Moral Distress and Resilience Associated with Cancer Care Priority Setting in a Resource Limited Context

Background
Moral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low- and middle-income countries (LMICs) are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions.

Methods
Semi-structured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method.

Results
Participants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team-building, fair procedures for priority setting, and collective advocacy for resource expansion and equity.

Conclusion
This study adds to the current literature an in-depth examination of the impact of resource constraints and inequities on clinicians in a low resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes.

The Concept and Current State of Neurosurgery in Southeast Europe

The term “Southeast Europe” was introduced by Austrian researcher Johann Georg von Hahn in the 19th century as a broader term than the traditional “Balkans,” designating the region settled by several different nations, mostly alike, but also richly diverse. The most appropriate definition describes the inhabitants as the people geographically, demographically, and culture related to Southeast Europe (1).

Contemporary neurosurgery in the Southeast Europe region has recently witnessed remarkable progress, guided by the “Think globally, act locally” concept as an essential driving force. This slogan has long been in use in environmental contexts and has been gaining increased significance in various disciplines over the past decades. In international education, this slogan was first introduced in 1950 and popularized by Stuart Grauer in 1989 (2). Neurosurgeons in Southeast Europe genuinely implement the concept of thinking globally and acting locally, working together to expand the horizons to the benefit of our patients and our well-being and recognition in the modern world. This mini-review aims to highlight the development and progress of the Southeast Europe neurosurgical society (SeENS) as a regional neurosurgical society dedicated to neurosurgical education, research, capacity building, and exchanging experiences within the Southeast region of Europe.

Is Independent Clinical Research Possible in Low- and Middle-Income Countries? A Roadmap to Address Persistent and New Barriers and Challenges

Cancer is an increasing and significant problem for both high- and low- and middle-income countries. Basic, translational, and clinical research efforts have been instrumental in generating the outstanding improvements we have witnessed over the last few decades, answering important questions, and improving patient outcomes. Arguably, a substantial portion of currently ongoing research is sponsored by the pharmaceutical industy and specifically addresses questions under industry interests, most of which apply to high-income countries, leaving behind problems related to the much larger and underserved population of patients with cancer in low- and middle-income countries. In this scenario, discussing independent academic research is an important challenge, particularly for these countries. Although different countries and institutions face different problems while establishing independent research agendas, some generalizable barriers can be identified. A solid regulatory and ethical framework, a strong and sustainable technical supporting infrastructure, and motivated and experienced investigators are all paramount to build a viable and productive academic research program. Securing funding for research, although not the only hurdle, is certainly one of the most basic hurdles to overcome. Noticeably, and as an added impediment, public and governmental support for cancer research has been decreasing in high-income countries and is almost nonexistent in the rest of the world. We propose an initial careful diagnostic assessment of the research resource scenario of each institution/country and adjustment of the strategic development plan according to four different research resource restriction levels. Although not necessarily applicable to all situations, this model can be helpful if adjusted to each local or regional situation

Placing equity at the core of vascular surgery research

Debus et al have performed a comprehensive longitudinal analysis of vascular surgery publications in 15 major international journals during a 10-year period. Their results confirm previous findings suggesting a dominance of high-income country authors and institutions, especially articles in English, a trend that maintains academic power imbalances, whereby barriers for non-English-speaking and low- and middle-income countries (LMICs) authors are upheld.

Barriers and facilitators of research in Cameroon (Part II) – an e-survey of medical students

Introduction: research fosters critical thinking and prepares students for a career in academic medicine. This study aimed to identify the facilitators and barriers to research among Cameroonian medical students.

Methods: an electronic survey was distributed between May 23, 2020, and June 07, 2020. The survey was made of closed-, opened-, and Likert scale questions. A Preference Score (PS) was used to quantify the medical students’ perception of barriers and facilitators to research. The Kruskal-Wallis H and Fisher’s Exact tests were used to evaluate bivariate relationships

Results: one hundred and eighty-eight (188) students with a mean age of 24.1 ± 2.3 years were enrolled. Most respondents were male (56.9%), francophone (69.1%), and in their final year of medical school (46.8%). Twenty-one students (11.1%) had a peer-reviewed article, and all the published students were in their sixth- or seventh-year of undergraduate medical studies. Barriers to research included lack of funding (PS=203), obsolete patient information management systems (PS=198), and limited understanding of biostatistics (PS=197). Facilitators to research included research focused on the student’s interests (PS=255), the study’s capacity to improve practice (PS=247), and scientific recognition (PS=198).
Conclusion: barriers to research among Cameroonian medical students are mainly institutional. However, facilitators are primarily linked to career goals. To improve research activities among these undergraduates, initiatives must target institutional barriers and incentives that foster career development.

Neurosurgical Randomized Trials in Low- and Middle-Income Countries

BACKGROUND:The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income countries (LMICs) to neurosurgical randomized trials has not been systematically described before. OBJECTIVE:To perform a systematic analysis of design characteristics and methodology, funding source, and interventions studied between trials led by and/or conducted in high-income countries (HICs) vs LMICs. METHODS:From January 2003 to July 2016, English-language trials with >5 patients assessing any one neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINE, Scopus, and Cochrane Library. Income classification for each country was assessed using the World Bank Atlas method. RESULTS:A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. If China is excluded, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs 1.8 sites in LMIC-led studies. Over half of LMIC-led trials were institutionally funded (54.7%). The majority of both HIC- and LMIC-led trials evaluated spinal neurosurgery, 68% and 71.7%, respectively. CONCLUSION:We have established that there is a substantial disparity between HICs and LMICs in the number of published neurosurgical trials. A concerted effort to invest in research capacity building in LMICs is an essential step towards ensuring context- and resource-specific high-quality evidence is generated.

Haves and have nots must find a better way: The case for open scientific hardware.

Many efforts are making science more open and accessible; they are mostly concentrated on issues that appear before and after experiments are performed: open access journals, open databases, and many other tools to increase reproducibility of science and access to information. However, these initiatives do not promote access to scientific equipment necessary for experiments. Mostly due to monetary constraints, equipment availability has always been uneven around the globe, affecting predominantly low-income countries and institutions. Here, a case is made for the use of free open source hardware in research and education, including countries and institutions where funds were never the biggest problem.