Does subtotal resection ameliorate hypothalamic morbidity in pediatric craniopharyngioma? A 30-year retrospective cohort study.

OBJECTIVE: The optimal extent of resection of craniopharyngiomas to minimize the long-term risks of hypothalamic and endocrine dysfunction (obesity and panhypopituitarism) in children remains uncertain. The purpose of this study was to report long-term outcomes of pediatric patients with craniopharyngioma undergoing surgical treatment and to study rates of endocrinological and hypothalamic dysfunction in association with extent of resection. METHODS: This retrospective study was performed in a cohort of children who underwent resection for craniopharyngioma at Children's of Alabama between 1990 and 2020. The primary outcome was hypothalamic dysfunction defined as a 0.5 increase in body mass index (BMI) Z-score and as a BMI > 2 SDs with or without psychiatric disturbances. Univariable analysis was performed using ANOVA, Wilcoxon rank-sum test, Pearson's chi-square test, and Fisher's exact test as appropriate. Missing data on the primary outcome were handled via multiple imputations. Relative risks were estimated using a multivariable generalized linear model with a priori variables selected using a modified Poisson regression approach with robust error variance to estimate risk ratios. RESULTS: The cohort includes 39 patients (24 girls and 15 boys; age range 1 month-16 years) who underwent resection of craniopharyngioma at the authors' center between 1990 and 2020. The preoperative goal of treatment was cyst decompression (CD) in 5, subtotal resection (STR) in 13, and gross-total resection (GTR) in 21 patients. The median long-term follow-up after surgery was 8.11 years (average 8.21, range 0.4-24.33 years). Univariate analysis demonstrated a statistically significant increase in hypothalamic dysfunction in patients undergoing GTR when compared to those undergoing STR or CD at 1 month postoperatively (p = 0.006) and 6-11 months postoperatively (p = 0.010), but with this difference not persisting beyond 1 year. Multivariable analysis showed patients older than 10 years at time of surgery to be the most affected and at highest risk of developing significant hypothalamic dysfunction. There was no significant difference in pituitary or neurological function between the STR/CD and GTR groups at 12-24 months or at most recent follow-up. There was no significant difference in BMI Z-scores between the STR/CD and GTR groups at 6-12 months or at most recent follow-up. CONCLUSIONS: Both STR and GTR of craniopharyngioma were associated with significant endocrinological sequelae after 1 year. These potential complications should be discussed with patients and their families, and postoperative protocols should include early nutritional and endocrinological interventions with endocrinologist consultation.

Understanding and identifying the needs of parent caregivers of children with hydrocephalus: a qualitative study.

OBJECTIVE: Hydrocephalus is inherently unpredictable. Most parents whose child is diagnosed with hydrocephalus do not anticipate the diagnosis, nor can anyone predict if or when a child's shunt will fail and require emergency surgery. Previous research has shown that children with hydrocephalus and their caregivers experience significant posttraumatic stress symptoms secondary to the diagnosis. This study aims to understand caregiver experiences and needs, identify gaps in resources/support, and determine opportunities to improve care. METHODS: Semistructured interviews were conducted with parent caregivers of children with hydrocephalus to learn about their experiences with the hydrocephalus diagnosis, hospitalizations, surgeries, coping and support, challenges of caring for a child with hydrocephalus, and logistics for a proposed support program. De-identified interviews were audio-recorded, transcribed, and analyzed for themes. RESULTS: Thematic saturation was reached after 17 interviews. Five major themes emerged: 1) coping with the diagnosis, 2) received support, 3) hydrocephalus management, 4) implications for intervention, and 5) psychosocial stressors for caregivers. A top priority was balanced, trustworthy information delivered with compassion and updated throughout the child's life. Caregivers described a variety of coping strategies, but a majority reported a need for support in processing complex emotions and dealing with the uncertainty of their child's hydrocephalus. Most agreed that having a caregiver support network, medical professionals available for referrals and questions, and referrals to support services and therapies would facilitate feeling supported and providing the best care for their children. CONCLUSIONS: Parent caregivers are critical to the health and well-being of children with hydrocephalus, and it is essential to understand their experiences to improve care. Providing well-defined information, psychosocial support, and resources will help to equip parent caregivers to be advocates for their children and to improve both the caregiver and the child's quality of life.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study.

OBJECTIVE: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. METHODS: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. RESULTS: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. CONCLUSION: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Preventing birth defects, saving lives, and promoting health equity: an urgent call to action for universal mandatory food fortification with folic acid.

July 20, 2021 marked the 30th anniversary of the publication of the landmark trial by the British Medical Research Council showing unequivocally that maternal intake of folic acid (vitamin B9) starting before pregnancy prevents most cases of infant spina bifida and anencephaly-two major neural tube defects that are severe, disabling, and often fatal. Mandatory food fortification with folic acid is a safe, cost-effective, and sustainable intervention to prevent spina bifida and anencephaly. Yet few countries implement fortification with folic acid; only a quarter of all preventable spina bifida and anencephaly cases worldwide are currently avoided by food fortification. We summarise scientific evidence supporting immediate, mandatory fortification with folic acid to prevent the development of spina bifida and anencephaly. We make an urgent call to action for the World Health Assembly to pass a resolution for universal mandatory folic acid fortification. Such a resolution could accelerate the slow pace of spina bifida and anencephaly prevention globally, and will assist countries to reach their 2030 Sustainable Development Goals on child mortality and health equity. The cost of inaction is profound, and disproportionately impacts susceptible populations in low-income and middle-income countries.

Evolution of Gender Disparities Among Brazilian Surgical, Anesthesia, and Obstetric Providers.

INTRODUCTION: Since 2010, most graduating physicians in Brazil have been female, nevertheless gender disparities among surgical specialties still exist. This study aims to explore whether the increase in female physicians has translated to increased female representation among surgical specialties in Brazil. METHODS: Data on gender, years of practice, and specialty was extracted from Demografia Médica do Brasil, from 2015 to 2020. The percentage of women across 18 surgical, anesthesia, and obstetric (SAO) specialties and the relative increases in female representation during the study period were calculated. RESULTS: Of the 18 SAO specialties studied, 16 (88%) were predominantly male (>50%). Only obstetrics/gynecology and breast surgery showed a female predominance, with 58% and 52%, respectively. Urology, neurosurgery, and orthopedic surgery and traumatology were the three specialties with the largest presence of men - and the lowest absolute growth in the female workforce from 2015 to 2020. CONCLUSIONS: In Brazil, where significant gender disparities persist, women are still underrepresented in surgical specialties. Female presence is predominant in surgical specialties dedicated to the care of female patients, while it remains poor in those with male patient dominance. Over the last 5 y, the proportion of women working in SAO specialties has grown, but not as much as in nonsurgical specialties. Future studies should focus on investigating the causes of gender disparities in Brazil to understand and tackle the barriers to pursuing surgical specialties.

A qualitative interview study on successful pregnancies in women with spina bifida.

BACKGROUND: Improvements in antenatal medicine and surgical management for conditions associated with spina bifida such as hydrocephalus have extended the lifespan for individuals with spina bifida (SB) into adulthood. Decisions and education regarding reproductive care and pregnancies for patients with spina bifida are increasingly important. Pregnancy in these patients can be particularly challenging due to physical limitations, previous abdominal surgery for urinary or bowel management and presence of a ventriculoperitoneal shunt. To date, little research has examined the unique challenges that women with spina bifida face during pregnancy. OBJECTIVE: The purpose of this descriptive study is to characterize the successful pregnancy histories of SB women and describe how pregnancy affected their mobility as well as bladder and bowel management. STUDY DESIGN: We conducted semi-structured interviews with women followed in our adult multidisciplinary SB clinic who previously had successful pregnancies. Questions regarding perinatal issues, obstetrical complications, urinary tract infections (UTI) and neurological changes were asked. Baseline mobility, bladder and bowel management were compared with changes during and after pregnancy. RESULTS: 121 women of childbearing age were followed per year by our adult multidisciplinary spina bifida clinic between 2009 and 2016. We identified 6 women who successfully carried 8 pregnancies to term. There were no miscarriages. Four women had ventriculoperitoneal (VP) shunts. No children were born with neural tube defects. Mean age at first pregnancy was 23.5 years. Average gestational age at delivery was 37 weeks. 50% of the women had a spontaneous vaginal delivery. Five of six women intended to get pregnant; only one patient consumed folic acid regularly prior to pregnancy. Two of six women had bladder augmentation surgery, one of whom had urologic changes during pregnancy that persisted after childbirth. The other patient had a concomitant bladder neck sling procedure and did not have urologic issues during pregnancy. 50% of the patients experienced bladder-bowel dysfunction during their pregnancy. While 67% patients had full baseline ambulatory function, 4 patients had decreased mobility and required additional assistance during pregnancy. All returned to their baseline functionality afterwards. CONCLUSION: Six of our patients had eight successful pregnancies, with no children born with neural tube defects. New changes to mobility, bladder and bowel management were experienced by over half of the women during their pregnancies. Future studies should focus on the role of multidisciplinary teams in reproductive health education and perinatal management of changes to activities of daily living during pregnancy in this population.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study / Avaliação da capacidade cirúrgica do estado do Amazonas utilizando uma ferramenta de avaliação cirúrgica. Estudo transversal

ABSTRACT Objective: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. Methods: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. Results: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. Conclusion: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

RESUMO Objetivo: o Brasil é um país com cobertura universal de saúde, mas o acesso à cirurgia entre populações remotas permanece pouco estudado. Este estudo avalia a capacidade cirúrgica em hospitais que servem populações rurais no estado do Amazonas, Brasil, por meio de avaliações aprofundadas das instalações. Métodos: foi realizada avaliação estratificada randomizada transversal de hospitais que relataram prestar assistência cirúrgica de julho de 2016 a março de 2017. A Ferramenta de Avaliação Cirúrgica desenvolvida pela Organização Mundial da Saúde e o Programa de Cirurgia Global e Mudança Social da Harvard Medical School foi administrada em hospitais remotos, incluindo uma revisão retrospectiva de registros médicos e livros cirúrgicos. Resultados: 18 hospitais foram pesquisados. Três hospitais (16,6%) não tinham salas cirúrgicas e 12 (66%) tinham 1-2. 14 hospitais (77,8%) relataram que a oximetria de pulso estava "sempre presente" e seis hospitais (33%) nunca têm um anestesiologista disponível. A anestesia inalatória estava disponível em 12 hospitais (66,7%), 77,8% não possuíam dispositivo de ventilação mecânica. Em média, 257 procedimentos por 100.000 foram realizados. 10 hospitais (55,6%) não possuem unidade de recuperação anestésica. Para as regiões de abrangência dos 18 hospitais, com população de 497.492 habitantes, a densidade média de força de trabalho cirúrgica, anestesista e obstétrica foi de 6,4. Conclusão: as populações que vivem em áreas rurais no Brasil enfrentam disparidades significativas no acesso à assistência cirúrgica, apesar da presença de cobertura universal de saúde. O desenvolvimento de um plano estadual de cirurgia é necessário para garantir acesso à assistência cirúrgica às populações rurais.

Scope of care in the first four years of life for individuals born with myelomeningocele: A single institution experience1.

PURPOSE: Children with myelomeningocele are known to be consumers of substantial healthcare resources, with many early hospital encounters. The purpose of this study was to survey the extent of medical and surgical care that patients with myelomeningocele receive during the first four years of life. METHODS: Clinical and demographic data were collected on newborn infants with open myelomeningocele from the Children's of Alabama Spina Bifida Web Tracker, a prospective, comprehensive spina bifida database. Additional data pertaining to all hospital admissions, surgical procedures, and clinic visits were collected from the medical record. RESULTS: One hundred and fourteen subjects with a primary diagnosis of myelomeningocele between 2004 and 2015 were included. Males slightly predominated (55%), 61.4% were Caucasian, 11% Hispanic/Latino; 28% had a mid-lumbar functional lesion level. Over the first four years of life, 688 total surgical procedures were performed (an average of 86 per child): 438 in year 1, 100 in year 2, 84 in year 3, and 66 in year 4. The mean number of hospital visits was 40.5. Total average drive time per patient over 4 years being 103.8 hours. Average number of nights spent in the hospital was 51. CONCLUSION: Children with myelomeningocele need multiple hospitalizations, surgeries, and medical encounters in the first 4 years of life. These data will be valuable when counselling new parents and prospective parents of children with this condition.

Implementation of a checklist to improve pediatric trauma assessment quality in a Brazilian hospital.

BACKGROUND: Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers. MATERIAL AND METHODS: A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed. RESULTS: A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed. CONCLUSION: In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

The Plastic Surgery Workforce and Its Role in Low-income Countries.

BACKGROUND: Plastic surgery varies in scope, especially in different settings. This study aimed to quantify the plastic surgery workforce in low-income countries (LICs), understand commonly treated conditions by plastic surgeons working in these settings, and assess the impact on reducing global disease burden. METHODS: We queried national and international surgery societies, plastic surgery societies, and non-governmental organizations to identify surgeons living and working in LICs who provide plastic surgical care using a cross-sectional survey. Respondents reported practice setting, training experience, income sources, and perceived barriers to care. Surgeons ranked commonly treated conditions and reported which of the Disease Control Priorities-3 essential surgery procedures they perform. RESULTS: An estimated 63 surgeons who consider themselves plastic surgeons were identified from 15 LICs, with no surgeons identified in the remaining 16 LICs. Responses were obtained from 43 surgeons (70.5%). The 3 most commonly reported conditions treated were burns, trauma, and cleft deformities. Of the 44 "Essential Surgical Package'' procedures, 37 were performed by respondents, with the most common being skin graft (73% of surgeons performing), cleft lip/palate repair (66%), and amputations/escharotomy (61%). The most commonly cited barrier to care was insufficient equipment. Only 9% and 5% of surgeons believed that there are enough plastic surgeons to handle the burden in their local region and country, respectively. CONCLUSIONS: Plastic surgery plays a significant role in the coverage of essential surgical conditions in LICs. Continued expansion of the plastic surgical workforce and accompanying infrastructure is critical to meet unmet surgical burden in low- and middle-income countries.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala.

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Post-Traumatic Stress Symptoms in Caregivers and Children with Hydrocephalus.

OBJECTIVE: Hydrocephalus is a disorder of cerebrospinal fluid dynamics, traditionally treated by placement of a ventricular shunt. Shunts are effective but imperfect as they fail in an unpredictable pattern, and the patient's well-being is dependent on adequate shunt function. The omnipresent threat of shunt failure along with the potential need for invasive investigations can be stressful for patients and caregivers. Our objective was to measure post-traumatic stress symptoms (PTSS) in children with hydrocephalus and their caregivers. METHODS: A cross-sectional analysis of children with hydrocephalus and their caregivers was conducted. Caregivers completed a measure of their own PTSS (the Post-Traumatic Stress Disorders Checklist for the Diagnostic and Statistical Manual of Mental Disorders-V) and resilience (the Connor Davidson Resilience Scale). Pediatric patients rated their own PTSS and resilience using the Acute Stress Checklist for Kids and Connor Davidson Resilience Scale. RESULTS: Ninety-one caregivers completed the Post-Traumatic Stress Disorders Checklist for the Diagnostic and Statistical Manual of Mental Disorders-V. Mean score was 17.0 (standard deviation 15.7; median 13.0). Fourteen percent scored above 33, the threshold suggestive of a preliminary diagnosis of post-traumatic stress disorder. There was a statistically significant association between caregiver post-traumatic stress and marital status, child's race, and caregiver education. More than half (52%) of caregivers reported their child's hydrocephalus as the most significant source of their PTSS. Children did not have markedly elevated levels of PTSS. Forty-one percent of caregivers and 60% of children scored in the lowest resilience quartile compared with the general population. CONCLUSIONS: Results from this study suggest that post-traumatic stress affects caregivers with hydrocephalus, yet levels of resilience for caregivers and pediatric patients are low.

Hydrocephalus-related quality of life as assessed by children and their caregivers.

OBJECTIVE: Hydrocephalus is a chronic medical condition that has a significant impact on children and their caregivers. The objective of this study was to measure the quality of life (QOL) of children with hydrocephalus, as assessed by both caregivers and patients. METHODS: Pediatric patients with hydrocephalus and their caregivers were enrolled during routine neurosurgery clinic visits. The Hydrocephalus Outcomes Questionnaire (HOQ), a report of hydrocephalus-related QOL, was administered to both children with hydrocephalus (self-report) and their caregivers (proxy report about the child). Patients with hydrocephalus also completed measures of anxiety, depression, fatigue, traumatic stress, and headache. Caregivers completed a proxy report of child traumatic stress and a measure of caregiver burden. Demographic information was collected from administration of the Psychosocial Assessment Tool (version 2.0) and from the medical record. Child and caregiver HOQ scores were analyzed and correlated with clinical, demographic, and psychological variables. RESULTS: The mean overall HOQ score (parent assessment of child QOL) was 0.68. HOQ Physical Health, Social-Emotional Health, and Cognitive Health subscore averages were 0.69, 0.73, and 0.54, respectively. The mean overall child self-assessment (cHOQ) score was 0.77, with cHOQ Physical Health, Social-Emotional Health, and Cognitive Health subscore means of 0.84, 0.79, and 0.66, respectively. Thirty-nine dyads were analyzed, in which both a child with hydrocephalus and his or her caregiver completed the cHOQ and HOQ. There was a positive correlation between parent and child scores (p < 0.004 for all subscores). Child scores were consistently higher than parent scores. Variables that showed association with caregiver-assessed QOL in at least one domain included child age, etiology of hydrocephalus, and history of endoscopic third ventriculostomy. There was a significant negative relationship (rho -0.48 to -0.60) between child-reported cHOQ score and child-reported measures of posttraumatic stress, anxiety, depression, and fatigue. There was a similar significant relationship between caregiver report of child's QOL (HOQ) and caregiver assessment of the child's posttraumatic stress symptoms as well as their assessment of burden of care (rho = -0.59 and rho = -0.51, respectively). No relationship between parent-reported HOQ and child-reported psychosocial factors was significant. No clinical or demographic variables were associated with child self-assessed cHOQ. CONCLUSIONS: Pediatric patients with hydrocephalus consistently rate their own QOL higher than their caregivers do. Psychological factors such as anxiety and posttraumatic stress may be associated with lower QOL. These findings warrant further exploration.

Pediatric trauma primary survey performance among surgical and non-surgical pediatric providers in a Brazilian trauma center.

INTRODUCTION: Trauma is the leading cause of death and disability among Brazilian children and adolescents. Trauma protocols such as those developed by the Advanced Trauma Life Support course are widely taught, but few studies have assessed the degree to which the use of protocolized trauma assessment improves outcomes. This study aims to quantify the adherence of trauma assessment protocols among different types of frontline trauma providers. METHODS: A prospective observational study of pediatric trauma care in one of the busiest Latin American trauma centers was conducted during 6 months. Trauma primary survey assessments were observed and adherence to each step of a standardized primary assessment protocol was recorded. Adherence to the assessment protocol was compared among different types of providers, the time of presentation and severity of injury. The relationship between protocol adherence and clinical outcomes including mortality, length of hospital stay, admission to pediatric intensive care unit, use of blood components, mechanical ventilation and number of imaging exams performed in the first 24 hours were also assessed. RESULTS: Emergency department evaluations of 64 patients out of 274 pediatric admissions were observed over a period of 6 months. 50% of the primary assessments were performed by general surgeons, 34.4% by residents in general surgery and 15.6% by pediatricians. There was an average adherence rate of 34.1% to the trauma protocol. Adherence among each specific step included airway: 17.2%; breathing: 59.4%; circulation: 95.3%; disability: 28.8%; exposure: 18.8%. No differences between specialties were observed. Patients with a more thorough primary assessment underwent fewer CT scans (receiver operating characteristic curve area: 0.661; p=0.027). CONCLUSIONS: Our study demonstrates that trauma assessment protocol adherence among trauma providers is low. Thorough initial assessment reduced the use of CT scans suggesting that standardized pediatric trauma assessments may be a way to reduce unnecessary radiological imaging among children. LEVEL OF EVIDENCE: IV. STUDY TYPE: Pediatric and global trauma.

Anxiety, depression, fatigue, and headache burden in the pediatric hydrocephalus population.

OBJECTIVE: Childhood hydrocephalus is a common chronic medical condition. However, little is known about the burden of headache and psychological comorbidities in children living with hydrocephalus. The purpose of this study was to determine the prevalence and severity of these conditions among the pediatric hydrocephalus population. METHODS: During routine neurosurgery clinic visits from July 2017 to February 2018, the authors administered four surveys to children ages 7 years and older: Pediatric Migraine Disability Assessment (PedMIDAS), Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, and PROMIS Fatigue. The PedMIDAS is an assessment of headache disability in pediatric and adolescent patients. The PROMIS measures are pediatric self-reported instruments to assess social and emotional health. PROMIS measures utilize T-scores (mean 50, SD 10) to compare anxiety, depression, and fatigue in specific populations to those in the US general population. Clinical and demographic data were collected from the medical record (hydrocephalus etiology, shunt infection, race, etc.) and tested for associations with survey measure scores. RESULTS: Forty children completed the PedMIDAS. Ten percent of them were in the severe headache range, 5% were in the moderate range, and 5% were in the mild range. There was a statistically significant association between undergoing a cluster of shunt operations and headache burden (p = 0.003).Forty children completed all three PROMIS measures. The mean anxiety score was 45.8 (SD 11.7), and 2.5% of children scored in the severe anxiety range, 17.5% in the moderate range, and 20% in the mild range. The mean depression score was 42.7 (SD 10.0), with 2.5% of children scoring in the severe depression range, 5% in the moderate range, and 12.5% in the mild range. The mean fatigue score was 45.1 (SD 16.4), with 15% percent of children scoring in the severe fatigue range, 10% in the moderate range, and 7.5% in the mild range. There were no statistically significant associations between child anxiety, depression, or fatigue and clinical or demographic variables. CONCLUSIONS: Children with hydrocephalus have an average burden of headache, anxiety, depression, and fatigue as compared to the general population overall. Having a cluster of shunt operations correlates with a higher headache burden, but no clinical or demographic variable is associated with anxiety, depression, or fatigue.

Prehospital Conditions and Outcomes After Craniotomy for Traumatic Brain Injury Performed Within 72 Hours in Central Cameroon: A Cross-Sectional Study.

BACKGROUND: Traumatic brain injury (TBI) is the most common neurosurgical condition globally. In Cameroon, there are 572 cases of TBI per 100,000 people, but <40% of Cameroonians live within 4 hours of a neurosurgical facility. We sought to understand the clinical outcomes at a neurosurgical center in Central Cameroon. METHODS: This cross-sectional study was conducted at the largest neurosurgical center of Cameroon, the Yaounde Central Hospital. Data included 100 consecutive patients undergoing an intervention 72 hours after their injury from February 1, 2015 to February 1, 2019. Patients with missing data or undergoing surgery >72 hours after injury were excluded. Analyses of covariance were performed, and a P value >0.05 was considered significant. A Kaplan-Meier survival curve was computed. RESULTS: The patients had a mean age of 31.3 ± 17.4 years, with a male predominance of 91.0%, and the principal mechanism of injury was road traffic accidents (68.0%). Only 11% arrived via ambulance, and 36.0% were admitted <3 hours after the traumatic event. The postoperative mortality was 15.0%, mean survival was 25.0 postoperative days (95% confidence interval, 23.42-26.52), and the mean Glasgow Outcome Scale score at 28 days was 3.9 ± 1.4. CONCLUSIONS: Most patients with TBI undergoing neurosurgery 72 hours after injury in Cameroon arrive at the hospital late and have a high mortality risk during the first postoperative week. Investments in prehospital care should be made to improve surgical outcomes.

Caregiver-provider communication after resection of pediatric brain tumors.

OBJECTIVE: Because caregivers are a crucial part of a child's medical care, it is important to understand how to best communicate with them during hospitalization. Qualitative research can elucidate the best strategies for effective parent-provider communication. This study aims to reveal communication styles of neurosurgery team members, and to identify areas for improvement in the future. METHODS: Caregivers of children with a newly diagnosed brain tumor requiring neurosurgery were enrolled during their child's hospitalization. During routine follow-up clinic visits within 3 months after diagnosis and tumor resection, caregivers participated in a semistructured interview, which assessed the quality of communication with the neurosurgery and oncology teams during hospitalization. Interviews were audio-recorded, transcribed, and coded for common themes until thematic saturation was reached. RESULTS: During caregiver interviews (N = 22), several domains were discussed including communicating the diagnosis to the patient and siblings, to the rest of the family/support network, and with the neurosurgery team. Regarding parent-neurosurgeon communication, 82% of caregivers identified at least one positive aspect and 55% identified at least one negative aspect of communication. Caregivers who provided positive feedback appreciated that their neurosurgeon was thorough (73%), direct (27%), or compassionate (14%). They also valued when providers would speak "on my level" (18%) and would speak directly to the patient (27%). In terms of negative feedback, caregivers identified miscommunications (32%), discussing the diagnosis in front of the child before feeling prepared to do so (14%), and a lack of clarity about expectations, medications, or treatment (32%). CONCLUSIONS: These data provide specific ways in which neurosurgery providers have communicated effectively with caregivers and identify areas for improvement. Results have been used to develop a navigator-led intervention geared toward improving parent-provider communication during hospitalization for resection of a brain tumor.