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Lebouille-Veldman AB, Singh T, Patel Y, Lassarén P, Nawabi N, Frankhauser F, Mammi M, Khawaja A, Mekary RA, Lepard JR, Smith TR. The Impact of Tort Reforms on the Neurosurgical Malpractice Environment: A Systematic Review of Literature. World Neurosurg 2023; 173:218-225.e4. [PMID: 36822400 DOI: 10.1016/j.wneu.2023.02.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Neurosurgeons, especially spine surgeons, have the highest risk of facing a malpractice claim. Average verdicts in spine surgery litigation has been shown to be over USD $1 million/case. This systematic review aimed to clarify the impact of tort reforms on neurosurgical health care environments across the United States, including patient outcomes, practice of defensive medicine, and physician supply aims. METHODS A systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases until May 13, 2022. Study quality was assessed using the quality assessment tool for studies reporting prevalence data. RESULTS Five studies (all rated as good quality) were included. Two studies found that in higher-risk state malpractice environments, risk of postoperative complications was higher and odds of nonhome discharge were larger (odds ratio 1.1169, 95% confidence interval 1.139-1.200). One study found that neurosurgeons reported practice of defensive medicine by ordering more imaging in a higher-risk environment, while this was not shown in a study examining imaging rates in different medicolegal environments. One study observed that noneconomic damage caps were associated with a 3.9% increase of physician supply in high-risk specialties. CONCLUSIONS There was a suggestive association between tort reforms and less practice of defensive medicine among neurosurgeons, improvement in postoperative outcomes in spinal fusion patients, and increase in physician supply. More elaborate studies on the medicolegal environment in neurosurgical practice are needed to give more insight on the current size of the problem that litigation presents in the United States and the effects tort reforms have on neurosurgical health care environments.
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Affiliation(s)
- Anna Baukje Lebouille-Veldman
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Tavneet Singh
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Yug Patel
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Philipp Lassarén
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Noah Nawabi
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; Medical University of South Carolina, College of Medicine, Charleston, South Carolina, USA
| | - Frederick Frankhauser
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Marco Mammi
- Neurosurgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Ayaz Khawaja
- Department of Neurology, Wayne State University, Detroit, Michigan, USA
| | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA.
| | - Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Lepard JR, Yaeger K, Mazzola C, Stacy J, Shuer L, Kimmel K. Mechanisms of Peer Review and Their Potential Impact on Neurosurgeons: A Pilot Survey. World Neurosurg 2022; 167:e469-e474. [PMID: 35973519 DOI: 10.1016/j.wneu.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Physician peer review is a universal practice in U.S. hospitals. While there are many commonalities in peer review procedures, many of them established by law, there is also much institutional variation, which should be well understood by practicing neurosurgeons. METHODS A 13-question pilot survey was conducted of a sample of 5 hospital systems with whom members of the Council of State Neurosurgical Societies Medico-Legal Committee are affiliated. Survey questions were constructed to qualitatively assess 3 features of hospital peer review: 1) committee composition and process, 2) committee outcomes, and 3) legal protections and ramifications. RESULTS The most common paradigm for a physician peer review committee was an interdisciplinary group with representatives from most major medical and surgical subspecialties. Referrals for peer review inquiry could be made by any hospital employee and were largely anonymous. Most institutions included a precommittee screening process conducted by the physician peer review committee leadership. The most common outcomes of an inquiry were resolution with no further action or ongoing focused professional practice evaluation. Hospital privileges were only rarely reported to be revoked or terminated. Members of the physician peer review committee were consistently protected from retaliatory litigation related to peer review participation. Most hospitals had a multilayered decision process and availability of appeal to minimize potential for punitive investigations. CONCLUSIONS According to a recent study, only 62% of hospitals consider their peer review process to be highly or significantly standardized. This pilot survey provides commentary of potential areas of commonality and variation among hospital peer review practices.
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Affiliation(s)
- Jacob R Lepard
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Kurt Yaeger
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Catherine Mazzola
- Division of Pediatric Neurological Surgery, New Jersey Pediatric Neuroscience Institute, Morristown, New Jersey, USA
| | - Jason Stacy
- Division of Neurosurgery, North Mississippi Medical Center, Tupelo, Mississippi, USA
| | - Lawrence Shuer
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kristopher Kimmel
- Department of Neurosurgery, Rochester Regional Health, Rochester, New York, USA
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Mediratta S, Lepard JR, Barthélemy EJ, Corley J, Park KB. Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers. J Neurosurg 2021; 137:1-10. [PMID: 34952519 DOI: 10.3171/2021.9.jns21916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers. METHODS The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk. RESULTS Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region. CONCLUSIONS While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.
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Affiliation(s)
- Saniya Mediratta
- 1Faculty of Medicine, Imperial College London, South Kensington Campus, London
- 2NIHR Global Health Research Group on Neurotrauma, University of Cambridge, United Kingdom
| | - Jacob R Lepard
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ernest J Barthélemy
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 5Department of Neurosurgery, Mount Sinai Health System, New York, New York; and
| | - Jacquelyn Corley
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 6Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Kee B Park
- 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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Lepard JR, Kim I, Arynchyna A, Lew SM, Bollo RJ, O'Neill BR, Perry MS, Donahue D, Smyth MD, Blount J. Early implementation of stereoelectroencephalography in children: a multiinstitutional case series. J Neurosurg Pediatr 2021:1-8. [PMID: 34479204 DOI: 10.3171/2021.5.peds20923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 05/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric stereoelectroencephalography (SEEG) has been increasingly performed in the United States, with published literature being limited primarily to large single-center case series. The purpose of this study was to evaluate the experience of pediatric epilepsy centers, where the technique has been adopted in the last several years, via a multicenter case series studying patient demographics, outcomes, and complications. METHODS A retrospective cohort methodology was used based on the STROBE criteria. ANOVA was used to evaluate for significant differences between the means of continuous variables among centers. Dichotomous outcomes were assessed between centers using a univariate and multivariate logistic regression. RESULTS A total of 170 SEEG insertion procedures were included in the study from 6 different level 4 pediatric epilepsy centers. The mean patient age at time of SEEG insertion was 12.3 ± 4.7 years. There was no significant difference between the mean age at the time of SEEG insertion between centers (p = 0.3). The mean number of SEEG trajectories per patient was 11.3 ± 3.6, with significant variation between centers (p < 0.001). Epileptogenic loci were identified in 84.7% of cases (144/170). Patients in 140 cases (140/170, 82.4%) underwent a follow-up surgical intervention, with 47.1% (66/140) being seizure free at a mean follow-up of 30.6 months. An overall postoperative hemorrhage rate of 5.3% (9/170) was noted, with patients in 4 of these cases (4/170, 2.4%) experiencing a symptomatic hemorrhage and patients in 3 of these cases (3/170, 1.8%) requiring operative evacuation of the hemorrhage. There were no mortalities or long-term complications. CONCLUSIONS As the first multicenter case series in pediatric SEEG, this study has aided in establishing normative practice patterns in the application of a novel surgical technique, provided a framework for anticipated outcomes that is generalizable and useful for patient selection, and allowed for discussion of what is an acceptable complication rate relative to the experiences of multiple institutions.
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Affiliation(s)
- Jacob R Lepard
- 1Department of Neurological Surgery, University of Alabama at Birmingham, Alabama
| | - Irene Kim
- 2Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anastasia Arynchyna
- 1Department of Neurological Surgery, University of Alabama at Birmingham, Alabama
| | - Sean M Lew
- 2Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert J Bollo
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Brent R O'Neill
- 4Department of Neurological Surgery, Colorado University, Colorado Springs, Colorado
| | - M Scott Perry
- 5Department of Neurology, Cook Children's Medical Center, Fort Worth
| | - David Donahue
- 6Department of Neurological Surgery, Cook Children's Medical Center, Fort Worth, Texas; and
| | - Matthew D Smyth
- 7Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Blount
- 1Department of Neurological Surgery, University of Alabama at Birmingham, Alabama
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Lepard JR, Spagiari R, Corley J, Barthélemy EJ, Kim E, Patterson R, Venturini S, Still MEH, Lo YT, Rosseau G, Mekary RA, Park KB. Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003795. [PMID: 34534215 PMCID: PMC8486090 DOI: 10.1371/journal.pmed.1003795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 10/01/2021] [Accepted: 09/03/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Jacob R. Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | | | - Jacquelyn Corley
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Ernest J. Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, United States of America
| | - Eliana Kim
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- University of California-San Francisco School of Medicine, San Francisco, California, United States of America
| | - Rolvix Patterson
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Sara Venturini
- Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom
| | - Megan E. H. Still
- Department of Neurosurgery, University of Florida, Gainesville, Florida, United States of America
| | - Yu Tung Lo
- Department of Neurosurgery, National Neuroscience Institute, Singapore
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Gail Rosseau
- Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America
| | - Rania A. Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- School of Pharmacy, MCPHS University, Boston, Massachusetts, United States of America
| | - Kee B. Park
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Can DDT, Lepard JR, Anh NM, Tuan PA, Tuan TD, Son VT, Grant JH, Johnston JM. Nonsyndromic craniosynostosis in Vietnam: initial surgical outcomes of subspecialty mentorship. J Neurosurg Pediatr 2021; 28:508-515. [PMID: 34450594 DOI: 10.3171/2021.5.peds20932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a global deficit of pediatric neurosurgical care, and the epidemiology and overall surgical care for craniosynostosis is not well characterized at the global level. This study serves to highlight the details and early surgical results of a neurosurgical educational partnership and subsequent local scale-up in craniosynostosis correction. METHODS A prospective case series was performed with inclusion of all patients undergoing correction of craniosynostosis by extensive cranial vault remodeling at Children's Hospital 2, Ho Chi Minh City, Vietnam, between January 1, 2015, and December 31, 2019. RESULTS A total of 76 patients were included in the study. The group was predominantly male, with a male-to-female ratio of 3.3:1. Sagittal synostosis was the most common diagnosis (50%, 38/76), followed by unilateral coronal (11.8%, 9/76), bicoronal (11.8%, 9/76), and metopic (7.9%, 6/76). The most common corrective technique was anterior cranial vault remodeling (30/76, 39.4%) followed by frontoorbital advancement (34.2%, 26/76). The overall mean operative time was 205.8 ± 38.6 minutes, and the estimated blood loss was 176 ± 89.4 mL. Eleven procedures were complicated by intraoperative durotomy (14.5%, 11/76) without any damage of dural venous sinuses or brain tissue. Postoperatively, 4 procedures were complicated by wound infection (5.3%, 4/76), all of which required operative wound debridement. There were no neurological complications or postoperative deaths. One patient required repeat reconstruction due to delayed intracranial hypertension. There was no loss to follow-up. All patients were followed at outpatient clinic, and the mean follow-up period was 32.3 ± 18.8 months postoperatively. CONCLUSIONS Surgical care for pediatric craniosynostosis can be taught and sustained in the setting of collegial educational partnerships with early capability for high surgical volume and safe outcomes. In the setting of the significant deficit in worldwide pediatric neurosurgical care, this study provides an example of the feasibility of such relationships in addressing this unmet need.
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Affiliation(s)
- Dang Do Thanh Can
- 1University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam.,2Neurosurgical Department, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Jacob R Lepard
- 3Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama.,4Section of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama; and
| | - Nguyen Minh Anh
- 1University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Pham Anh Tuan
- 1University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Tran Diep Tuan
- 1University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Vo Tan Son
- 1University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - John H Grant
- 5Department of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Johnston
- 3Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama.,4Section of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama; and
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Lepard JR, Barthélemy EJ, Corley J, Nalwanga J, Dewan M. In Reply to the Letter to the Editor Regarding "The Resident's Role in Global Neurosurgery". World Neurosurg 2021; 146:433. [PMID: 33607753 DOI: 10.1016/j.wneu.2020.11.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Jacquelyn Corley
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Juliet Nalwanga
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Michael Dewan
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
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Lepard JR, Dupépé E, Davis M, DeWolfe J, Agee B, Bentley JN, Riley K. Surgically treatable adult epilepsy: a changing patient population. Experience from a level 4 epilepsy center. J Neurosurg 2021:1-6. [PMID: 34049280 DOI: 10.3171/2020.10.jns201629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Invasive monitoring has long been utilized in the evaluation of patients for epilepsy surgery, providing localizing information to guide resection. Stereoelectroencephalography (SEEG) was introduced at the authors' level 4 epilepsy surgery program in 2013, with responsive neurostimulation (RNS) becoming available the following year. The authors sought to characterize patient demographics and epilepsy-related variables before and after SEEG introduction to understand whether differences emerged in their patient population. This information will be useful in understanding how SEEG, possibly in conjunction with RNS availability, may have changed practice patterns over time. METHODS This is a retrospective cohort study of consecutive patients who underwent surgery for epilepsy from 2006 to 2018, comprising 7 years before and 5 years after the introduction of SEEG. The authors performed univariate analyses of patient characteristics and outcomes and used generalized estimating equations logistic regression for predictive analysis. RESULTS A total of 178 patients were analyzed, with 109 patients in the pre-SEEG cohort and 69 patients in the post-SEEG cohort. In the post-SEEG cohort, more patients underwent invasive monitoring for suspected bilateral seizure onsets (40.6% vs 22.0%, p = 0.01) and extratemporal seizure onsets (68.1% vs 8.3%, p < 0.0001). The post-SEEG cohort had a higher proportion of patients with seizures arising from eloquent cortex (14.5% vs 0.9%, p < 0.001). Twelve patients underwent RNS insertion in the post-SEEG group versus none in the pre-SEEG group. Fewer patients underwent resection in the post-SEEG group (55.1% vs 96.3%, p < 0.0001), but there was no significant difference in rates of seizure freedom between cohorts for those patients having undergone a follow-up resection (53.1% vs 59.8%, p = 0.44). CONCLUSIONS These findings demonstrate that more patients with suspected bilateral, eloquent, or extratemporal epilepsy underwent invasive monitoring after adoption of SEEG. This shift occurred coincident with the adoption of RNS, both of which likely contributed to increased patient complexity. The authors conclude that their practice now considers invasive monitoring for patients who likely would not previously have been candidates for surgical investigation and subsequent intervention.
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Haji FA, Lepard JR, Davis MC, Lien ND, Can DDT, Hung CV, Thang LN, Rocque BG, Johnston JM. A model for global surgical training and capacity development: the Children's of Alabama-Viet Nam pediatric neurosurgery partnership. Childs Nerv Syst 2021; 37:627-636. [PMID: 32720077 DOI: 10.1007/s00381-020-04802-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Training capable and competent neurosurgeons to work in underserved regions of the world is an essential component of building global neurosurgical capacity. One strategy for achieving this goal is establishing longitudinal partnerships between institutions in low- and middle-income countries (LMICs) and their counterparts in high-income countries (HICs) utilizing a multi-component model. We describe the initial experience of the Children's of Alabama (COA) Global Surgery Program partnership with multiple Vietnamese neurosurgical centers. METHODS The training model developed by the COA Global Surgery Program utilizes three complementary and interdependent methods to expand neurosurgical capacity: in-country training, out-of-country training, and ongoing support and mentorship. Multiple Vietnamese hospital systems have participated in the partnership, including three hospitals in Hanoi and one hospital in Ho Chi Minh City. RESULTS During the 7 years of the partnership, the COA and Viet Nam teams have collaborated on expanding pediatric neurosurgical care in numerous areas of clinical need including five subspecialized areas of pediatric neurosurgery: cerebrovascular, epilepsy, neuroendoscopy for hydrocephalus management, craniofacial, and neuro-oncology. CONCLUSION Long-term partnerships between academic departments in LMICs and HICs focused on education and training are playing an increasingly important role in scaling up global surgical capacity. We believe that our multi-faceted approach consisting of in-country targeted hands-on training, out-of-country fellowship training at the mentor institution, and ongoing mentorship using telecollaboration and Internet-based tools is a viable and generalizable model for enhancing surgical capacity globally.
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Affiliation(s)
- Faizal A Haji
- Division of Neurosurgery, Kingston Health Sciences Centre, Kingston, Ontario, Canada. .,Department of Surgery, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Jacob R Lepard
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Neurosurgery, Children's of Alabama Hospital, Birmingham, AL, USA
| | - Matthew C Davis
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Neurosurgery, Children's of Alabama Hospital, Birmingham, AL, USA
| | - Nguyen Duc Lien
- Department of Neurosurgery, Viet Nam National Cancer Hospital, Hanoi, Vietnam
| | - Dang Do Thanh Can
- Department of Neurosurgery, Children's Hospital #2, Ho Chi Minh City, Vietnam
| | - Cao Vu Hung
- Department of Neurology, Viet Nam National Chrildren's Hospital, Hanoi, Vietnam
| | - Le Nam Thang
- Department of Neurosurgery, Viet Nam National Children's Hospital, Hanoi, Vietnam
| | - Brandon G Rocque
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Neurosurgery, Children's of Alabama Hospital, Birmingham, AL, USA
| | - James M Johnston
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Neurosurgery, Children's of Alabama Hospital, Birmingham, AL, USA
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Abstract
BACKGROUND In the last 20 yr, the rate of neurosurgical guideline publication has increased. However, despite the higher volume and increasing emphasis on quality there remains no reliable means of measuring the overall impact of clinical practice guidelines (CPGs). OBJECTIVE To utilize citation analysis to evaluate the dispersion of neurosurgical CPGs. METHODS A list of neurosurgical guidelines was compiled by performing electronic searches using the Scopus (Elsevier, Amsterdam, Netherlands) and National Guideline Clearinghouse databases. The Scopus database was queried to obtain current publication and citation data for all included documents and categorized based upon recognized neurosurgical specialties. The h-index, R-index, h2-index, i10-index, and dissemination index (D-Index) were manually calculated for each subspecialty. RESULTS After applying screening criteria the search yielded 372 neurosurgical CPGs, which were included for bibliometric analysis. The overall calculated h-index for neurosurgery was 56. When broken down by subspecialty trauma/critical care had the highest value at 35, followed by spine and peripheral nerve at 30, cerebrovascular at 28, tumor at 16, pediatrics at 14, miscellaneous at 11, and functional/stereotactic/pain at 6. Cerebrovascular neurosurgery was noted to have the highest D-Index at 3.4. CONCLUSION A comprehensive framework is useful for guideline impact analysis. Bibliometric data provides a novel and adequate means of evaluating the successful dissemination of neurosurgical guidelines. There remains a paucity of data regarding implementation and clinical outcomes of individual guidelines.
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Affiliation(s)
- Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Lepard JR, Markert JM, Walters BC. Letter: Neurosurgeons and Curves: The Need for Critical Appraisal of Modeling in the Post-COVID Era. Neurosurgery 2020; 87:E523-E524. [DOI: 10.1093/neuros/nyaa298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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12
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Alford EN, Rotman LE, Lepard JR, Agee BS, Markert JM. Interrater and Intrarater Reliability of the Colloid Cyst Risk Score. Neurosurgery 2020; 86:E47-E53. [PMID: 31552408 DOI: 10.1093/neuros/nyz399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/05/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Colloid Cyst Risk Score (CCRS) was developed to identify symptomatic patients and stratify risk of hydrocephalus among patients with colloid cysts. Its components consider patient age, cyst diameter, presence/absence of headache, fluid-attenuated inversion recovery (FLAIR) hyperintensity, and location within the third ventricle. OBJECTIVE To independently evaluate the inter- and intrarater reliability of the CCRS. METHODS Patients with a colloid cyst were identified from billing records and radiology archives. Three independent raters reviewed electronic medical records to determine age, presence/absence of headache, cyst diameter (mm), FLAIR hyperintensity, and risk zone location. Raters made 53 observations, including 5 repeat observations.Fleiss' generalized kappa (κ) was calculated for all of the nominal criteria, whereas Kendall's coefficient of concordance (W) and the intraclass correlation coefficient (ICC) were calculated for the overall score. RESULTS Total CCRS score demonstrated extremely strong agreement (W = 0.83) using Kendall's W coefficient and good agreement (ICC = 0.74) using the ICC (P < .001). For interrater reliability of individual criteria, age (κ = 1.00) and FLAIR hyperintensity (κ = 0.89) demonstrated near perfect agreement. Axial diameter (κ = 0.63) demonstrated substantial agreement, whereas agreement was moderate for risk zone (κ = 0.51) and fair for headache (κ = 0.26). Intrarater reliability for total CCRS score was extremely strong using Kendall's W, good to excellent using ICC, and fair to substantial using weighted kappa. CONCLUSION The CCRS has good inter- and intrarater reliability when tested in an independent sample of patients, though strength of agreement varies among individual criteria. The validity of the CCRS requires independent evaluation.
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Affiliation(s)
- Elizabeth N Alford
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren E Rotman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bonita S Agee
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Lepard JR, Corley J, Sankey EW, Prentiss T, Rocque B, Park KB, Rock J, Hlaing K, Myaing W. Training Neurosurgeons in Myanmar and Surrounding Countries: The Resident Perspective. World Neurosurg 2020; 139:75-82. [PMID: 32251819 DOI: 10.1016/j.wneu.2020.03.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION In recent decades there has been a significant expansion of neurosurgical capabilities in low- and middle-income countries, particularly in Southeast Asia. Despite these developments, little is known about the structure and quality of local neurosurgical training paradigms. METHODS A 36-question survey was administered to neurosurgical trainees in person at the Southeast Asian Neurosurgical Bootcamp to assess demographics, structure, and exposure of neurosurgical training in Southeast Asia. RESULTS A total of 45 out of 47 possible respondents participated in the survey; 78% were men, with an age range of 26-40 years. Neurosurgical training most commonly consisted of 3 (n = 22, 49%) or 6 years (n = 14, 31%). The majority of respondents (70.5%) were from Myanmar, with the remainder coming from Indonesia, Cambodia, Thailand, and Nepal. Most residents (n = 38, 84%) used textbooks as their primary study resource. Only 24 (53%) residents indicated that they had free access to online neurosurgical journals via their training institution. The majority (n = 27, 60%) reported that fewer than 750 cases were performed at their institution per year; with a median of 70% (interquartile range: 50%-80%) being emergent. The most commonly reported procedures were trauma craniotomies and ventriculoperitoneal shunting. The least commonly reported procedures were endovascular techniques and spinal instrumentation. CONCLUSIONS Although the unmet burden of neurosurgical disease remains high, local training programs are devoting significant efforts to provide a sustainable solution to the problem of neurosurgical workforce. High-income country institutions should partner with global colleagues to ensure high-quality neurosurgical care for all people regardless of location and income.
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Affiliation(s)
- Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jacquelyn Corley
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tyler Prentiss
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Brandon Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kee B Park
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Jack Rock
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Kyi Hlaing
- Department of Neurosurgery, North Okkalapa Hospital, Yangon, Myanmar
| | - Win Myaing
- Department of Neurosurgery, North Okkalapa Hospital, Yangon, Myanmar
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Affiliation(s)
- Jacob R Lepard
- Department of Neurological Surgery The University of Alabama at Birmingham Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurological Surgery The University of Alabama at Birmingham Birmingham, Alabama
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Lepard JR, Dewan MC, Chen SH, Bankole OB, Mugamba J, Ssenyonga P, Kulkarni AV, Warf BC. The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric hydrocephalus in low-resource settings. BMJ Glob Health 2020; 5:e002100. [PMID: 32133193 PMCID: PMC7042585 DOI: 10.1136/bmjgh-2019-002100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/07/2019] [Accepted: 12/23/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Managing paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context. Methods A prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol). Results The age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 3.0), p=0.6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55.2% in Nigeria vs 53.4% in Uganda, p=0.74). Conclusion Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.
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Affiliation(s)
- Jacob R Lepard
- Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Michael C Dewan
- Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Health System, Miami, Florida, USA
| | | | - John Mugamba
- Neurosurgery, CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Peter Ssenyonga
- Neurosurgery, CURE Children's Hospital of Uganda, Mbale, Uganda
| | | | - Benjamin C Warf
- Program for Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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17
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Lepard JR, Akbari SHA, Haji F, Davis MC, Harkness W, Johnston JM. The initial experience of InterSurgeon: an online platform to facilitate global neurosurgical partnerships. Neurosurg Focus 2020; 48:E15. [DOI: 10.3171/2019.12.focus19859] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDespite 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.METHODSOne 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.RESULTSThere 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.CONCLUSIONSWithin 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.
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Affiliation(s)
- Jacob R. Lepard
- 1Department of Neurological Surgery, University of Alabama at Birmingham
- 2Division of Neurosurgery, Children’s of Alabama Hospital, Birmingham, Alabama
| | - S. Hassan A. Akbari
- 1Department of Neurological Surgery, University of Alabama at Birmingham
- 2Division of Neurosurgery, Children’s of Alabama Hospital, Birmingham, Alabama
| | - Faizal Haji
- 3Division of Neurosurgery, Queen’s University School of Medicine, Kingston, Ontario, Canada; and
| | - Matthew C. Davis
- 1Department of Neurological Surgery, University of Alabama at Birmingham
- 2Division of Neurosurgery, Children’s of Alabama Hospital, Birmingham, Alabama
| | - William Harkness
- 4Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - James M. Johnston
- 1Department of Neurological Surgery, University of Alabama at Birmingham
- 2Division of Neurosurgery, Children’s of Alabama Hospital, Birmingham, Alabama
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Duc Lien N, Tuan DA, Vu Hung C, Lepard JR, Rocque BG. Corpus callosotomy for treatment of drug-resistant epilepsy: a review of 16 pediatric cases in northern Vietnam. J Neurosurg Pediatr 2020; 25:1-6. [PMID: 32109876 DOI: 10.3171/2019.12.peds19638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate postoperative seizure outcome in children with drug-resistant epilepsy not eligible for focal resection who underwent corpus callosotomy. METHODS The study included 16 patients undergoing corpus callosotomy between September 2015 and May 2018. Seizure semiology and frequency, psychomotor status, and video electroencephalography and imaging findings were evaluated for all patients. RESULTS Of the 16 patients who underwent callosotomy during the study period, 11 underwent complete callosotomy and 5 underwent anterior only. Seizure improvement greater than 75% was achieved in 37.5% of patients, and another 50% of patients had seizure improvement of 50%-75%. No sustained neurological deficits were observed in these patients. There were no significant complications. Duration of postoperative follow-up ranged from 12 to 44 months. CONCLUSIONS Corpus callosotomy is an effective treatment for selected patients with drug-resistant epilepsy not eligible for focal resection in resource-limited settings. Fostering and developing international epilepsy surgery centers should remain a high priority for the neurosurgical community at large.
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Affiliation(s)
- Nguyen Duc Lien
- 1Neurosurgical Department, Vietnam National Cancer Hospital, Hanoi
| | - Dang Anh Tuan
- 2Neurology Department, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Cao Vu Hung
- 2Neurology Department, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Jacob R Lepard
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
- 4The Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Brandon G Rocque
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
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Can DDT, Lepard JR, Tri TT, Van Duong T, Thuy NT, Thach PN, Johnston JM, Oakes WJ, Dong A T. The growth of pediatric neurosurgery in southern Vietnam and the first separation of pygopagus twins: case report. J Neurosurg Pediatr 2020; 25:1-7. [PMID: 31952040 DOI: 10.3171/2019.11.peds19291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/14/2019] [Indexed: 11/06/2022]
Abstract
Conjoined twins are a rare congenital abnormality with an estimated incidence of 1:50,000 pregnancies and 1:200,000 live births. Pygopagus twins are characterized by sacrococcygeal fusion that is commonly associated with perineal and spinal abnormalities. Management of this complex disease requires a well-developed surgical system with multidisciplinary capacity and expertise.A decade ago there were no dedicated pediatric neurosurgeons in southern Vietnam. This has changed within a few short years; there are now 10 dedicated pediatric neurosurgeons with continually expanding technical capacity. In August 2017 a multidisciplinary surgical and anesthetic team successfully separated female pygopagus twins with fused sacrum and spinal cord with associated myelomeningocele defect.The authors present here the first successful separation of pygopagus twins in Vietnam as a representative case of gradual and sustainable pediatric neurosurgical scale-up.
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Affiliation(s)
- Dang D T Can
- 1Neurosurgical Department, Children's Hospital 2, and
- 9University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | - Jacob R Lepard
- 1Neurosurgical Department, Children's Hospital 2, and
- 2Department of Neurological Surgery, University of Alabama at Birmingham
- 8Harvard Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Tran T Tri
- 4Pediatric Surgery Department, Children's Hospital 2, Ho Chi Minh City
| | - Tran Van Duong
- 5Plastic Surgery Department, Cho Ray Hospital, Ho Chi Minh City
| | | | - Pham N Thach
- 7Urology Department, Children's Hospital 2, Ho Chi Minh City, Vietnam; and
| | - James M Johnston
- 2Department of Neurological Surgery, University of Alabama at Birmingham
- 3Section of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - W Jerry Oakes
- 2Department of Neurological Surgery, University of Alabama at Birmingham
- 3Section of Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Tran Dong A
- 4Pediatric Surgery Department, Children's Hospital 2, Ho Chi Minh City
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Lepard JR, Zimmerman KD, Arynchyna AA, Gutman JA, Salehani AA, Rocque BG, Rozzelle CJ. Pediatric herniated lumbar disc: a population-based risk factor analysis. J Neurosurg Pediatr 2019; 25:1-8. [PMID: 31783360 DOI: 10.3171/2019.9.peds19167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 09/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical treatment of herniated lumbar disc (HLD) remains rare in children. The purpose of this study was to evaluate for potential disease risk factors leading to surgery based on a large single-center experience. METHODS Data for all patients who had undergone surgical treatment for HLD between December 2008 and December 2016 at a single pediatric tertiary care referral center were collected and compared to data for a healthy control population obtained through a Youth Risk Behavior Surveillance System (YRBSS) survey in order to determine relevant disease risk factors. Univariate and multivariate logistic regression were used to determine the effect of potential risk factors. RESULTS Twenty-seven patients in the disease cohort and 5212 healthy controls from the general population were included in the risk factor analysis. The mean body mass index was significantly higher in the disease population (30.2 vs 24.0 kg/m2, p < 0.0001). Children who had undergone microdiscectomy were more likely to be obese (OR 7.4, 95% CI 3.46-15.8, p < 0.001). No association was found between lumbar microdiscectomy and sports participation (OR 1.0, 95% CI -0.002 to 0.005, p = 0.37). CONCLUSIONS Microdiscectomy remains a viable and safe option in the setting of failed conservative management for pediatric HLD. Childhood obesity is a risk factor for HLD and many other diseases, which increases its importance as a public health priority.
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Shank CD, Lepard JR, Walters BC, Hadley MN. Towards Evidence-Based Guidelines in Neurological Surgery. Neurosurgery 2019; 85:613-621. [PMID: 30239922 DOI: 10.1093/neuros/nyy414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/03/2018] [Indexed: 11/15/2022] Open
Abstract
Neurological surgery practice is based on the science of balancing probabilities. A variety of clinical guidance documents have influenced how we collectively practice our art since the early 20th century. The quality of the science within these guidelines varies widely, as does their utility in positively shaping our practice. The guidelines development process in neurological surgery has evolved significantly over the last 30 yr. Historically based in expert opinion, as a specialty we have increasingly relied on objective medical evidence to guide our clinical practice. We assessed the changing practice guidelines development process and the impact of scientifically robust guidelines on patient care. The evolution of the guidelines development process in neurological surgery was chronicled. Several subspecialty guidelines were extracted and reviewed in detail. Their impact on practice patterns was evaluated. The importance of evidence-based research and practice guidelines development was discussed. Evidence-based practice guidelines serve to chronicle multiple acceptable treatment options and help us move towards more standardized care for specific disease processes. They help refute false "standards of care." Guidelines-based care supported by solid medical evidence has the potential to streamline patient care and improve patient outcomes. The guidelines development process identifies areas, issues, and strategies for which little medical evidence exists, as well as topics that need focused scientific investigation and future study. The production of evidence-based practice recommendations is a vital part of furthering our specialty. Guidelines development advances our science, augments the resident education process, and protects our practice from undue external influence.
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Affiliation(s)
- Christopher D Shank
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jacob R Lepard
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark N Hadley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Barthélemy EJ, Spaggiari R, Corley J, Lepard JR, Staffa SJ, Iv V, Servadei F, Park KB. Injury-to-Admission Delay Beyond 4 Hours Is Associated with Worsening Outcomes for Traumatic Brain Injury in Cambodia. World Neurosurg 2019; 126:e232-e240. [PMID: 30825623 DOI: 10.1016/j.wneu.2019.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Ernest J Barthélemy
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | | | - Jacquelyn Corley
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Duke Department of Neurosurgery, Durham, North Carolina, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jacob R Lepard
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Massachusetts, USA
| | - Vycheth Iv
- Department of Neurosurgery, Preah Kossamak Hospital, Phnom Penh, Cambodia
| | | | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Robertson FC, Lepard JR, Mekary RA, Davis MC, Yunusa I, Gormley WB, Baticulon RE, Mahmud MR, Misra BK, Rattani A, Dewan MC, Park KB. Epidemiology of central nervous system infectious diseases: a meta-analysis and systematic review with implications for neurosurgeons worldwide. J Neurosurg 2018:1-20. [PMID: 29905514 DOI: 10.3171/2017.10.jns17359] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/24/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVECentral nervous system (CNS) infections cause significant morbidity and mortality and often require neurosurgical intervention for proper diagnosis and treatment. However, neither the international burden of CNS infection, nor the current capacity of the neurosurgical workforce to treat these diseases is well characterized. The objective of this study was to elucidate the global incidence of surgically relevant CNS infection, highlighting geographic areas for targeted improvement in neurosurgical capacity.METHODSA systematic literature review and meta-analysis were performed to capture studies published between 1990 and 2016. PubMed, EMBASE, and Cochrane databases were searched using variations of terms relating to CNS infection and epidemiology (incidence, prevalence, burden, case fatality, etc.). To deliver a geographic breakdown of disease, results were pooled using the random-effects model and stratified by WHO region and national income status for the different CNS infection types.RESULTSThe search yielded 10,906 studies, 154 of which were used in the final qualitative analysis. A meta-analysis was performed to compute disease incidence by using data extracted from 71 of the 154 studies. The remaining 83 studies were excluded from the quantitative analysis because they did not report incidence. A total of 508,078 cases of CNS infections across all studies were included, with a total sample size of 130,681,681 individuals. Mean patient age was 35.8 years (range: newborn to 95 years), and the male/female ratio was 1:1.74. Among the 71 studies with incidence data, 39 were based in high-income countries, 25 in middle-income countries, and 7 in low-income countries. The pooled incidence of studied CNS infections was consistently highest in low-income countries, followed by middle- and then high-income countries. Regarding WHO regions, Africa had the highest pooled incidence of bacterial meningitis (65 cases/100,000 people), neurocysticercosis (650/100,000), and tuberculous spondylodiscitis (55/100,000), whereas Southeast Asia had the highest pooled incidence of intracranial abscess (49/100,000), and Europe had the highest pooled incidence of nontuberculous vertebral spondylodiscitis (5/100,000). Overall, few articles reported data on deaths associated with infection. The limited case fatality data revealed the highest case fatality for tuberculous meningitis/spondylodiscitis (21.1%) and the lowest for neurocysticercosis (5.5%). In all five disease categories, funnel plots assessing for publication bias were asymmetrical and suggested that the results may underestimate the incidence of disease.CONCLUSIONSThis systematic review and meta-analysis approximates the global incidence of neurosurgically relevant infectious diseases. These results underscore the disproportionate burden of CNS infections in the developing world, where there is a tremendous demand to provide training and resources for high-quality neurosurgical care.
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Affiliation(s)
- Faith C Robertson
- 1Harvard Medical School.,2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts
| | - Jacob R Lepard
- 3Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Rania A Mekary
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts.,4MCPHS University, Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Boston
| | - Matthew C Davis
- 3Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Ismaeel Yunusa
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts.,4MCPHS University, Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Boston
| | - William B Gormley
- 1Harvard Medical School.,2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts.,5Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronnie E Baticulon
- 6University of the Philippines College of Medicine, Philippine General Hospital, Manila, Philippines
| | - Muhammad Raji Mahmud
- 7Department of Surgery, National Hospital Abuja, PMB 425, Federal Capital Territory, Nigeria
| | - Basant K Misra
- 8Department of Neurosurgery & Gamma Knife Radiosurgery, P. D. Hinduja National Hospital, Mahim, Mumbai, India
| | - Abbas Rattani
- 9Meharry Medical College, School of Medicine, Nashville, Tennessee.,10Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and
| | - Michael C Dewan
- 10Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and.,11Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kee B Park
- 10Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and
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Lepard JR, Walters BC, Rozzelle CJ. Damage capitation in the modern liability climate: a primer for neurosurgeons and systematic review of the literature. J Neurosurg Spine 2018; 28:446-454. [PMID: 29372862 DOI: 10.3171/2017.3.spine16832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurosurgery, and particularly spine surgery, is among the most highly litigated medical specialties in the US, rendering the current malpractice climate of primary importance to spine surgeons nationwide. One of the primary methods of tort reform in the civil justice system is malpractice damage capitation (or "caps"); however, its efficacy is widely debated. The purpose of this article is to serve as a review for the practicing neurosurgeon, with particular emphasis on short- and long-term effects of damage caps and on the current debate regarding their utility, based on a systematic review of the literature. METHODS The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines for systematic review of observational studies were used in the design of the study. Multiple medical and legal online databases (MEDLINE, Scopus, EMBASE, and JSTOR) were queried using the key words "malpractice" and "damage capitation" for articles from 2000 to 2014. A total of 96 abstracts were screened for inclusion and exclusion criteria. Of these, 22 articles were reviewed in full and another 15 were excluded for study design or poor quality of data. Five more studies were added after cross-checking the bibliographies of the included articles. The resulting 12 articles were evaluated; relevant data were extracted using a standardized metric. RESULTS Five studies were found showing varying effects of capitation on physician availability, with only 1 of these specifically showing increased availability of neurosurgery and elective spine coverage in states with capitation. Four studies demonstrated that capitation overall succeeds in decreasing jury awards and frequency of claims filed. Last, 3 studies were found showing an overall decrease in malpractice premiums for states that passed damage capitation. CONCLUSIONS There is evidence in the literature showing that total and noneconomic damage capitation has the potential to improve the practice environment for neurosurgeons nationwide. Additionally, there are other factors that affect malpractice premium rates, such as the investment markets, which are not affected by these laws. All of these are important for spine surgeons to consider and be aware of in advocating for appropriate reform measures in their states.
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25
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Taylor DR, Venable GT, Jones GM, Lepard JR, Roberts ML, Saleh N, Sidiqi SK, Moore A, Khan N, Selden NR, Michael LM, Klimo P. Five-year institutional bibliometric profiles for 103 US neurosurgical residency programs. J Neurosurg 2015; 123:547-60. [DOI: 10.3171/2014.10.jns141025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Various bibliometric indices based on the citations accumulated by scholarly articles, including the h-index, g-index, e-index, and Google’s i10-index, may be used to evaluate academic productivity in neurological surgery. The present article provides a comprehensive assessment of recent academic publishing output from 103 US neurosurgical residency programs and investigates intradepartmental publishing equality among faculty members.
METHODS
Each institution was considered a single entity, with the 5-year academic yield of every neurosurgical faculty member compiled to compute the following indices: ih(5), cumulative h, ig(5), ie(5), and i10(5) (based on publications and citations from 2009 through 2013). Intradepartmental comparison of productivity among faculty members yielded Gini coefficients for publications and citations. National and regional comparisons, institutional rankings, and intradepartmental publishing equality measures are presented.
RESULTS
The median numbers of departmental faculty, total publications and citations, ih(5), summed h, ig(5), ie(5), i10(5), and Gini coefficients for publications and citations were 13, 82, 716, 12, 144, 23, 16, 17, 0.57, and 0.71, respectively. The top 5 most academically productive neurosurgical programs based on ih(5)-index were University of California, San Francisco, University of California, Los Angeles, University of Pittsburgh, Brigham & Women’s Hospital, and Johns Hopkins University. The Western US region was most academically productive and displayed greater intradepartmental publishing equality (median ih[5]-index = 18, median Ginipub = 0.56). In all regions, large departments with relative intradepartmental publishing equality tend to be the most academically productive. Multivariable logistic regression analysis identified the ih(5)-index as the only independent predictor of intradepartmental publishing equality (Ginipub ≤ 0.5 [OR 1.20, 95% CI 1.20–1.40, p = 0.03]).
CONCLUSIONS
The ih(5)-index is a novel, simple, and intuitive metric capable of accurately comparing the recent scholarly efforts of neurosurgical programs and accurately predicting intradepartmental publication equality. The ih(5)-index is relatively insensitive to factors such as isolated highly productive and/or no longer academically active senior faculty, which tend to distort other bibliometric indices and mask the accurate identification of currently productive academic environments. Institutional ranking by ih(5)-index may provide information of use to faculty and trainee applicants, research funding institutions, program leaders, and other stakeholders.
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Affiliation(s)
- Douglas R. Taylor
- 1University of Tennessee Health Science Center and
- Departments of 2Neurosurgery and
| | | | - G. Morgan Jones
- Departments of 2Neurosurgery and
- 3Clinical Pharmacy, University of Tennessee
| | | | | | - Nabil Saleh
- 1University of Tennessee Health Science Center and
| | | | - Andrew Moore
- 1University of Tennessee Health Science Center and
| | | | - Nathan R. Selden
- 4Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - L. Madison Michael
- Departments of 2Neurosurgery and
- 5Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee; and
| | - Paul Klimo
- Departments of 2Neurosurgery and
- 5Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee; and
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