Ventriculoperitoneal shunt complication in pediatric hydrocephalus: Risk factor analysis from a single institution in Nepal

Objective
Ventriculoperitoneal (VP) shunt surgery is one of the commonly performed neurosurgical procedures. Complications due to shunt failure are associated with high morbidity and mortality. We report an analysis of risk factors for shunt failure in pediatric patients from a single institution in Nepal.
Materials and methods
A retrospective analytical study with prospective data was designed. All children younger than 15 years, with first time VP shunting, at a tertiary government hospital in Kathmandu during 2014-2017 were followed up. Association of independent variables with the primary outcome variable (complication of VP shunt) was analyzed using Chi-square test. Bivariate logistic regression was performed to identify unadjusted odds ratio (OR) with 95% confidence interval (CI). Multivariate logistic regression model was designed to calculate adjusted OR with 95% CI.
Results
Of 120 patients, more than half (55.8%) of the patients were male. Mean age was 62.97 months. Maximum duration of follow-up was 30 months. Most common cause of hydrocephalus was congenital aqueductal stenosis (40.8%) followed by tumors (29.2%). Overall shunt complication was found in 26.7% (95% CI 19.0%-35.5%). Shunt infection was seen in 5% while malfunction without infection was found in 21.7%. Bivariate logistic regression showed duration of surgery more than 1 h (OR 2.67, 95% CI 1.11-6.42, P = 0.028) compared to 1 h or less, experienced surgeon (OR 0.37, 95% CI 0.16-0.89, P = 0.026) compared to residents, and emergency surgery (OR 3.97, 95% CI 1.69-9.29, P = 0.001) compared to elective surgery as significant risk factors, while emergency surgery was the only significant variable for shunt failure on multivariate regression analysis (OR 3.3, 95% CI 1.16-9.35, P = 0.025).
Conclusion
Longer duration of surgery, less experience of the surgeon, and the priority of the case (emergency) were independent risk factors for shunt complications.

Management and outcomes following emergency surgery for traumatic brain injury – A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group

Background: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training.

Methods: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries.

Results: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country’s need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries.

Conclusions: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Linking household and health facility surveys to assess obstetric service availability, readiness and coverage: evidence from 17 low- and middle-income countries.

Improving access and quality of obstetric service has the potential to avert preventable maternal, neonatal and stillborn deaths, yet little is known about the quality of care received. This study sought to assess obstetric service availability, readiness and coverage within and between 17 low- and middle-income countries.We linked health facility data from the Service Provision Assessments and Service Availability and Readiness Assessments, with corresponding household survey data obtained from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Based on performance of obstetric signal functions, we defined four levels of facility emergency obstetric care (EmOC) functionality: comprehensive (CEmOC), basic (BEmOC), BEmOC-2, and low/substandard. Facility readiness was evaluated based on the direct observation of 23 essential items; facilities “ready to provide obstetric services” had ?20 of 23 items available. Across countries, we used medians to characterize service availability and readiness, overall and by urban-rural location; analyses also adjusted for care-seeking patterns to estimate population-level coverage of obstetric services.Of the 111?500 health facilities surveyed, 7545 offered obstetric services and were included in the analysis. The median percentages of facilities offering EmOC and “ready to provide obstetric services” were 19% and 10%, respectively. There were considerable urban-rural differences, with absolute differences of 19% and 29% in the availability of facilities offering EmOC and “ready to provide obstetric services”, respectively. Adjusting for care-seeking patterns, results from the linking approach indicated that among women delivering in a facility, a median of 40% delivered in facilities offering EmOC, and 28% delivered in facilities “ready to provide obstetric services”. Relatively higher coverage of facility deliveries (?65%) and coverage of deliveries in facilities “ready to provide obstetric services” (?30% of facility deliveries) were only found in three countries.The low levels of availability, readiness and coverage of obstetric services documented represent substantial missed opportunities within health systems. Global and national efforts need to prioritize upgrading EmOC functionality and improving readiness to deliver obstetric service, particularly in rural areas. The approach of linking health facility and household surveys described here could facilitate the tracking of progress towards quality obstetric care.

Epilepsy in Asia: Disease burden, management barriers, and challenges.

This article reviews the burden of epilepsy in Asia, the challenges faced by people with epilepsy, and the management of epilepsy. Comparison is made with other parts of the world. For this narrative review, data were collected using specified search criteria. Articles investigating the epidemiology of epilepsy, diagnosis, comorbidities and associated mortality, stigmatization, and treatment were included. Epilepsy is a global health care issue affecting up to 70 million people worldwide. Nearly 80% of people with epilepsy live in low- and middle-income countries with limited resources. People with epilepsy are prone to physical and psychological comorbidities, including anxiety and depression, which can negatively impact their quality of life. Furthermore, people with epilepsy are at higher risk of premature death than people without epilepsy. Discrimination or stigmatization of people with epilepsy is common in Asia and can affect their education, work, and marriage opportunities. Access to epilepsy treatment varies throughout Asia. Although highly advanced treatment is available in some countries, up to 90% of people with epilepsy are not adequately treated or are not treated with conventional antiepileptic therapy in resource-limited countries. People in remote areas often do not receive any epilepsy care. First-generation antiepileptic drugs (AEDs) are available, but usually only in urban areas, and second-generation AEDs are not available in all countries. Newer AEDs tend to have more favorable safety profiles than first-generation AEDs and provide options to tailor therapy for individual patients, especially those with comorbidities. Active epilepsy surgery centers are present in some countries, although epilepsy surgery is often underutilized given the number of patients who could benefit. Further epidemiologic research is needed to provide accurate epilepsy data across the Asian region. Coordinated action is warranted to improve access to treatment and care.