The Concept and Current State of Neurosurgery in Southeast Europe

The term “Southeast Europe” was introduced by Austrian researcher Johann Georg von Hahn in the 19th century as a broader term than the traditional “Balkans,” designating the region settled by several different nations, mostly alike, but also richly diverse. The most appropriate definition describes the inhabitants as the people geographically, demographically, and culture related to Southeast Europe (1).

Contemporary neurosurgery in the Southeast Europe region has recently witnessed remarkable progress, guided by the “Think globally, act locally” concept as an essential driving force. This slogan has long been in use in environmental contexts and has been gaining increased significance in various disciplines over the past decades. In international education, this slogan was first introduced in 1950 and popularized by Stuart Grauer in 1989 (2). Neurosurgeons in Southeast Europe genuinely implement the concept of thinking globally and acting locally, working together to expand the horizons to the benefit of our patients and our well-being and recognition in the modern world. This mini-review aims to highlight the development and progress of the Southeast Europe neurosurgical society (SeENS) as a regional neurosurgical society dedicated to neurosurgical education, research, capacity building, and exchanging experiences within the Southeast region of Europe.

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.

Epidemiology of Traumatic Brain Injury in Georgia: A Prospective Hospital-Based Study

Purpose: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality worldwide, disproportionally affecting low- and middle-income countries (LMICs). Epidemiological characteristics of TBI at a national level are absent for most LMICs including Georgia. This study aimed to establish the registries and assess causes and outcomes in TBI patients presenting to two major trauma hospitals in the capital city –Tbilisi.
Patients and Methods: The prospective observational study was conducted at Acad. O. Gudushauri National Medical Center and M. Iashvili Children’s Central Hospital from March, 1 through August, 31, 2019. Patients of all age groups admitted to one of the study hospitals with a TBI diagnosis were eligible for participation. Collected data were uploaded using the electronic data collection tool –REDCap, analyzed through SPSS software and evaluated to provide detailed information on TBI-related variables and outcomes using descriptive statistics.
Results: Overall, 542 hospitalized patients were enrolled during the study period, about 63% were male and the average age was 17.7. The main causes of TBI were falls (58%) and struck by or against an object (22%). The 97% suffered from mild TBI (GCS 13– 15). Over 23% of patients arrived at the hospital more than 1 hour after injury and 25% after more than 4-hours post-injury. Moderate and severe TBI were associated with an increased hospital length of stay. Mortality rate of severe TBI was 54%.
Conclusion: This study provides important information on the major epidemiological characteristics of TBI in Georgia, which should be considered for setting priorities for injury management

Survey-based experiential learning as a means of raising professional awareness: a new educational approach for developing healthcare settings

Background This study outlines key aspects of professional development among health professionals in low- and middle-income countries (LMIC). LMICs need support in developing their continuing medical
education, and non-technical skills (NTS) that have been neglected in this respect. Given the nature of NTS, educational methods should be used experientially. This study aims to explore an interactive
an educational approach to increase NTS among health care professionals in an LMIC setting.

Methods. Key NTS concepts were identified and these directed the selection of research-based surveys. A series of workshops was designed in which a survey-based experiential approach was developed. The
educational process followed a pattern of individual reflection, small group discussion and relating the concepts to the local practice in a wider group.

Results. An approach to increase NTS in LMIC settings emerged in iterative development through conducting workshops with health care teams in the Balkans. The topics could be grouped into
individual, team, and organisational dimensions. The approach can be described as survey-based experiential learning involving steps in recurring interaction with participants. The steps include
identifying concepts in individual, team and organization dimensions and contextualising them using experiential learning on the individual and group levels.

Conclusion An overarching approach has been developed that addresses NTS in an LMIC setting. The survey-based experiential learning approach can be beneficial for raising professional awareness and the
development of sustainable healthcare settings in LMICs.

Real-world Treatment Patterns of Lung Cancerexperience of Resource Restricted Country

Background:

Lung cancer (LC) continues to be a significant worldwide public health issue. In recent years there have been several publications addressing specifics of LC worldwide, but none concerning Georgia- country with high number of smoking population and LC cases. We conducted the first study in Georgian population, that aims current LC practice.

Methods:

The aim of the study was to provide an overview of treatment of LC, with discussion situation in this field and indicating the future strategies for improved cancer care in the country. Medical, radiation and surgical oncologists providing treatment of LC in main hospitals (n=13) over the country, filled questionnaire that addressed specific information regarding the treatment aspects of LC reflecting current surgical aspects, systemic treatment and radiotherapy (RT).

Results

There is no national screening program, while radiologic imaging is readily available. The vast majority of patients in the country present with advanced stages at diagnosis and they are treated with systemic therapy and/or RT.

The surgical treatment is largely underutilized with the differences being observed among surgeons on the optimal timing and the extent of surgery, as well as role of surgery in specific clinical situations.

Improved health care system, well equipped hospitals, availability of many anticancer drugs and existence of modern RT technology, are coupled with slow appearance of country-adapted guidelines and protocols as well as enforcing MDT meetings.

There is limited access to expensive novel agents, psychological support and high quality palliative care.

Conclusions

There is still much work to be done, with all above steps considered mandatory to improve effectiveness and quality of care of LC patients.

Incidence of Keratoconus in Refractive Surgery Population of Vojvodina – Single Center Study

Introduction
Keratoconus (KCN) is known to affect all ethnicities but its incidence exhibits geographical variability plausibly due to subclinical forms of the disease, differences in diagnostic methods and criteria, or differences in genetic variations in populations.
Aim
To examine the prevalence of keratoconus among the refractive surgery population of Vojvodina, who underwent refractive surgery screening at Eye Clinic Svjetlost Novi Sad, Serbia from September 2018 to September 2019. This is a single-center study.
Methods
Retrospective analysis of 876 patients who presented for refractive surgery evaluation. Corneal tomographers represent the gold standard in the detection and classification of corneal ectatic diseases and screening is an essential part of the preoperative diagnostics before any refractive surgery. The corneal tomographer used in this study was a Scheimpflug imaging device (Pentacam AXL, Oculus Optikgeräte GmbH, Wetzlar, Germany). The device was realigned before each measurement.
Results
Out of a total number of patients, 619 (70,7%) were candidates for corneal refractive surgery procedure, and 257 patients (29.3%) were not. Out of 257 patients that were not candidates for the procedure 157 (61,0%) patients had thin corneas, high myopia/hypermetropia or had some retinal disease; 75 patients (29,1) were keratoconus suspect and 25 patients (9,7%) had keratoconus. KCN patients had a mean age of 29.5 ± 7.7 years, 18 patients (72.0%) were male and 7 patients were female (28%)
Conclusion
The most cited annual incidence of KCN is 2 approximately 1 per 2,000. Recent data from the biggest Netherland study revealed many different epidemiological results which deprive keratoconus of the community of rare diseases. The incidence of keratoconus in Vojvodina refractive surgery population presented in our Clinic was 2.9%

Epidemiology of severe traumatic brain injury.

About 5.48 million people are estimated to suffer from severe traumatic brain injury (TBI) each year (73 cases per 100,000 people). The WHO estimates that almost 90% of deaths due to injuries occur in low- and middle-income countries (LMICs), where the 85% of population live. Of these trauma-related deaths TBI is the main cause of one-third to one-half and represents the greatest cause of death and disability globally among all trauma-related injuries. The primary causes of TBI vary by age, socioeconomic factors, and geographic region, so any planned interventions must take in account this variability. The road traffic injuries (RTI) scenario is still strictly connected to the analysis of the global incidence of TBI, and to the reason why the LMICs experience nearly 3 times as many cases of TBI proportionally than high-income countries (HICs). The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). In HICs, falls and RTIs were reported most frequently as cause of TBI, but the traumas attributable to RTIs dropped from 39% in 2003 to 24% in 2012, while those attributable to falls increased from 43% to 54% respectively, with an increase TBI in the elderly (>65 years) due to falls. Differently from HICs, the population with the peak of TBI incidence is younger in LMICs, with an age between 28.8 and 33.1, as extensively reported. The burden of disease is significant; between 1,730,000 and 1,965,000 lives could be saved if global trauma care were improved in LMICs. Clinical practice recommendation should be developed and created in environments where the severe TBI mainly occurs. The applicability of high-income-country clinical research standards in LMICs is an important topic for future international research.

Uniportal Thoracoscopic Approach For Pulmonary Hydatid Cyst: Preliminary Results.

Pulmonary hydatid cyst is a preventable parasitary disease with high prevalence in low-medium income countries. Thoracoscopic approach is seen in the literature as small-case groups and multiple-port incisions are observed in these studies. Unlike other thoracoscopic approaches for the surgical treatment, we describe the single-port technique for the first time in our study. We attempt to compare the clinical outcomes and preliminary results of patients with pulmonary hydatid cyst treated with either minimally invasive or thoracotomy.The medical records of 66 patients undergoing surgery for pulmonary hydatid cyst disease between January 2013 and July 2017 were reviewed. The number of patients who underwent thoracotomy was 48, whereas 18 were managed by single-port video-assisted thoracoscopic surgery. Variables statistically compared between the 2 groups were age, diameter of the cystic, operation time, volume and duration of the drainage, postoperative complications, length of stay, duration of narcotic analgesic usage, and pain score.Thoracoscopic approach was superior to conventional thoracotomy in terms of operation time, drainage volume, time to drain removal, hospital stay, narcotic analgesic treatment duration, and postoperative pain scores. All thoracoscopic procedures were concluded successfully, and conversion to open surgery was not required. No postoperative mortality was seen in either group. During the follow-up period, no recurrence was encountered in either group.Uniportal thoracoscopic approach is a safe option for the treatment of hydatid cyst disease. It can be used as an alternative to thoracotomy, depending on the size and location of the lesion.

Cost-effectiveness of colorectal cancer screening in Ukraine.

Background
Colorectal cancer is one of the most common cancers worldwide and is associated with high mortality when detected at a later stage. There is a paucity of studies from low and middle income countries to support the cost-effectiveness of colorectal cancer screening. We aim to analyze the cost-effectiveness of colorectal cancer screening compared to no screening in Ukraine, a lower-middle income country.

Methods
We developed a deterministic Markov cohort model to assess the cost-effectiveness of three colorectal cancer screening strategies [fecal occult blood test (FOBT) every year, flexible sigmoidoscopy with FOBT every 5 years, and colonoscopy every 10 years] compared to no screening. We modeled outcomes in terms of cost per quality-adjusted life-years (QALYs) over a lifetime time horizon. We performed sensitivity analyses on treatment adherence, test characteristics and costs. Analyses were conducted from the perspective of the Ministry of Health of Ukraine.

Results
The base-case lifetime cost-effectiveness analysis showed that all three screening strategies were cost saving compared to no screening, and among the three strategies, colonoscopy every 10 years was the dominant strategy compared to no screening with standard adherence to treatment. When decreased adherence to treatment was modeled, colonoscopy every 10 years was the most cost-effective strategy with an incremental cost-effectiveness ratio of $843 per QALY compared with no screening.

Conclusion
Our findings indicate that colorectal cancer screening can save money and improve health compared to no screening in Ukraine. Colonoscopy every 10 years is superior to the other screening modalities evaluated in this study. This knowledge can be used to concentrate efforts on developing a national screening program in Ukraine.