Search

BACKGROUND: Neurosurgical task shifting and task sharing (TS/S), delegating clinical care to non-neurosurgeons, is ongoing in many hospital systems in which neurosurgeons are scarce. Although TS/S can increase access to treatment, it remains highly controversial. This survey investigated perceptions of neurosurgical TS/S to elucidate whether it is a permissible temporary solution to the global workforce deficit. METHODS: The survey was distributed to a convenience sample of individuals providing neurosurgical care. A digital survey link was distributed through electronic mailing lists of continental neurosurgical societies and various collectives, conference announcements, and social media platforms (July 2018-January 2019). Data were analyzed by descriptive statistics and univariate regression of Likert Scale scores. RESULTS: Survey respondents represented 105 of 194 World Health Organization member countries (54.1%; 391 respondents, 162 from high-income countries and 229 from low- and middle-income countries [LMICs]). The most agreed on statement was that task sharing is preferred to task shifting. There was broad consensus that both task shifting and task sharing should require competency-based evaluation, standardized training endorsed by governing organizations, and maintenance of certification. When perspectives were stratified by income class, LMICs were significantly more likely to agree that task shifting is professionally disruptive to traditional training, task sharing should be a priority where human resources are scarce, and to call for additional TS/S regulation, such as certification and formal consultation with a neurosurgeon (in person or electronic/telemedicine). CONCLUSIONS: Both LMIC and high-income countries agreed that task sharing should be prioritized over task shifting and that additional recommendations and regulations could enhance care. These data invite future discussions on policy and training programs.

BACKGROUND: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. METHODS: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. RESULTS: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). CONCLUSIONS: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.

ANTECEDENTES: El contexto de un ensayo aleatorio puede determinar si sus hallazgos son generalizables y, por lo tanto, pueden aplicarse a diferentes entornos. La contribución de los países de ingresos bajos y medianos (PIBM) a los ensayos aleatorizados de neurocirugía no se ha descrito sistemáticamente antes. OBJETIVO: Realizar un análisis sistemático de las características del diseño y la metodología, la fuente de financiación y las intervenciones estudiadas entre los ensayos dirigidos y / o realizados en países de altos ingresos (HIC) frente a LMIC. MÉTODOS: Desde enero de 2003 hasta julio de 2016, los ensayos en inglés con> 5 pacientes que evaluaban cualquier procedimiento neuroquirúrgico frente a otro procedimiento, tratamiento no quirúrgico o ningún tratamiento se recuperaron de MEDLINE, Scopus y Cochrane Library. La clasificación de ingresos de cada país se evaluó mediante el método Atlas del Banco Mundial. RESULTADOS: Un total de 73,3% de los 397 estudios que cumplieron con los criterios de inclusión fueron dirigidos por países de ingresos bajos, mientras que el 26,7% fueron dirigidos por países de ingresos bajos y medianos. Si se excluye a China, solo el 8,8% fueron liderados por países de ingresos bajos y medianos. Los ensayos dirigidos por HIC inscribieron una mediana de 92 pacientes frente a una mediana de 65 pacientes en los ensayos dirigidos por LMIC. Ensayos dirigidos por HIC inscritos en 7,6 sitios frente a 1,8 sitios en estudios dirigidos por LMIC. Más de la mitad de los ensayos dirigidos por LMIC fueron financiados institucionalmente (54,7%). La mayoría de los ensayos dirigidos por HIC y LMIC evaluaron la neurocirugía espinal, 68% y 71,7%, respectivamente. CONCLUSIÓN: Hemos establecido que existe una disparidad sustancial entre los HIC y los LMIC en el número de ensayos neuroquirúrgicos publicados. Un esfuerzo concertado para invertir en el desarrollo de la capacidad de investigación en los PIBM es un paso esencial para garantizar que se generen pruebas de alta calidad específicas del contexto y de los recursos. 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 highincome 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, 71were 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.

19 June 2019 | REPORT Dr Ramon Pacheco Pardo, Dr Kee B. Park, Mr. Maximilian Ernst, Ms. Eliana Kim Mass casualty incidents such as building collapses and bus crashes are perhaps just the tip of the iceberg when it comes to the injury burden in the DPRK – only the worst cases of injury are highlighted in the media. Current economic and geopolitical developments within and surrounding the DPRK point towards more future activity in sectors such as construction, traffic, and tourism. Thus, it is not unreasonable to anticipate a surge in accidents and injuries inside the DPRK. In this context, it is necessary to understand the North Korean healthcare system and its needs to be able to deal with the current and anticipated injury burden. In this study, we seek to assess the current burden of traumatic injuries in the DPRK and analyze the injury care capacity in place to manage them. Furthermore, we also estimate the projected surge in injuries in the DPRK and its economic con- sequences in the near future. Finally, we propose a road map for multilateral assistance for strengthening the injury care system in the DPRK.

Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Background Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.