Health system assessment for access to care after injury in low- or middle-income countries: A mixed methods study from Northern Malawi.

BACKGROUND: Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings. METHODS AND FINDINGS: To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system. We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers "cost," "transport," and "physical resources" had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers-25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework. CONCLUSIONS: By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system's ability to provide injury care. This approach allowed more holistic appraisal of this health system's issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy.

Advances in the management of primary bone sarcomas of the skull base.

Skull base primary malignancies represent a heterogeneous group of histologic diagnoses and sarcomas of the skull base are specific malignant tumors that arise from mesenchymal cells and can be classified by site of origin into bony and soft tissue sarcomas. The most common bony sarcomas include: chondrosarcoma, osteosarcoma, chordoma, Ewing's sarcoma. Given the relative rarity of each histologic diagnosis, especially in the skull base, there is limited published data to guide the management of patients with skull base sarcomas. An electronic search of the literature was performed to obtain key publications in the management of bony sarcomas of the skull base published within the last decade. This article is thus a review of the multi-disciplinary management principles of primary bony sarcomas of the skull base. Of note, there have been several recent advancements in the realm of skull base sarcoma management that have resulted in improved survival. These include advances in: imaging and diagnostic techniques, surgical techniques that incorporate oncologic surgical principles, conformal radiation paradigms and targeted systemic therapies. Early access to coordinated multi-disciplinary subspecialty care immediately at suspicion of diagnosis has further improved outcomes. There are several ongoing trials in the realms of radiation therapy and systemic therapy that will hopefully provide further insight about the optimal management of bony sarcomas of the skull base.

Intraoperative Flash Visual Evoked Potential Recording and Relationship to Visual Outcome.

OBJECTIVE: To determine the relationship between intraoperative flash visual evoked potential (FVEP) monitoring and visual function. METHODS: Intraoperative FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex (Oz) after flashing red light stimulation delivered by Cadwell LED stimulating goggles in 89 patients. Restrictive filtering (typically 10-100 Hz), optimal reject window settings, mastoid reference site, total intravenous anesthetic (TIVA), and stable retinal stimulation (ensured by concomitant electroretinogram [ERG] recording) were used to enhance FVEP reproducibility. RESULTS: The relationship between FVEP amplitude change and visual outcome was determined from 179 eyes. One eye had a permanent intraoperative FVEP loss despite stable ERG, and this eye had new, severe postoperative visual dysfunction. Seven eyes had transient significant FVEP change (>50% amplitude decrease that recovered by the end of surgery), but only one of those had a decrease in postoperative visual acuity. FVEP changes in all eight eyes (one permanent FVEP loss plus seven transient FVEP changes) were related to surgical manipulation. In each case the surgeon was promptly informed of the FVEP deterioration and took remedial action. The other eyes did not have FVEP changes, and none of those eyes had new postoperative visual deficits. CONCLUSIONS: Our FVEP findings relate to visual outcome with a sensitivity and specificity of 1.0. New methods for rapidly acquiring reproducible FVEP waveforms allowed for timely reporting of significant FVEP change resulting in prompt surgical action. This may have accounted for the low postoperative visual deficit rate (1%) in this series.

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement.

BACKGROUND: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data.

OBJECTIVES: To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care. DESIGN: Retrospective analysis of existing VA data routinely collected by a demographic surveillance site. SETTING: Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi. PARTICIPANTS: Fatally injured members of the HDSS. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system. RESULTS: Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49). CONCLUSIONS: VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.

A prospective qualitative study on patients' perceptions of endoscopic endonasal transsphenoidal surgery.

BACKGROUND: Endoscopic transsphenoidal surgery has been shown to be a safe and effective treatment option for patients with pituitary tumours, but no study has explored patients' perceptions before and after this surgery. OBJECTIVE: The authors in this study aim to explore patients' perceptions on endoscopic transsphenoidal surgery. METHODS: Using qualitative research methodology, two semi-structured interviews were conducted with 30 participants who were adults aged > 18 undergoing endoscopic transsphenoidal surgery for the resection of a pituitary tumour between December 2008 and June 2011. The interviews were audiotaped and transcribed. The resulting data was analyzed using a modified thematic analysis. RESULTS: Seven overarching themes were identified: (1) Patients had a positive surgical experience; (2) patients were satisfied with the results of the procedure; (3) patients were initially surprised that neurosurgery could be performed endonasally; (4) patients expected a cure and to feel better after the surgery; (5) many patients feared that something might go wrong during the surgery; (6) patients were psychologically prepared for the surgery; (7) most patients reported receiving adequate pre-op and post-op information. CONCLUSIONS: This is the first qualitative study reporting on patients' perceptions before and after an endoscopic endonasal transsphenoidal pituitary surgery, which is increasingly used as a standard surgical approach for patients with pituitary tumours. Patients report a positive perception and general satisfaction with the endoscopic transsphenoidal surgical experience. However, there is still room for improvement in post-surgical care. Overall, patients' perceptions can help improve the delivery of comprehensive care to future patients undergoing pituitary tumour surgery.

Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges.

BACKGROUND: Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC. OBJECTIVE: To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa. METHODS: We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included. RESULTS: Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources. CONCLUSION: Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.

Quality of life after transsphenoidal pituitary surgery: a qualitative study.

BACKGROUND: Microscopic and endoscopic approaches are both utilized for transsphenoidal resection of sellar/parasellar lesions. The endoscopic approach has been gaining popularity over the past decade; however, quality-of-life studies comparing the microscopic and endoscopic approaches are lacking. We aimed to compare the patients' perceptions of their postoperative recovery periods following microscopic and endoscopic procedures. METHODS: Qualitative research methodology was used for this study. Each participant underwent a single semi-structured, open-ended interview based on an interview guide. Each participant had undergone at least one microscopic and one endoscopic transsphenoidal procedure for resection of a sellar/parasellar lesion. The interviews were audiotaped and transcribed. The transcripts were then analyzed for overarching themes. Demographic information was also collected. RESULTS: The following five overarching themes emerged from the data: (1) the endoscopic procedure was better tolerated than the microscopic procedure and was the preferred approach by 22 out of 27 patients should they require another surgery in the future; (2) most patients did not know that they had undergone two different surgical approaches; (3) other than an unpleasant malodorous smell, rhinologic complications (including drainage, crusting, and alterations in smell) following the endoscopic procedures were comparable to those following the microscopic procedures; (4) the patient's postoperative experience after the microscopic procedure had an impact on his/her expectations of the endoscopic procedure; (5) any significant pain or discomfort experienced from either procedure was mainly related to the nasal packing or fascia lata graft donor site. CONCLUSIONS: The endoscopic procedure was the preferred approach over the microscopic approach by the majority of patients because of its better tolerability, despite comparable rhinologic complications.

Soft Tissue Sarcomas of the Head and Neck Region with Skull Base/Intracranial Invasion: Review of Surgical Outcomes and Multimodal Treatment Strategies: A Retrospective Case Series.

Soft tissue sarcomas (STS) invading the skull base are rare with little data to guide surgical management. Here we aimed to determine the factors affecting tumor control rates and survival in patients with T4 stage head and neck STS involving the skull base. A retrospective review of STS patients, surgically treated at our institution between 1994 and 2017 was conducted. Variables were collected and assessed against progression-free survival. Tumors were graded using the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) system. A total of 51 patients (mean age of 35) were included, of whom 17 (33.3%) patients were FNCLCC grade 1, 8 (15. 7%) were FNCLCC grade 2 and 26 (51%) were FNCLCC grade 3. The median PFS was 236.4 months while the 5- and 10-year PFS rates were 44% and 17%, respectively. Recurrence occurred in 17 (33.3%) patients. Local recurrence occurred in 10 (58.8%). Univariate analysis revealed R0 resection had a near-significant impact on tumor control in radiation-naïve patients. Otherwise, prior radiation (HR 6.221, CI 1.236-31.314) and cavernous sinus involvement (HR 14.464, CI 3.326-62.901) were negative predictors of PFS. The most common cause of treatment failure was local recurrence. In T4 stage head and neck STS with skull-base involvement, FNCLCC grade, radiation status, and anatomic spread should be considered in determining the overall treatment strategy.

External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study.

OBJECTIVE: Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies. SETTING: Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa. PARTICIPANTS: Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals. METHODS: A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the 'three delays framework' (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs-a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care. RESULTS: Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems. CONCLUSIONS: A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

Planum-Clival Angle Classification: A Novel Preoperative Evaluation for Sellar/Parasellar Surgery.

Objective Endonasal approaches are increasingly used to treat sellar pathologies, leading to increased interest in achieving maximal safe resection. We propose a tool-the planum-clival angle (PCA)-and explore its surgical implications for sellar pathology resections. Design Retrospective analysis. Participants Consecutive patients with pituitary lesions between 2003 and 2013. Outcome Measures The PCA and suprasellar extension ratios; head position and extent of surgical resection. Results We enrolled 89 patients (ages 21-88 years). There were 15 type A patients (17%), 13 with suprasellar extension (89%) and ratios between 0.12 and 0.70. There were 61 type B patients (70%), 49 with suprasellar extension (81%) and ratios from 0.09 to 0.66. Finally, there were 13 type C patients (13%), 10 with suprasellar extension (73%) and ratios from 0.21 to 0.76. Type B was treated with a sphenoidectomy and neutral head positioning, type A with 10 to 20 degrees of flexion and an additional posterior ethmoidectomy with or without posterior planum resection, and type C with 10 to 20 degrees of extension and an additional superior clival resection. Conclusions Sellar anatomy and PCA influence the growth patterns of sellar lesions. Thus PCA should allow for better surgical planning and thereby improve surgical efficacy.

Transclival pseudomeningocele secondary to ecchordosis physaliphora: case report and literature review.

We describe a 52-year-old woman who presented with meningitis secondary to a pseudomeningocele within the sphenoid sinus derived from a bony defect in the clivus. The bony defect was radiologically characteristic of an ecchordosis physaliphora (EP). She underwent surgical repair of the defect and had resolution of her symptoms. This case report will discuss the second case of transclival pseudomeningocele in the English literature and present EP as a cause.