Surgical care and trauma patients capacity in Piura, Perú - Cross-sectional study.

Introduction: Low and medium income countries face challenges in access and delivery of surgical care, resulting in a high number of deaths and disabled individuals. Objective: To estimate the capacity to provide surgical and trauma care in public hospitals in the Piura region, Perú, a middle income country. Methods: A survey was administered in public hospitals in the Peruvian region of Piura, which combined the Spanish versions of the PIPES and INTACT surveys, and the WHO situational analysis tool. The extent of the event was assessed based in the absolute differences between the medians of the scores estimated, and the Mann-Whitney bilateral tests, according to the geographical location and the level of hospital complexity. Results: Seven public hospitals that perform surgeries in the Piura region were assessed. Three provinces (3/8) did not have any complexity healthcare institutions. The average hospital in the peripheral provinces tended to be smaller than in the capital province in INTACT (8.25 vs. 9.5, p = 0.04). Additionally, water supply issues were identified (2/7), lack of incinerator (3/7), lack of uninterrupted availability of a CT-scanner (5/7) and problems with working hours; in other words, the blood banks in two hospitals were not open 24 hours. Conclusions: There is a significant inequality among the provinces in the region in terms of their trauma care capacities and several shortfalls in the public sector healthcare infrastructure. This information is required to conduct future research on capacity measurements in every public and private institution in the Peruvian region of Piura.

Introducción: Los países de ingresos bajos y medianos tienen problemas en el acceso y la provisión de atención quirúrgica, lo cual ocasiona un alto número de fallecimientos y de personas con discapacidad. Objetivo: Estimar la capacidad para la atención quirúrgica y de pacientes traumatizados en los hospitales públicos en la región de Piura, Perú, un país de ingreso mediano. Métodos: En los hospitales públicos de la región peruana de Piura se aplicó una encuesta que combinaba las versiones en español de las encuestas PIPES e INTACT y de la herramienta de análisis situacional de la Organizacion Mundial de la Salud (OMS). Se evaluó la magnitud del evento mediante las diferencias absolutas entre las medianas de los puntajes calculados y pruebas bilaterales de Mann-Whitney según la ubicación geográfica y el nivel de complejidad hospitalaria. Resultados: Se evaluaron siete hospitales públicos que realizan cirugía en la región de Piura. Tres provincias (3/8) no contaban con instituciones sanitarias con complejidad de hospital. La mediana de los hospitales de las provincias periféricas tuvo tendencia a ser menor que la de la provincia capital en la INTACT (8,25 vs. 9,5, p = 0,04). Asimismo, se hallaron problemas de abastecimiento de agua (2/7), ausencia de incinerador (3/7), falta de funcionamiento permanente de tomógrafo (5/7) y problemas con el horario de funcionamiento de los bancos de sangre, ya que no funcionaban las 24 horas del día en 2 hospitales (2/7). Conclusiones: Se describe la alta desigualdad entre las provincias de la región en la capacidad de atención de trauma y varias carencias en la infraestructura sanitaria del sector público. Esta información es necesaria para desarrollar futura investigación de medición de capacidades en todos los establecimientos públicos y privados de la región peruana de Piura.

The impact of voluntary folate fortification of corn masa flour on US pregnancies complicated by neural tube defects.

INTRODUCTION: In 1996, the US Food and Drug Administration (FDA) mandated folic acid fortification for all enriched cereal grains. This resulted in a reduction of neural tube defect (NTD)-affected pregnancies. However, Hispanic women continued to be twice as likely to give birth to a child affected by NTD compared to non-Hispanic White women. Some hypotheses explaining this difference focus on cultural variation in dietary intake of cereal grains. In 2016, the FDA approved voluntary folic acid fortification for corn masa flour products to focus on the Hispanic diet staple. This study investigates rates of NTDs in predominantly Hispanic-populated zip codes before and after the voluntary fortification of corn masa flour with folic acid. METHODS: Normal pregnancies and those complicated by NTDs between 1/1/2016 and 9/30/2020 were identified using ICD-9 and ICD-10 codes in an all-payor claims database. The post-fortification period began 12 months after the fortification recommendation. The US Census data was used to stratify pregnancies in predominantly Hispanic zip codes (≥ 75% of households) vs. non-Hispanic zip codes. The causal impact of the FDA's recommendation was assessed by means of a Bayesian structural time series model. RESULTS: A total of 2,584,366 pregnancies were identified among females aged 15-50 years. Of these, 365,983 took place in predominantly Hispanic zip codes. Mean quarterly NTDs per 100,000 pregnancies did not significantly differ between predominantly Hispanic zip codes and predominantly non-Hispanic zip codes pre-FDA recommendation (184.5 vs. 175.6; p = 0.427), nor post-recommendation (188.2 vs. 185.9; p = 0.713). Rates of NTDs predicted to occur if no FDA recommendation had been made were compared to the actual rate post-recommendation: no significant difference was observed in predominantly Hispanic zip codes (p = 0.245) or overall (p = 0.116). CONCLUSIONS: Rates of neural tube defects were not significantly reduced in predominantly Hispanic zip codes following the 2016 FDA approval of voluntary folic acid fortification of corn masa flour. Further research and implementation of comprehensive approaches to advocacy, policy, and public health are necessary to decrease preventable congenital disease rates. Mandatory rather than voluntary fortification of corn masa flour products may achieve more substantial prevention of neural tube defects in at-risk US populations.

Global Neurosurgery: Progress and Resolutions at the 75th World Health Assembly.

Neurosurgical advocates for global surgery/neurosurgery at the 75th World Health Assembly gathered in person for the first time after the COVID-19 pandemic in Geneva, Switzerland, in May 2022. This article reviews the significant progress in the global health landscape targeting neglected neurosurgical patients, emphasizing high-level policy advocacy and international efforts to support a new World Health Assembly resolution in mandatory folic acid fortification to prevent neural tube defects. The process of developing global resolutions through the World Health Organization and its member states is summarized. Two new global initiatives focused on the surgical patients among the most vulnerable member states are discussed, the Global Surgery Foundation and the Global Action Plan on Epilepsy and other Neurological Disorders. Progress toward a neurosurgery-inspired resolution on mandatory folic acid fortification to prevent spina bifida-folate is described. In addition, priorities for moving the global health agenda forward for the neurosurgical patient as it relates to the global burden of neurological disease are reviewed after the COVID-19 pandemic.

Surgical care and trauma patients capacity in Piura, Peru - Cross-sectional study / Capacidades para la atención quirúrgica y de pacientes traumatizados en la región de Piura, Perú. Estudio de corte transversal

Abstract Introduction: Low and medium income countries face challenges in access and delivery of surgical care, resulting in a high number of deaths and disabled individuals. Objective: To estimate the capacity to provide surgical and trauma care in public hospitals in the Piura region, Perú, a middle income country. Methods: A survey was administered in public hospitals in the Peruvian region of Piura, which combined the Spanish versions of the PIPES and INTACT surveys, and the WHO situational analysis tool. The extent of the event was assessed based in the absolute differences between the medians of the scores estimated, and the Mann-Whitney bilateral tests, according to the geographical location and the level of hospital complexity. Results: Seven public hospitals that perform surgeries in the Piura region were assessed. Three provinces (3/8) did not have any complexity healthcare institutions. The average hospital in the peripheral provinces tended to be smaller than in the capital province in INTACT (8.25 vs. 9.5, p = 0.04). Additionally, water supply issues were identified (2/7), lack of incinerator (3/7), lack of uninterrupted availability of a CT-scanner (5/7) and problems with working hours; in other words, the blood banks in two hospitals were not open 24 hours. Conclusions: There is a significant inequality among the provinces in the region in terms of their trauma care capacities and several shortfalls in the public sector healthcare infrastructure. This information is required to conduct future research on capacity measurements in every public and private institution in the Peruvian region of Piura.

Resumen Introducción: Los países de ingresos bajos y medianos tienen problemas en el acceso y la provisión de atención quirúrgica, lo cual ocasiona un alto número de fallecimientos y de personas con discapacidad. Objetivo: Estimar la capacidad para la atención quirúrgica y de pacientes traumatizados en los hospitales públicos en la región de Piura, Perú, un país de ingreso mediano. Métodos: En los hospitales públicos de la región peruana de Piura se aplicó una encuesta que combinaba las versiones en español de las encuestas PIPES e INTACT y de la herramienta de análisis situacional de la Organización Mundial de la Salud (OMS). Se evaluó la magnitud del evento mediante las diferencias absolutas entre las medianas de los puntajes calculados y pruebas bilaterales de Mann-Whitney según la ubicación geográfica y el nivel de complejidad hospitalaria. Resultados: Se evaluaron siete hospitales públicos que realizan cirugía en la región de Piura. Tres provincias (3/8) no contaban con instituciones sanitarias con complejidad de hospital. La mediana de los hospitales de las provincias periféricas tuvo tendencia a ser menor que la de la provincia capital en la INTACT (8,25 vs. 9,5, p = 0,04). Asimismo, se hallaron problemas de abastecimiento de agua (2/7), ausencia de incinerador (3/7), falta de funcionamiento permanente de tomógrafo (5/7) y problemas con el horario de funcionamiento de los bancos de sangre, ya que no funcionaban las 24 horas del día en 2 hospitales (2/7). Conclusiones: Se describe la alta desigualdad entre las provincias de la región en la capacidad de atención de trauma y varias carencias en la infraestructura sanitaria del sector público. Esta información es necesaria para desarrollar futura investigación de medición de capacidades en todos los establecimientos públicos y privados de la región peruana de Piura.

Managing Severe Traumatic Brain Injury Across Resource Settings: Latin American Perspectives.

Severe traumatic brain injury (sTBI) is a condition of increasing epidemiologic concern worldwide. Outcomes are worse as observed in low- and middle-income countries (LMICs) versus high-income countries. Global targets are in place to address the surgical burden of disease. At the same time, most of the published literature and evidence on the clinical approach to sTBI comes from wealthy areas with an abundance of resources. The available paradigms, including the Brain Trauma Foundation guidelines, the Seattle International Severe Traumatic Brain Injury Consensus Conference, Consensus Revised Imaging and Clinical Examination, and multimodality approaches, may fit differently depending on local resources, expertise, and sociocultural factors. A first step toward addressing heterogeneity in practice is to consider comparative effectiveness approaches that can capture actual practice patterns and record short-term and long-term outcomes of interest. Decompressive craniectomy (DC) decreases intracranial pressure burden and can be lifesaving. Nevertheless, completed randomized controlled trials took place within high-income settings, leaving important questions unanswered and making extrapolations to LMICs questionable. The concept of preemptive DC specifically to address limited neuromonitoring resources may warrant further study to establish a benefit/risk profile for the procedure and its role within local protocols of care.

Global incidence proportion of intraventricular haemorrhage of prematurity: a meta-analysis of studies published 2010-2020.

OBJECTIVE: To investigate differences and calculate pooled incidence of any intraventricular haemorrhage (IVH), severe IVH (Grade III/IV, sIVH) and ventriculoperitoneal shunt (VPS) placement in preterm infants across geographical, health and economic regions stratified by gestational age (GA). DESIGN: MEDLINE, Embase, CINAHL and Web of Science were searched between 2010 and 2020. Studies reporting rates of preterm infants with any IVH, sIVH and VPS by GA subgroup were included. Meta-regression was performed to determine subgroup differences between study designs and across United Nations geographical regions, WHO mortality strata and World Bank lending regions. Incidence of any IVH, sIVH and VPS by GA subgroups<25, <28, 28-31, 32-33 and 34-36 weeks were calculated using random-effects meta-analysis. RESULTS: Of 6273 publications, 97 met inclusion criteria. Incidence of any IVH (37 studies 87 993 patients) was: 44.7% (95% CI 40.9% to 48.5%) for GA <25 weeks, 34.3% (95% CI 31.2% to 37.6%) for GA <28 weeks, 17.4% (95% CI 13.8% to 21.6%) for GA 28-31 weeks, 11.3% (95% CI 7.3% to 17.0%) for GA32-33 weeks and 4.9% (95% CI 1.4% to 15.2%) for GA 34-36 weeks. Incidence of sIVH (49 studies 328 562 patients) was 23.7% (95% CI 20.9% to 26.7%) for GA <25 weeks, 15.0% (95% CI 13.1% to 17.2%) for GA <28 weeks, 4.6% (95% CI 3.5% to 6.1%) for GA 28-31 weeks, 3.3% (95% CI 2.1% to 5.1%) for GA 32-33 weeks and 1.8% (95% CI 1.2% to 2.8%) for GA 34-36 weeks. Europe had lower reported incidence of any IVH and sIVH relative to North America (p<0.05). Proportion of VPS across all GA groups was 8.4% (95% CI 4.7% to 14.7%) for any IVH and 17.2% (95% CI 12.2% to 26.2%) for sIVH. Heterogeneity was high (I2 >90%) but 64%-85% of the variance was explained by GA and study inclusion criteria. CONCLUSIONS: We report the first pooled estimates of IVH of prematurity by GA subgroup. There was high heterogeneity across studies suggesting a need for standardised incidence reporting guidelines.

Neurocysticercosis control for primary epilepsy prevention: a systematic review.

Neurocysticercosis (NCC) is a leading cause of preventable epilepsy in lower- and upper- middle-income countries (LMICs/UMICs). NCC is a human-to-human transmitted disease caused by ingestion of Taenia solium eggs from a Taenia carrier. T. solium infection control is the key to reduce NCC incidence. This systematic review aims to identify T. solium control programs that can provide frameworks for endemic areas to prevent NCC-related epilepsy. A systematic search was conducted in PubMed/Medline, Embase, Web of Science, and Cochrane Library databases in March 2021. After title and abstract review, full texts were screened for qualitative analysis. Additional articles were identified via citation search. Of 1322 total results, 34 unique studies were included. Six major intervention types were identified: national policy (8.8%), community sanitation improvement (8.8%), health education (8.8%), mass drug administration (29.4%), pig vaccination and treatment (32.4%), and combined human and pig treatment (11.8%). Overall, 28 (82.4%) studies reported decreased cysticercosis prevalence following the intervention. Only health education and combined human and pig treatment were effective in all selected studies. NCC causes preventable epilepsy in LMICs/UMICs and its incidence can be reduced through T. solium control. Most interventions that disrupt the T. solium transmission cycle are effective. Long-term sustained results require comprehensive programs, ongoing surveillance, and collaborative effort among multisectoral agencies.

Pediatric traumatic brain injury prehospital guidelines: a systematic review and appraisal.

BACKGROUND: Traumatic brain injury (TBI) disproportionately affects children within low- and middle-income countries (LMICs). Prehospital emergency care can mitigate secondary brain injury and improve outcomes. Here, we systematically review clinical practice guidelines (CPGs) for pediatric TBI with the goal to inform LMICs prehospital care. METHODS: A systematic search was conducted in PubMed/Medline, Embase, and Web of Science databases. We appraised evidence-based CPGs addressing prehospital management of pediatric TBI using the Appraisal of Guidelines for Research & Evaluation (AGREE) tool. CPGs were rated as high-quality if ≥ 5 (out of 6) AGREE domains scored > 60%. RESULTS: Of the 326 articles identified, 10 CPGs were included in analysis. All 10 were developed in HICs, and 4 were rated as high-quality. A total of 154 pediatric prehospital recommendations were grouped into three subcategories, initial assessment (35.7%), prehospital treatment (38.3%), and triage (26.0%). Of these, 79 (51.3%) were evidence-based with grading, and 31 (20.1%) were consensus-based without direct evidence. CONCLUSION: Currently available CPGs for prehospital pediatric TBI management were all developed in HICs. Four CPGs have high-quality, and recommendations from these can serve as frameworks for LMICs or resource-limited settings. Context-specific evaluation and implementation of evidence-based recommendations allow LMIC settings to respond to the public health crisis of pediatric TBI and address gaps in trauma care systems.

Neuropalliative care for the neurosurgeon: a primer.

Many neurosurgical conditions are incurable, leading to disability or severe symptoms, poor quality of life, and distress for patients and families. The field of neuropalliative care (NPC) addresses the palliative care (PC) needs of individuals living with neurological conditions. Neurosurgeons play an important role within multidisciplinary NPC teams because of their understanding of the natural history of and treatment strategies for neurosurgical conditions, longitudinal patient-physician relationships, and responsibility for neurosurgical emergencies. Moreover, patients with neurosurgical conditions have unique PC needs given the trajectories of neurosurgical diseases, the realities of prognostication, psychosocial factors, communication strategies, and human behavior. PC improves outcomes among neurosurgical patients. Despite the importance of NPC, neurosurgeons often lack formal training in PC skills, which include identifying patients who require PC, assessing a patient's understanding and preferences regarding illness, educating patients, building trust, managing symptoms, addressing family and caregiver needs, discussing end-of-life care, and recognizing when to refer patients to specialists. The future of NPC involves increasing awareness of the approach's importance, delineating priorities for neurosurgeons with regard to NPC, increasing emphasis on PC skills during training and practice, expanding research efforts, and adjusting reimbursement structures to incentivize the provision of NPC by neurosurgeons.

Progress in neurosurgery: Contributions of women neurosurgeons in Latin America.

Nearly 75 years after the first woman neurosurgeon was trained in Latin America, the field of neurosurgery is changing and the prominence of women neurosurgeons within the specialty is increasing. By researching the histories of individual physicians and neurosurgeons, as well as neurosurgical departments and societies, we present, for the first time, the history of the women in neurosurgery in Latin America. Women neurosurgeons in the region have made notable progress, inspiring subsequent generations and actively participating in organized neurosurgery, medical leadership outside neurosurgery, academic neurosurgery, and leadership in contemporary society. The establishment of "Women in Neurosurgery" networks and organizations has been important to the success of many of these efforts. This collaborative study, which identifies the known women neurosurgeons in Latin America for the first time, may serve to provide background and context for further contributions of women neurosurgeons for our profession and our patients.

A National Survey Evaluating the Impact of the COVID-19 Pandemic on Students Pursuing Careers in Neurosurgery.

Background: The COVID-19 pandemic has profoundly disrupted medical education and the residency application process. Methods: We conducted a descriptive observational study in April 2020 of medical students and foreign medical graduates considering or pursuing careers in neurosurgery in the United States to examine the impact of the pandemic. Results: A total of 379 respondents from 67 medical schools completed the survey. Across all participants, 92% (n = 347) stopped in-person didactic education, and 43% (n = 161) experienced basic science and 44% (n = 167) clinical research delays. Sixty percent (n = 227) cited a negative impact on academic productivity. Among first year students, 18% (n = 17) were less likely to pursue a career in neurosurgery. Over half of second year and third year students were likely to delay taking the United States Medical Licensing Examination Steps I and II. Among third year students, 77% (n = 91) reported indefinite postponement of sub-internships, and 43% (n = 53) were unsatisfied with communication from external programs. Many fourth-year students (50%, n = 17) were graduating early to participate in COVID-19-related patient care. Top student-requested support activities included access to student-focused educational webinars and sessions at upcoming conferences. Conclusions: Medical students pursuing careers in neurosurgery faced unique academic, career, and personal challenges secondary to the pandemic. These challenges may become opportunities for new initiatives guided by professional organizations and residency programs.

Surgical Outcomes after Myelomeningocele Repair in Lusaka, Zambia.

OBJECTIVE: Spina bifida disproportionally affects low-and-middle-income countries. We describe myelomeningocele surgical outcomes in Zambia and predictors of postoperative complications and mortality. METHODS: This 2-center retrospective cohort study includes children who underwent surgical treatment for myelomeningocele in Lusaka, Zambia from 2017 to 2019. Primary outcomes included mortality and 30-day postoperative complications. RESULTS: Seventy-five patients were identified. Median age at first neurosurgical evaluation was 9 days (interquartile range [IQR], 6-21) and at surgery was 21 days (IQR 15-36). Lumbosacral myelomeningocele was most common (73%, n = 54). At first preoperative evaluation, 28% of the neural tube defects were deemed infected (n = 21), and 30% were leaking cerebrospinal fluid (n = 21). Postoperatively, 7% of patients died (n = 5), whereas 31% experienced a complication (n = 23). Most common complications included wound dehiscence (n = 10, 42%) and wound purulence (n = 6, 25%). Median follow-up duration was 41 days (IQR, 6-128). On univariable analysis, mortality was significantly associated with shorter follow-up duration (5 days [IQR, 2-7] vs. 46 days [IQR, 12-132]; P = 0.02) and any complication (P < 0.001). No variable was significantly associated with postoperative complication; however, 2 variables that notably neared significance were preoperative infection of the lesion (P = 0.05) and longer surgical delay (P = 0.06). CONCLUSIONS: Most patients born with myelomeningocele in Zambia present for first neurosurgical evaluation after 1 week of age. Preoperative infection of the lesion and postoperative complications are relatively common, and complications are a significant predictor of postoperative mortality. Further investigation into preoperative efforts to mitigate risk of postoperative complications and mortality is warranted.

Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review.

BACKGROUND: Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH. METHODS: A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes. RESULTS: Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults. CONCLUSIONS: Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.

Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006-2016.

OBJECTIVE: The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006-2016. METHODS: We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders. RESULTS: A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients. CONCLUSION: Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time.

Recurrent brainstem cavernous malformations following primary resection: blind spots, fine lines, and the right-angle method.

OBJECTIVE: Proximity of brainstem cavernous malformations (BSCMs) to tracts and cranial nerve nuclei make it costly to transgress normal tissue in accessing the lesion or disrupting normal tissue adjacent to the lesion in the separation plane. This interplay between tissue sensitivity and extreme eloquence makes it difficult to avoid leaving a remnant on occasion. Recurrences require operative intervention, which may increase morbidity, lengthen recovery, and add to overall costs. An approximately 20-year experience with patients with recurrent BSCM lesions following primary microsurgical resection was reviewed. METHODS: A prospectively maintained database of 802 patients who underwent microsurgical resection of cerebral cavernous malformations during 1997-2018 was queried to identify 213 patients with BSCMs. A retrospective chart review was conducted for patients with recurrent BSCM after primary resection who required a second surgery. RESULTS: Fourteen of 213 patients (6.6%) underwent repeat resection for recurrent BSCM. Thirty-four hemorrhagic events were observed among these 14 patients over 576 patient-years (recurrent hemorrhage rate, 5.9% per year; median discrete hemorrhagic events, 2; median time to rehemorrhage, 897 days). BSCM occurred in the pons in 10 cases, midbrain in 2 cases, and medulla in 2 cases. A blind spot in the operative corridor was the most common cause of residual BSCM (9 patients). All recurrent BSCMs were removed completely, although 2 patients each required 2 operations to treat recurrence. Twelve patients had unchanged or improved modified Rankin Scale scores at last clinical evaluation compared with admission, and 2 patients had worse scores. Recurrence was more common among patients who were operated on in the first versus the second half of the series (8.5% vs 4.7%). CONCLUSIONS: The 6.6% rate of BSCM recurrence requiring reoperation reflects the fine lines between complete resection and recurrence and between safe and harmful surgery. The detection of remnants is difficult postoperatively and remains so even at 6 months when the resection bed has healed. The 5.9% annual hemorrhage risk associated with recurrent BSCM in this experience is consistent with that reported for unoperated BSCMs. The right-angle method helps to anticipate blind spots and meticulously inspect the resection cavity for residual BSCM during surgery. A low percentage of recurrent BSCM (5%-10%) ensures ongoing effort toward an acceptable balance of safety and completeness.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part I): Demographics, Resources, and Education.

BACKGROUND: Providing a comprehensive and effective neurosurgical service requires adequate numbers of well-trained, resourced, and motivated neurosurgeons. The survey aims to better understand 1) the demographics of young neurosurgeons worldwide; 2) the challenges in training and resources that they face; 3) perceived barriers; and 4) needs for development. METHODS: This was a cross-sectional study in which a widely disseminated online survey (April 2018-November 2019) was used to procure a nonprobabilistic sample from current neurosurgical trainees and those within 10 years of training. Data were grouped by World Bank income classifications and analyzed using χ2 tests because of its categorical nature. RESULTS: There were 1294 respondents, with 953 completed responses included in the analysis. Of respondents, 45.2% were from high-income countries (HICs), 23.2% from upper-middle-income countries, 26.8% lower-middle-income countries, and 4.1% from low-income countries. Most respondents (79.8%) were male, a figure more pronounced in lower-income groups. Neuro-oncology was the most popular in HICs and spinal surgery in all other groups. Although access to computed tomography scanning was near universal (98.64%), magnetic resonance imaging access decreased to 66.67% in low-income countries, compared with 98.61% in HICs. Similar patterns were noted with access to operating microscopes, image guidance systems, and high-speed drills. Of respondents, 71.4% had dedicated time for neurosurgical education. CONCLUSIONS: These data confirm and quantify disparities in the equipment and training opportunities among young neurosurgeons practicing in different income groups. We hope that this study will act as a guide to further understand these differences and target resources to remedy them.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part II): Barriers to Professional Development and Service Delivery in Neurosurgery.

BACKGROUND: Strengthening health systems requires attention to workforce, training needs, and barriers to service delivery. The World Federation of Neurosurgical Societies Young Neurosurgeons Committee survey sought to identify challenges for residents, fellows, and consultants within 10 years of training. METHODS: An online survey was distributed to various neurosurgical societies, personal contacts, and social media platforms (April-November 2018). Responses were grouped by World Bank income classification into high-income countries (HICs), upper middle-income countries (UMICs), low-middle-income countries (LMICs), and low-income countries (LICs). Descriptive statistical analysis was performed. RESULTS: In total, 953 individuals completed the survey. For service delivery, the limited number of trained neurosurgeons was seen as a barrier for 12.5%, 29.8%, 69.2%, and 23.9% of respondents from HICs, UMICs, LMICs, and LICs, respectively (P < 0.0001). The most reported personal challenge was the lack of opportunities for research (HICs, 34.6%; UMICs, 57.5%; LMICs, 61.6%; and LICs, 61.5%; P = 0.03). Other differences by income class included limited access to advice from experienced/senior colleagues (P < 0.001), neurosurgical journals (P < 0.0001), and textbooks (P = 0.02). Assessing how the World Federation of Neurosurgical Societies could best help young neurosurgeons, the most frequent requests (n = 953; 1673 requests) were research (n = 384), education (n = 296), and subspecialty/fellowship training (n = 232). Skills courses and access to cadaver dissection laboratories were also heavily requested. CONCLUSIONS: Young neurosurgeons perceived that additional neurosurgeons are needed globally, especially in LICs and LMICs, and primarily requested additional resources for research and subspecialty training.

Pediatric hydrocephalus outcomes in Lusaka, Zambia.

OBJECTIVE: Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia. METHODS: This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications. RESULTS: A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001). CONCLUSIONS: Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.

A Bibliographic Analysis of the Most Cited Articles in Global Neurosurgery.

OBJECTIVE: Global neurosurgery is the practice of neurosurgery with the primary purpose of delivering timely, safe, and affordable neurosurgical care to all who need it. The aim of this study is to identify the most frequently cited articles in global neurosurgery through a bibliographic review to characterize articles and trends around this growing topic. METHODS: The top most-cited articles in global neurosurgery were determined by searching the Web of Science database using a priori search terms. Articles with at least 5 citations were selected, and there were no time period or language restrictions. The data were extracted from each included article and all characteristics were summarized. RESULTS: A total of 932 articles were identified using the search terms; 69 articles fulfilled inclusion criteria and 17 articles were selected that had more than 5 citations. The articles' number of citations ranged from 6 to 98 for the most-cited article. Authors from, or affiliated with, 14 countries contributed to the 17 articles, and the country that had the greatest representation was the United States. The main topic discussed was surgical capacity, the second topic was the treatment of different neurosurgical conditions, and volunteerism was the third topic. CONCLUSIONS: There is currently a deficit in both the amount of literature surrounding the topic of global neurosurgery and how much that literature is cited. Developing innovative ways to increase academic productivity within, or in collaboration with, low-middle income countries is essential to contribute to global neurosurgery.