key: cord-0845447-2yj0bveo
authors: Goyal, Nishant; Gupta, Kanav
title: Letter to the Editor Regarding- COVID-19 impact on neurosurgical practice: lockdown attitude and experience of a European academic center
date: 2020-09-28
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.09.117
sha: 8a1008ecbd3236653b2e1187dea335564d8edd52
doc_id: 845447
cord_uid: 2yj0bveo

nan

Sir,

We read with great interest the article by Lubansu et al, 1 "COVID-19 impact on neurosurgical practice: lockdown attitude and experience of a European academic center." In this article, the authors have shared their experience during COVID-19 pandemic in Belgium, discussed their institute protocol and workflow for management of neurosurgical patients. In Belgium, the first patient of COVID-19 was reported on February 4 and the first COVID-19-related death was confirmed on March 11. As a response to the pandemic, certain measures were taken at their institute, like use of tele-medicine, replacement of meetings and physical classes with videoconferences or webinars and implementation of social-distancing policy. Non-urgent elective surgeries and outpatient activities were suspended. Wards, resources, and teams were re-deployed to anticipate any potential congestion according to the latest national and institutional forecasts. As surgical activity was reserved for critical and semi-urgent surgeries, the total number of operated patients fell from 308 to 154 (-50%), and emergent surgeries showed a fall from 75 to 29 when compared to a similar period in 2019.

The COVID-19 pandemic is sweeping across the world and has stretched the capacities of health systems globally. At the time of writing this article on 18 th September 2020, India's tally of confirmed COVID-19 cases has reached 5,130,305 making it the second most affected country in terms of absolute numbers. Till date, there have been 84,372 COVID-19-related deaths in the country, which is the third highest after USA and Brazil. 2, 3 Since the onset of the pandemic in our country, we adopted measures very similar to those outlined by the authors like use of telemedicine, webinars, socialdistancing policy, appropriate modification in operation rooms, creation of dedicated COVID-19 areas and suspension of non-emergent surgeries. [4] [5] [6] [7] [8] [9] Our department has seen a major change in the volume and spectrum of the patients. During the period of lockdown in India (25 th March to 31 st May 2020), our surgical volume decreased from 111 to 53 (-52.3%) while the number of emergent surgeries remained the same (47 cases), when compared to the same duration in 2019. 4 Thus, we were able to continue providing emergency services even during the lockdown, while most of the 'non-emergent' cases had been postponed/cancelled. Similarly, a large number of elective surgeries have been cancelled/ postponed in hospitals across the world as a response to the COVID-19 pandemic. [10] [11] [12] [13] [14] [15] [16] [17] [18] We have adopted an institute policy of testing all patients being admitted to the ward and now, we are testing them once more before surgery. 4 

In spite of this, 20 (11.4%) of 176 cases admitted under neurosurgery tested positive for COVID-19 in their study. Thirteen patients (65%) in the COVID-19 group presented with stroke compared to 17% in the non-COVID-19 group. Mortality rate was remarkably high at 45% and even higher in patients requiring surgical intervention (77%; 7 of 9 patients). 1 In contrast to this, between April and August, 2020 we have had 284 neurosurgical admissions, of which only six (2.1%) were COVID-19 positive.

Only one patient had stroke at presentation (Patient 2). Three patients underwent surgical intervention; two were managed conservatively while one refused surgery (Table 1) . We have a policy to postpone surgery in COVID-19-positive patients when the situation permits. This is supported by a seminal article which showed that in patients with perioperative COVID 19 infection, the 30 day mortality of elective surgery was 23.8% and pulmonary complications were seen in 51.2%. 19 Two patients (patients 5 and 6) requiring surgery tested positive for COVID-19 pre-operatively. For both of these patients, the surgery was done only after isolating the patients for 14 days in dedicated COVID-19 area and with three consecutive negative test results. There was no mortality in the six COVID-19 positive patients in our series.

This difference in proportion of COVID-19 positivity and low mortality rate amongst patients can be attributed to different genetics and immune system responses, regional contrasts in obesity levels and general health apart from the quick reaction time to the crisis in India. 20 In addition, coronavirus stains prevalent in India and China also appears to be less virulent than the ones isolated from Italy, Spain and USA. 21 COVID-19 related deaths per million population for India and China is three, five for South Korea and Indonesia, six for Pakistan, seven for Japan and under one for Thailand. On the other hand, there were about 100 COVID-19 related deaths per million population in Germany, about 180 in Canada, nearly 300 in the United States and more than 500 in Britain, Italy and Spain. 20 Belgium has witnessed a high deaths per one million inhabitants ratio (801 per 1 million), and a case-fatality ratio of 16.3%. 1 It would also be interesting to know whether COVID-19 patients reported by Lubansu et al underwent surgery immediately or after being isolated and with COVID-19 negative results, as the peri-operative mortality is significantly higher in patients with peri-operative COVID-19 infection. In addition, it would be interesting to know, how many out of 176 patients actually underwent testing for COVID-19.

https://www.hindustantimes.com/world-news/why-us-europe-were-hit-harder-by-covid-19scientists-look-at-regional-disparities-immune-system/story-5PRVoDaGsRjS9Xn2H6MaSO.html 21. US, Italy strain more virulent than one in India: Top Indian microbiologists. National Herald. Accessed August 10, 2020. https://www.nationalheraldindia.com/national/us-italy-strain-morevirulent-than-one-in-india-top-indian-microbiologists J o u r n a l P r e -p r o o f 

☒ 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:

COVID-19 impact on neurosurgical practice: lockdown attitude and experience of a European academic center

Countries where Coronavirus has spread -Worldometer

Collateral damage caused by COVID-19: Change in volume and spectrum of neurosurgery patients

Impact of the COVID-19 Pandemic on Neurosurgical Practice in India: Results of an Anonymized National Survey

Getting Neurosurgery Services back on its feet: 'Learning to live' with COVID-19

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