Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study

Regin Jay Mallari; Michael B. Avery; Alex Corlin; Amalia Eisenberg; Terese C. Hammond; Neil A. Martin; Garni Barkhoudarian; Daniel F. Kelly

doi:10.1371/journal.pone.0254958

Peer Review History

Original SubmissionApril 30, 2021
7 Jun 2021 Decision Letter - Robert Jeenchen Chen, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-21-14344 Streamlining brain tumor surgery care during the COVID-19 pandemic: a case-control study PLOS ONE Dear Dr. Kelly, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please revise accordingly. Please submit your revised manuscript by Jul 12 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Journal Requirements: 1) Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. 2) Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 3) Thank you for stating the following in the Competing Interests section: [I have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Kelly receives royalties from Mizuho, Inc., Dr. Barkhoudarian is a consultant for Vascular Technologies and Cerevasc, Inc. No other authors have conflicts of interests to disclose.]. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf. Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests 4) PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is a clinical useful research article emphasizing streamlining brain tumor surgery care during the COVID-19 pandemic. This result may provide the detailed strategy such as more rigorous patient preparation and education, enhanced patient motivation, and care team engagement when dealing with brain tumor surgery. This strategy may be suitable for other field of surgery. Accept is my final decision. Reviewer #2: This is a very-well conducted retrospective study, nicely demonstrating that sometimes, as also authors stated in their discussion, a bad crisis can lead to positive consequences. The authors were capable of demonstrating that it is possible to significantly reduce the LOS and particularly the utilization of ICU in the pandemic period, without changing the case mix and case load. I have only one suggestion: - the authors should include a more detailed description of post-operative management in order to reduce the need for ICU utilization. In fact, in MM section, they described a general protocol in which they stated thad admittance to ICU is "generally reserved for patients with significant comorbidities, severe preoperative neurological deficits, severe preoperative brain edema, high seizure risk, new postoperative deficits, requiring continued mechanical ventilation or at significant risk of airway compromise". However, they did not specify if this somehow changed during pandemic period. Considering that case mix did not change in the pandemic period, I suppose that not only patient and family counseling was the key factor in reducing ICU admission. Was a dedicated protocol of recovery room monitoring of the patient applied (how many hours, what parameters, etc) in order to more accurately select patients really needing ICU? It has been already demonstrated in previous studies that this could reduce ICU utilization without impacting on post-operative complication and mortality. Reviewer #3: One of the major impacts of COVID-19 to neurosurgery is that this pandemic induces scarcity of ICU beds and other medical resources. In this article, the authors implemented a protocol including minimally invasive surgery, total intravenous anesthesia, early postoperative CT and MR studies to reduce ICU bed and other resources utilization in brain tumor surgery during the pandemic. They analyzed data from two cohorts of patients underwent brain tumor surgery at two epochs before the pandemic and during the pandemic. Their results revealed that patients in the pandemic epoch cohort treated with this protocol with vigorous preoperative education and early ambulation had significantly decreased rate of ICU using and shorter hospital stay without increased postoperative complications. The most important implication of the results of this study is that it is possible to reduce ICU and hospital stay without compromising surgical outcome for patients undergo elective brain tumor surgery with this streamlined care protocol. This paradigm can also be used to reduce health care resources and cost in the future even after the current pandemic has obtained a good control. It will be meaningful to accept this article for publication. According to the description of the authors, this protocol was already used in the pre-pandemic epoch (Table 1). Yet, there were significant differences between these two cohorts in terms of rates of ICU utilization and length of hospital stay in this study. Therefore, these favorable trends cannot be attributed to the using of minimally invasive surgery, total intravenous anesthesia, less postoperative narcotics using and early postoperative imaging. Instead, more vigorous patient education and encourage of early mobilization were the key factors to make the differences. Therefore, discussion of this study should be focused on the elucidation of patient education enhancement and ways of promoting early ambulation. The attached figure showing length of hospital stay of this study is ambiguous and cannot help the readers to understand this article better. The suggestion is either to delete this figure from this article or to redesign this bar chart with separated bars to illustrate the length of stay of these two patient groups underwent two different procedures. The unit of the length (day) also need to be specified. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes: Francesco Acerbi MD PHD Reviewer #2: Yes:** Yong-Kwang Tu [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0254958.r001
Revision 1
16 Jun 2021 Author Response June 14, 2021 Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Re: Revision of manuscript PONE-D-21-14344: “Streamlining brain tumor surgery care during the COVID-19 pandemic: a case-control study” Dear Dr. Chen: Thank you for the helpful critique of our manuscript. Here in is our response to the reviewers’ critiques. Reviewer #1: no response needed. Reviewer #2: The authors should include a more detailed description of post-operative management in order to reduce the need for ICU utilization. In fact, in MM section, they described a general protocol in which they stated that admittance to ICU is "generally reserved for patients with significant comorbidities, severe preoperative neurological deficits, severe preoperative brain edema, high seizure risk, new postoperative deficits, requiring continued mechanical ventilation or at significant risk of airway compromise". However, they did not specify if this somehow changed during pandemic period. Considering that case mix did not change in the pandemic period, I suppose that not only patient and family counseling was the key factor in reducing ICU admission. Was a dedicated protocol of recovery room monitoring of the patient applied (how many hours, what parameters, etc) in order to more accurately select patients really needing ICU? It has been already demonstrated in previous studies that this could reduce ICU utilization without impacting on post-operative complication and mortality. Response: This is an excellent point – indeed part of the overall paradigm shift was enhanced observation in recovery room for the team to feel comfortable for patient recovery in a non-ICU bed. As such we have provided more detail on post-operative management as it relates to our protocol in the recovery room and on early patient assessment to determine if non-ICU admission was safe. These additions are in the abstract, author summary, methods (pages 8,10) and discussion (pages 18,20). We also modified Table 1 section 2, line a:“low likelihood of needing ICU observation” and added line b: “Recovery room assessment assuring safety of non-ICU admission.” Reviewer #3: According to the description of the authors, this protocol was already used in the pre-pandemic epoch (Table 1). Yet, there were significant differences between these two cohorts in terms of rates of ICU utilization and length of hospital stay in this study. Therefore, these favorable trends cannot be attributed to the using of minimally invasive surgery, total intravenous anesthesia, less postoperative narcotics using and early postoperative imaging. Instead, more vigorous patient education and encourage of early mobilization were the key factors to make the differences. Therefore, discussion of this study should be focused on the elucidation of patient education enhancement and ways of promoting early ambulation. Response: The reviewer is correct that our protocol of minimally invasive surgery, TIVA, complication avoidance protocols, early imaging, and limited narcotics use was already in place. We have already emphasized this point in the abstract conclusion, introduction, methods, discussion and Table 1. We stress that our reduced LOS and ICU use resulted from more extensive patient prep, team prep and awareness, more rapid patient mobilization and early contact with the patient and their caregivers on POD1 post-discharge. We clearly acknowledge that these practices were layered upon our existing foundational practice of minimally invasive surgery as detailed in Table 1 section 1. We also added as per Reviewer #2 that more rigorous recovery room assessment was utilized to assure safety of non-ICU admission. Reviewer #3: The attached figure showing length of hospital stay of this study is ambiguous and cannot help the readers to understand this article better. The suggestion is either to delete this figure from this article or to redesign this bar chart with separated bars to illustrate the length of stay of these two patient groups underwent two different procedures. The unit of the length (day) also need to be specified. Response: Regarding Figure 1, we have added the units (days) along the x axis (thank you for this suggestion). We appreciate the Reviewer’s concern and we have tried other iterations of this graph (including separating craniotomy and endonsal cohorts). However, we believe the current figure version adds an important and relatively clear visual representation of the data showing a favorable shift in LOS during the pandemic epoch. Given that Reviewers 1 and 2 did not have any issues with Figure 1, we request to leave it in the manuscript as is but modified with days added on x-axis. We hope these revisions are acceptable. Sincerely, Daniel F. Kelly, M.D. Attachments Attachment Submitted filename: Response to Reviewers PONE-D-21-14344 June 14 2021.docx https://doi.org/10.1371/journal.pone.0254958.r002
7 Jul 2021 Decision Letter - Robert Jeenchen Chen, Editor Streamlining brain tumor surgery care during the COVID-19 pandemic: a case-control study PONE-D-21-14344R1 Dear Dr. Kelly, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: After full evaluation, I find this revised manuscript was well organized and written. I have no more comments. Accept is my final decision Reviewer #3: The authors has answer all my questions and made pertinent changes to my suggestions. I have no further comment. This manuscript is now good for publication ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #3: Yes:** Yong-Kwang Tu https://doi.org/10.1371/journal.pone.0254958.r003
Formally Accepted
14 Jul 2021 Acceptance Letter - Robert Jeenchen Chen, Editor PONE-D-21-14344R1 PONE-D-21-14344: Streamlining brain tumor surgery care during the COVID-19 pandemic: a case-control study Dear Dr. Kelly: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Robert Jeenchen Chen Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0254958.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .