The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model.

OBJECTIVE: The objective of this study was to describe the experience of a volunteering neurosurgeon during an 18-week stay at the Neurosurgery Education and Development (NED) Institute and to report the general situation regarding the development of neurosurgery in Zanzibar, identifying the challenges and opportunities and explaining the NED Foundation's model for safe practice and sustainability. METHODS: The NED Foundation deployed the volunteer neurosurgeon coordinator (NC) for an 18-week stay at the NED Institute at the Mnazi Mmoja Hospital, Stonetown, Zanzibar. The main roles of the NC were as follows: management of patients, reinforcement of weekly academic activities, coordination of international surgical camps, and identification of opportunities for improvement. The improvement opportunities were categorized as clinical, administrative, and sociocultural and were based on observations made by the NC as well as on interviews with local doctors, administrators, and government officials. RESULTS: During the 18-week period, the NC visited 460 patients and performed 85 surgical procedures. Four surgical camps were coordinated on-site. Academic activities were conducted weekly. The most significant challenges encountered were an intense workload, deficient infrastructure, lack of self-confidence among local physicians, deficiencies in technical support and repairs of broken equipment, and lack of guidelines. Through a series of interviews, the sociocultural factors influencing the NED Foundation's intervention were determined. Factors identified for success were the activity of neurosurgical societies in East Africa; structured pan-African neurosurgical training; the support of the Foundation for International Education in Neurological Surgery (FIENS) and the College of Surgeons of East, Central and Southern Africa (COSECSA); motivated personnel; and the Revolutionary Government of Zanzibar's willingness to collaborate with the NED Foundation. CONCLUSIONS: International collaboration programs should balance local challenges and opportunities in order to effectively promote the development of neurosurgery in East Africa. Support and endorsement should be sought to harness shared resources and experience. Determining the caregiving and educational objectives within the logistic, administrative, social, and cultural framework of the target hospital is paramount to success.

The NED foundation experience: A model of global neurosurgery.

Introduction: The Neurosurgery Education and Development (NED) Foundation (NEDF) started the development of local neurosurgical practice in Zanzibar (Tanzania) in 2008. More than a decade later, multiple actions with humanitarian purposes have significantly improved neurosurgical practice and education for physicians and nurses. Research question: To what extent could comprehensive interventions (beyond treating patients) be effective in developing global neurosurgery from the outset in low and middle-income countries? Material and method: A retrospective review of a 14- year period (2008-2022) of NEDF activities highlighting landmarks, projects, and evolving collaborations in Zanzibar was carried out. We propose a particular model, the NEDF model, with interventions in the field of health cooperation that have simultaneously aimed to equip, treat, and educate in a stepwise manner. Results: 138 neurosurgical missions with 248 NED volunteers have been reported. In the NED Institute, between Nov 2014-Nov 2022, 29635 patients were seen in the outpatient clinics and 1985 surgical procedures were performed. During the course of NEDF's projects, we have identified three different levels of complexity (1, 2 and 3) that include the areas of equipment ("equip"), healthcare ("treat") and training ("educate"), facilitating an increase of autonomy throughout the process. Discussion and Conclusion: In the NEDF's model, the interventions required in each action area (ETE) are coherent for each level of development (1, 2 and 3). When applied simultaneously, they have a greater impact. We believe the model can be equally useful for the development of other medical and/or surgical specialties in other low-resource healthcare settings.

Experience in the Early Surgical Management of Myelomeningocele in Zanzibar.

BACKGROUND: Neural tube defects are a large health burden for East African countries. Health strategies in the prevention of this disease include nutritional prophylaxis, prenatal diagnosis, and availability of early neonatal neurosurgery. The main objective of this study is to describe our experience in the early surgical management of neural tube defects in the Zanzibar archipelago. METHODS: From December 2016 to December 2017, we prospectively collected data on all patients admitted with the diagnosis of myelomeningocele. We collected variables regarding demographics, maternal health, preoperative imaging, surgical procedures, and complications at follow-up. RESULTS: We collected data on 19 patients. Mean age was 9.8 ± 18.7 days. Of these patients, 52.6% were male and 47.3% were female; 47.3% patients were from Unguja, 42.0% from Pemba, and 5.2% from mainland Tanzania; 68.4% of all mothers were found to have undergone prenatal ultrasonography and 89.5% of all patients received surgery. Surgical wound infection was present in 29.4% of all surgical patients and 52.9% developed secondary hydrocephalus. CONCLUSIONS: Neural tube defects are a prevailing condition in East Africa. We believe that more health initiatives should address its prevention, mainly through maternal nutrition. On the basis of our findings, we consider early neonatal neurosurgery as the most important factor in reducing immediate morbidity and mortality.

Treating Pediatric Hydrocephalus at the Neurosurgery Education and Development Institute: The Reality in the Zanzibar Archipelago, Tanzania.

BACKGROUND: Pediatric hydrocephalus is a health burden for East African countries, with an estimated incidence of 6000 new cases per year. The objective of this study is to describe the epidemiology and surgical outcomes of patients treated for pediatric hydrocephalus in the single neurosurgical center of Zanzibar. METHODS: From December 2016 to December 2017, we prospectively collected data on all patients admitted with the diagnosis of hydrocephalus. Information was gathered regarding demographics, maternal health, preoperative imaging, surgical procedures, and postsurgical complications. RESULTS: We collected data on 63 patients. Average age was 203 days, and gender was 49.2% female and 50.8% male. All mothers of patients attended an antenatal clinic for routine screening during pregnancy. Folic acid prophylaxis was used by 9.5% of the mothers during pregnancy. At the first visit, 46.0% of patients presented with signs of infection, 20.6% with congenital abnormalities, and 20.6% with seizures. Regarding etiology of hydrocephalus, 22.2% of all cases were uncertain; 20.6% were associated with neural tube defects; 39.7% were postinfectious hydrocephalus; 3.2% were aqueduct stenosis; 4.8% were associated with brain tumor; and 9.6% were malformative. We performed 7 endoscopic third ventriculostomies and placed 40 ventriculoperitoneal shunts. The complication rate at follow-up was 12.5%. CONCLUSIONS: It seems that hydrocephalus in Zanzibar has similar causes, progression, and complication rates to previous reports from other African hospitals. Further studies of postinfectious hydrocephalus need to be conducted because recent findings suggest that it is a potentially preventable cause of the disease.

The ponticulus posticus: implications for screw insertion into the first cervical lateral mass.

BACKGROUND: The arcuate foramen is an important osseous anomaly of the first cervical vertebra (the atlas) that must be taken into consideration during placement of lateral mass screws into the atlas. METHODS: The prevalence of this anomaly in our patient population was determined through a retrospective review of 464 lateral radiographs of the neck. The anatomy of the arcuate foramen was identified in a study of cadavers. RESULTS: Seventy-two arcuate foramina, complete or incomplete, were identified on the 464 lateral radiographs of the neck; thus, the prevalence was 15.5% in our patient population. CONCLUSIONS: Although the arcuate foramen is a common anomaly, it is often not recognized. Proper identification of this anomaly on preoperative lateral radiographs should alert the surgeon to avoid using the ponticulus posticus as a starting point for a lateral mass screw in order to not injure the vertebral artery.

Meningioma associated with abscess formation--a case report.

A rare case of meningioma associated with both intratumoral and peritumoral abscess formation occurred in a 38-year-old man presenting with signs and symptoms of elevated intracranial pressure, intracranial infection, and right temporal pole mass lesion. The mass lesion was totally removed, revealing a meningioma. Group B streptococcus and peptostreptococcus were cultured from both the tumor and peritumoral white matter. Hematogenous spread of the organisms related to recent dental work was the likely mechanism.

Degenerative disc disease in childhood and adolescence.

Degenerative disk disease (DDD) is a common cause of low back pain and leg pain in children and infants. DDD is often unrecognized and under-diagnosed. This paper presents six cases of DDD in children and discusses the clinical presentation and pathophysiology of DDD.

Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training.

OBJECT A shortage of neurosurgeons and a lack of knowledge of neuroendoscopic management of hydrocephalus limits modern care in sub-Saharan Africa. Hence, a mobile teaching project for endoscopic third ventriculostomy (ETV) procedures and a subsequent program to develop neurosurgery as a permanent specialty in Kenya and Zanzibar were created and sponsored by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery. The objective of this work was to evaluate the results of surgical training and medical care in both projects from 2006 to 2013. METHODS Two portable neuroendoscopy systems were purchased and a total of 38 ETV workshops were organized in 21 hospitals in 7 different countries. Additionally, 49 medical expeditions were dispatched to the Coast General Hospital in Mombasa, Kenya, and to the Mnazi Moja Hospital in Zanzibar. RESULTS From the first project, a total of 376 infants with hydrocephalus received surgery. Six-month follow-up was achieved in 22%. In those who received follow-up, ETV efficacy was 51%. The best success rates were achieved with patients 1 year of age or older with aqueductal stenosis (73%). The main causes of hydrocephalus were infection (56%) and spina bifida (23%). The mobile education program interacted with 72 local surgeons and 122 nurses who were trained in ETV procedures. The second project involved 49 volunteer neurosurgeons who performed a total of 360 nonhydrocephalus neurosurgical operations since 2009. Furthermore, an agreement with the local government was signed to create the Mnazi Mmoja NED Institute in Zanzibar. CONCLUSIONS Mobile endoscopic treatment of hydrocephalus in East Africa results in reasonable success rates and has also led to major developments in medicine, particularly in the development of neurosurgery specialty care sites.

Skull base surgery in a large, resource-poor, developing country with few neurosurgeons: prospects, challenges, and needs.

BACKGROUND: Upon returning home to Nigeria from postresidency fellowship training in skull base surgery, using expertise gained overseas, we applied appropriate treatment to various skull base pathologies. This is an audit of our initial experience. METHODS: This is a prospective, descriptive survey of all the skull base pathologies operated on during 30 months. Clinical-demographic data, surgical procedures, and the postoperative outcome are presented statistically. Simple inferential statistics was performed for associations deemed significant at P≤0.05. RESULTS: Fifty-one individuals (27 men and 24 women, mean age 32 years) were operated on for skull base pathologies. Clinical presentation had a mean symptom duration of 22 months and a poor clinical status in more than 60% of the patients. Congenital, infective, traumatic, and neoplastic lesions were encountered, including craniofacial malignancies operated on jointly with other craniofacial surgeons. Other intracranial neurosurgical pathologies like jugular foramen and brain stem tumors, and meningiomas of various skull base corridors, including the cavernous sinus and the foramen magnum, were encountered. Our skull base dissections were craniofacial in 23.5% of cases, anterolateral in 33.3%, midbasal in 15.7%, and posterior fossa in 27.5% of patients. Surgery was successful in 86.3%. The patients' status improved on hospital discharge in 70.6% of cases. The postoperative outcome was significantly worse (P=0.03) in those patients with postbasal lesions with poor clinical performance index preoperatively. CONCLUSIONS: In spite of the many inherent challenges of a typical developing country health system, there are great prospects for skull base surgical practice in Nigerian neurological surgery.

Anti-diabetic properties of three common Bidens pilosa variants in Taiwan.

Bidens pilosa L. var. radiata (BPR), B. pilosa L. var. pilosa (BPP), and B. pilosa L. var. minor (BPM) are common variants of a plant often used as a folk remedy for diabetes in Taiwan. However, the three variants are often misidentified and little is known about their relative anti-diabetic efficacy and chemical composition. In this paper, we have first developed a method based on GC-MS and cluster analysis with visualization to assist in rapidly determining the taxonomy of these three Bidens variants. GC-MS was used to determine the chemical compositions of supercritical extracts, and differences and similarities in the variants were determined by hierarchical cluster analysis. Next, the HPLC profiles of the methanol crude extracts in the Bidens plants and evaluated anti-diabetic effects of methanol crude extracts were compared, as well as three polyacetylenic compounds of the Bidens plants using db/db mice. Single-dose and long-term experiments showed that the BPR extract had higher glucose-lowering and insulin-releasing activities than extracts from the other two variants, and that cytopiloyne was the most effective pure compound among the three polyacetylenic compounds. BPR extract and cytopiloyne also significantly reduced the percentage of the glycosylated hemoglobin A1c in db/db mice. Besides, both animal studies and HPLC analysis demonstrated a good correlation between anti-diabetic efficacy of the Bidens extracts and the particular polyacetylenes present.

Impacto de la neuroendoscopia móvil en el desarrollo de la neurocirugía en África. Un modelo original español / Impact of mobile neuroendoscopy in the development of neurosurgery in Africa. An original Spanish model

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