Epidemiology of pediatric hydrocephalus in Haiti: analysis of a surgical case series

Cumulative Damage: Cell Death in Posthemorrhagic Hydrocephalus of Prematurity

Globally, approximately 11% of all infants are born preterm, prior to 37 weeks’ gestation. In these high-risk neonates, encephalopathy of prematurity (EoP) is a major cause of both morbidity and mortality, especially for neonates who are born very preterm (<32 weeks gestation). EoP encompasses numerous types of preterm birth-related brain abnormalities and injuries, and can culminate in a diverse array of neurodevelopmental impairments. Of note, posthemorrhagic hydrocephalus of prematurity (PHHP) can be conceptualized as a severe manifestation of EoP. PHHP impacts the immature neonatal brain at a crucial timepoint during neurodevelopment, and can result in permanent, detrimental consequences to not only cerebrospinal fluid (CSF) dynamics, but also to white and gray matter development. In this review, the relevant literature related to the diverse mechanisms of cell death in the setting of PHHP will be thoroughly discussed. Loss of the epithelial cells of the choroid plexus, ependymal cells and their motile cilia, and cellular structures within the glymphatic system are of particular interest. Greater insights into the injuries, initiating targets, and downstream signaling pathways involved in excess cell death shed light on promising areas for therapeutic intervention. This will bolster current efforts to prevent, mitigate, and reverse the consequential brain remodeling that occurs as a result of hydrocephalus and other components of EoP.

Timely Access to Neurosurgical Care in the Caribbean Using Geospatial Analysis

BACKGROUND

Access to timely neurosurgical care in particular remains limited worldwide, and is associated with increased morbidity and mortality, a decrease in overall life expectancy, and catastrophic economic costs. To date, access to neurosurgical care has not been completely studied and reported in the Caribbean neurosurgical literature. In this study, we aim to understand the geographic distribution of hospital facilities with neurosurgical capacity among the CARICOM member states to determine timely access to neurosurgical care.

METHODS

We assessed geographical access to facilities capable of providing neurosurgical care in the Caribbean. The GPS coordinates of the hospitals that provide neurosurgical care were identified using street addresses and satellite imaging from Google Maps. Facilities with neurosurgical care were mapped in ArcGIS Pro (Version 2.6.0). using Manhattan distance. We identified the area around each facility and stratified by 30- minute, 1-hour, 2-hour, and 4-hour geographic driving intervals.

RESULTS

A total of 16 hospitals were identified as providing neurosurgical care in the Caribbean. Our results suggest that 14 million people (76% of the population) had 4-hour geographic access to a facility capable of providing neurosurgical care. In addition, 7 million people (40% of the population) had 2-hour geographical access to neurosurgical care.

CONCLUSIONS

Timely access to care is an important tenet of global neurosurgery. We found that 3.5 million Caribbean residents are outside of the access zone to neurosurgical capacity. Public health advocates, governments, providers, and patients should be aware of the inequity in access to neurosurgical care and should collectively work to close the gap.

The initial experience of InterSurgeon: an online platform to facilitate global neurosurgical partnerships

OBJECTIVE

Despite general enthusiasm for international collaboration within the organized neurosurgical community, establishing international partnerships remains challenging. The current study analyzes the initial experience of the InterSurgeon website in partnering surgeons from across the world to increase surgical collaboration.

METHODS

One year after the launch of the InterSurgeon website, data were collected to quantify the number of website visits, average session duration, total numbers of matches, and number of offers and requests added to the website each month. Additionally, a 15-question survey was designed and distributed to all registered members of the website.

RESULTS

There are currently 321 surgeon and institutional members of InterSurgeon representing 69 different countries and all global regions. At the time of the survey there were 277 members, of whom 76 responded to the survey, yielding a response rate of 27.4% (76/277). Twenty-five participants (32.9%) confirmed having either received a match email (12/76, 15.8%) or initiated contact with another user via the website (13/76, 17.1%). As expected, the majority of the collaborations were either between a high-income country (HIC) and a low-income country (LIC) (5/18, 27.8%) or between an HIC and a middle-income country (MIC) (9/18, 50%). Interestingly, there were 2 MIC-to-MIC collaborations (2/18, 11.1%) as well as 1 MIC-to-LIC (1/18, 5.6%) and 1 LIC-to-LIC partnership. At the time of response, 6 (33.3%) of the matches had at least resulted in initial contact via email or telephone. One of the partnerships had involved face-to-face interaction via video conference. A total of 4 respondents had traveled internationally to visit their partner’s institution.

CONCLUSIONS

Within its first year of launch, the InterSurgeon membership has grown significantly. The partnerships that have already been formed involve not only international visits between HICs and low- to middle-income countries (LMICs), but also telecollaboration and inter-LMIC connections that allow for greater exchange of knowledge and expertise. As membership and site features grow to include other surgical and anesthesia specialties, membership growth and utilization is expected to increase rapidly over time according to social network dynamics.

Endoscopic third ventriculostomy with choroid plexus cauterization for the treatment of infantile hydrocephalus in Haiti

OBJECTIVE

Untreated hydrocephalus poses a significant health risk to children in the developing world. In response to this risk, global neurosurgical efforts have increasingly focused on endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of infantile hydrocephalus in low- and middle-income countries (LMICs). Here, the authors report their experience with ETV/CPC at the Hospital Bernard-Mevs/Project Medishare (HBMPM) in Port-au-Prince, Haiti.

METHODS

The authors conducted a retrospective review of a series of consecutive children who had undergone ETV/CPC for hydrocephalus over a 1-year period at HBMPM. The primary outcome of interest was time to ETV/CPC failure. Univariate and multivariate analyses using a Cox proportional hazards regression were performed to identify preoperative factors that were associated with outcomes.

RESULTS

Of the 82 children who underwent ETV/CPC, 52.2% remained shunt free at the last follow-up (mean 6.4 months). On univariate analysis, the ETV success score (ETVSS; p = 0.002), success of the attempted ETV (p = 0.018), and bilateral CPC (p = 0.045) were associated with shunt freedom. In the multivariate models, a lower ETVSS was independently associated with a poor outcome (HR 0.072, 95% CI 0.016-0.32, p < 0.001). Two children (2.4%) died of postoperative seizures.

CONCLUSIONS

As in other LMICs, ETV/CPC is an effective treatment for hydrocephalus in children in Haiti, with a low but significant risk profile. Larger multinational prospective databases may further elucidate the ideal candidate for ETV/CPC in resource-poor settings.