Transitioning care for adolescents with spina bifida in the US: challenges for management.

Open spina bifida (OSB) is a common neural tube defect. Medical and surgical care involves addressing the baseline orthopedic, urologic, and neurological dysfunction as well as the changes or declines that may occur as the patient ages. Given the complexity of this disease, coordinated, multidisciplinary care involving specialists in neurosurgery, orthopedics, urology, rehabilitation and physical medicine, pediatrics, and psychology is necessary to establish and optimize baseline function. Traditionally in the US, pediatric multispecialty spina bifida clinics have provided the patient with a coordinated medical support system. Unfortunately, this coordinated, medical home has been difficult to establish during the transition from pediatric to adult care. Medical professionals must have a strong understanding of OSB to properly manage the disease and detect and prevent associated complications. In this manuscript, we (1) describe the changing needs and challenges of people living with OSB over a lifespan, (2) delineate current practices in the transition of care for people with OSB from childhood to adulthood, and (3) provide recommendations for best practices in navigating the transition process for clinicians who provide care for those afflicted with this most complex congenital abnormality of the nervous system compatible with long term survival.

Barriers and facilitators to the implementation of mandatory folate fortification as an evidence-based policy to prevent neural tube defects.

BACKGROUND: Neural tube defects continue to be one of the main congenital malformations affecting the development of the nervous system and a significant cause of disability and disease burden to individuals living with these conditions. Mandatory food fortification with folic acid is, by far, one of the most efficacious, safe, and cost-effective interventions to prevent neural tube defects. However, most countries fail to effectively fortify staple foods with folic acid, impacting public health and healthcare systems and generating dismal disparities. AIM: This article discusses the main barriers and facilitators for implementing mandatory food fortification as an evidence-based policy to prevent neural tube defects worldwide. METHODS: A comprehensive review of the scientific literature allowed the identification of the determinant factors acting as barriers or facilitators for the reach, adoption, implementation, and scaling up of mandatory food fortification with folic acid as an evidence-based policy. RESULTS: We identified eight barriers and seven facilitators as determinant factors for food fortification policies. The identified factors were classified as individual, contextual, and external, inspired by the Consolidated Framework for Implementation of Research (CFIR). We discuss mechanisms to overcome obstacles and seize the opportunities to approach this public health intervention safely and effectively. CONCLUSIONS: Several determinant factors acting as barriers or facilitators influence the implementation of mandatory food fortification as an evidence-based policy worldwide. Notoriously, policymakers in many countries may lack knowledge of the benefits of scaling up their policies to prevent folic acid-sensitive neural tube defects, improve the health status of their communities, and promote the protection of many children from these disabling but preventable conditions. Not addressing this problem negatively affects four levels: public health, society, family, and individuals. Science-driven advocacy and partnerships with essential stakeholders can help overcome the barriers and leverage the facilitators for safe and effective food fortification.

International Women in Neurosurgery.

The history of women in neurosurgery worldwide has been characterized by adversity and hardships in a male-dominated field, where resilient, tenacious, and ingenious women have nevertheless left their mark. The first women in neurosurgery appeared in Europe at the end of the 1920s, and since then have emerged in all continents in the world. Women neurosurgeons all over the globe have advanced the field in numerous directions, introducing neurosurgical subspecialties to their countries, making scientific and technical advances, and dedicating themselves to humanitarian causes, to name a few. The past 30 years, in particular, have been a period of increasing involvement and responsibility for women in neurosurgery. We must now focus on continual system improvements that will promote a diverse and talented workforce, building a welcoming environment for all aspiring neurosurgeons, in order to advance the specialty in the service of neurosurgical patients.

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

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

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement.

BACKGROUND: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

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

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

Reducing inequities in preventable neural tube defects: the critical and underutilized role of neurosurgical advocacy for folate fortification.

Neural tube defects (NTDs) are one of the greatest causes of childhood mortality and disability-adjusted life years worldwide. Global prevalence at birth is approximately 18.6 per 10,000 live births, with more than 300,000 infants with NTDs born every year. Substantial strides have been made in understanding the genetics, pathophysiology, and surgical treatment of NTDs, yet the natural history remains one of high morbidity and profound impairment of quality of life. Direct and indirect costs of care are enormous, which ensures profound inequities and disparities in the burden of disease in countries of low and moderate resources. All indices of disease burden are higher for NTDs in developing countries. The great tragedy is that the majority of NTDs can be prevented with folate fortification of commercially produced food. Unequivocal evidence of the effectiveness of folate to reduce the incidence of NTDs has existed for more than 25 years. Yet, the most comprehensive surveys of effectiveness of implementation strategies show that more than 100 countries fail to fortify, and consequently only 13% of folate-preventable spina bifida is actually prevented. Neurosurgeons harbor a disproportionate, central, and fundamental role in the management of NTDs and enjoy high standing in society. No organized group in medicine can speak as authoritatively or convincingly. As a result, neurosurgeons and organized neurosurgery harbor disproportionate potential to advocate for more comprehensive folate fortification, and thereby prevent the most common and severe birth defect to impact the human nervous system. Assertive, proactive, informed advocacy for folate fortification should be a central and integral part of the neurosurgical approach to NTDs. Only by making the prevention of dysraphism a priority can we best address the inequities often observed worldwide.

Opportunities and Considerations for the Incorporation of Artificial Intelligence into Global Neurosurgery: A Generative Pretrained Transformer Chatbot-Based Approach.

OBJECTIVE: Global neurosurgery is a public health focus in neurosurgery that seeks to ensure safe, timely, and affordable neurosurgical care to all individuals worldwide. Although investigators have begun to explore the promise of artificial intelligence (AI) for neurosurgery, its applicability to global neurosurgery has been largely hypothetical. We characterize opportunities and considerations for the incorporation of AI into global neurosurgery by synthesizing key themes yielded from a series of generative pretrained transformers (GPTs), discuss important limitations of GPTs and cautions when using AI in neurosurgery, and develop a framework for the equitable incorporation of AI into global neurosurgery. METHODS: ChatGPT, Bing Chat/Copilot, You, Perplexity.ai, and Google Bard were queried with the prompt "How can AI be incorporated into global neurosurgery?" A layered ChatGPT-based thematic analysis was performed. The authors synthesized the results into opportunities and considerations for the incorporation of AI in global neurosurgery. A Pareto analysis was conducted to determine common themes. RESULTS: Eight opportunities and 14 important considerations were synthesized. Six opportunities related to patient care, 1 to education, and another to public health planning. Four of the important considerations were deemed specific to global neurosurgery. The Pareto analysis included all 8 opportunities and 5 considerations. CONCLUSIONS: AI may be incorporated into global neurosurgery in a variety of capacities requiring numerous considerations. The framework presented in this manuscript may facilitate the incorporation of AI into global neurosurgery initiatives while balancing contextual factors and the reality of limited resources.

Raney: a ubiquitous neurosurgical eponym.

Prior to the 1937 invention of the Raney clip, surgeons relied on hemostatic sutures, pneumatic tourniquets, sequentially applied hemostatic forceps, and the administration of local vasoconstrictive agents to achieve scalp hemostasis. The Raney clip is now the quintessential tool for achieving scalp hemostasis in cranial neurosurgery; with nearly 13.8 million cranial neurosurgical cases per year globally, Raney clips are in high demand and their use is ubiquitous. What is less known, however, is the story of their invention and the related stories of those who bear the Raney name. This paper fills these gaps in neurosurgical history, using information obtained during an extensive series of contemporary interviews and correspondence with the Raney family.

Education and Training in Global Neurosurgery: Current State and Path Toward a Uniform Curriculum.

Education is a sustainable long-term measure to address the global burden of neurosurgical disease. Neurosurgery residencies in high-income countries are accredited by a regional governing body and incorporate various educational activities. Few opportunities for training may be present in low-income and middle-income countries due to a lack of neurosurgery residency programs, tuition, and health care workforce reductions. Core components of a neurosurgical training curriculum include operative room experience, clinical rounds, managing inpatients, and educational conferences. A gold standard for neurosurgical education is essential for creating comprehensive training experience, though training must be contextually appropriate.

Tracking the Global Burden of Neural Tube Defects and Assessing Disparities Across World Health Organization Regions: A Scoping Literature Review.

BACKGROUND AND OBJECTIVES: Neural tube defects (NTDs) are an important cause of global morbidity worldwide. Well-planned global neurosurgery and public health efforts can aid vulnerable communities, but there is a need to elucidate the global burden of NTDs and identify regions without available data to better target interventions. METHODS: A scoping review to quantify worldwide NTD prevalence using the PubMed/Medline and birth defects surveillance registries was conducted. Data published after January 1, 1990, encompassing prevalence values of at least the 2 most prevalent NTDs-spina bifida and encephalocele-were abstracted. Average NTD prevalence rates were aggregated by World Health Organization (WHO) region and World Bank classification, and differences were determined using the analysis of variance test. Differences in availability of nationally representative data by WHO region and World Bank classification were determined using χ2 tests. RESULTS: This review captured 140 studies from a total of 93 of 194 WHO member countries. The percentage of countries within a geographic region with available NTD prevalence data was highest in the Eastern Mediterranean (EMR) (85.7%) and lowest in Africa (AFR) (31.3%). The NTD prevalence range was 0.9-269.6 per 10 000 births. Statistically significant differences in reported NTD prevalence rates existed by WHO Region (P = .00027) and World Bank income level of study country (P = .00193). Forty countries (43%) had conducted national-level studies assessing NTD prevalence. There was a statistically significant difference in the availability of nationally representative prevalence data depending on the WHO region (P = .0081) and World Bank classification of study country (P = .0017). CONCLUSION: There is a gap in availability of NTD prevalence data worldwide, with many WHO member states lacking national-level NTD prevalence estimates. These findings highlight the need for greater NTD surveillance efforts to identify the countries with the greatest need for targeted global intervention.

Global Neurosurgery: A Path Forward Through Health System Strengthening.

The future of global neurosurgery should focus on addressing the unmet neurosurgical need from a health system approach should we hope to achieve sustainable and ethical change. In this article, we review the global building blocks, as defined by the World Health Organization, and use this framework to propose strategies to strengthen neurosurgical care on the global frontier. The targets for Universal Healthcare Coverage by 2030, as outlined by the United Nations Sustainable Development Goals, are reviewed, and the role of neurosurgeons in addressing the global targets is discussed. Surgical indicators according to the Lancet Commission on Global Surgery are also reviewed, and neurosurgical indicators are proposed according to the 6 surgical indicators of the commission. The execution of these global targets and indicators within the context of health system strengthening will be a persistent challenge, given the complexity of health system and its components. The neurosurgical community must continue to support, promote, and diversify collaborations, especially among deserts of neurosurgical care across the world. Innovative technology and education are essential to this global dilemma.

Achieving Equity Through Global Neurosurgery Research.

Since the release of the Lancet Commission on Global Surgery report in 2015, there has been an increase in the number of published papers on global neurosurgery, gaining widespread support from major neurosurgery journals. However, there remains no consensus on what may be considered part of global neurosurgery literature. Here, we propose that global neurosurgery research encompasses all scholarly work that measure, explore, or address inequity in the care of neurosurgical disease. We describe the growth of global neurosurgery research, cite landmark papers, and discuss barriers to participation, particularly among neurosurgeons in low- and middle-income countries. We introduce the 3Rs framework, advocating for global neurosurgery research that is rigorous, responsive, and responsible. This narrative review aims to guide young neurosurgeons and other researchers interested in the field, and to provide a framework through which global neurosurgery practitioners and advocates can evaluate previously accomplished work, paving the way toward neurosurgery that is timely, safe, and affordable to all.

Neurosurgical Advocacy in the Prevention of Neural Tube Defects: Impacting Global Fortification Policies Through Leadership, Collaboration, and Stakeholder Engagement.

The G4 Alliance and its member organizations formed a delegation that participated in the 76th World Health Assembly (WHA) in 2023, which unanimously adopted the resolution to address micronutrient deficiencies through safe, effective food fortification to prevent congenital disorders such as spina bifida and anencephaly, the first neurosurgery-led resolution since the founding of the World Health Organization. The WHA included other resolutions and side events by the G4 Alliance and other organizations relevant to neurosurgery. An opportunity exists for neurosurgeons to harness the momentum from this resolution to promote initiatives to prevent neurosurgical disease or expand access to neurosurgical care.

The Impact of Colonialism on Surgical Training Structures in Africa Part 1: Contextualizing the Past, Present, and Future.

Since the first African country attained independence from colonial rule, surgical training on the continent has evolved along 3 principal models. The first is a colonial, local master-apprentice model, the second is a purely local training model, and the third is a collegiate intercountry model. The 3 models exist currently and there are varied perceptions of their relative merits in training competent neurosurgeons. We reviewed the historical development of training and in an accompanying study, seek to describe the complex array of surgical training pathways and explore the neocolonial underpinnings of how these various models of training impact today the development of surgical capacity in Africa. In addition, we sought to better understand how some training systems may contribute to the widely recognized "brain drain" of surgeons from the African continent to high income countries in Europe and North America. To date, there are no published studies evaluating the impact of surgical training systems on skilled workforce emigration out of Africa. This review aims to discover potentially addressable sources of improving healthcare and training equity in this region.

The Impact of Colonialism on Surgical Training Structures In Africa Part 2: Surveying Current and Past Trainees.

BACKGROUND: As a result of gradual independence from colonial rule over the course of the past century, Africa has developed and evolved 3 primary surgical training structures: an extracontinental colonial model, an intracontinental college-based model, and several smaller national or local models. There is consistent evidence of international brain drain of surgical trainees and an unequal continental distribution of surgeons; however there has not, to date, been an evaluation of the impact colonialism on the evolution of surgical training on the continent. This study aims to identify the etiologies and consequences of this segmentation of surgical training in Africa. METHODS: This is a cross-sectional survey of the experience and perspectives of surgical training by current African trainees and graduates. RESULTS: A surgeon's region of residence was found to have a statistically significant positive association with that of a surgeon's training structure (P <0.001). A surgeon's professional college or structure of residency has a significantly positive association with desire to complete subspecialty training (P = 0.008). College and structure of residency also are statistically significantly associated with successful completion of subspecialty training (P < 0.001). CONCLUSIONS: These findings provide evidence to support the concept that the segmentation of surgical training structures in Africa, which is the direct result of prior colonization, has affected the distribution of trainees and specialists across the continent and the globe. This maldistribution of African surgical trainees directly impacts patient care, as the surgeon-patient ratios in many African countries are insufficient. These inequities should be acknowledged addressed and rectified to ensure that patients in Africa receive timely and appropriate surgical care.

Global Neurosurgery: An Overview.

In the following article, we define the practice of global neurosurgery and review the major historical events defining this movement within the larger context of global surgery. The current state of the neurosurgical workforce, disease burden, and ongoing collaborative efforts are highlighted. Ethical practice leading the sustainability is discussed, as well as future targets for the global community as we look beyond the next decade of opportunities to affect the neurosurgical burden of disease.

Education and Training in Global Neurosurgery: The Quest for Diversity and Equitable Collaborations.

Education and training are essential components of global neurosurgery because they provide a sustainable solution to address the workforce deficits in the neurosurgical burden of disease. Neurosurgery training programs and opportunities exist in most areas of the world, but some countries still lack formal mechanisms to train future generations. In this special article, we review the neurosurgical workforce deficit, characterize factors influencing the absence or inadequacy of neurosurgical training, and identify strategies that could facilitate global efforts in building a stronger workforce. We summarize the key neurosurgical training models worldwide and the factors influencing the standardization of neurosurgical education by region. In addition, we evaluate the "brain drain" issue in the larger context of the healthcare workforce and propose solutions to mitigate this phenomenon in neurosurgical practice. Future generations of neurosurgical trainees depend on our efforts to intensify and expand education and training in this new virtual era. As we look to the future, we must prioritize education to strengthen the future neurosurgeons who will lead and shape the frontiers of our field.

Neurosurgery Training in Greece.

OBJECTIVE: The structure and specifics of neurosurgery residency training vary substantially across programs and countries, potentially leading to differences in clinical reasoning, surgical skills, and professionalism. The Greek neurosurgical training system is unique in numerous respects. This manuscript delineates the current state of neurosurgical residency training in Greece and outlines future directions. METHODS: A narrative review was conducted to describe the Greek neurosurgical residency training structure. The perspectives of the authors regarding challenges in training and future directions were synthesized. RESULTS: This manuscript describes the neurosurgery residency curriculum and board certification process, existing training programs, and key challenges in neurosurgery residency training in Greece. The authors propose future directions to reform neurosurgical training in Greece. CONCLUSIONS: Neurosurgery residency training in Greece has been largely unchanged for many years. This review leads to suggested modification of the existing training process may improve the quality of training and equip neurosurgeons to respond to the rapidly changing landscape of the field.