Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data

Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya.
Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care.
Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.

Management and outcomes of sellar, suprasellar, and parasellar masses in low-and middle- income countries: a scoping review

Background: There are several studies which describe the current management strategies and outcomes of SMs in High-Income Countries (HICs). However, there is little known the situation regarding SMs in Low and Middle-Income Countries (LMICs) apart from studies describing the experience from tertiary centres. With this study, we identified the epidemiology, diagnosis, management, and outcomes of SMs, SSMs, and PSMs in LMICs while reviewing and synthesising the relevant literature. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis extension for Scoping Review (PRISMA-ScR) guidelines were used to report the findings. MEDLINE, Embase, Global Index Medicus, and African Journals OnLine were the databases of choice. Cases were included if the pathology was related to the sellar, parasellar or suprasellar regions. The dataset was analysed using descriptive statistics via SPSS. Results: We have includedn=16589 patients from 49 LMICs. LMICs with the most studies were in China (n=49, 4.9%). Headache was the most reported symptomn=3995 with a mean of 29.82 cases per study (Range 0–130). Most reported tumour location was the sellar regionn=12933 (85%). Somatotroph adenomas was the most diagnosed pituitary adenoma (n=3297). The most frequently diagnosed non-pituitary adenomatous mass was arachnoid cysts (n=282). Endoscopic approaches were far more utilised compared to microsurgical approaches, n=3418 and n=1730, respectively. Hormonal therapies with Cabergoline were administered in 1700 patients with prolactinoma. Radiosurgery was performed in n=357 patients. The average follow-up duration was 33.26 months. Conclusion: Neuro-oncology and pituitary research in LMICs remains under-reported. Our understanding of the current landscape of the management and outcomes of sellar, suprasellar and parasellar masses show that there is similarity to the management approaches utilised compared to HICs. The surgical outcomes, although largely underreported, were worse in LMICs compared to HICs, highlighting the need for more research and education.

State of African neurosurgical education: a protocol for an analysis of publicly available curricula

Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.

Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.

Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.

Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.

Global neurosurgery over a 60-year period: Conceptual foundations, time reference, emerging Co-ordinates and prospects for collaborative interventions in low and middle income countries

Introduction
We evaluated salient initiatives invested in global neurosurgery over a 60-year period,

Research question
What are the Phases, Achievements, Challenges, and Lessons of Global Neurosurgery.

Methods
A 60-year retrospective study from 1960 to 2020 analyzing the major phases, lessons, and progress notes. We reviewed the foundational need questions and innovated tools used to answer them.

Results
Three phases defining our study period were identified. In the early phase, birthing academic units and the onset of individual volunteerism were dominant concepts. The 2nd phase is summarized by the rise of volunteerism and surgical camps.

The third phase is heralded by advocacy and strategies for achieving care equity. The defining moment is the Lancet commission for global surgery summit in 2015. Lessons include the need for evaluation of the resources of recipient and donor locations using novel global surgery tools.

Conclusion
Global neurosurgery over the 60-year study period is summarized by indelible touchstones of personal and group efforts as well as triumphs derived from innovations in the face of formidable challenges.

Outcomes of Children With Low-Grade Gliomas in Low- and Middle-Income Countries: A Systematic Review

PURPOSE
Pediatric CNS tumors are increasingly a priority, particularly with the WHO designation of low-grade glioma (LGG) as one of six index childhood cancers. There are currently limited data on outcomes of pediatric patients with LGGs in low- and middle-income countries (LMICs).

METHODS
To better understand the outcomes of LGGs in LMICs, this systematic review interrogated nine literature databases.

RESULTS
The search identified 14,977 publications. Sixteen studies from 19 countries met the selection criteria and were included for data abstraction and analysis. Eleven studies (69%) were retrospective reviews from single institutions, and one (6%) captured institutional data prospectively. The studies captured a total of 957 patients with a median of 49 patients per study. Seven (44%) of the studies described the treatment modalities used. Of 373 patients for whom there was information, 173 (46%) had a gross total or near total resection, 109 (29%) had a subtotal resection, and 91 (24%) had only a biopsy performed. Seven studies, with a total of 476 patients, described the frequency of use of radiotherapy and/or chemotherapy in the cohorts: 83 of these patients received radiotherapy and 76 received chemotherapy. The 5-year overall survival ranged from 69.2% to 93.5%, although lower survival rates were reported at earlier time points. We identified limitations in the published studies with respect to the cohort sizes and methodologies.

CONCLUSION
The included studies reported survival rates frequently exceeding 80%, although the ultimate number of studies was limited, pointing to the paucity of studies describing the outcomes of children with LGGs in LMICs. This study underscores the need for more robust data on outcomes in pediatric LGG.

Neurotrauma clinicians’ perspectives on the contextual challenges associated with traumatic brain injury follow up in low-income and middle-income countries: A reflexive thematic analysis

Background
Traumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified.

Objective
To explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings.

Methods
A cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke’s six-stage Reflexive Thematic Analysis.

Results
18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do?

Conclusion
The collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

Access to training in neurosurgery (Part 2): The costs of pursuing neurosurgical training

Introduction
Opportunities for in-country neurosurgical training are severely limited in LMICs, particularly due to rigorous educational requirements and prohibitive upfront costs.

Research question
This study aims to evaluate financial barriers aspiring neurosurgeons face in accessing and completing neurosurgical training, specifically in LMICs, in order to determine the barriers to equitable access to training.

Material and methods
In order to assess the financial costs of accessing and completing neurosurgery residency, an electronic survey was administered to those with the most recent experience with the process: aspiring neurosurgeons, neurosurgical trainees, and recent neurosurgery graduates. We attempted to include a broad representation of World Health Organization (WHO) geographic regions and World Bank income classifications in order to determine differences among regions and countries of different income levels.

Results
Our survey resulted in 198 unique responses (response rate 31.3%), of which 83% (n ​= ​165) were from LMICs. Cost data were reported for 48 individual countries, of which 26.2% were reported to require trainees to pay for their neurosurgical training. Payment amounts varied amongst countries, with multiple countries having costs that surpassed their annual gross national income as defined by the World Bank.

Discussion and conclusions
Opportunities for formal neurosurgical training are severely limited, especially in LMICs. Cost is an important barrier that can not only limit the capacity to train neurosurgeons but can also perpetuate inequitable access to training. Additional investment by governments and other stakeholders can help develop a sufficient workforce and reduce inequality for the next generation of neurosurgeons worldwide.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers’ perspective

Background
Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce.

Methods
This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate).

Results
The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer.

Conclusions
The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Expanding Access to Microneurosurgery in Low-Resource Settings: Feasibility of a Low-Cost Exoscope in Transforaminal Lumbar Interbody Fusion

Objectives Less than a quarter of the world population has access to microneurosurgical care within a range of 2 hours. We introduce a simplified exoscopic visualization system to achieve optical magnification, illumination, and video recording in low-resource settings.

Materials and Methods We purchased a 48 megapixels industrial microscope camera with a heavy-duty support arm, a wide field c-mount lens, and an LED ring light at a total cost of US$ 125. Sixteen patients with lumbar degenerative disk disease were divided into an exoscope group and a conventional microscope group. In each group we performed four open and four minimally invasive transforaminal lumbar interbody fusion procedures. We further conducted a questionnaire-based assessment of the user experience.

Results The overall user experience was positive. The exoscope achieved similar postoperative improvement with comparable blood loss and operating time as the conventional microscope. It provided a similar image quality, magnification and illumination. Yet, the lack of stereoscopic perception and the cumbersome adjustability of the camera position and angle resulted in a shallow learning curve. Most users strongly agreed that the exoscope would significantly improve surgical teaching. Over 75% reported they would recommend the exoscope to colleagues and all users saw its great potential for low-resource environments.

Conclusion Our low-budget exoscope is technically non-inferior to the conventional binocular microscope and purchasable at a significantly lower price. It may thus help expand access to neurosurgical care and training worldwide.