Global Neurosurgery – The Problem and Solution -The Asian Perspective

The world of Neurosurgery has witnessed a quantum jump in the last few decades. However, this progress has reaped benefits for patients’ income countries; the preventable deaths due to surgical deficit are as high as 47 million annually (1). Given this uneven balance of facilities in the health sector, the WHO has agreed to resolve the issues by participating in worldwide governing bodies of neurosurgery faculties in the individual country. The former president of the world bank was quoted that “surgery is an indivisible, indispensable part of health care and progress towards universal health coverag

Global Surgery indicators and pediatric hydrocephalus: a multicenter cross-country comparative study building the case for health systems strengthening

Purpose: The aim of this study is to compare specific three-institution, cross-country data that are relevant to the Global Surgery indicators and the functioning of health systems.

Methods: We retrospectively reviewed clinical and socioeconomic characteristics of pediatric patients who underwent CSF diversion surgery for hydrocephalus in three different centers: University of Tsukuba Hospital in Ibaraki, Japan (HIC), Jose R. Reyes Memorial Medical Center in Manila, Philippines (LMIC), and the Federal Neurosurgical Center in Novosibirsk, Russia (UMIC). The outcomes of interest were timing of CSF diversion surgery and mortality. Statistical tests included descriptive statistics, Cox proportional hazards model, and logistic regression. Nation-level data were also obtained to provide the relevant socioeconomic contexts in discussing the results.

Results: In total, 159 children were included—13 from Japan, 99 from the Philippines, and 47 from the Russian Federation. The median time to surgery at the specific neurosurgical centers were 6 days in the Philippines and 1 day in both Japan and Russia. For the cohort from the Philippines, non-poor patients were more likely to receive CSF diversion surgery at an earlier time (HR=4.74, 95%CI 2.34–9.61, p<0.001). In the same center, those with infantile or post-hemorrhagic hydrocephalus (HR=3.72, 95%CI 1.70–8.15, p=0.001) were more likely to receive CSF diversion earlier compared to those with congenital hydrocephalus, and those with post-infectious (HR=0.39, 95%CI 0.22–0.70, p=0.002) or myelomeningocele-associated hydrocephalus (HR=0.46, 95%CI 0.22–0.95, p=0.037) were less likely to undergo surgery at an earlier time. For Russia, older patients were more likely to receive or require early CSF diversion (HR=1.07, 95%CI 1.01–1.14, p=0.035). EVD insertion was found to be associated with mortality (cOR 14.45, 95% CI 1.28–162.97, p = 0.031).

Conclusion: In this study, Filipino children underwent late time-interval of CSF diversion surgery and had mortality differences compared to their Japanese and Russian counterparts. These disparities may reflect on the functioning of the respective country’s health systems.

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia–Pacific Region

Introduction
Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia–Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country’s healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30–31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC.

Methods
The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention.

Results
The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability.

Conclusions
Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Andersen’s utilization model for cataract surgical rate and empirical evidence from economically-developing areas

Abstract
Background
Un-operated cataract is the leading cause of vision loss worldwide, responsible for 33% of visual impairment, and half of global blindness. The study aimed to build a fast evaluation method utilizing Andersen’s utilization framework and identify predictors of cataract surgical rate in sub-Saharan Africa and China.

Methods
The study was a cross-over ecological epidemiology study with a total of 19 countries in sub-Saharan Africa, and 31 provinces in China. Information was extracted from public data and published studies. Linear regression and structural equation modeling with Bootstrap were used to analyze predictors of CSR and their pathways to impact in sub-Saharan Africa and China separately.

Results
Cataract surgical resources in sub-Saharan Africa were linearly correlated with CSR (β = 0.74, 95% CI: 0.09, 0.91), while GDP/P didn’t impact cataract surgical resources (β = 0.29, 95% CI: − 0.12, 0.75). In China, residents’ average ability to pay was confirmed as the mediator between GDP/P and CSR (p = 0.32, RMSEA = 0.07; βCSR-paying = 0.77, 95% CI: 0.25, 0.90; βpaying-GDP/P = 0.89, 95% CI: 0.82, 0.93).

Conclusions
In sub-Saharan Africa, CSR is determined by health care provision. Local economic development may not directly influence CSR. Therefore, international assistance aimed to providing free cataract surgery directly is crucial. In China, CSR is determined principally by health care demand (ability to pay). To increase CSR in underserved areas of China, ability to pay must be enhanced through social insurance, and reduced surgical fees.

Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [V T ] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median V T was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8–8.9], 8.0 [6.8–9.2], and 7.0 [5.8–8.4] mL/kg Predicted body weight; P = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5–7], five [5–8], and 10 [5–12] cmH2O; P < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66–71) and 7% (95% CI: 6–8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; P = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; P < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54–0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of V T is globally in line with current recommendations.

Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians

Background
In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers’ perspectives.

Methods
We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience.

Results
We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery.

Conclusion
Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.

The embodiment of low-field MRI for the diagnosis of infant hydrocephalus in Uganda

Compared to other parts of the world, theincidence of hydrocephalus in children is very high in subSaharan Africa. Magnetic resonance imaging (MRI) would be the
preferred diagnostic method for infant hydrocephaleus. However, in practice, MRI is seldom used in sub-Saharan Africa due to its high prize, low mobility, and high power consumption.
A low-cost MRI technology is under development by reducing the strength of the magnetic field and the use of alternative technologies to create the magnetic field. This paper describes the embodiment design process to match this new MRI technology under development with the specific characteristics of the healthcare system in Uganda.

A context exploration was performed to identify factors that may affect the design and implementation of the low-field MRI in Ugandan hospitals and Ugandan healthcare environment. The key-insights from the technology- and context-exploration were translated into requirements which were the starting point for the design process. The concept development did have a focus on Cost-effective design, Design for durability & reliability, and Design for repairability. The final design was validated by stakeholders from the Ugandan Healthcare context.

Challenges and opportunities for managing pediatric central nervous system tumors in China

Central nervous system (CNS) tumors represent the most deadly cancer in pediatric age group. In China, thousands of children are diagnosed with CNS tumors every year. Despite the improving socioeconomic status and availability of medical expertise within the country, unique challenges remain for the delivery of pediatric neuro‐oncology service. In this review, we discuss the existing hurdles for improving the outcome of children with CNS tumors in China. Need for precise disease burden estimation, lack of intra‐ and inter‐hospital collaborative networks, high probability of treatment abandonment, along with financial toxicities from treatment represent the key challenges that Chinese healthcare providers encounter. The tremendous opportunities for advancing the status of pediatric neuro‐oncology care in and beyond the country are explored.

Psychological Status of Surgical Staff During the COVID-19 Outbreak

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which appeared in early December 2019, had an atypical viral pneumonia outbreak in Wuhan, Hubei, China. And there is a high risk of global proliferation and impact. The sudden increase in confirmed cases has brought tremendous stress and anxiety to frontline surgical staff. The results showed that the anxiety and depression of surgical staff during the outbreak period were significantly higher and mental health problems appeared, so psychological interventions are essential.

Epidemiological Characteristics of Spinal Cord Injury in Northwest China: A Single Hospital-Based Study

Background: While the cities in China in which spinal cord injury (SCI) studies have been conducted previously are at the forefront of medical care, northwest China is relatively underdeveloped economically, and the epidemiological characteristics of SCI have rarely been reported in this region.

Methods: The SCI epidemiological survey software developed was used to analyze the data of patients treated with SCI from 2014 to 2018. The sociodemographic characteristics of patients, including name, age, sex, and occupation, were recorded. The following medical record data, obtained from physical and radiographic examinations, were included in the study: data on the cause of injury, fracture location, associated injuries, and level of injury. Neurological function was evaluated using the American Spinal Injury Association (ASIA) impairment scale. In addition, the treatment and complications during hospitalization were documented.

Results: A total of 3487 patients with SCI with a mean age of 39.5 ± 11.2 years were identified in this study, and the male to female ratio was 2.57:1. The primary cause of SCI was falls (low falls 47.75%, high falls 37.31%), followed by traffic accidents (8.98%), and impact with falling objects (4.39%). Of all patients, 1786 patients (51.22%) had complications and other injuries. According to the ASIA impairment scale, the numbers of grade A, B, C, and D injuries were 747 (21.42%), 688 (19.73%), 618 (17.72%), and 1434 (41.12%), respectively. During the hospitalization period, a total of 1341 patients experienced complications, with a percentage of 38.46%. Among all complications, pulmonary infection was the most common (437, 32.59%), followed by hyponatremia (326, 24.31%), bedsores (219, 16.33%), urinary tract infection (168, 12.53%), deep venous thrombosis (157, 11.71%), and others (34, 2.53%). Notably, among 3487 patients with SCI, only 528 patients (15.14%) received long-term rehabilitation treatment.

Conclusion: The incidence of SCI in northwest China was on the rise with higher proportion in males; fall and the MCVs were the primary causes of SCI. The occupations most threatened by SCI are farmers and workers. The investigation and analysis of the epidemiological characteristics of SCI in respiratory complications are important factors leading to death after SCI, especially when the SCI occurs in the cervical spinal cord. Finally, the significance of SCI rehabilitation should be addressed.