A guide to interpreting systematic reviews and meta-analyses in neurosurgery and surgery.

INTRODUCTION: Systematic reviews (SRs) and meta-analyses (MAs) are methods of data analysis used to synthesize information presented in multiple publications on the same topic. A thorough understanding of the steps involved in conducting this type of research and approaches to data analysis is critical for appropriate understanding, interpretation, and application of the findings of these reviews. METHODS: We reviewed reference texts in clinical neuroepidemiology, neurostatistics and research methods and other previously related articles on meta-analyses (MAs) in surgery. Based on existing theories and models and our cumulative years of expertise in conducting MAs, we have synthesized and presented a detailed pragmatic approach to interpreting MAs in Neurosurgery. RESULTS: Herein we have briefly defined SRs sand MAs and related terminologies, succinctly outlined the essential steps to conduct and critically appraise SRs and MAs. A practical approach to interpreting MAs for neurosurgeons is described in details. Based on summary outcome measures, we have used hypothetical examples to illustrate the Interpretation of the three commonest types of MAs in neurosurgery: MAs of Binary Outcome Measures (Pairwise MAs), MAs of proportions and MAs of Continuous Variables. Furthermore, we have elucidated on the concepts of heterogeneity, modeling, certainty, and bias essential for the robust and transparent interpretation of MAs. The basics for the Interpretation of Forest plots, the preferred graphical display of data in MAs are summarized. Additionally, a condensation of the assessment of the overall quality of methodology and reporting of MA and the applicability of evidence to patient care is presented. CONCLUSION: There is a paucity of pragmatic guides to appraise MAs for surgeons who are non-statisticians. This article serves as a detailed guide for the interpretation of systematic reviews and meta-analyses with examples of applications for clinical neurosurgeons.

Spina bifida management in low- and middle-income countries - a comprehensive policy approach.

INTRODUCTION: Globally, spina bifida (SB) occurs more often in low- and middle-income countries, where the healthcare demands are often quite challenging. Several social/societal issues and/or lack of government support makes for incomplete SB management in many areas. Clearly, neurosurgeons should be knowledgeable about initial closure techniques and the basics of SB management, but must also advocate for the patients outside our immediate scope of care. METHODS: Recently, the Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low- and Middle-Income Countries (CHYSPR) and the Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders (IGAP) publications emphasized the need for a more unified approach to SB care. Although both documents discuss other neurological conditions, they support SB as a congenital malformation needing attention. RESULTS: We identified several similarities for comprehensive SB care in these approaches - including education, governance, advocacy, and the need for continuum of care. Prevention was recognized as the most important aspect for SB going forward. A significant return of investment was noted, and both documents recommend more active neurosurgical involvement (i.e., folic acid fortification). CONCLUSION: A new call for holistic and comprehensive care for SB management is recognized. Neurosurgeons are called upon to use solid science to educate governments and actively participate to advocate for better care and most importantly, prevention. Folic acid fortification schemes are mandatory and neurosurgeons should advocate for global strategies.

Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis.

BACKGROUND: The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels. METHODS AND FINDINGS: A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle-Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg's and Egger's tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case-control study, and 5 pre-post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present. CONCLUSIONS: In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.

Delivery of essential surgery by family physicians.

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care's dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.

Les soins de santé primaires établissent le cadre requis pour des soins complets adaptés aux patients, gages d'un système de santé solide. Ils jouent donc un rôle central dans la mise en place d'une couverture maladie universelle. Dans ce contexte, les médecins de famille sont les mieux placés pour incarner une double perspective, la santé communautaire et la santé des populations, car ils travaillent souvent dans des hôpitaux ruraux ou de district qui disposent de ressources humaines limitées, surtout en termes de spécialistes. Le présent document montre dans quelle mesure une formation complémentaire dédiée aux médecins de famille, acteurs clés des soins de santé primaires, peut avoir un impact décisif sur la diminution des inégalités d'accès aux interventions chirurgicales, obstétriques et anesthésiques dans les pays à faible et moyen revenu, ainsi que dans les milieux ruraux ou isolés. Il existe de nombreux exemples qui illustrent la façon dont les programmes de formation peuvent être mis en œuvre dans les endroits manquant de ressources afin que les médecins de famille acquièrent des compétences chirurgicales vitales, et qui indiquent comment les médecins de famille des pays à haut revenu peuvent apprendre des techniques de chirurgie essentielles pour travailler outre-mer ou dans des régions plus défavorisées. Les législateurs devraient promouvoir la pratique chirurgicale chez les médecins de famille en soutenant les programmes qui incluent une formation complémentaire aux techniques de chirurgie, et en multipliant les opportunités et sources de motivation pour que les médecins de famille exercent dans les zones rurales. Par ailleurs, les projets nationaux devraient comporter une stratégie de soins de santé primaires pour les actes chirurgicaux et, globalement, les médecins de famille devraient être pris en compte dans les discussions consacrées aux interventions chirurgicales. Enfin, chirurgiens, anesthésistes, obstétriciens et médecins de famille devraient être encouragés à collaborer pour s'assurer que tous les patients, quel que soit leur lieu de résidence, puissent bénéficier de soins chirurgicaux au moment opportun et en toute sécurité.

La atención primaria de salud establece el marco para la prestación de una atención socialmente informada, integral y centrada en el paciente, que es la base de los sistemas sólidos de atención sanitaria y, por lo tanto, es fundamental para lograr la cobertura sanitaria universal. Los médicos de familia son los que mejor pueden asumir el doble enfoque de la atención primaria en la salud de la comunidad y de la población porque trabajan con frecuencia en hospitales rurales o de distrito que tienen recursos humanos limitados, en especial por la falta de especialistas. En este documento, se pretende ilustrar cómo la capacitación adicional de los médicos de familia, quienes son los profesionales clínicos clave en la atención primaria, puede desempeñar una función esencial en la reducción de las desigualdades que existen para acceder a los procedimientos quirúrgicos, obstétricos y de anestesia en los países de ingresos bajos y medios y en los zonas rurales o remotas. También se dan ejemplos de cómo se pueden elaborar programas de capacitación en entornos de bajos recursos para preparar a los médicos de familia con técnicas quirúrgicas que salvan vidas y de cómo se puede capacitar a los médicos de familia de los países de altos ingresos sobre las técnicas quirúrgicas esenciales para que trabajen en el extranjero en entornos de bajos ingresos. Los responsables de formular políticas deben promover la práctica quirúrgica entre los médicos de familia mediante su apoyo a los programas de medicina familiar que incluyan una capacitación adicional sobre técnicas quirúrgicas, así como la ampliación de las oportunidades y de los incentivos para que los médicos de familia presten servicios en las zonas rurales. Además, los planes quirúrgicos nacionales deben incluir una estrategia de atención primaria de salud para la intervención quirúrgica y, a nivel mundial, los médicos de familia se deben tener en cuenta en los debates sobre la intervención quirúrgica. Por último, se debe alentar a los cirujanos, anestesiólogos, obstetras y médicos de familia a que colaboren para garantizar que todos los pacientes, sea cual sea su lugar de residencia, reciban servicios quirúrgicos seguros y oportunos.

Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery.

Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners - individuals and institutions - help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.

A comparison of publication to TBI burden ratio of low- and middle-income countries versus high-income countries: how can we improve worldwide care of TBI?

OBJECTIVE: Traumatic brain injury (TBI) is a global public health problem and more than 70% of trauma-related deaths are estimated to occur in low- and middle-income countries (LMICs). Nevertheless, there is a consistent lack of data from these countries. The aim of this work is to estimate the capacity of different and heterogeneous areas of the world to report and publish data on TBI. In addition, we wanted to estimate the countries with the highest and lowest number of publications when taking into account the relative TBI burden. METHODS: First, a bibliometric analysis of all the publications about TBI available in the PubMed database from January 1, 2008, to December 31, 2018, was performed. These data were tabulated by country and grouped according to each geographical region as indicated by the WHO: African Region (AFR), Region of the Americas (PAH), South-East Asia Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), and Western Pacific Region (WPR). In this analysis, PAH was further subdivided into Latin America (AMR-L) and North America (AMR-US/Can). Then a "publication to TBI volume ratio" was derived to estimate the research interest in TBI with respect to the frequency of this pathology. RESULTS: Between 2008 and 2018 a total of 8144 articles were published and indexed in the PubMed database about TBI. Leading WHO regions in terms of contributions were AMR-US/Can with 4183 articles (51.36%), followed by EUR with 2003 articles (24.60%), WPR with 1507 (18.50%), AMR-L with 141 articles (1.73%), EMR with 135 (1.66%), AFR with 91 articles (1.12%), and SEAR with 84 articles (1.03%). The highest publication to TBI volume ratios were found for AMR-US/Can (90.93) and EUR (21.54), followed by WPR (8.71) and AMR-L (2.43). Almost 90 times lower than the ratio of AMR-US/Can were the ratios for AFR (1.15) and SEAR (0.46). CONCLUSIONS: An important disparity currently exists between countries with a high burden of TBI and those in which most of the research is conducted. A call for improvement of data collection and research outputs along with an increase in international collaboration could quantitatively and qualitatively improve the ability of LMICs to ameliorate TBI care and develop clinical practice guidelines.

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.

Global neurosurgery: current and potential impact of neurosurgeons at the World Health Organization and the World Health Assembly. Executive summary of the World Federation of Neurosurgical Societies-World Health Organization Liaison Committee at the 71st World Health Assembly.

Since the creation of the World Health Organization (WHO) in 1948, the annual World Health Assembly (WHA) has been the major forum for discussion, debate, and approval of the global health agenda. As such, it informs the framework for the policies and budgets of many of its Member States. For most of its history, a significant portion of the attention of health ministers and Member States has been given to issues of clean water, vaccination, and communicable diseases. For neurosurgeons, the adoption of WHA Resolution 68.15 changed the global health landscape because the importance of surgical care for universal health coverage was highlighted in the document. This resolution was adopted in 2015, shortly after the publication of The Lancet Commission on Global Surgery Report titled "Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development." Mandating global strengthening of emergency and essential surgical care and anesthesia, this resolution has led to the formation of surgical and anesthesia collaborations that center on WHO and can be facilitated via the WHA. Participation by neurosurgeons has grown dramatically, in part due to the official relations between WHO and the World Federation of Neurosurgical Societies, with the result that global neurosurgery is gaining momentum.

Cost-Effectiveness of Craniotomy for Epidural Hematomas at a Major Government Hospital in Cambodia.

BACKGROUND: Epidural hematoma (EDH) is a common and potentially deadly occurrence following a severe traumatic brain injury. Our aim was to determine whether craniotomy is cost-effective when indicated for the treatment of EDH when a trained neurosurgeon is available. METHODS: A decision tree was used to model the cost-effectiveness of craniotomy available versus craniotomy unavailable for the management of traumatic EDH from a Cambodian societal and provider perspective. Costs and effectiveness parameters were obtained from patient data at a large government hospital in Cambodia. Outcomes were measured in quality-adjusted life years (QALYs). Incremental cost per QALY and budget impact were calculated for each intervention at a willingness-to-pay (WTP) threshold of $9787.80/QALY (3× GDP per capita PPP). The time horizon reflected full life span, and costs and QALYs were discounted at 3%. Sensitivity analysis was also conducted. RESULTS: Compared to craniotomy unavailable for EDH ($945.80; 11.78 QALYs), craniotomy available came at a higher cost and greater effectiveness ($1520.73; 12.78 QALYs), resulting in an incremental cost-effectiveness ratio (ICER) of $574.93. One-way analysis demonstrated that craniotomy unavailable became more cost-effective than craniotomy available when the percent chance of having a GOS of 4 or 5 was 60% for patients with an EDH where craniotomy was indicated but not performed. Probabilistic sensitivity analysis revealed that craniotomy available was more cost-effective than conservative management in 84.4% of simulations at the WTP threshold. CONCLUSIONS: Craniotomy is a cost-effective treatment for patients with a traumatic EDH who meet criteria for operation when trained neurosurgeons are available onsite.

Understanding pediatric surgical needs in North Korea: a modeling analysis.

Background: Sixty-five percent of children worldwide lack access to surgical care, the majority of whom live in low-income and middle-income countries (LMICs). Developing surgical infrastructure requires information on surgical need; however, this information is often limited in LMICs. North Korea (Democratic People's Republic of Korea, DPRK) has a low amount of publicly available data. Here, we analyzed available modeled data to understand the causes of pediatric deaths due to conditions treatable with surgery in DPRK. Methods: We used World Bank data and models from the Institute for Health Metrics and Evaluation to identify causes of pediatric deaths affecting pediatric patients (age <20 years). We compared mortality of disease between DPRK and countries with similar economic status. Results: Between 1990 and 2019, the number of overall pediatric deaths has decreased. In 2019, 32.2% of all pediatric deaths in DPRK were caused by surgical conditions. The leading categories of surgical conditions were injuries (53.9%), congenital conditions (34.2%), tumors (8.8%), and abdominal conditions (3.2%). DPRK has a lower relative rate of pediatric deaths compared with other LMICs with similar gross domestic product per capita. However, it has a higher relative rate of pediatric deaths due to conditions requiring treatment with surgery. Transport injuries contribute significantly to the high rate of pediatric deaths in DPRK. Conclusions: Although DPRK may be allocating overall resources toward pediatric healthcare more efficiently than economic peers, DPRK may benefit from improvement in pediatric surgical capacity. Improved availability of data and close international collaboration could be potential solutions to bridge this gap.

Neurosurgery and the World Health Organization Intersectoral Global Action Plan for Epilepsy and Other Neurological Disorders 2022-2031.

The World Health Organization's Intersectoral Global Action Plan (IGAP) on Epilepsy and Other Neurological Diseases 2022-2031 is a holistic, interdisciplinary, and intersectoral plan with a strong focus on equity and human rights. The IGAP was unanimously approved by all World Health Organization Member States at the 75th World Health Assembly in May 2022 and provides a framework for researchers and clinicians to study and address national and global inadequacies in the evaluation and management of people suffering from neurological disorders and their prevention. While IGAP has applied epilepsy as an entry point for other neurological disorders, advocacy by neurologists and neurosurgeons has broadened it to include diseases with a large and growing global health footprint such as stroke, hydrocephalus, traumatic brain injury, and brain and spine cancers. The IGAP is important to neurosurgeons globally because it provides the first ever roadmap for comprehensively addressing unmet neurological and neurosurgical care in low- and middle-income countries. Furthermore, it creates an opportunity for neurologists and neurosurgeons to scale up services for neurological diseases in tandem. As such, it provides a structure for the neurosurgery community to become involved in global health initiatives at all levels.

Temporal Delays in the Management of Traumatic Brain Injury: A Comparative Meta-Analysis of Global Literature.

OBJECTIVE: A meta-analysis was conducted to compare: 1) time from traumatic brain injury (TBI) to the hospital, and 2) time within the hospital to intervention or surgery, by country-level income, World Health Organization region, and healthcare payment system. METHODS: A comprehensive literature search was conducted and followed by a meta-analysis comparing duration of delays (prehospital and intrahospital) in TBI management. Means and standard deviations were pooled using a random effects model and subgroup analysis was performed using R software. RESULTS: Our analysis comprised 95,554 TBI patients from 45 countries. BY COUNTRY-LEVEL INCOME: From 23 low- and middle-income countries, a longer mean time from injury to surgery (862.53 minutes, confidence interval [CI]: 107.42-1617.63), prehospital (217.46 minutes, CI: -27.34-462.25), and intrahospital (166.36 minutes, 95% CI: 96.12-236.60) durations were found compared to 22 high-income countries. BY WHO REGION: African Region had the greatest total (1062.3 minutes, CI: -1072.23-3196.62), prehospital (256.57 minutes [CI: -202.36-715.51]), and intrahospital durations (593.22 minutes, CI: -3546.45-4732.89). BY HEALTHCARE PAYMENT SYSTEM: Multiple-Payer Health Systems had a greater prehospital duration (132.62 minutes, CI: 54.55-210.68) but greater intrahospital delays were found in Single-Payer Health Systems (309.37 minutes, CI: -21.95-640.69). CONCLUSION: Our study concludes that TBI patients in low- and middle-income countries within African Region countries face prolonged delays in both prehospital and intrahospital management compared to high-income countries. Additionally, patients within Single-Payer Health System experienced prolonged intrahospital delays. An urgent need to address global disparities in neurotrauma care has been highlighted.

Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Scoping Review of the Workforce Challenges.

BACKGROUND: Brain tumors pose a significant threat to public health, with high rates of mortality and morbidity, affecting individuals of all ages and having a significant impact on healthcare systems. Limited neurosurgical workforces remain one of the critical problems experienced in low resource settings. OBJECTIVE: To explore and summarize the key challenges to neurosurgical care of brain tumors in terms of workforce in LMICs METHODS: A comprehensive literature search was conducted using Scopus, PubMed, CINAHL, and Google Scholar from inception to October 20, 2022. All extracted data was screened independently by two reviewers and thematically analyzed. RESULTS: We found and screened 3764 articles, of which 33 studies were included in our final analysis as per our inclusion criteria. Among the studies included, 33% highlighted the limited number of neurosurgeons, 39% emphasized the absence of specialized surgical teams, 7% pointed out a shortage of nursing staff, and 4% noted suboptimal anesthesia teams. The study uncovered the need for improved training programs in neuro-oncology (32%) and neuro-anesthesia (3%), as well as improved collaboration (32%) and multidisciplinary team structures (15%), are essential for tackling these workforce challenges and improving patient outcomes. CONCLUSION: It is crucial to implement targeted interventions and policy changes to address the barriers to the workforce in providing effective neurosurgical care to patients with brain tumors in developing countries. This might entail capacity building and training programs for healthcare professionals. Policymakers should consider allocating resources and funding for workforce development and making neurosurgical care a priority in healthcare plans.

Barriers to Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of the Service Delivery Challenges.

INTRODUCTION: Brain tumors pose a major challenge in low- and middle-income countries (LMICs) due to limited resources and high costs, resulting in hampered service delivery of neurosurgical care and significant disparities in patient outcomes compared to high-income nations. Therefore, our systematic review aims to identify barriers to service delivery in providing adequate surgical care for the management of brain tumors in LMICs. METHODS: We searched Scopus, PubMed, Google Scholar, and CINAHL, from inception to October 20, 2022. The data from the eligible studies were extracted and analyzed qualitatively. RESULTS: The final analysis included 35 articles, which highlighted significant challenges in providing adequate surgical care for brain tumors in LMICs. Among the cited studies, 10% reported lack of multidisciplinary team structures, 61% noted delayed patient presentation, 16% highlighted delays in neuroimaging, 10% reported delays in scheduling surgery, lack of training for specialized surgery (3%), lack of intra-operative facilities (19%), power supply interruption (6%), and lack of advanced diagnostic and specialized surgery facilities (19%). Strategies for addressing these challenges include cross-border collaboration (7%), public education, and awareness (13%), establishing multidisciplinary teams (20%), utilizing alternative surgical techniques (13%), 7% intraoperative ultrasound, 13% intraoperative cytology smear), and establishing satellite hospitals for low-risk care (7%), standard operating procedure and infection control (13%). CONCLUSION: Targeted interventions considering economic constraints are essential to improve the availability, affordability, and quality of neuro-oncologic services in developing countries. International collaborations and building capacity are vital for improving patient outcomes and service delivery, as well as forming multidisciplinary teams and utilizing resource-saving, innovative methods.

Follow-Up Care for Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of Existing Challenges and Strategies for the Future.

BACKGROUND AND OBJECTIVES: Brain tumors have a poor prognosis and a high death rate. Sufficient aftercare is necessary to enhance patient results. But follow-up care provision is fraught with difficulties in low- and middle-income countries (LMICs), where a variety of variables can impede access to care. Therefore, our systematic review aimed to identify challenges to follow-up care for brain tumors and possible solutions in LMICs. METHODS: A thorough search of the literature was performed from the beginning until October 20, 2022, using Google Scholar, PubMed, Scopus, and CINAHL. Studies focusing on the aftercare of brain tumors in LMICs met the inclusion criteria. Two reviewers used the National Surgical, Obstetric, and Anesthesia Plan categories to identify themes, extract relevant data, and evaluate individual articles. After being discovered, these themes were arranged in Microsoft Excel to make reporting and comprehension simpler. RESULTS: A total of 27 studies were included in the review. Among the studies included, the most frequently cited barriers to follow-up care were financial constraints (54%), long-distance travel (42%), and a lack of awareness about the importance of follow-up care (25%). Other challenges included preference for traditional or alternative medications (4%) and high treatment costs (8%). Proposed strategies included implementing mobile clinics (20%), establishing a documentation system (13%), and educating patients about the importance of follow-up care (7%). CONCLUSION: In LMICs, several issues pertaining to personnel, infrastructure, service delivery, financing, information management, and governance impede the provision of follow-up treatment for patients with brain tumors. As established by the suggested techniques found in the literature, addressing these issues will necessitate concurrent action by stakeholders, legislators, health ministries, and government agencies.