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Neurosurgery and Global Health ; : 341-356, 2022.
Article in English | Scopus | ID: covidwho-2315872


The novel coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), first appeared in December 2019 and was declared a pandemic by the World Health Organization on March 11, 2020 (World Health Organization. WHO director-general's opening remarks at the media briefing on COVID-19—11 March 2020. Accessed 2020). By September 9, 2020, 27.7 million cases and 0.9 million deaths were confirmed globally (Center for Systems Science and Engineering – Johns Hopkins Coronavirus Resource Center: COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Accessed 2020). This disease placed an unprecedented strain on healthcare systems around the world (Remuzzi and Remuzzi. Lancet. 395(10231):1225–8, 2020) and had a substantial effect on clinical practice across all surgical specialties, with neurosurgery being no exception (Bernstein. J Neurosurg. 2020:1–2. Many hospitals implemented no-visitor policies and COVID-19 testing for all inpatients in order to prevent spread and protect patients and healthcare workers (Calderwood. Infect Control Hosp Epidemiol. 2020:1–9. To conserve beds, workforce, and valuable resources such as masks, gowns, and ventilators, surgeons had to restrict operations to emergency and essential interventions. Some neurosurgeons were redeployed to new intradepartmental roles, others lateralized to provide care for coronavirus patients. In order to limit in-person interactions and contagion, there was a surge in telehealth and digital innovation for remote monitoring and management. Research laboratories were closed for prolonged periods. Medical education and residency training were also substantially altered, with cancellation of many in-person events and a transformation to online meetings and educational sessions. In this chapter, we discuss the impact of COVID-19 on the global neurosurgery community with respect to clinical care, education, and research. While the pandemic has caused tremendous disruption in global neurosurgery already, there is hope that many of the lessons learned during this time have contributed to our resilience and preparedness for the future, be it a second wave of COVID-19 or a new unexpected challenge. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Neuro-Oncology ; 24:i166, 2022.
Article in English | EMBASE | ID: covidwho-1956581


INTRODUCTION: Unplanned reoperations and mortality within 30 days are important indicators when evaluating the quality of care provided by surgical systems. We reviewed these outcomes among children with primary central nervous system (CNS) tumors treated during the COVID- 19 pandemic. METHODS: This is a retrospective study of all pediatric patients who underwent neurosurgery for primary CNS tumors at the Philippine General Hospital, the national university hospital, from January 1, 2020 until December 31, 2021. Their clinical presentation, perioperative course, and outcomes were analyzed. During this time, our hospital concurrently served as a COVID-19 referral center, thus, the workforce was restructured, and resources were reallocated to care for COVID-19 patients. RESULTS: A total of 92 pediatric patients with CNS tumors underwent 140 neurosurgical operations during the study period. Two-thirds of the patients were males, and mean age was 9.3 ± 5.0 years (range: 3 months to 18 years). Average preoperative length of stay was 3.9 ± 2.6 days. Tumor resection was performed in 73 patients (79%). Most common histologic diagnoses were medulloblastoma (20%) and low-grade glioma including pilocytic astrocytoma (20%). Overall, the 30-day mortality and unplanned reoperation rates were 12% and 22%, respectively. Eight patients died from brain herniation and/or tumor progression. Reasons for unplanned reoperations were postoperative hydrocephalus (20%), infection (9%), hematoma (7%), and tumor residual (3%). DISCUSSION: Worldwide, the COVID-19 pandemic has altered hospital protocols and shifted resources considerably. The observed high rates of death and reoperation are likely due to delays in seeking care leading to worse neurologic status at presentation, delays in performing essential surgery within the hospital, and shortage of health workers providing specialist care. It is important to periodically assess perioperative outcomes to improve the quality of surgical care given to children with CNS tumors, who remain a vulnerable population during the COVID-19 pandemic.

Neuro-Oncology ; 24:i166, 2022.
Article in English | EMBASE | ID: covidwho-1956580


INTRODUCTION: Central nervous system (CNS) tumors account for 20 - 30% of all childhood cancers. The Philippines is a lower-middle income country, wherein brain centers are located mostly in urban areas. We aimed to identify challenges that pediatric patients with CNS tumors encountered during the COVID-19 pandemic, which aggravated delays in their diagnosis and treatment. METHODS: This is a retrospective review of all pediatric patients who underwent neurosurgery for CNS tumors at the Jose R. Reyes Memorial Medical Center, a tertiary referral center, from January 2020 until December 2021. We summarized patients' demographic data, clinical course, and perioperative outcomes. RESULTS: A total of 38 pediatric patients underwent neuro-oncologic surgery in our center during the study period. There were 18 males and 20 females, with a mean age of 7.5 ± 4.9 years. Tumor was biopsied and/or resected in 35 cases (92%). The most common histologic diagnoses were medulloblastoma (n=8, 21%) and high-grade glioma/glioblastoma (n=5, 13%). Median preoperative length of stay and total length of stay were 10 (IQR: 17) and 28 (IQR 33.75), respectively. There was a high perioperative mortality rate in 2020 (71%), but this decreased to 20% in 2021. Six patients (16%) developed COVID-19 infection during the perioperative period. There were nine patients (24%) who had documented tumor progression because of delays in adjuvant therapy. DISCUSSION: Aside from geographic barriers and catastrophic health expenditure, the major challenges that disrupted the care of pediatric patients with CNS tumors in our center during the COVID-19 pandemic were delays in neuroimaging for diagnosis, unavailability of operating room slots, deficiency in critical care beds, and workforce shortage due to COVID-19 infection among health workers. Health care systems must adapt to the changes brought about by the pandemic, so that children with CNS tumors are not neglected.

Neuro-Oncology ; 24:i165, 2022.
Article in English | EMBASE | ID: covidwho-1956579


INTRODUCTION: A multidisciplinary team (MDT) approach is essential for quality cancer care. Since 2019, we have conducted regular MDT meetings to discuss pediatric patients with central nervous system (CNS) tumors at the Philippine General Hospital. Because of COVID-19, an abrupt transition from in-person to virtual meetings became necessary. METHODS: We reviewed the proceedings of MDT meetings for pediatric CNS tumors from March 2020-December 2021. We identified the strategies and adaptations of our pediatric neuro-oncology group, and outlined recommendations for other institutions in low- and middle-income countries. RESULTS: Our pediatric neuro-oncology group conducted 18 virtual MDT meetings during the study period. Meetings were scheduled every last Tuesday of the month, with pediatric oncologists, neurologists, neurosurgeons, radiation oncologists, radiologists, and neuropathologists regularly attending. We invited other specialists as needed. In total, we had 135 case discussions for 79 unique patients, or about 8 patients per meeting. These included both inpatients (74%) and outpatients (26%). Ten patients received prior treatment elsewhere. At the time of the meeting, 86% were postoperative, 8% were preoperative, and 6% did not require surgery. Most (60%) had malignant CNS tumors and 15% had disseminated/leptomeningeal disease. Histopathologic diagnosis was obtained for 62 patients (79%). Concerns addressed were: formulating a treatment plan (88%), surveillance strategy (10%), and diagnostic workup (5%). DISCUSSION: Several factors contributed to the ease of online transition: (1) motivated care providers including a patient navigator, (2) fixed schedule, (3) institutional Zoom account for securing data privacy, and (4) availability of picture archiving and communication system (PACS) for neuroimaging. Challenges included: (1) delays due to internet connectivity, (2) Zoom fatigue and online distractions, and (3) risk for miscommunication or misunderstanding. Commitment of the entire neuro-oncology team is essential to ensure the delivery of best possible care for pediatric patients with CNS tumors.

Neuro-Oncology ; 24:i145, 2022.
Article in English | EMBASE | ID: covidwho-1956576


INTRODUCTION: Surgery in patients diagnosed with COVID-19 is associated with increased risk of morbidity and mortality, especially within 6 weeks of SARSCoV- 2 infection. Furthermore, most studies have focused on adults, and little is known about perioperative outcomes in children with COVID-19. METHODS: We reviewed the operative census of the Division of Neurosurgery of Philippine General Hospital from March 2020 until December 2021. We identified all pediatric patients with brain tumors and confirmed COVID-19 infection within two weeks of their neuro-oncologic surgery. Their clinical course and outcomes are described herein. RESULTS: Four patients were included in this case series: three had tumors in the cerebellum, one in the pineal region. All of them were boys, with ages ranging from 4 months to 13 years. All tumors were malignant, and two were confirmed to be medulloblastoma after tumor resection. COVID-19 infection was diagnosed by the presence of SARS-CoV-2 RNA through a nasopharyngeal swab. Three patients acquired the virus post-operatively, likely from nosocomial transmission. In the remaining patient, it was community-acquired. All the patients had chest radiographs consistent with pneumonia but none had marked elevation of serum inflammatory markers. No patient received remdesivir or tocilizumab. At the time of their presentation, either the COVID-19 vaccine was not yet available in the country, or the patient was not yet eligible for vaccination. One patient died because of brain herniation from tumor progression, two were discharged and eventually underwent adjuvant therapy, and one remained in-hospital as of this writing. DISCUSSION: COVID-19 infection resulted in delays in the management of patients with pediatric CNS tumors. Given the high risk of these patients for potential complications, consensus guidelines must be established to achieve good outcomes and prolong survival.

Neuro-Oncology ; 24:i74-i75, 2022.
Article in English | EMBASE | ID: covidwho-1956572


INTRODUCTION: High-grade gliomas account for <5% of all pediatric brain tumors with a 20% 5-year overall survival even with maximal safe resection followed by concurrent radiotherapy and chemotherapy. Patients in low-and middle-income countries already face delays and barriers to the treatment they require. The current COVID pandemic has added unique challenges to the delivery of complex, multidisciplinary health services to these patients. METHODOLOGY AND RESULTS: We retrospectively reviewed the records of four patients, ages 2-18 years old, with histologically confirmed high-grade glioma managed in a tertiary government institution from 2020-2021. Three of the patients had a supratentorial tumor and one patient had multiple tumors located in both supra-and infratentorial compartments. Neurosurgical procedures performed were: gross total excision (1), subtotal excision (2), and biopsy (1). The tissue diagnoses obtained were glioblastoma (3) and high-grade astrocytoma (1). Two patients survived and are currently undergoing adjuvant radiotherapy and chemotherapy. The remaining two patients expired: one from hospital-acquired pneumonia and the other from COVID-19 infection. DISCUSSION: Decreased mobility due to lockdowns, the burden of requiring negative COVID-19 results before admission for surgery, reduced hospital capacity to comply with physical distancing measures, the postponement of elective surgery to minimize COVID-19 transmission, physician and nursing shortages due to infection or mandatory isolation of staff, cancellation of face-to-face outpatient clinics, and hesitation among patients and their families to go to the hospital for fear of exposure were found to be common causes of delays in treatment. Also, the redirection of health resources and other government and hospital policies to handle the COVID-19 pandemic resulted in an overall delay in the delivery of health services. In particular, the management of pediatric patients with cancers, especially high-grade gliomas, was significantly disrupted.