Myths and Misconceptions of Traumatic Brain Injuries Among High School Learners and University Students in South Africa

Traumatic Brain Injury (TBI) is a major cause of disability and death around the world with an annual worldwide prevalence rate ranging from 369 per 100 000 people (James et al., 2019). TBI is specifically more concerning in adolescents and young adults as rates of injuries acquired during this period are similar to adult rates, but with more far-reaching effects, especially in low and middle-income countries (Dewan et al., 2016). TBI has significant long-term effects (e.g., cognitive, behavioural, social) on adolescents and young adults, which are compounded in low and middle income countries (LMICs) like South Africa. However, myths and misconceptions regarding TBI and associated outcomes often cloud the understanding thereof and contribute to poor help-seeking behaviours post-TBI. Poor help-seeking behaviours post-TBI can impact TBI recovery and result in even worse impairments if appropriate help is not sought. This study aimed to describe and compare myths and misconceptions about head injuries or traumatic brain injuries (HI/TBI), including concussions, for high school learners (with/without HI/TBI) and university students (with/without HI/TBI). In terms of misconceptions, students (n=393) scored significantly higher on HI/TBI and concussion knowledge, compared to learners (n=80). Regression analyses showed that adolescence (learners) vs young adulthood (students) was a significant predictor of myths and misconceptions regarding TBI/HI; F (44, 369) = 3.32, p < .001; but not for concussion knowledge and attitudes; F (44, 369) = 1.10, p =.31 and F (44, 369) = .725, p =.904. Understanding what high school learners know and how this differs from university students' knowledge about TBI will help inform interventions tailored to adolescents and young adults – which is needed as they are a vulnerable population group.

Letter: Global Neurosurgery Scope and Practice

To the Editor:

Russell Andrews, the global neurosurgery section editor at the World Neurosurgery journal, argues that it is difficult to define global neurosurgery because of the breadth of articles labeling themselves as global neurosurgery.1 There are numerous definitions of global neurosurgery, but we will discuss 2 commonly used definitions. First, the World Federation of Neurosurgical Societies’ Global Neurosurgery Committee (WFNS GNC) defines global neurosurgery as, “The clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.”2 Next, we can define global neurosurgery based on the definition of global surgery by Bath et al,3 that is, “the enterprise of providing improved and equitable [neuro]surgical care to the world’s population, with its core tenets as the issues of need, access, and quality.”3 The 2 definitions have more in common than they differ from one another, and the differences alone cannot explain the confusion around what is and is not global neurosurgery.

Multiple factors are responsible for the confusion around the definition and scope of global neurosurgery. A chasm separates the academic global neurosurgery community from neurosurgeons and neurosurgical organizations working toward increasing accessibility in low-resource settings.1,4 Academic neurosurgery is responsible for the 2 definitions mentioned above (de facto definitions), whereas many within the neurosurgical community are familiar with a de jure definition. Historically, global neurosurgery has been viewed as high-income country (HIC) neurosurgeons and neurosurgical organizations delivering care or investing in low- and middle-income countries (LMICs).1 This narrative is responsible for the misconception that global neurosurgery is humanitarian or international neurosurgery. While all humanitarian and international neurosurgery falls in the realm of global neurosurgery, all global neurosurgery is not international or humanitarian. This de jure definition puts LMICs on the receiving end of partnerships and fails to acknowledge that global neurosurgery initiatives equally benefit HIC institutions and neurosurgeons. For example, neurosurgery has benefited greatly from reverse innovation, including the development of endoscopic third ventriculostomy with choroid plexus cauterization in Uganda.5

Moreover, the de jure definition assumes that lack of access to safe, timely, and affordable neurosurgical care is only true in LMICs. We know from recent studies that this is not true—for example, Rahman et al6 reported significant disparities in the geographic distribution of US neurosurgeons. Also, in a review of out-of-pocket expenditures for cranial surgery at a US center, Yoon et al7 reported an increase in the proportion of patients facing financial risk.

To clarify the misconception, we must return to the WFNS GNC’s definition. This definition does not differentiate between HICs and LMICs, and it does not focus on times of humanitarian crisis. As a result, we can say that global neurosurgery is not defined by the country’s income category but rather by the existence of barriers to seeking, reaching, and receiving safe, timely, and affordable neurosurgical care. To reach this goal, global neurosurgery borrows from health systems research to devise holistic solutions that will increase access to care.2–4

Early global neurosurgeons learned that staff education and purchase of equipment and consumables without buy-in from local leadership or investments in information management were unsustainable and inefficient.3,4 As a result, global neurosurgeons have adopted a systems-engineering mindset to identify problems and map out solutions.4 They analyze interactions between the health system’s components (workforce, service delivery, infrastructure, information management, funding, and governance). They design interventions in collaboration with stakeholders because they understand that health systems are complex and have many essential parts.8 No part can independently provide the output of the whole, and the health system’s performance is not always improved if its parts are improved independently.8 Similarly, a sports team will not be improved simply because the best players at each position have been recruited. Team managers must factor in the relationships between players, players’ strengths and weaknesses, and team culture during recruitment.

Direct Cost of Illness for Spinal Cord Injury: A Systematic Review

Study Design:
Systematic review.

Objective:
Providing a comprehensive review of spinal cord injury cost of illness studies to assist health-service planning.

Methods:
We conducted a systematic review of the literature published from Jan. 1990 to Nov. 2020 via Pubmed, EMBASE, and NHS Economic Evaluation Database. Our primary outcomes were overall direct health care costs of SCI during acute care, inpatient rehabilitation, within the first year post-injury, and in the ensuing years.

Results:
Through a 2-phase screening process by independent reviewers, 30 articles out of 6177 identified citations were included. Cost of care varied widely with the mean cost of acute care ranging from $290 to $612,590; inpatient rehabilitation from $19,360 to $443,040; the first year after injury from $32,240 to $1,156,400; and the ensuing years from $4,490 to $251,450. Variations in reported costs were primarily due to neurological level of injury, study location, methodological heterogeneities, cost definitions, study populations, and timeframes. A cervical level of the injury, ASIA grade A and B, concomitant injuries, and in-hospital complications were associated with the greatest incremental effect in cost burden.

Conclusion:
The economic burden of SCI is generally high and cost figures are broadly higher for developed countries. As studies were only available in few countries, the generalizability of the cost estimates to a regional or global level is only limited to countries with similar economic status and health systems. Further investigations with standardized methodologies are required to fill the knowledge gaps in the healthcare economics of SCI.

Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.

Emergency Department Outcome of Patients with Traumatic Brain Injury – A Retrospective Study from Pakistan

Introduction: Traumatic brain injury (TBI) is a leading cause of global morbidity and mortality in both adults and children. As with other severe injuries, the outcome of TBIs is also gravely related to the quality of emergency care. Effective emergency care significantly contributes to reduced morbidity and mortality. This study was ensued to evaluate the characteristics of TBIs in Pakistan and their outcomes in the emergency department (ED).

Methods: This retrospective review included records of all TBI patients seen in the Neurosurgical ED of Jinnah Postgraduate Medical Centre, Karachi, Pakistan from 1st September 2019 till 7th December 2019.

Results: During the study period, 5,546 patients with TBI were seen in the ED; an estimated 56.5 patients per day. There were 4,054 (73.1%) male and 1,492 (26.9%) female patients. Most of these (26%) were of age <10 years. The most common culprit of TBI was road traffic accidents (RTAs) (n=2,163; 39%) followed by accidental fall (n=1,785; 32.2%). Head injury was mostly mild (n=4,034; 72.8%) and only 265 (4.7%) had a severe injury. Only 10% (n=549) patients were admitted for further treatment, 16% were managed in the ED then discharged, and 67% were immediately discharged from the ED after the first examination and necessary management. The ED mortality rate of TBIs was 2.2% (n=123/5,546) in our study. All of these cases had severe head injuries.

Conclusion: Major culprits of TBI are RTAs and accidental falls. TBIs are mostly mild-to-moderate and the ED mortality rate is low.

Global Landscape of Glioblastoma Multiforme Management in the Stupp Protocol Era: Systematic Review Protocol

Background: Glioblastoma multiforme is the most common and aggressive primary adult brain neoplasm. The current standard of care is maximal safe surgical resection, radiotherapy with concomitant temozolomide, followed by adjuvant temozolomide according to the Stupp protocol. Although the protocol is well adopted in high-income countries (HICs), little is known about its adoption in low- and middle-income countries (LMICs). The aim of this study is to describe a protocol design for a systematic review of published studies outlining the differences in GBM management between HICs and LMICs.

Methods: A systematic review will be conducted. MedLine via Ovid, Embase and Global Index Medicus will be searched from inception to date in order to identify the relevant studies. Adult patients (>18 years) with histologically confirmed primary unifocal GBM will be included. Surgical and chemoradiation management of GBM tumours will be considered. Commentaries, original research, non-peer reviewed pieces, opinion pieces, editorials and case reports will be included.

Results: Primary outcomes will include rates of complications, disability-adjusted life years (DALYs), prognosis, progression-free survival (PFS), overall survival (OS) as well as rate of care abandonment and delay. Secondary outcomes will include the presence of neuro-oncology subspecialty training programs.

Discussion: This systematic review will be the first to compare the current landscape of GBM management in HICs and LMICs, highlighting pertinent themes that may be used to optimise treatment in both financial brackets.

Systematic Review Registration: The protocol has been registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020215843).

Neurotrauma Registry Implementation in Colombia: A Qualitative Assessment

Objectives Latin America is among several regions of the world that lacks robust data on injuries due to neurotrauma. This research project sought to investigate a multi-institution brain injury registry in Colombia, South America, by conducting a qualitative study to identify factors affecting the creation and implementation of a multi-institution TBI registry in Colombia before the establishment of the current registry.

Methods Key informant interviews and participant observation identified barriers and facilitators to the creation of a TBI registry at three health care institutions in this upper-middle-income country in South America.

Results The study identified barriers to implementation involving incomplete clinical data, limited resources, lack of information and technology (IT) support, time constraints, and difficulties with ethical approval. These barriers mirrored similar results from other studies of registry implementation in low- and middle-income countries (LMICs). Ease of use and integration of data collection into the clinical workflow, local support for the registry, personal motivation, and the potential future uses of the registry to improve care and guide research were identified as facilitators to implementation. Stakeholders identified local champions and support from the administration at each institution as essential to the success of the project.

Conclusion Barriers for implementation of a neurotrauma registry in Colombia include incomplete clinical data, limited resources and lack of IT support. Some factors for improving the implementation process include local support, personal motivation and potential uses of the registry data to improve care locally. Information from this study may help to guide future efforts to establish neurotrauma registries in Latin America and in LMICs.

Letter: Operationalizing Global Neurosurgery Research in Neurosurgical Journals

Traumatic brain injury (TBI) affects roughly 69 million individuals per year, many of who reside in low- and middle-income countries (LMICs).1 While there exist several limitations to treating TBI in LMICs, many can be properly addressed if given the attention and focus required to usher in change. Case in point, the governing body of neurotrauma literature is produced in high-income countries (HICs), which pose additional constraints in settings with limited medical equipment, health infrastructure, and available staff, as seen in several LMICs.1-3 In addition, approximately 23 300 additional neurosurgeons are required to address more than 5 million essential neurosurgical cases that are unmet annually, all of which occur in LMICs.4 We believe operationalizing global neurosurgery research in neurosurgical journals can serve to bridge this gap and provide a space for leaders across the world to share pearls of knowledge toward reducing the global burden of neurological diseases and disorders, including TBI.

Fortunately, there is a growing movement to ensure the provision of timely, safe, and affordable neurosurgical care to all individuals who require it. In 2015, the Lancet commission on surgery published an article that brought attention to the need for neurosurgical enhancement on a global scale.5 This group offered targets focusing on increasing access to surgery and expanding knowledge of barriers to equitable care in LMICs by the year 2030. Still, inequities in access to neurosurgical care remain rampant, stressing a need for targeted efforts as potential remedy.

Global Neurosurgery has gained significant momentum as evident by the upward trend of peer-reviewed abstracts and articles submitted and published in neurosurgical journals. A PubMed search of the phrase “global neurosurgery” displays an ascending trend with 3 published articles in 2015, 42 articles in 2018, and 82 in the year 2020.6 This positive trend speaks to the impact of efforts made by communities such as The Lancet, the World Federation of Neurosurgical Societies (WFNS), Global Neurosurgery Committee (GNC), American Association of Neurological Surgeons (AANS), and many other organizations aimed at strengthening neurosurgery globally. Global neurosurgery conferences provide additional unique opportunities to connect partners in LMICs and HICs to develop education, advocacy, and policy. Importantly, the rise in the digital world amid the COVID-19 pandemic has enabled participants—particularly from LMICs—to overcome barriers such as visa acquisition, funding for travel and lodging, and time away from school and/or work.7,8

Cerebral aneurysms in Africa: A scoping review

Introduction
The epidemiology, management, and prognosis of cerebral aneurysms in Africa remain poorly understood. Most data to date has been from modeling studies. The authors aimed to describe the landscape of cerebral aneurysms in Africa based on published literature.

Methods
Articles on cerebral aneurysms in Africa from inception to June 9, 2020, were pulled from multiple databases (Medline, World Health Organization (WHO) Global Health Library/Global Index Medicus African Journals Online, and Google Scholar). The search results were merged, uploaded into Rayyan. After deduplication, titles and abstracts were screened independently by four reviewers (FDT, USK, IN, NDAB) based on the pre-defined inclusion and exclusion criteria. A full-text review was conducted, followed by data extraction of study, patient, neuroimaging, therapeutic, and prognostic characteristics.

Results
Thirty-three articles were included in the full-text retrieval. These studies were published across 13 (24.0%) countries, notably in Morocco (30.3%, n = 10) and South Africa (15.2%, n = 5), and 14 (42.4%) of them were published on or after 2015. Together, the studies totaled 2289 patients; there was a female predominance in 18 (54.5%) study cohorts, and the most frequently cited aneurysms were located in the internal carotid (12.1%, n = 352) and anterior cerebral arteries (9.5%, n = 275). Open surgery (27.3%, n = 792) was the most widely used option in these studies ahead of coiling (3.2%, n = 94). The reported mortality rate following surgical intervention was 7.9%.

Conclusion
There are few peer-reviewed reports of aneurysm practice and variability in access to cerebral aneurysm care in Africa.

Global survey on disruption and mitigation of neurological services during COVID-19: the perspective of global international neurological patients and scientific associations

Background
The COVID-19 pandemic outbreak has dramatically disrupted healthcare systems. Two rapid WHO pulse surveys studied disruptions in mental health services, but did not particularly focus on neurology. Here, a global survey was conducted and addresses the impact of the pandemic on neurology services.

Methods
A cross-sectional study was carried out in which 34 international neurological associations were asked to distribute the survey to national associations. The responses represented the national situation, in November–December 2020, with regard to the main disrupted neurological services, reasons and the mitigation strategies implemented as well as the disruption on training of residents and on neurological research. A comparison with the situation in February–April 2020, first pandemic wave, was also requested.

Findings
54 completed surveys came from 43 countries covering all the 6 WHO regions. Overall, neurological services disruption was reported as mild by 26%, moderate by 30%, complete by 13% of associations. The most affected services were cross-sectoral neurological services (57%) and neurorehabilitation (56%). The second wave of the pandemic, however, was associated with the improvement of service provision for diagnostics services (44%) and for neurorehabilitation (41%). Governmental directives were the major cause of services’ disruption (56%). Mitigation strategies were mostly established through telemedicine (48%). Almost half of respondents reported a significant impact on neurological research (48%) and educational activities (60%). Most associations (67%) were not involved in decision making for neurological patients’ issues by their national government.

Interpretation
The COVID-19 pandemic affects neurological services and raises the universal need for the development of neurological health care at the policy, systems and services levels. A global national plan on mitigation strategies for disruption of neurological services during pandemic situations should be established and neurological scientific and patients associations should get involved in decision making.