COVID-19 Outcome

COVID-19 Outcome

The possible risk factors that lead to death in critical inpatients with coronavirus disease 2019 (COVID-19) are not yet fully understood.

Old age (>70 years), neutrophiliaC-reactive protein greater than 100 mg/L and lactate dehydrogenase over 300 U/L are high-risk factors for mortality in critical patients with COVID-19Sinus tachycardia and ventricular arrhythmia are independent ECG risk factors for mortality from COVID-19 1).

While the disease itself is often mild, approximately 11% of cases require acute medical care, and this cohort quickly overwhelmed healthcare systems around the world 2).

In anticipation of such a demand, hospitals in many countries quickly stopped all nonurgent visits, procedures, and surgeries, freeing up beds, equipment, and workforce 3)

The mortality rate for COVID-19 is not as high (approximately 2-3%), but its rapid propagation has resulted in the activation of protocols to stop its spread. 4).

A total of 174 consecutive patients confirmed with COVID-19 were studied. Demographic data, medical history, symptoms and signs, laboratory findings, chest computed tomography (CT) as well we treatment measures were collected and analyzed.

Guo et al. found that COVID-19 patients without other comorbidities but with diabetes (n=24) were at higher risk of severe pneumonia, the release of tissue injury-related enzymes, excessive uncontrolled inflammation responses and hypercoagulable state associated with dysregulation of glucose metabolism. Furthermore, serum levels of inflammation-related biomarkers such as IL-6, C-reactive protein, serum ferritin, and coagulation index, D-dimer, were significantly higher (p< 0.01) in diabetic patients compared with those without, suggesting that patients with diabetes are more susceptible to an inflammatory storm eventually leading to rapid deterioration of COVID-19.

Data support the notion that diabetes should be considered as a risk factor for a rapid progression and bad prognosis of COVID-19. More intensive attention should be paid to patients with diabetes, in case of rapid deterioration 5).

see Racism and discrimination in COVID-19 responses 6).


Li L, Zhang S, He B, Chen X, Wang S, Zhao Q. Risk factors and electrocardiogram characteristics for mortality in critical inpatients with COVID-19. Clin Cardiol. 2020 Oct 22. doi: 10.1002/clc.23492. Epub ahead of print. PMID: 33094522.

Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395(10231):P1225-P1228.

Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth. 2020;395:497.

Palacios Cruz M, Santos E, Velázquez Cervantes MA, León Juárez M. COVID-19, a worldwide public health emergency. Rev Clin Esp. 2020 Mar 20. pii: S0014-2565(20)30092-8. doi: 10.1016/j.rce.2020.03.001. [Epub ahead of print] Review. English, Spanish. PubMed PMID: 32204922.

Guo W, Li M, Dong Y, Zhou H, Zhang Z, Tian C, Qin R, Wang H, Shen Y, Du K, Zhao L, Fan H, Luo S, Hu D. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab Res Rev. 2020 Mar 31:e3319. doi: 10.1002/dmrr.3319. [Epub ahead of print] PubMed PMID: 32233013.

Devakumar D, Shannon G, Bhopal SS, Abubakar I. Racism and discrimination in COVID-19 responses. Lancet. 2020 Apr 1. pii: S0140-6736(20)30792-3. doi: 10.1016/S0140-6736(20)30792-3. [Epub ahead of print] PubMed PMID: 32246915.

Very small intracranial aneurysm

Very small intracranial aneurysm

Very small intracranial aneurysm (VSIA) (< 3 mm).

Ruptured VSIA group has higher percentage of females and lower aspect ratio than ruptured non-VSIA group. Further studies regarding the characteristics of ruptured and unruptured VSIA patients is required for assistance in clinical decision related to treatment of VSIA group before the aneurysm sac rupture 1).

The most common site of rupture of very small aneurysm was the anterior communicating artery (ACoA). Rupture of small and very small aneurysms is unpredictable, and treatment may be considered in selected high-risk patients according to factors such as young age, ACoA location, and hypertension 2).

Treatment of very small unruptured intracranial aneurysms (VSUIAs, defined as ≤3 mm) can be indicated in selected circumstances. The feasibility and outcomes of endovascular therapy for VSUIAs have been recently published; however, the efficacy and complication rate of surgical clipping has not been reported in any large series to date.

In a study, 183 patients (128 women, mean age 51.3 years) were treated with 190 procedures for a total of 228 aneurysms. Most were anterior circulation aneurysms (n = 215). The majority were directly clipped (n = 222, 97.4%), with coagulation or wrapping in the remainder. After 1 reoperation for incomplete clipping, postoperative imaging of 225 aneurysms confirmed complete occlusion in 221 (98.2%), 1 neck remnant (0.44%), and 3 partial occlusions (1.3%). Mortality was 0%. Early postoperative neurological deficit developed in 12 patients (6.6%); posterior circulation location was a significant risk factor for early neurological deficit (P < .001). Middle cerebral artery aneurysms had the lowest rate of postoperative deficits at 1.5% (P = .023). After the initial 30-day perioperative period, all deficits related to treatment of posterior circulation aneurysms recovered; overall neurological morbidity decreased to 2.7% with no mortality.

VSUIA clipping is highly effective and is associated with a low morbidity rate. For VSUIAs selected for treatment, our data support surgical clipping as the modality of choice 3).

Aneurysms treated with a Pipeline Embolization Device in vessels less than 2.5 mm between June 2012 and August 2014 were included. They evaluated risk factors, family history of aneurysms, aneurysm characteristics, National Institute of Health Stroke Scale (NIHSS), and modified Rankin scale (mRS) on admission and angiography and clinical outcome at discharge, 6 months, and 1 year.

They included seven patients with a mean age of 65 years. The parent vessel size ranged from 1.5 to 2.3 mm; mean 1.9 mm. Location of the aneurysms was as follows: two aneurysms centered along the pericallosal artery (one left, one right), one on the right angular artery, one aneurysm at the anterior communicating artery (ACom), one at the ACom-right A2 anterior cerebral artery (ACA), one at the lenticulostriate artery, and one at the A1-A2 ACA artery. Aneurysms ranged from 1 to 12 mm in diameter. All aneurysms were treated with a single Pipeline™ Embolization Device (PED). No peri- or post-procedural complications or mortality occurred. The patients were discharged with no change in NIHSS or mRS score. Angiographic follow-up was available in six patients. Angiography showed complete aneurysm occlusion in all. NIHSS and mRS remained unchanged at follow-up.

The preliminary results show that flow diversion technology is an effective and safe therapy for aneurysms located on small cerebral arteries. Larger studies with long-term follow-up are needed to validate our promising results 4).


Park GT, Kim JH, Jung YJ, Chang CH. Characteristics of patients with ruptured very small intracranial aneurysm sized less than 3 mm. J Cerebrovasc Endovasc Neurosurg. 2020 Oct 22. doi: 10.7461/jcen.2020.E2020.07.001. Epub ahead of print. PMID: 33086456.

Lee GJ, Eom KS, Lee C, Kim DW, Kang SD. Rupture of Very Small Intracranial Aneurysms: Incidence and Clinical Characteristics. J Cerebrovasc Endovasc Neurosurg. 2015 Sep;17(3):217-22. doi: 10.7461/jcen.2015.17.3.217. Epub 2015 Sep 30. PubMed PMID: 26526401; PubMed Central PMCID: PMC4626345.

Bruneau M, Amin-Hanjani S, Koroknay-Pal P, Bijlenga P, Jahromi BR, Lehto H, Kivisaari R, Schaller K, Charbel F, Khan S, Mélot C, Niemela M, Hernesniemi J. Surgical Clipping of Very Small Unruptured Intracranial Aneurysms: A Multicenter International Study. Neurosurgery. 2016 Jan;78(1):47-52. doi: 10.1227/NEU.0000000000000991. PubMed PMID: 26317673.

Puri AS, Massari F, Asai T, Marosfoi M, Kan P, Hou SY, Howk M, Perras M, Brooks C, Clarencon F, Gounis MJ, Wakhloo AK. Safety, efficacy, and short-term follow-up of the use of Pipeline™ Embolization Device in small (<2.5mm) cerebral vessels for aneurysm treatment: single institution experience. Neuroradiology. 2015 Dec 23. [Epub ahead of print] PubMed PMID: 26700827.



Twitter is a piece of information network made up of 140-character messages called “tweets”. The brevity of the messages is key to its success: it takes very little time to scan a large amount of information. The tweets contain either a piece of concise information (a message, a question, a thought) or a weblink to more information elsewhere (a website, an image). Scanning recent tweets may be compared with scanning headlines in a newspaper, but with one major difference – you determine what kind of headlines you want to see 1).

The increasing popularity of social media platforms, such as Twitter, have also allowed for the ability to quickly and effectively advertise and promote educational programs to a wide audience 2) 3).

There is a significant difference between social media and reality even within the ‘MedTwitter’ sphere, which is likely due to strong publication bias in Twitter-reported cases. Content on ‘MedTwitter’, as with most social media, should be accepted cautiously 4).

Twitter has demonstrated an expanding role in scientific discussion, surgical news, and conferences.

Twitter has been used to supplement surgical conferences 5).

The Atlas Twitter account, established in August 2012, has more than 12,000 followers, primarily hailing from the United States, the United Kingdom, Canada, and Saudi Arabia. The Atlas Facebook account, established in 2013, has just over 13,000 followers, primarily from India, Egypt, and Mexico. The Atlas Instagram account (established most recently, in December 2018) has more than 16,000 followers and the highest percentage (31%) of younger users (aged 18-24 years). The Atlas app was officially launched in May 2019, largely via promotion on the Atlas social media platforms, and has since recorded more than 60,000 viewing sessions, 80% of which were from users outside the United States.

The Neurosurgical Atlas has attempted to leverage the many e-learning resources at its disposal to assist in spreading neurosurgical best practice on an international scale in a novel and comprehensive way. By incorporating multiple social media platforms into its repertoire, the Atlas is able to ensure awareness of and access to these resources regardless of the user’s location or platform of preference. In so doing, the Atlas represents a novel way of advancing access to neurosurgical educational resources in the digital age 6).

The Virtual Global Spine Conference (VGSC) was created in April 2020 by a multi-institutional team of spinal neurosurgeons and a neuroradiologist. Biweekly virtual meetings were established wherein invited national and international spine care providers would deliver case-based presentations on spine and spine surgery-related conditions via teleconferencing. The promotion was coordinated through social media platforms such as Twitter 7).

The influence of social media and Twitter in general surgery research, mentorship, networking, and education is growing. Limited data exist regarding individuals who control the dialogue 8).

The Brain Tumor Social Media (#BTSM) Twitter hashtag was founded in February 2012 as a disease-specific hashtag for patients with a brain tumor.

To understand #BTSM’s role as a patient support system, Feliciano et al. described user descriptors, growth, interaction, and content sharing.

They analyzed all tweets containing #BTSM from 2012 to 2018 using the Symplur Signals platform to obtain data and to describe Symplur-defined user categories, tweet content, and trends in use over time. They created a network plot with all publicly available retweets involving #BTSM in 2018 to visualize key stakeholders and their connections to other users.

From 2012 to 2018, 59,764 unique users participated in #BTSM, amassing 298,904 tweets. The yearly volume of #BTSM tweets increased by 264.57% from 16,394 in 2012 to 43,373 in 2018 with #BTSM constantly trending in the top 15 list of disease hashtags, as well the top 15 list of tweet chats. Patient advocates generated the most #BTSM tweets (33.13%), while advocacy groups, caregivers, doctors, and researchers generated 7.01%, 4.63%, 3.86%, and 3.37%, respectively. Physician use, although still low, has increased over time. The 2018 network plot of retweets including #BTSM identifies a number of key stakeholders from the patient advocate, patient organization, and medical researcher domains and reveals the extent of their reach to other users.

From its start in 2012, #BTSM has grown exponentially over time. They believe its growth suggests its potential as a global source of brain tumor information on Twitter for patients, advocates, patient organizations as well as health care professionals and researchers 9).

Workewych et al. hypothesized that Twitter data might be useful for understanding public perceptions and misperceptions of sport-related traumatic brain injuries. We performed a content and sentiment analysis of 7483 Twitter® tweets related to traumatic brain injuries in sports collected during June and July 2013.

They identified five major themes. Users tweeted about personal traumatic brain injuries experiences, reported traumatic brain injuries in professional athletes, shared research about sport-related concussions, and discussed policy and safety in injury prevention, such as helmet use. We identified mixed perceptions of and sentiment toward traumatic brain injuries in sports: both an understanding that brain injuries are serious and disregard for activities that might reduce the public burden of traumatic brain injuries were prevalent in our Twitter analysis.

While the scientific and medical community considers a concussion a form of traumatic brain injuries, our study demonstrates a misunderstanding of this fact among the public. In our current digital age, social media can provide useful insight into the culture around a health issue, facilitating implementation of prevention and treatment strategies 10).

Meng et al. searched two major social media platforms (Facebook and Twitter) for public accounts dedicated to epilepsy. Results were analyzed using qualitative and quantitative methodologies. The former involved thematic and word count analysis for online posts and tweets on these platforms, while the latter employed descriptive statistics and non-parametric tests.

Results: Facebook had a higher number of pages (840 accounts) and users (3 million) compared to Twitter (137 accounts and 274,663 users). Foundation and support groups comprised most of the accounts and users on both Facebook and Twitter. The number of accounts increased by 100% from 2012 to 2016. Among the 403 posts and tweets analyzed, “providing information” on medications or correcting common misconceptions in epilepsy was the most common theme (48%). Surgical interventions for epilepsy were only mentioned in 1% of all posts and tweets.

Conclusions: The current study provides a comprehensive reference on the usage of social media in epilepsy. The number of online users interested in epilepsy is likely the highest among all neurological conditions. Surgery, as a method of treating refractory epilepsy, however, could be underrepresented on social media 11).

A pilot application of the system in a hospital showed successful information transfer, allowing medical staff to discuss patients’ diagnosis and management using a Twitter system.

The system (i-Stroke) may become a useful tool for acute patient management in the field of neurology and neurosurgery 12).


Kubben PL. Twitter for neurosurgeons. Surg Neurol Int. 2011 Mar 14;2:28. doi: 10.4103/2152-7806.77596. PMID: 21451727; PMCID: PMC3062806.

Szmuda T, Ali S, Słoniewski P, Group NW. Telemedicine in neurosurgery during the novel coronavirus (COVID-19) pandemic. Neurol Neurochir Pol. 2020;54(2):207-208. doi: 10.5603/PJNNS.a2020.0038. Epub 2020 Apr 22. PMID: 32319670.

Linzey JR, Robertson F, Haider AS, Graffeo CS, Wang JZ, Shasby G, Alotaibi NM, Cohen-Gadol AA, Rutka JT. Online Impact and Presence of a Specialized Social Media Team for the Journal of Neurosurgery: Descriptive Analysis. J Med Internet Res. 2020 May 19;22(5):e17741. doi: 10.2196/17741. PMID: 32163371; PMCID: PMC7267990.

Dmytriw AA, Sorenson TJ, Morris JM, Nicholson PJ, Hilditch CA, Graffeo CS, Brinjikji W. #Fake news: a systematic review of mechanical thrombectomy results among neurointerventional stroke surgeons on Twitter. J Neurointerv Surg. 2019 May;11(5):460-463. doi: 10.1136/neurintsurg-2018-014319. Epub 2018 Sep 15. PMID: 30219792.

Chung A, Woo H. Twitter in urology and other surgical specialties at global conferences. ANZ J Surg. 2016 Apr;86(4):224-7. doi: 10.1111/ans.13393. Epub 2015 Dec 3. PMID: 26631323.

Teton ZE, Freedman RS, Tomlinson SB, Linzey JR, Onyewuenyi A, Khahera AS, Hendricks BK, Cohen-Gadol AA. The Neurosurgical Atlas: advancing neurosurgical education in the digital age. Neurosurg Focus. 2020 Mar 1;48(3):E17. doi: 10.3171/2019.12.FOCUS19820. PMID: 32114553.

Rasouli JJ, Shin JH, Than KD, Gibbs WN, Baum GR, Baaj AA. Virtual Spine: A Novel, International Teleconferencing Program Developed to Increase the Accessibility of Spine Education During the COVID-19 Pandemic. World Neurosurg. 2020 Aug;140:e367-e372. doi: 10.1016/j.wneu.2020.05.191. Epub 2020 May 28. PMID: 32474104; PMCID: PMC7255710.

Elson NC, Le DT, Johnson MD, Reyna C, Shaughnessy EA, Goodman MD, Lewis JD. Characteristics of General Surgery Social Media Influencers on Twitter. Am Surg. 2020 Oct 15:3134820951427. doi: 10.1177/0003134820951427. Epub ahead of print. PMID: 33054321.

Feliciano JT, Salmi L, Blotner C, Hayden A, Nduom EK, Kwan BM, Katz MS, Claus EB. Brain Tumor Discussions on Twitter (#BTSM): Social Network Analysis. J Med Internet Res. 2020 Oct 8;22(10):e22005. doi: 10.2196/22005. PMID: 33030435.

Workewych AM, Ciuffetelli Muzzi M, Jing R, Zhang S, Topolovec-Vranic J, Cusimano MD. Twitter and traumatic brain injury: A content and sentiment analysis of tweets pertaining to sport-related brain injury. SAGE Open Med. 2017 Aug 25;5:2050312117720057. doi: 10.1177/2050312117720057. PMID: 28890783; PMCID: PMC5574478.

Meng Y, Elkaim L, Wang J, Liu J, Alotaibi NM, Ibrahim GM, Fallah A, Weil AG, Valiante TA, Lozano AM, Rutka JT. Social media in epilepsy: A quantitative and qualitative analysis. Epilepsy Behav. 2017 Jun;71(Pt A):79-84. doi: 10.1016/j.yebeh.2017.04.033. Epub 2017 May 26. PMID: 28554148.

Takao H, Murayama Y, Ishibashi T, Karagiozov KL, Abe T. A new support system using a mobile device (smartphone) for diagnostic image display and treatment of stroke. Stroke. 2012 Jan;43(1):236-9. doi: 10.1161/STROKEAHA.111.627943. Epub 2011 Oct 13. PMID: 21998052.
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