Establishing collaborations in global neurosurgery: The role of InterSurgeon

The global deficiency in surgical care has been highlighted in the past several years, through the publication of the Lancet Commission on Global Surgery in 2015, the passage of WHA Resolution 68.15, and concerted efforts by advocacy organizations such as the G4 Alliance. Approximately 23,300 additional neurosurgeons are estimated to be needed to address the greater than 5 million essential neurosurgical cases that are not performed annually, most in low- and middle-income countries (LMICs).

However, increasing recognition of the ease and feasibility of virtual technology prompted a shift towards virtual modes of communication. InterSurgeon (https://www.intersurgeon.org/), an independent, internet-based social network platform, has allowed for formal connection between global surgery advocates who may have complementary needs and resources. This manuscript aims to: 1) characterize the current progress of InterSurgeon, 2) describe lessons learned from the creation and use of InterSurgeon, and 3) discuss future directions for InterSurgeon.

Equitable, well-designed collaborations are central to progress in global neurosurgery. InterSurgeon has catalyzed collaborations within global neurosurgery across world regions and country income status. In addition to its role in facilitating traditional in person collaborations, InterSurgeon will become an increasingly important tool for connecting surgeons worldwide as virtual collaboration and augmented reality training paradigms become important components of global surgery capacity building.

Clinicopathological Patterns and Surgical Outcomes of Primary Brain Tumors Managed at a Tertiary Hospital in Arusha, Tanzania:a Cross-sectional Analysis

Purpose: The epidemiology of brain tumors varies globally between different countries and there is observed poor outcomes in lower- and middle-income countries. Our aim is to analyze the clinicopathological pattern of intracranial tumors in our setting and their post-surgical outcomes.

Methods: This is a retrospective study. Data was obtained from clinical records of patients with intracranial tumors treated at our neurosurgery unit between 2019 and 2020. Only patients with primary brain tumors who underwent surgical intervention were included. Analysis was done to identify factors associated with patient outcomes (mortality/survival and performance status).

Results: 39 patients with primary brain tumors underwent surgery (adults 72.8%, males 53.8%, mean age 35.8years). Gliomas (46.2%) comprised the most common tumor diagnosis overall and craniopharyngiomas were the most common tumors in pediatric patients (27.3%). Most patients (83.3%) had a poor performance status before surgery. Gross tumor resection (25.6%) was low and few patients (31.4%) underwent adjuvant therapy. 30-day mortality rate (10.3%) and one year mortality rate (46.2%) were high. Pediatric patients had a much worse outcome (46.2% mortality rate compared to 25% in adults, and 80% with poor performance status) as did males (38.1% mortality rate compared to 27.8% in females). Gliomas accounted for majority (69.2%) of the deaths.

Conclusion: Delayed presentation and poor access to adjuvant therapies are important contributors of the high mortality and abandonment of treatment. Inadequate long-term follow-up is a hinderance to optimal neurooncological care in our setting.

Patterns and Surgical Outcomes of Primary Brain Tumors Managed at a Tertiary Hospital in Arusha, Tanzania: a Cross-sectional Analysis

Purpose: The epidemiology of brain tumors varies globally between different countries and there is observed poor outcomes in lower- and middle-income countries. Our aim is to analyze the clinicopathological pattern of intracranial tumors in our setting and their post-surgical outcomes.

Methods: This is a retrospective study. Data was obtained from clinical records of patients with intracranial tumors treated at our neurosurgery unit between 2019 and 2020. Only patients with primary brain tumors who underwent surgical intervention were included. Analysis was done to identify factors associated with patient outcomes (mortality/survival and performance status).

Results: 39 patients with primary brain tumors underwent surgery (adults 72.8%, males 53.8%, mean age 35.8years). Gliomas (46.2%) comprised the most common tumor diagnosis overall and craniopharyngiomas were the most common tumors in pediatric patients (27.3%). Most patients (83.3%) had a poor performance status before surgery. Gross tumor resection (25.6%) was low and few patients (31.4%) underwent adjuvant therapy. 30-day mortality rate (10.3%) and one year mortality rate (46.2%) were high. Pediatric patients had a much worse outcome (46.2% mortality rate compared to 25% in adults, and 80% with poor performance status) as did males (38.1% mortality rate compared to 27.8% in females). Gliomas accounted for majority (69.2%) of the deaths.

Conclusion: Delayed presentation and poor access to adjuvant therapies are important contributors of the high mortality and abandonment of treatment. Inadequate long-term follow-up is a hinderance to optimal neurooncological care in our setting.

Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a protocol for a continental, cross-sectional study

Introduction
Africa has the second highest neurosurgical workforce deficit globally. Despite the many recent advancements in increasing neurosurgical access in Africa, published reports have shown that the vast majority of undergraduate students have little or no exposure to neurosurgery. The lack of exposure may pose a challenge in reducing the neurosurgical workforce deficit, which is one of the long-term strategies of tackling the unmet burden of disease. Students may also miss the opportunity to appreciate the specialty and its demands as well as nurture their interest in the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students towards a career in neurosurgery.

Methods
The cross-sectional study will be conducted through the dissemination of a self-administered e-survey hosted on Google Forms from 21st February 2021 to 20th March 2021. The survey will contain five-point Likert scale, multiple-choice and free-text questions. The structured questionnaire will have four sections with 27 items: (i) socio-demographic background, (ii) neurosurgical experience, (iii) perception towards a neurosurgical career and (iv) interest in a neurosurgical career. All consenting medical students in African medical schools who are in their clinical years (defined as fourth to sixth years or higher years of study) will be eligible. Odds ratios and their 95% confidence intervals, Wilcoxon rank-sum test, Welch t-test and adjusted logistic regression models will be used to test for associations between independent and dependent variables. Statistical significance will be accepted at P < 0.05.

Pediatric Hydrocephalus in Northwest Tanzania: a descriptive cross-sectional study of clinical characteristics and early surgical outcomes from the Bugando Medical Centre.

Objectives
In this study, we present data from a neurosurgical training program in Tanzania for the treatment of pediatric hydrocephalus. The objectives of the study were to identify the demographics and clinical characteristics of pediatric patients with hydrocephalus that were admitted to Bugando Medical Centre in Mwanza, Tanzania as well as to describe their surgical treatment and early clinical outcomes.

Methods
This cross-sectional study included 38 pediatric patients. Physical examinations were conducted pre- and post-operatively, and their mothers completed a questionnaire providing demographic and clinical characteristics.

Results
There was a slight preponderance of male sex (21/38; 55.3%) with median age at the time of admission of 98.5 days. The majority of patients were surgically treated (33/38; 86.8%). Among those surgically treated, most received a ventriculoperitoneal shunt (23/33; 69.7%), while seven were treated with an endoscopic third ventriculostomy (7/33; 21.2%). At the time of admission, the majority of patients (86%) had head circumferences that met criteria for macrocephaly. The median time between admission and surgery was 23 days (2-47 days). Overall, five patients (13.2%) died, including two that did not receive surgical intervention.

Conclusions
We found that in our population, pediatric patients with hydrocephalus often present late for treatment with additional significant delays prior to receiving any surgical intervention. Five patients died, of which two had not undergone surgery. Our study reinforces that targeted investments in clinical services are needed to enable access to care, improve surgical capacity, and alleviate the burden of neurosurgical disease from pediatric hydrocephalus in sub-Saharan Africa.

Hosting an Educational Careers Day Within the Virtual Paradigm: The Neurology and Neurosurgery Interest Group Experience

Introduction: To explore our experience of hosting the 10th Annual Neurology and Neurosurgery Interest Group-Society of British Neurological Surgeons (NANSIG-SBNS) Neurosurgery Careers Day, held virtually for the first time.

Methods: Reflective feedback and review of an international, virtual neurosurgery careers day. The authors reflect on the logistics of organizing the event, and the pre- and post-event feedback provided by delegates. Recommendations have been made on how to successfully host a virtual event. The key themes that permeated the event have been outlined and discussed in the context of the feedback received.

Results: The event was attended by 231 delegates from 20 countries worldwide. Knowledge of neurosurgery as a career and the application process increased after attending the careers day (4.27/5 to 4.51/5, p=0.003 and 3.12/5 to 4.31/5, p<0.001 respectively). The key themes identified from the event include attendance, networking, and education. Qualitative feedback was positive and indicated a positive perception of the careers day.

Conclusions: The future of educational events is unclear, and a hybrid approach is recommended to retain the benefits of the online space when in-person events eventually return.

Practice variation in perioperative steroid dosing for brain tumor patients: an international survey

Objective
Steroids are commonly used against peritumoral edema and increased intracranial pressure in brain tumor patients. Despite the widespread use of steroids, relatively little evidence is available about their optimal perioperative dosing scheme. This study aims to increase insight into practice variation of perioperative steroid dosing and tapering schedules used in the neurosurgical community.

Methods
An electronic survey consisting of 27 questions regarding steroid dosing, tapering schedules, and adverse events was conducted among neurosurgeons between December 6th, 2019 and June 1st, 2020. The survey was distributed through the European Association of Neurosurgical Societies and social media platforms. Collected data were assessed for quantitative and qualitative analysis.

Results
The survey obtained 175 responses from 55 countries across six continents, including 30 from low- or middle-income countries; 152 (87%) respondents completed all questions. In total, 130 respondents (80%) indicated prescribing perioperative steroids. Reported doses ranged from 2 to 64 mg/day in schedules ranging from one to four times daily. The most prescribed steroid was dexamethasone in a dose of 16 mg/day (n = 49; 31%), followed by 12 mg/day (n = 31; 20%) and 8 mg/day (n = 18; 12%). No significant association was found between prescribed dose and physician and institutional characteristics.

Conclusion
Steroids are commonly prescribed perioperatively in brain tumor patients. However, there is a great practice variation in dosing and schedules among neurosurgeons. Future investigation in a prospective and preferably randomized manner is needed to identify an optimal dosing scheme and implement (inter)national guidelines for steroid use.

Diagnosis and Management of Traumatic Subarachnoid Hemorrhage: Protocol for a Scoping Review

Background:
Globally, 69 million people suffer from traumatic brain injury (TBI) each year and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and an increase in morbidity and mortality, but there are a limited number of studies which evaluate recent trends in the diagnostic and management of SAH in the context of trauma.

Objective:
The objective of this scoping review was to understand the extent and type of evidence in relation to the diagnostic criteria and management of TSAH.

Methods:
This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. A 3-step search strategy (an initial limited search in PubMed and Scopus databases; a main search of EMBASE, Web of Science, EBSCO, MEDLINE; and manual searches of reference lists of included articles) will be utilized. The search will be limited to studies with human participants and published in English, Spanish, and French between 2005 and 2020. This review will consider studies of adolescent and adult patients with SAH secondary to trauma. Study selection will be performed by 2 authors (DG and LF) in a 2-phase process; if any disagreement arises, a third author (AR) will be consulted. Data to be extracted from each study will include population, intervention, comparator and outcome measures, and a summary of findings. Citation screening, full-text review, risk of bias assessment, and extraction of study characteristics and outcomes will be carried out using a web-based software platform that streamlines the production of scoping reviews.

Results:
Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in December 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at conferences that engage the most pertinent stakeholders.

Conclusions:
This scoping review will serve as an initial step in providing more evidence for health care professionals, economists, and policymakers so that they might devote more resources toward this significant problem affecting both health and economic outcomes worldwide.

The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review

The COVID-19 pandemic has disrupted neurosurgical training worldwide, with the shutdown of academic institutions and the reduction of elective surgical procedures. This impact has disproportionately affected LMICs (lower- and/or middle-income countries), already burdened by a lack of neurosurgical resources. Thus, a systematic review was conducted to examine these challenges and innovations developed to adapt effective teaching and learning for medical students and neurosurgical trainees. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and The Cochrane Handbook of Systematic Reviews of Interventions. MEDLINE, PubMed, Embase and Cochrane databases were accessed, searching and screening literature from December 2019 to 5th December 2020 with set inclusion and exclusion criteria. Screening identified 1254 articles of which 26 were included, providing data from 96 countries. Twenty-three studies reported transition to online learning, with 8 studies also mentioned redeployment into COVID wards with 2 studies mentioning missed surgical exposure as a consequence. Of 7 studies conducted in LMICs, 3 reported residents suffering financial insecurities from reduced surgical caseload and recession. Significant global disruption in neurosurgical teaching and training has arisen from the COVID-19 pandemic. Decreased surgical exposure has negatively impacted educational provision. However, advancements in virtual technology have allowed for more affordable, accessible training especially in LMICs. Using this, initiatives to reduce physical and mental stress experienced by trainees should be paramount.

Neurosurgery in Egypt from ancient Egyptians to Modern Neurosurgery, African Perspective

Neurosurgery has been practiced for more than 12,000 years worldwide. Cranial and transnasal approaches to the brain have been practiced for variable religious, mystical, or therapeutic purposes in ancient civilizations of Africa and specifically in Egypt (1). Ancient Egyptian medicine is documented in the paintings on the walls of temples and numerous papyri (figure 1) (2-4).

Ancient Egyptian medicine dates to 3500 BC when Athotis (Hor-Aha), the second king of the first dynasty, was found to have in his tomb the first “Book of the Dead” that was later quoted with modifications till it reached “Practical Medicine and Anatomic Book” in Ani’s papyrus