Tranexamic acid for patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of 2991 patients.

OBJECTIVE: We aimed to synthesize evidence from published clinical trials on the efficacy and safety of tranexamic acid (TXA) administration in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: We followed the standard methods of the Cochrane Handbook of Systematic Reviews for interventions and the PRISMA statement guidelines 2020 when conducting and reporting this study. A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted from inception until 1 January 2022. We selected observational studies and clinical trials comparing TXA versus no TXA in aSAH patients. Data of all outcomes were pooled as the risk ratio (RR) with the corresponding 95% confidence intervals in the meta-analysis models. RESULTS: Thirteen studies with a total of 2991 patients were included in the analysis. TXA could significantly cut the risk of rebleeding (RR 0.56, 95% CI 0.44 to 0.72) and mortality from rebleeding (RR 0.60, 95% CI 0.39 to 0.92, p = 0.02). However, TXA did not significantly improve the overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus (all p > 0.05). In terms of safety, no significant adverse events were reported. No statistical heterogeneity or publication bias was found in all outcomes. CONCLUSION: In patients with aSAH, TXA significantly reduces the incidence of rebleeding and mortality from rebleeding. However, current evidence does not support any benefits in overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus.

Towards zero infection for ventriculoperitoneal shunt insertion in resource-limited settings: a multicenter prospective cohort study.

INTRODUCTION: Shunting for hydrocephalus can lead to improvement in the quality of life although the latter has been subdued by complications like shunt infection. Established protocols have contributed to the reduction of ventriculoperitoneal shunt (VPS) infections. Previously, we retrospectively demonstrated a low infection rate despite some of the protocol recommendations not being implemented. The aim of this study was to prospectively establish the incidence of shunt infection in the early post-shunt period following our protocol and elucidate on associated risk factors. PATIENTS AND METHODS: A multicenter prospective descriptive cohort study of consecutive 209 under-5 children requiring VPS for hydrocephalus was conducted between January 2013 and November 2018. An innovative protocol insisting on intermittent application of povidone-iodine on the skin during the operation was implemented. The patients were followed-up for 3 months post-surgery. RESULTS: Included were 211 VPS procedures performed on 209 children. The median age was 9 months and 84 were males. Hydrocephalus was non-communicative in 72.0% and aqueductal stenosis was its most frequent cause (84.9%). Most surgeries were performed in the morning (90.5%), electively (95.3%), and for the first time (91%). The median duration of surgery was 65 min. Shunt infection rate was 1.9% (n = 4) (95% CI 0.7 to 5.0%) per procedure. CONCLUSION: The observed infection rate was low. This suggests that the protocol followed captured the most critical components necessary to ensure low infection rates and that simple measures implemented in economically challenged environments may achieve internationally acceptable infection rates.

Evidence-based neurosurgery. Basic concepts for the appraisal and application of scientific information to patient care (Part II).

Medical evidence is obtainable from approaches, which might be descriptive, analytic and integrative and ranked into levels of evidence, graded according to quality and summarized into strengths of recommendation. Sources of evidence range from expert opinions through well-randomized control trials to meta-analyses. The conscientious, explicit, and judicious use of current best evidence in making decisions related to the care of individual patients defines the concept of evidence-based neurosurgery (EBN). We reviewed reference books of clinical epidemiology, evidence-based practice and other previously related articles addressing principles of evidence-based practice in neurosurgery. Based on existing theories and models and our cumulative years of experience and expertise conducting research and promoting EBN, we have synthesized and presented a holistic overview of the concept of EBN. We have also underscored the importance of clinical research and its relationship to EBN. Useful electronic resources are provided. The concept of critical appraisal is introduced.

Essentials of research methods in neurosurgery and allied sciences for research, appraisal and application of scientific information to patient care (Part I).

Every neurosurgeon ought to be acquainted with the basics of research methods to enhance the comprehension of the research process and critical appraisal procedures of a scientific write-up. This in turn will ensure the appropriate application of scientific knowledge to patient care. Recent publications reveal that a significant proportion of articles published in neurosurgery are mislabeled with dire consequences on the sorting and indexing of evidence. Furthermore, many clinicians report that they feel unqualified to read the medical literature critically hence, it is for this reason that we conducted this review. Herein, we present a simple algorithm to facilitate the comprehension of research methods, as well as elucidate on the anatomy of common study designs in neurosurgery. Illustrative examples are provided when necessary. Understanding research methods and the critical analysis of published reports of clinical investigation is a fundamental skill of the physician to enable the incorporation of new clinical knowledge to practice.

Case series and descriptive cohort studies in neurosurgery: the confusion and solution.

BACKGROUND: Case series (CS) are well-known designs in contemporary use in neurosurgery but are sometimes used in contexts that are incompatible with their true meaning as defined by epidemiologists. This inconsistent, inappropriate and incorrect use, and mislabeling impairs the appropriate indexing and sorting of evidence. METHOD: Using PubMed, we systematically identified published articles that had "case series" in the "title" in 15 top-ranked neurosurgical journals from January 2008 to December 2012. The abstracts and/or full articles were scanned to identify those with descriptions of the principal method as being "case series" and then classified as "true case series" or "non-case series" by two independent investigators with 100 % inter-rater agreement. RESULTS: Sixty-four articles had the label "case series" in their "titles." Based on the definition of "case series" and our appraisal of the articles using Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, 18 articles (28.13 %) were true case series, while 46 (71.87 %) were mislabeled. Thirty-five articles (54.69 %) mistook retrospective (descriptive) cohorts for CS. CS are descriptive with an outcome-based sampling, while "descriptive cohorts" have an exposure-based sampling of patients, followed over time to assess outcome(s). A comparison group is not a defining feature of a cohort study and distinguishes descriptive from analytic cohorts. CONCLUSION: A distinction between a case report, case series, and descriptive cohorts is absolutely necessary to enable the appropriate indexing, sorting, and application of evidence. Researchers need better training in methods and terminology, and editors and reviewers should scrutinize more carefully manuscripts claiming to be "case series" studies.

Marburg Virus Outbreak in Equatorial Guinea: Need for Speed.

The co-existence of deadly viral pandemics can be considered a nightmare for public health authorities. The surge of a Marburg virus disease (MVD) outbreak in Africa at a time when the coronavirus-19 (COVID-19) pandemic is partially controlled with its limited resources is an urgent call for concern. Over the past decades, several bouts of MVD outbreaks have occurred in Africa with an alarming case fatality rate. Despite this, little has been done to end its recurrence, and affected countries essentially depend on preventative rather than curative measures of management. The recent outbreak of MVD declared by the health officials of Equatorial Guinea, causing several deaths in the context of the COVID-19 pandemic, signals the need for speed in the establishment and the implementation of appropriate health policies and health system strategies to contain, destroy, and prevent the spread of this deadly virus to other neighboring countries.

Reducing the Gap in Neurosurgical Education in LMICs: A Report of a Non-Profit Educational Program.

INTRODUCTION: Central to neurosurgical care, neurosurgical education is particularly needed in low- and middle-income countries (LMICs), where opportunities for neurosurgical training are limited due to social and economic constraints and an inadequate workforce. The present paper aims (1) to evaluate the validity and usability of a cadaver-free hybrid system in the context of LMICs and (2) to report their learning needs and whether the courses meet those needs via a comprehensive survey. METHODS: From April to November 2021, a non-profit initiative consisting of a series of innovative cadaver-free courses based on virtual and practical training was organized. This project emerged from a collaboration between the Young Neurosurgeons Forum of the World Federation of Neurological Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and UpSurgeOn, an Italian hi-tech company specialized in simulation technologies, creator of the UpSurgeOn Box, a hyper-realistic simulator of cranial approaches fused with augmented reality. Over that period, 11 cadaver-free courses were held in LMICs using remote hands-on Box simulators. RESULTS: One hundred sixty-eight participants completed an online survey after course completion of the course. The anatomical accuracy of simulators was overall rated high by the participant. The simulator provided a challenging but manageable learning curve, and 86% of participants found the Box to be very intuitive to use. When asked if the sequence of mental training (app), hybrid training (Augmented Reality), and manual training (the Box) was an effective method of training to fill the gap between theoretical knowledge and practice on a real patient/cadaver, 83% of participants agreed. Overall, the hands-on activities on the simulators have been satisfactory, as well as the integration between physical and digital simulation. CONCLUSIONS: This project demonstrated that a cadaver-free hybrid (virtual/hands-on) training system could potentially participate in accelerating the learning curve of neurosurgical residents, especially in the setting of limited training possibilities such as LMICs, which were only worsened during the COVID-19 pandemic.

Authorship Disparities in International Neurosurgical Research Collaborations: A Bibliometric Analysis.

BACKGROUND: Research is pivotal to neurosurgical training and practice. The objectives of this study were to quantify neurosurgical research output by authors from low-income countries (LICs), using author affiliation as a proxy, and to understand the patterns of collaboration between LIC authors and their international partners. METHODS: PubMed, CINAHL, and EMBASE were searched for neurosurgical literature published by authors from the 27 World Bank LICs from 2010 to 2020. These articles were screened for relevance. Information about publication type, study design, and author demographics was then extracted from included articles. Scopus was subsequently used to determine the H-indices of the authors. RESULTS: The rate at which LIC authors have been publishing neurosurgical research has increased significantly from 2010 to 2020. Overall, 19 of the 27 LICs were represented. The LICs with the most research output includes Uganda, Ethiopia, and Rwanda. When LIC authors collaborated with authors from middle-or-high-income countries, these LIC researchers were solely listed in a middle authorship position more than 70% of the time. On average, the H-index of LIC authors was 4.9, compared with average H-indices of 8.7 and 16.8 for their MIC and HIC collaborators, respectively. CONCLUSIONS: The positioning of LIC researchers as middle author contributors revealed significant authorship disparities in international neurosurgical research collaborations. The average H-indices of authors from middle-or-high-income countries were more than 3 times greater than those of LIC authors. Quantifying this issue allows neurosurgical organizations to understand the current landscape and to set concrete goals for research capacity building in LICs.

Variation in postoperative outcomes of patients with intracranial tumors: insights from a prospective international cohort study during the COVID-19 pandemic.

BACKGROUND: This study assessed the international variation in surgical neuro-oncology practice and 30-day outcomes of patients who had surgery for an intracranial tumor during the COVID-19 pandemic. METHODS: We prospectively included adults aged ≥18 years who underwent surgery for a malignant or benign intracranial tumor across 55 international hospitals from 26 countries. Each participating hospital recorded cases for 3 consecutive months from the start of the pandemic. We categorized patients' location by World Bank income groups (high [HIC], upper-middle [UMIC], and low- and lower-middle [LLMIC]). Main outcomes were a change from routine management, SARS-CoV-2 infection, and 30-day mortality. We used a Bayesian multilevel logistic regression stratified by hospitals and adjusted for key confounders to estimate the association between income groups and mortality. RESULTS: Among 1016 patients, the number of patients in each income group was 765 (75.3%) in HIC, 142 (14.0%) in UMIC, and 109 (10.7%) in LLMIC. The management of 200 (19.8%) patients changed from usual care, most commonly delayed surgery. Within 30 days after surgery, 14 (1.4%) patients had a COVID-19 diagnosis and 39 (3.8%) patients died. In the multivariable model, LLMIC was associated with increased mortality (odds ratio 2.83, 95% credible interval 1.37-5.74) compared to HIC. CONCLUSIONS: The first wave of the pandemic had a significant impact on surgical decision-making. While the incidence of SARS-CoV-2 infection within 30 days after surgery was low, there was a disparity in mortality between countries and this warrants further examination to identify any modifiable factors.

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.

Gender Differences in Perceptions and Attitudes of Medical Students Toward Neurosurgery: A German Nationwide Survey.

BACKGROUND: Despite advances in gender equity, the paucity of women neurosurgeons remains. In Germany, women accounted for only 24% of the specialists who completed their neurosurgical training in 2019. We sought to explore the perceptions of medical students in Germany toward a neurosurgical career, focusing on gender-specific differences. METHODS: A digital 26-item questionnaire with a Likert 4-point scale and open-ended questions was distributed to the German medical school student bodies. Data were analyzed to determine statistically significant intragroup variability between women and men. RESULTS: Two hundred ten medical students participated in the survey. Women and men were equally interested in brain pathologies (38% vs. 47%, strongly agreed), whereas interest in neurosurgery was significantly greater in men (12% vs. 26%, strongly agreed). Men were less likely to believe that women neurosurgery residents would face inequality at work. They were also less likely to support a gender quota in neurosurgery. Yet, both women and men were convinced that a rise in the number of women would positively impact the field. No gender dependency was seen in students' strive for success and prestige. Men felt discouraged from pursuing neurosurgery because they feared an unpleasant work environment, whereas women were concerned about neurosurgery not being family-friendly. Regardless of gender, the greatest factor deterring students from neurosurgery was poor work-life balance. CONCLUSIONS: Awareness must be raised concerning gender inequity and discrimination in our specialty. A multifaceted approach is imperative to develop neurosurgery into a profession where gender no longer hinders access to training and success in the field.

The Value and Potential of Qualitative Research Methods in Neurosurgery.

OBJECTIVE: To explore the value and potential of qualitative research to neurosurgery and provide insight and understanding to this underused methodology. METHODS: The definition of qualitative research is critically discussed and the heterogeneity within this field of inquiry explored. The value of qualitative research to the field of neurosurgery is articulated through its contribution to understanding complex clinical problems. DISCUSSION: To resolve some of the misunderstanding of qualitative research, this paper discusses research design choices. We explore approaches that use qualitative techniques but are not, necessarily, situated within a qualitative paradigm in addition to how qualitative research philosophy aids researchers to conduct interpretive inquiry that can reveal more than simply what was said by participants. Common research designs associated with qualitative inquiry are introduced, and how complex analysis may contribute more in-depth insights is explained. Approaches to quality are discussed briefly to support improvements in qualitative methods and qualitative manuscripts. Finally, we consider the future of qualitative research in neurosurgery, and suggest how to move forward in the qualitative neurosurgical evidence base. CONCLUSIONS: There is enormous potential for qualitative research to contribute to the advancement of person-centered care within neurosurgery. There are signs that more qualitative research is being conducted and that neurosurgical journals are increasingly open to this methodology. While studies that do not engage fully within the qualitative paradigm can make important contributions to the evidence base, due regard should be given to immersive inquiry within qualitative paradigms to allow complex, in-depth, investigations of the human experience.

More Laboratory Simulations-Fewer Brain Complications: Prospects from the First Neurosurgery Laboratory in Iraq.

BACKGROUND: The intensive training requirements needed to achieve the requisiste microneurosurgical milestones makes proper training and skill acquisition a challenge to the novice neurosurgeon. This problem is compounded in low- and middle-income nations, where neurosurgery is subject to a myriad of human and financial resource constraints. A temporary solution may be provided by low-cost laboratories that are adaptive to local needs. METHODS: The "HOZ NeuroSurgery LAB" is a nonprofit facility dedicated to microneurosurgery education and skills training. The laboratory, established in June 2015, is housed at the Neurosurgery Teaching Hospital in Baghdad, Iraq. It operates under the motto "More Laboratory Simulation-Fewer Brain Complications.". The fundamental infrastructure of the facility consists of a relatively inexpensive microscope, indigenous locally created training equipment, and animal-based models. RESULTS: Since its inception, this lab has functioned as a hub for resident education and microneurosurgery service, in addition to contributing to the specialty's academic output in the nation. The lab is directly responsible for training 4 vascular neurosurgeons who are currently directing the nation's first organized neurovascular service. Also, it has delivered 53 microneurosurgery skills courses, coordinated 8 student neurosurgery elective cycles with a total of 532 participants, and published approximately 70 research articles. CONCLUSIONS: Our experience may serve as a model for other low- and middle-income countries interested in using the principle of "doing more with less" to overcome some of the challenges associated with microneurosurgery in these parts of the world.

Neurotrauma clinicians' perspectives on the contextual challenges associated with traumatic brain injury follow up in low-income and middle-income countries: A reflexive thematic analysis.

BACKGROUND: Traumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified. OBJECTIVE: To explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings. METHODS: A cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke's six-stage Reflexive Thematic Analysis. RESULTS: 18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do? CONCLUSION: The collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.

COVID-19 and Autoimmune Diseases: A Systematic Review of Reported Cases.

INTRODUCTION: Over 4.9 million cases of Coronavirus disease 2019 (COVID-19) have been confirmed since the worldwide pandemic began. Since the emergence of COVID-19, a number of confirmed cases reported autoimmune manifestations. Herein, we reviewed the reported COVID-19 cases with associated autoimmune manifestations. METHODS: We searched PubMed database using all available keywords for COVID-19. All related studies between January 1st, 2020 to May 22nd, 2020 were reviewed. Only studies published in English language were considered. Articles were screened based on titles and abstracts. All reports of confirmed COVID-19 patients who have associated clinical evidence of autoimmune disease were selected. RESULTS: Among the 10006 articles, searches yielded thirty-two relevant articles for full-text assessment. Twenty studies has met the eligibility criteria. The twenty eligible articles reported 33 cases of confirmed COVID-19 diagnosis who developed an autoimmune disease after the onset of covid-19 symptoms. Ages of patients varied from a 6 months old infant to 89 years old female (Mean=53.9 years of 28 cases); five cases had no information regarding their age. The time between symptoms of viral illness and onset of autoimmune symptoms ranged from 2 days to 33 days (Mean of the 33 cases=9.8 days). Autoimmune diseases were one case of subacute thyroiditis (3%), two cases of Kawasaki Disease (6.1%), three cases of coagulopathy and antiphospholipid syndrome (9.1%), three cases of immune thrombocytopenic purpura (9.1%), eight cases of autoimmune hemolytic anemia (24.2%), and sixteen cases of Guillain-Barré syndrome (48.5%). CONCLUSION: COVID-19 has been implicated in the development of a range of autoimmune diseases, which may shed light on the association between autoimmune diseases and infections.

PubMed-indexed neurosurgical research productivity of Iraq-based neurosurgeons.

BACKGROUND: Research is a central component of neurosurgical training and practice and is increasingly viewed as a quintessential indicator of academic productivity. In this study, we focus on identifying the current status and challenges of neurosurgical research in Iraq. METHODS: An online PubMed Medline database search was conducted to identify all articles published by Iraq-based neurosurgeons between 2003 and 2020. Information was extracted in relation to the following parameters: authors, year of publication, author's affiliation, author's specialty, article type, article citation, journal name, journal impact factor, and topic. This data were then tabulated and analyzed. RESULTS: Between 2003 and 2021, a total of 52 PubMed indexed papers were published from Iraq. All publications have been clustered in the period of 2012-2020. From 2012 to 2016, only four papers were published, one per year. The number of publications increased from 2017 to 2021, with an average of 12 publications per year. The most common article type was "case reports" (n = 14). Neurotrauma (n = 10) and vascular neurosurgery (n = 10) were the two most common topics. Most of the studies came from the city of Bagdad (n = 46), with just nine studies coming from peripheral governorates. The Neurosurgery Teaching Hospital in Bagdad was the neurosurgery center with the highest research output (n = 38). CONCLUSION: The number of publications per year has been showing a, relatively, promising trend since 2012. However, to promote sustained growth in academic productivity, a strategic plan that acknowledges the political, financial, and health-system-related challenges are urgently needed.

Neurosurgeons' experiences of conducting and disseminating clinical research in low-income and middle-income countries: a reflexive thematic analysis.

OBJECTIVES: Low-income and-middle-income countries (LMICs) are increasing investment in research and development, yet there remains a paucity of neurotrauma research published by those in LMICs. The aim of this study was to understand neurosurgeons' experiences of, aspirations for, and ability to conduct and disseminate clinical research in LMICs. DESIGN: This was a two-stage inductive qualitative study situated within the naturalistic paradigm. This study committed to an interpretivist way of knowing (epistemology), and considered reality subjective and multiple (ontology). Data collection used online methods and included a web-based survey tool for demographic data, an asynchronous online focus group and follow-up semistructured interviews. Data were analysed using Braun and Clarke's Reflexive Thematic Analysis supported by NVivo V.12. SETTING: LMICs. PARTICIPANTS: In April-July 2020, 26 neurosurgeons from 11 LMICs participated in this study (n=24 in the focus groups, n=20 in follow-up interviews). RESULTS: The analysis gave rise to five themes: The local landscape; creating capacity; reach and impact; collaborative inquiry; growth and sustainability. Each theme contained an inhibitor and stimulus to neurosurgeons conducting and disseminating clinical research, interpreted as 'the neurosurgical research potential in LMICs'. Mentorship, education, infrastructure, impact and engagement were identified as specific accelerators. Whereas lack of generalisability, absence of dissemination and dissemination without peer review may desensitise the impact of research conducted by neurosurgeons. CONCLUSION: The geographical, political and population complexities make research endeavour challenging for neurosurgeons in LMICs. Yet in spite of, and because of, these complexities LMICs provide rich opportunities to advance global neurosurgery. More studies are required to evaluate the specific effects of accelerators of research conducted by neurosurgeons and to understand the effects of desensitisers on high-quality, high-impact clinical research.

Identifying Barriers and Facilitators to the Improvement of Healthcare Delivery and Ethics in Two Cameroonian Neurosurgical Centers.

BACKGROUND: Low-and middle-income countries (LMICs) are disproportionately affected by neurosurgical burden of disease. This health inequity causes constraints in decision-making. Neurosurgical ethics helps us to assess the moral acceptability and effectiveness of clinical decisions. We aimed to assess ethical neurosurgical care and its effect on patient satisfaction in Cameroon. METHODS: Two questionnaires hosted on Google Forms were administered among inpatients and staff at two Cameroonian neurosurgery centers. The questionnaires covered the factors influencing health outcomes and ethics. Data were collected from November 11, 2020, to March 11, 2021 and analyzed with SPSS v 26 to generate non-parametric tests with a threshold of significance at 0.05. RESULTS: Seventy patients and twenty healthcare providers responded to the survey. Most patients faced financial hardship (57.1%; 95% CI = 45.7-68.6%), and felt that this affected the care they received (P = 0.02). Patients noticed changes in the care plan and care delivery attributable to the neurosurgical units' lack of resources. According to the patients and caregivers, these changes happened 31.0-50.0% of the time (42.9%, 95% CI = 5.7-21.4%). The majority of patients were pleased with their involvement in the decision-making process (58.6%; 95% CI = 47.1-70.0%) and felt their autonomy was respected (87.1%; 95% CI = 78.6-94.3%). CONCLUSION: Multiple challenges to neurosurgical ethical care were seen in our study. Multimodal interventions based on the four ethical principles discussed are necessary to improve ethical neurosurgical decision-making in this low resource setting.

Neurotrauma clinicians' perspectives on the contextual challenges associated with long-term follow-up following traumatic brain injury in low-income and middle-income countries: a qualitative study protocol.

INTRODUCTION: Traumatic brain injury (TBI) is a global public health concern; however, low/middle-income countries (LMICs) face the greatest burden. The WHO recognises the significant differences between patient outcomes following injuries in high-income countries versus those in LMICs. Outcome data are not reliably recorded in LMICs and despite improved injury surveillance data, data on disability and long-term functional outcomes remain poorly recorded. Therefore, the full picture of outcome post-TBI in LMICs is largely unknown. METHODS AND ANALYSIS: This is a cross-sectional pragmatic qualitative study using individual semistructured interviews with clinicians who have experience of neurotrauma in LMICs. The aim of this study is to understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs. For the purpose of the study, we define 'long-term' as any data collected following discharge from hospital. We aim to conduct individual semistructured interviews with 24-48 neurosurgeons, beginning February 2020. Interviews will be recorded and transcribed verbatim. A reflexive thematic analysis will be conducted supported by NVivo software. ETHICS AND DISSEMINATION: The University of Cambridge Psychology Research Ethics Committee approved this study in February 2020. Ethical issues within this study include consent, confidentiality and anonymity, and data protection. Participants will provide informed consent and their contributions will be kept confidential. Participants will be free to withdraw at any time without penalty; however, their interview data can only be withdrawn up to 1 week after data collection. Findings generated from the study will be shared with relevant stakeholders such as the World Federation of Neurosurgical Societies and disseminated in conference presentations and journal publications.

The Impact of COVID-19 on Neurosurgical Services in Africa.

INTRODUCTION: COVID-19 has affected the global provision of neurosurgical services. We sought to review the impact of COVID-19 on the neurosurgical services in Africa. METHODS: A cross-sectional survey was distributed to African neurosurgeons seeking to review demographics, national and neurosurgical preparedness, and change in clinical services in April 2020. RESULTS: A total of 316 responses from 42 countries were received. Of these, 81.6% of respondents were male and 79.11% were under the age of 45 years. In our sample, 123 (38.92%) respondents were in training. Most (94.3%) respondents stated they had COVID-19 cases reported in their country as of April 2020. Only 31 (41.50%) had received training on managing COVID-19. A total of 173 (54.70%) respondents were not performing elective surgery. There was a deficit in the provision of personal protective equipment (PPE): surgical masks (90.80%), gloves (84.80%), N95 masks (50.80%), and shoe covers (49.10%). Health ministry (80.40%), World Health Organization (74.50%), and journal papers (41.40%) were the most common sources of information on COVID-19. A total of 43.60% had a neurosurgeon in the COVID-19 preparedness team; 59.8% were concerned they may contract COVID-19 at work with a further 25.90% worried they may infect their family. Mental stress as a result of COVID-19 was reported by 14.20% of respondents. As of April 2020, 73.40% had no change in their income. CONCLUSIONS: Most African countries have a national COVID-19 policy response plan that is not always fully suited to the local neurosurgery services. There is an ongoing need for PPE and training for COVID-19 preparedness. There has been a reduction in clinical activities both in clinic and surgeries undertaken.