Opportunities For Improvement in The Administration of Neoadjuvant Chemotherapy For T4 Breast Cancer: A Comparison of The United States and Nigeria

BACKGROUND
Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions.

MATERIALS AND METHODS
Cross‐sectional retrospective analysis included all non‐metastatic T4 BCa patients treated from 2010‐2016 at Memorial Sloan Kettering Cancer Center (New York, U.S.) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated.

RESULTS
308 patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. 56/93 (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt.

Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative vs. 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five‐year survival was significantly shorter in Nigeria vs. the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5‐year survival (67% vs. 72%) and 5‐year recurrence‐free survival (48% vs. 61%) did not significantly differ between countries.

CONCLUSION
Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria.

Role of North America and AANS in Global Neurosurgery

Approximately 28% of the global burden of disease is surgical (1). There is an estimated deficit of 90,909 neurosurgeons globally, who must care for an additional 14 million neurosurgical patients annually (2). In a study published by Alkire et al. on global access to surgical care, it was revealed that approximately two-thirds of the world’s population, comprising 4.8 billion people, do not have access to timely, affordable, or safe surgical care. The study also concluded that 99.3% of Lower-Income Countries (LICs) and 96.7% of Lower Middle-Income Countries (LMICs) populations do not have access to safe surgery (3).

Historically, global health policies focused on specific issues like access to healthcare and outcomes of infectious disease treatment and vaccinations. In January 2014, the Lancet Commission on Global Surgery (LCoGS), headed by healthcare leaders from 111 countries, gathered in Boston to research and propose strategies to improve surgery access globally. One of the committee’s goals was to bring surgeons from different socio-economic strata under one roof to facilitate collaboration and fruitful exchange of ideas. The committee also motivated the higher-income countries of North America to collaborate and shrink the existing hiatus in surgical access present in lower and middle-income countries (4). Since then, significant progress has been achieved in this regard under the leadership of North American academic institutes, neurosurgical societies, non-governmental organizations (NGOs), and even individual surgeons

Global Neurosurgery at the University of Toronto: Past and Present Efforts, and a Charter for the Future

Kenneth McKenzie arrived in Toronto in 1923, bringing the legacy of being the first neurosurgeon in Canada. Since then, Toronto has established itself as the hub of Canadian neurosurgery, in both volumes of cases, the strength of trainees, and research output (1). As one of the most extensive training programs in North America (2), Toronto has had ongoing international connections, chiefly through the fellowship programs within our division. The earliest instance in which Toronto demonstrated a concerted work efford in global neurosurgery was through the persistent and continued struggle of Ab Guha (1957-2009), who amongst many philanthropic activities, establish the National Neuroscience Institute in Calcutta (India), his city of birth, as his goal. Since then, interest in global neurosurgery has remained strong within our division, with multiple continued and consistent collaboration areas. These include Mark Bernstein’s travels within Africa and SouthEast Asia, expanding the reach of awake craniotomies; James Rutka’s efforts to strengthen local surgeons throughout Ukraine; George Ibrahim’s collaborations in Haiti to expand the surgical treatment of pediatric neurosurgical conditions; and Mojgan Hodaie’s work on structured curricula for neurosurgery residents. Simultaneously, Toronto neurosurgery has focused on encouraging fellows from low- and middle-income countries (LMIC’s) to join our center, in many cases funded by the first Chair in International Neurosurgery (3).

As a result of these activities, several clinical fellows who trained in Toronto and returned to bring their expertise to their local sites must be highlighted, including Grace Mutango (pediatric neurosurgery, Uganda), Nilesh Mohan (neuro-oncology, Kenya), Claire Karakezi (neuro-oncology, Rwanda), Selfy Oswari (Indonesia), and a substantial number of short-term visitors from a breadth of international sites.

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening

Background
The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.
Methods
This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/−]) or negative throughout (COVID[−/−]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.
Results
Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[−/−] to be 8.4 (C.I. 4.9–14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.
Discussion
Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.

The Withdrawal of the United States From the World Health Organization and Its Impact on Global Neurosurgery

To the Editor:

Right now, in any low to middle income country (LMIC), a child has developed postinfectious life-threatening hydrocephalus or a mother has suffered a brain bleed after a motor vehicle collision. Their lives could be saved by neurosurgical procedures such as shunting, third ventriculostomies, or burr holes. In the poor countries of the world, these conditions are incredibly common and result in significant morbidity and mortality while taking a tremendous toll on national economies. The Lancet Commission on Global Surgery clearly demonstrated the utility in ensuring access to life-saving surgical interventions such as these.1 However, the efforts to help vulnerable people lead full and productive lives are now at profound risk due to the unfortunate decision by the United States to withdraw funding from the World Health Organization (WHO).

On July 7, 2020, the United States announced its withdrawal of large financial support to WHO due to concerns surrounding the agency’s coronavirus response. Global efforts in infectious disease control, nutrition, and education will certainly be impacted by this decision, but so will global neurosurgery. Defunding WHO could have a profound impact on the gains made in capacity-building efforts and improving access to neurosurgical care.

Global neurosurgery is the public health and clinical care of neurosurgical patients with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it.2 The Lancet Commission on Global Surgery incorporates all surgical disciplines, including global neurosurgery. The release of the Commission sounded the alarm on the investment of interdependent components of a surgical system such as anesthesia staff, nurses, operating rooms, critical care services, and biomedical engineers.3 With better capacity comes better neurosurgery and consequently improved treatment of the millions of patients every year with life-altering neurosurgical disease.

So where does WHO fit in? The United Nations (UN) has outlined its Sustainable Developmental Goals, which are to be reached by 2030. Global neurosurgery is related to targets #3 and #17—the promotion of healthy lives and global partnerships, respectively.4 WHO is the coordinating authority regarding health within the UN.

WHO is mandated to implement the health priorities set by its member states (MSs). In 2015, the members of WHO unanimously passed a resolution calling for “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage.” The United States was a cosponsor of this historic resolution. Today, with the help of WHO and its key partners, more than 40 LMICs are currently in various stages of implementing the mandates of this resolution. Subspecialists such as neurosurgeons are transforming the profession by integrating the principle of health equity with WHO’s support. For example, WHO has partnered with the World Federation of Neurosurgical Societies (WFNS), the largest professional society within neurosurgery, to better understand the global neurosurgical disease burden and workforce deficits. This partnership also permits better access to local stakeholders to continue important advocacy efforts. Individual LMICs, under the WFNS-WHO partnership, can effectively push the agenda of improved neurosurgical care that is nationally or regionally specific.

At the World Health Assembly meeting in 2018, it was clear that WHO was increasing collaboration and communication between neurosurgical systems around the world.5 As Rosseau describes, neurosurgeons convened with health ministries and other key players to commit to “…sharing training, equipment, and other resources with the rest of the global surgery community.” Neurosurgeons seated at the table with WHO was a significant step in the right direction.

Finally, it is well known that WHO is one of the most significant champions of Universal Health Coverage (UHC). Neurosurgical care is part of UHC and thus needs to be protected at all costs. In a country like Uganda, where the average person makes $2280 USD/yr and may spend up to $1220 USD for a neurosurgical procedure, the economic burden on patients can be devastating.6 WHO encourages governments to strategically partner with the public and private sectors to ensure that all health needs, including neurosurgical ones, are economically met with the best quality of medicine available.

The global neurosurgery movement, as part of the broader global surgery movement, would not have been possible without WHO. The key stakeholders respect and depend on WHO to set global priorities and support the MS implementation of their mandates. Yes, WHO can improve. But the United States will be far more effective in driving the improvement as an MS. The consequences of withdrawal of funding from WHO are devastating and will adversely affect millions of people around the world and, in particular, neurosurgical patients.

Rising Global Opportunities Among Orthopaedic Surgery Residency Programs

Objective:
We surveyed Orthopaedic Surgery Residency (OSR) programs to determine international opportunities by the academic institutional region within the United States, location of the international experience, duration, residency program year (PGY), funding source, and resident participation to date.

Design:
We emailed a survey to all OSR programs in the United States to inquire about global opportunities in their residency programs. Further contact was made through an additional e-mail and up to three telephone calls. Data were analyzed using descriptive and chi-square statistics. This study was institutional review board exempt.

Setting:
This research study was conducted at the University of Nebraska Medical Center, a tertiary care facility in conjunction with the University of Nebraska Medical Center College of Medicine.

Participants:
The participants of this research study included program directors and coordinators of all OSR programs (185) across the United States.

Results:
A total of 102 OSR programs completed the survey (55% response rate). Notably, 50% of the responding programs offered a global health opportunity to their residents. Of the institutions that responded, those in the Midwest or South were more likely to offer the opportunity than institutions found in other US regions, although regional differences were not significant. Global experiences were most commonly: in Central or South America (41%); 1 to 2 weeks in duration (54%); and during PGY4 or PGY5 (71%). Furthermore, half of the programs provided full funding for the residents to participate in the global experience. In 33% of the programs, 10 or more residents had participated to date.

Conclusions:
Interest in global health among medical students is increasing. OSR programs have followed this trend, increasing their global health opportunities by 92% since 2015. Communicating the availability of and support for international opportunities to future residents may help interested students make informed decisions when applying to residency programs.

Improving Pediatric Neuro-Oncology Survival Disparities in the United States–Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico

PURPOSE
Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children’s Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP.

PATIENTS AND METHODS
We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017.

RESULTS
Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017. CONCLUSION The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.

Global Surgery: The Perspective of Public Health Students

Current research has emphasized the importance of increased involvement of medical professionals and global health specialists for the success of global surgery efforts. This quantitative descriptive study aimed to examine public health students’ perceptions of global surgery. A 21- question mixed method online survey was distributed over eight weeks via student email to all students enrolled in the Masters of Public Health Program at A.T. Still University (ATSU) College of Graduate Health Studies. Of 212 students, 35 (16.5%) respondents completed the survey with 30 students reporting interest in global health in their future public health careers. Two-thirds of students erroneously identified infectious diseases as the leading cause of death worldwide, not traumatic injury. Participants identified infectious disease and OB/GYN as the two medical fields to contribute significantly to global health. Surgical care was felt to be the least economically cost-effective medical field for low and middle-income countries (LMICs). As the first project to report perspectives of public health students regarding global surgery, this study highlighted several significant misconceptions concerning global surgery. Like the results from similar studies in medical students, it is alarming that there is such a paucity of community health knowledge surrounding surgery and its effects on global surgical needs. Further research should focus on the effect on student perceptions after curriculum modification include education regarding the burden of surgical disease and role of global surgery.

Considerations for Oral and Maxillofacial Surgeons in COVID-19 Era: Can We Sustain the Solutions to Keep Our Patients and Healthcare Personnel Safe?

Several uncertainties exist regarding how we will conduct our clinical, didactic, business, and social activities as the coronavirus disease 2019 (COVID-19) global pandemic abates and social distancing guidelines are relaxed. We anticipate changes in how we interact with our patients and other providers, how patient workflow is designed, the methods used to conduct our teaching sessions, and how we perform procedures in different clinical settings. The objective of the present report was to review some of the changes to consider in the clinical and academic oral and maxillofacial surgery workflow to allow for a smoother and more efficient transition, with less risk to our patients and healthcare personnel. New infection control policies should be strictly enforced and monitored in all clinical and nonclinical settings, with an overall goal of decreasing the risk of exposure and transmission. Screening for COVID-19 symptoms, testing when indicated, and establishing the epidemiologic linkage will be crucial to containing and preventing new COVID-19 cases until a vaccine or an alternate solution is available. Additionally, the shortage of essential supplies such as drugs and personal protective equipment, the design and ventilation of workspaces and waiting areas, the increase in overhead costs, and the possible absence of staff, if quarantine is necessary, must be considered. This shift in our workflow and patient care paths will likely continue in the short term at least through 2021 or the next 12 to 24 months. Thus, we must prioritize surgery, balancing patient preferences and healthcare personnel risks. We have an opportunity now to make changes and embrace telemedicine and other collaborative virtual platforms for teaching and clinical care. It is crucial that we maintain COVID-19 awareness, proper surveillance in our microenvironments, good clinical judgment, and ethical values to continue to deliver high-quality, economical, and accessible patient care.

Academic Advancement in Global Surgery Appointment, Promotion, and Tenure Recommendations From the American Surgical Association Working Group on Global Surgery

There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).