesson plan using Gagne's nine events of instruction, in this case using burr hole evacuation of chronic subdural haematomas as an example. The ordered nature of Gagne's nine-step model allows a complete picture to be formed and structures teaching for a comparable learning experience. Conclusions: One particular strength of this teaching method is placing the learned skill in the wider context of patient care includes perioperative management. By empowering trainees to consider all aspects of the underlying reasoning for a procedure, well-rounded clinicians can be developed who are comfortable in the real-world application of procedural skills. The creative lesson plan optimises the learning process and ensures that the objectives are comprehensively fulfilled. The structured approach fortifies a good basis for understanding the operation and ensures that progression to independence is a safe approach.