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.

Predictors of poor outcome from aneurysmal subarachnoid hemorrhage and an exploratory analysis into the causes of delayed neurosurgical clipping at a major public hospital in the Philippines

The provision of neurosurgical care for patients with aneurysmal subarachnoid hemorrhage (SAH) is beset with particular challenges in low- to middle-income countries (LMICs) like the Philippines. In this study located in a low-resource setting, we identify the factors that contribute to unfavorable outcomes of dependency and death.
The authors retrospectively reviewed 106 patients who underwent surgery for aneurysmal subarachnoid hemorrhage in a single institution from January 2016 to September 2018. Data were obtained on exposure variables comprising patient demographics, clinical features, perioperative management, and complications and other interventions; while outcomes on discharge were investigated using the modified Rankin scale (mRS). Descriptive statistics and multivariate logistic regression analyses were done. Root cause analysis was done to identify the causes of delay.
The percentage of patients who had unfavorable outcome (mRS ≥ 3) was 29.2%. The timing of surgery—whether early (10 days)—was not found to be significantly associated with dependency or mortality. On multiple logistic regression, the factors associated with unfavorable outcome were: intraoperative rupture (OR 23.98, 95%CI 3.56–161.33, p=0.001), vasospasm (OR 12.47, 95%CI 3.01–51.57, p<0.001), and a high Hunt & Hess grade (OR 5.96, 95%CI 1.47–24.18, p=0.012). Intraoperative rupture and vasospasm were further found to be independent predictors of mortality. Many causes of delay were identified in terms of patient-, provider-, and health system-levels. These constitute as barriers to timely care and also contribute to the gap in quality and efficiency of neurosurgical treatment situated in low-resource settings in LMICs.
The identified predictors of poor outcomes, as well as the causes delays in neurosurgical treatment, pose as significant challenges to the care of socioeconomically-disadvantaged SAH patients. When considering the solutions to these challenges, the broader environment of practice ought to be taken into account.

COVID-19’s Impact on Neurosurgical Training in Southeast Asia

Objective: Neurosurgery departments worldwide have been forced to restructure their training programs due to the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia.

Methods: We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from 22 to 31 May 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.

Results: A total of 298 out of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median=100% for both) was significantly greater compared with other countries (p <.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median=80% and 70%, respectively) compared with trainees in Singapore and Thailand (median=20% and 50%, respectively, p <.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.

Conclusions: An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories, to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.