Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines

Objective

The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden.

Methods

Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes.

Results

Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01).

Conclusions

This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.

Neurosurgery in the Brazilian Amazon: Is It Possible?

BACKGROUND

The need for neurosurgical care across the globe remains a public health issue. The creation of sustainable neurological surgery departments and training programs will be indispensable in alleviating the burden of neurological disease in low to middle income countries (LMICs).

METHODS

We reviewed the history of the neurological surgery department and residency program of Santarém in the state of Pará, Brazil, from 1999 to the present. We have described the epidemiology unique to the region and provided evidence of a sustainable practice in a LMIC. The challenges, limitations, and resources were explored.

RESULTS

We have provided a historical vignette of the evolution of neurological surgery in the Brazilian Amazon, including the creation of a sustainable neurological surgery practice and accredited residency program. In addition, we assessed the neurological surgery burden and epidemiology unique to the region, with an emphasis on the community and indigenous health in this remote area. We also explored the future directions of this example, which could affect the international neurological surgery community.

CONCLUSION

A sustainable neurosurgery practice and training program is possible in a LMIC. Training neurosurgeons in developing regions of LMICs is a sustainable method to decrease the morbidity and mortality of neurological diseases and prevent the misdistribution of physicians in a country. We encourage adaptation of sustainable neurological surgery practices in similar regions across the world to increase access to necessary neurosurgical care.

Systematic review of clinician awareness of mycotoxin impact in neural tube defects and best practices for pediatric neurosurgeons: implications for public health and policy

PURPOSE

In lower-income populations, high rates of neural tube defects (NTDs) are a concern. Nutritional folate deficiencies and mycotoxins in contaminated food supplies increase risk of NTDs. As physicians in public health and involved in the care of children with NTDs, pediatric neurosurgeons have an interest in the treatment and prevention of NTDs. We aimed to evaluate the literature to assess the awareness and the existence of best practices/educational materials on this issue to better guide management.

METHODS

A systematic review using the National Library of Medicine PubMed database was conducted to find articles related to mycotoxins in foods causing neural tube defects. Additional citation searches of key publications and personal collections were used. Two reviewers evaluated the resulting studies for subject area analysis. Best practice recommendations were drawn from articles selected for full-text review.

RESULTS

Seventy-three articles were identified. Most articles were found in "nutritional sciences" (18), "teratology" (14), and "toxicology" (13). No articles were found in neurosurgery. Thirty-two additional articles were identified through other sources to screen best practice recommendations. Of the 105 articles, 34 journal articles were included in best practice recommendation guidelines. Key recommendations included education of proper food storage, hygienic agricultural practices, decontamination techniques, diet diversification, folate supplementation, risk assessment, and food safety policy and public health initiatives.

CONCLUSION

There is an absence of neurosurgical literature-related mycotoxins and NTDs. We suggest a set of best practices/educational materials on this topic and advocate pediatric neurosurgery engagement in public health initiatives targeted towards populations most affected by mycotoxins.

Neurosurgical Oncology in Vietnam

BACKGROUND

In conjunction with Vietnam's unparalleled economic growth over the past 20 years, our scope of neurosurgical interventions has considerably diversified throughout this time period.

METHODS

Although still appreciably limited, healthcare resources and infrastructure have expanded and shifted the focus within neurosurgery at Ho Chi Minh City's Cho Ray Hospital from head trauma (which remains highly prevalent) to an equal proportion of elective cases for vascular lesions, tumors, and degenerative spine disease. Arguably the most significant progress throughout the new millennium has been achieved in the realm of neurosurgical oncology.

RESULTS

About 1000 craniotomies are performed annually for brain tumors at our institution, most of which are for lower-grade lesions that result in excellent surgical outcomes. We continue to strive to improve the standard of care for patients with malignant brain tumors, as the first multidisciplinary neuro-oncology care team was founded recently in 2016.

CONCLUSIONS

This article is the first in the English neurosurgical literature to report on the current state and outcomes of neuro-oncology in Vietnam, as we highlight our experiences in caring for patients with brain tumors at Cho Ray Hospital.

Injury-to-Admission Delay Beyond 4 Hours Is Associated with Worsening Outcomes for Traumatic Brain Injury in Cambodia

BACKGROUND

In Cambodia, the most common victims of traumatic brain injury (TBI) are men 20-30 years of age involved in motor vehicle collision. Secondary injury sustained by these patients occurs during the time period between initial insult and hospital admission. Strengthening prehospital systems for TBI in low- and middle-income countries (LMICs) such as Cambodia is therefore a key element of the development agenda for universal health equity. We report a retrospective analysis of the relationship between prehospital delays and TBI outcomes among patients from a large government hospital in Cambodia.

METHODS

Data were collected from 3476 patients with TBI admitted to a major government hospital in Phnom Penh, Cambodia, from June 2013 to June 2018. Patients with missing data or those admitted >8 hours postinjury were excluded. Statistical analyses examined associations between injury-to-admission delay (IAD) and outcomes such as Glasgow Outcome Scale (GOS) score and length of stay (LOS).

RESULTS

A total of 2125 patients with TBI (76.85% men) were included. The median age was 27 years (interquartile range, 22-37 years). Injury severity at presentation included 1406 mild (66%), 464 moderate (22%), and 240 severe cases (11%). No Glasgow Coma Scale (GCS) data were available for 15 patients (1%). We found an inverse relationship between IAD and GOS score, most evidently for mild and moderate TBI (n = 1870; 88%). Regression analysis revealed a marked decrease in GOS score at the IAD >4-hour threshold. Each 30-minute delay in IAD was correlated with >2-hour increase in LOS for mild (P < 0.001) and moderate TBI (P < 0.001).

CONCLUSIONS

In a retrospective cohort of >2000 patients with TBI from Cambodia, we found that increasing IAD was associated with worsening outcome, especially beyond the 4-hour threshold. These data should inform development of prehospital guidelines for TBI care in LMICs.

The Growth of Neurosurgery in East Africa: Challenges

As the second of 3 articles in this series, the aim of this article is to provide readers with an understanding of the development of neurosurgery in East Africa (foundations), the challenges that arise in providing neurosurgical care in developing countries (challenges), and an overview of traditional and novel approaches to overcoming these challenges and improving health care in the region (innovations). Recognizing the challenges that need to be addressed is the first step to implementing efficient and qualified surgery delivery systems in low- and middle-income countries. We reviewed the major challenges facing health care in East Africa and grouped them into 5 categories: 1) burden of surgical disease and workforce crisis; 2) global health view of surgery as "the neglected stepchild"; 3) need for recognizing the surgical system as an interdependent network and importance of organizational and equipment deficits; 4) lack of education in the community, failure of primary care systems, and net result of overwhelming tertiary care systems; 5) personal and professional burnout as well as brain drain of promising human resources from low- and middle-income countries in East Africa and similar regions across the world. Each major challenge was detailed and analyzed by authors who have worked or are currently working in the region, providing a personal perspective.

Life After the Neurosurgical Ward in Sub-Saharan Africa: Neurosurgical Treatment and Outpatient Outcomes in Uganda

BACKGROUND

In the past decade, neurosurgery in Uganda experienced increasing surgical volume and a new residency training program. Although research has examined surgical capacity, minimal data exist on the patient population treated by neurosurgery and their eventual outcomes in sub-Saharan Africa.

METHODS

Patients admitted to Mulago National Referral Hospital neurosurgical ward over 2 years (2014 and 2015) were documented in a prospective database. In total, 1167 were discharged with documented phone numbers and thus eligible for follow-up. Phone surveys were developed and conducted in the participant's language to assess mortality, neurologic outcomes, and follow-up health care.

RESULTS

During the study period, 2032 patients were admitted to the neurosurgical ward, 80% for traumatic brain injury. A total of 7.8% received surgical intervention. The in-hospital mortality rate was 18%. A total of 870 patients were reached for phone follow-up, a 75% response rate, and 30-day and 1-year mortality were 4% and 8%, respectively. Almost one-half of patients had not had subsequent health care after the initial encounter. Most patients had Glasgow Outcome Scale-Extended scores consistent with good recovery and mild disability, with patients experiencing trauma faring best and patients with tumor faring worst. A total of 85% felt they returned to baseline work performance, and 76% of guardians felt that children returned to baseline school performance.

CONCLUSIONS

The neurosurgical service provided health care to a large proportion of nonoperative patients. Phone surveys captured data on patients in whom nearly one-half would be lost to subsequent health care. Although mortality during initial hospitalization was high, more than 90% of those discharged survived at 1-year follow up, and the vast majority returned to work and school.

Outcomes Following Exploratory Burr Holes for Traumatic Brain Injury in a Resource Poor Setting

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The incidence of TBI in low- and middle-income countries (LMICs) is disproportionately high, with an associated increased risk of mortality from TBI relative to high-income countries. Although computed tomography is the diagnostic method of choice, this is often unavailable in LMICs. Exploratory burr holes may provide a suitable choice for diagnosis and treatment of TBI.

METHODS

We performed a retrospective review of prospectively collected data at KCH, a tertiary care center in Lilongwe, Malawi. All trauma patients presenting between June 2012 and July 2015 with a deteriorating level of consciousness and localizing signs and who underwent exploratory burr holes were included. Additionally, we included all patients admitted with TBI, requiring higher-level care during 2011. No patients underwent exploratory burr hole during this time. We performed logistic regression to identify predictors of mortality in the total population of TBI patients.

RESULTS

Among the 241 patients who presented to KCH with TBI requiring higher-level care, the total mortality was 16.4%. More than half (163, or 68%) underwent exploratory burr hole with a mortality of 6.8%. Mortality in patients who did not undergo exploratory burr hole was 43.9%. Upon adjusted logistic regression, not undergoing exploratory burr hole significantly increased the odds of mortality (odds ratio = 12.0, P = 0.000, 95% confidence interval = 4.48-31.9).

CONCLUSION

Exploratory burr holes remain an important diagnostic and therapeutic procedure for TBI in LMICs. Exploratory burr hole technique should be integrated into general surgery education to attenuate TBI-related mortality.

"To Operate" Versus "Not to Operate" in Low-Resource Settings: Example of Aneurysm Surgery in Rural Iran and Impact of Mastery of Neurosurgical Anatomy

BACKGROUND

Subarachnoid hemorrhage (SAH) has a global incidence of 9/100,000. In low-resource settings, where neurosurgical capacity is diminished through fewer human and technological resources, neurosurgeons may not be prepared to operate on aneurysm cases in emergent situations. We report a patient presented with aneurysmal SAH in rural Iran, creating the dilemma of the will for the neurosurgeon. We discuss the impact of the knowledge of neurosurgical anatomy on the resolution of this dilemma.

CASE DESCRIPTION

A 30-year-old female presented with aneurysmal SAH to a remote medical facility in rural Iran. A safe and fast referral to a nearby vascular neurosurgery center was not available. A contrasted computed tomography (the only available imaging modality) revealed a carotid bifurcation aneurysm. The situation was explained to the patient and family, and they decided to proceed with surgery. With the minimum technical radiological and surgical equipment available, the surgeon managed to successfully treat the patient, aided by his mastery of the neurosurgical anatomy. The patient was discharged without any complication.

CONCLUSIONS

We highlight the importance of mastery of neurosurgical anatomy, which was critical in achieving a favorable patient outcome. The necessity of developing low-cost platforms to enhance neurosurgical anatomy learning in neurosurgical residency programs of low-resource regions and countries is discussed.