Background
The Lancet Commission on Global Surgery (LCoGS) published its seminal report in 2015, carving a niche for global surgery academia. Six years after the LCoGS, a scoping review was conducted ...to see how the term 'global surgery' is characterized by the literature and how it relates to LCoGS and its domains.
Methods
PubMed was searched for publications between January 2015 and February 2021 that used the term ‘global surgery’ in the title, abstract, or key words or cited the LCoGS. Variables extracted included LCoGS domains, authorship metrics, geographic scope, and clinical specialty.
Results
The search captured 938 articles that qualified for data extraction. Nearly 80% of first and last authors had high-income country affiliations. Africa was the most frequently investigated region, though many countries within the region were under-represented. The
World Journal of Surgery
was the most frequent journal, publishing 13.9% of all articles. General surgery, pediatric surgery, and neurosurgery were the most represented specialties. Of the LCoGS domains, healthcare delivery and management were the most studied, while economics and financing were the least studied.
Conclusion
A lack of consensus on the definition of global surgery remains. Additional research is needed in economics and financing, while obstetrics and trauma are under-represented in literature using the term ‘global surgery’. Efforts in academic global surgery must give a voice to those carrying the global surgery agenda forward on the frontlines. Focusing on research capacity-building and encouraging contribution by local partners will lead to a stronger, more cohesive global surgery community.
Improving access to information for health professionals and researchers in low- and middle-income countries (LMICs) is under-prioritized. This study examines publication policies that affect authors ...and readers from LMICs.
We used the SHERPA RoMEO database and publicly available publishing protocols to evaluate open access (OA) policies, article processing charges (APCs), subscription costs, and availability of health literature relevant to authors and readers in LMICs. Categorical variables were summarized using frequencies with percentages. Continuous variables were reported with median and interquartile range (IQR). Hypothesis testing procedures were performed using Wilcoxon rank sum tests, Wilcoxon rank sum exact tests, and Kruskal-Wallis test.
A total of 55 journals were included; 6 (11%) were Gold OA (access to readers and large charge for authors), 2 (3.6%) were subscription (charge for readers and small/no charge for authors), 4 (7.3%) were delayed OA (reader access with no charge after embargo), and 43 (78%) were hybrid (author's choice). There was no significant difference between median APC for life sciences, medical, and surgical journals ($4,850 $3,500-$8,900 vs. $4,592 $3,500-$5,000 vs. $3,550 $3,200-$3,860; p = 0.054). The median US individual subscription costs (USD/Year) were significantly different for life sciences, medical, and surgical journals ($259 $209-$282 vs. $365 $212-$744 vs. $455 $365-$573; p = 0.038), and similar for international readers. A total of seventeen journals (42%) had a subscription price that was higher for international readers than for US readers.
Most journals offer hybrid access services. Authors may be forced to choose between high cost with greater reach through OA and low cost with less reach publishing under the subscription model under current policies. International readers face higher costs. Such hindrances may be mitigated by a greater awareness and liberal utilization of OA policies.
There is a fundamental need to establish the most ethical and effective way of tracking disease in the postpandemic era. The ubiquity of mobile phones is generating large amounts of passive data ...(collected without active user participation) that can be used as a tool for tracking disease. Although discussions of pragmatism or economic issues tend to guide public health decisions, ethical issues are the foremost public concern. Thus, officials must look to history and current moral frameworks to avoid past mistakes and ethical pitfalls. Past pandemics demonstrate that the aftermath is the most effective time to make health policy decisions. However, an ethical discussion of passive data use for digital public health surveillance has yet to be attempted, and little has been done to determine the best method to do so. Therefore, we aim to highlight four potential areas of ethical opportunity and challenge: (1) informed consent, (2) privacy, (3) equity, and (4) ownership.
Awake mapping has been associated with decreased neurological deficits and increased extent of resection in eloquent glioma resections. However, its effect within clinically relevant glioblastoma ...subgroups remains poorly understood. We aimed to assess the benefit of this technique in subgroups of patients with glioblastomas based on age, preoperative neurological morbidity, and Karnofsky Performance Score (KPS).
In this propensity score-matched analysis of an international, multicentre, cohort study (GLIOMAP), patients were recruited at four tertiary centres in Europe (Erasmus MC, Rotterdam and Haaglanden MC, The Hague, Netherlands, and UZ Leuven, Leuven, Belgium) and the USA (Brigham and Women's Hospital, Boston, MA). Patients were eligible if they were aged 18–90 years, undergoing resection, had a histopathological diagnosis of primary glioblastoma, their tumour was in an eloquent or near-eloquent location, and they had a unifocal enhancing lesion. Patients either underwent awake mapping during craniotomy, or asleep resection, as per treating physician or multidisciplinary tumour board decision. We used propensity-score matching (1:3) to match patients in the awake group with those in the asleep group to create a matched cohort, and to match patients from subgroups stratified by age (<70 years vs ≥70 years), preoperative National Institute of Health Stroke Scale (NIHSS) score (score of 0–1 vs ≥2), and preoperative KPS (90–100 vs ≤80). We used Cox proportional hazard regressions to analyse the effect of awake mapping on the primary outcomes including postoperative neurological deficits (measured by deterioration in NIHSS score at 6 week, 3 months, and 6 months postoperatively), overall survival, and progression-free survival. We used logistic regression to analyse the predictive value of awake mapping and other perioperative factors on postoperative outcomes.
Between Jan 1, 2010, and Oct 31, 2020, 3919 patients were recruited, of whom 1047 with tumour resection for primary eloquent glioblastoma were included in analyses as the overall unmatched cohort. After propensity-score matching, the overall matched cohort comprised 536 patients, of whom 134 had awake craniotomies and 402 had asleep resection. In the overall matched cohort, awake craniotomy versus asleep resection resulted in fewer neurological deficits at 3 months (26 22% of 120 vs 107 33% of 323; p=0·019) and 6 months (30 26% of 115 vs 125 41% of 305; p=0·0048) postoperatively, longer overall survival (median 17·0 months 95% CI 15·0–24·0 vs 14·0 months 13·0–16·0; p=0·00054), and longer progression-free survival (median 9·0 months 8·0–11·0 vs 7·3 months 6·0–8·8; p=0·0060). In subgroup analyses, fewer postoperative neurological deficits occurred at 3 months and at 6 months with awake craniotomy versus asleep resection in patients younger than 70 years (3 months: 22 21% of 103 vs 93 34% of 272; p=0·016; 6 months: 24 24% of 101 vs 108 42% of 258; p=0·0014), those with an NIHSS score of 0–1 (3 months: 22 23% of 96 vs 97 38% of 254; p=0·0071; 6 months: 27 28% of 95 vs 115 48% of 239; p=0·0010), and those with a KPS of 90–100 (3 months: 17 19% of 88 vs 74 35% of 237; p=0·034; 6 months: 24 28% of 87 vs 101 45% of 223, p=0·0043). Additionally, fewer postoperative neurological deficits were seen in the awake group versus the asleep group at 3 months in patients aged 70 years and older (two 13% of 16 vs 15 43% of 35; p=0·033; no difference seen at 6 months), with a NIHSS score of 2 or higher (3 months: three 13% of 23 vs 21 36% of 58; p=0·040) and at 6 months in those with a KPS of 80 or lower (five 18% of 28 vs 34 39% of 88; p=0·043; no difference seen at 3 months). Median overall survival was longer for the awake group than the asleep group in the subgroups younger than 70 years (19·5 months 95% CI 16·0–31·0 vs 15·0 months 13·0–17·0; p<0·0001), an NIHSS score of 0–1 (18·0 months 16·0–31·0 vs 14·0 months 13·0–16·5; p=0·00047), and KPS of 90–100 (19·0 months 16·0–31·0 vs 14·5 months 13·0–16·5; p=0·00058). Median progression-free survival was also longer in the awake group than in the asleep group in patients younger than 70 years (9·3 months 95% CI 8·0–12·0 vs 7·5 months 6·5–9·0; p=0·0061), in those with an NIHSS score of 0–1 (9·5 months 9·0–12·0 vs 8·0 months 6·5–9·0; p=0·0035), and in those with a KPS of 90–100 (10·0 months 9·0–13·0 vs 8·0 months 7·0–9·0; p=0·0010). No difference was seen in overall survival or progression-free survival between the awake group and the asleep group for those aged 70 years and older, with NIHSS scores of 2 or higher, or with a KPS of 80 or lower.
These data might aid neurosurgeons with the assessment of their surgical strategy in individual glioblastoma patients. These findings will be validated and further explored in the SAFE trial (NCT03861299) and the PROGRAM study (NCT04708171).
None.
BACKGROUND AND OBJECTIVES: Digital phenotyping (DP) enables objective measurements of patient behavior and may be a useful tool in assessments of quality-of-life and functional status in ...neuro-oncology patients. We aimed to identify trends in mobility among patients with glioblastoma (GBM) using DP. METHODS: A total of 15 patients with GBM enrolled in a DP study were included. The Beiwe application was used to passively collect patient smartphone global positioning system data during the study period. We estimated step count, time spent at home, total distance traveled, and number of places visited in the preoperative, immediate postoperative, and late postoperative periods. Mobility trends for patients with GBM after surgery were calculated by using local regression and were compared with preoperative values and with values derived from a nonoperative spine disease group. RESULTS: One month postoperatively, median values for time spent at home and number of locations visited by patients with GBM decreased by 1.48 h and 2.79 locations, respectively. Two months postoperatively, these values further decreased by 0.38 h and 1.17 locations, respectively. Compared with the nonoperative spine group, values for time spent at home and the number of locations visited by patients with GBM 1 month postoperatively were less than control values by 0.71 h and 2.79 locations, respectively. Two months postoperatively, time spent at home for patients with GBM was higher by 1.21 h and locations visited were less than nonoperative spine group values by 1.17. Immediate postoperative values for distance traveled, maximum distance from home, and radius of gyration for patients with GBM increased by 0.346 km, 2.24 km, and 1.814 km, respectively, compared with preoperative values. CONCLUSIONS :Trends in patients with GBM mobility throughout treatment were quantified through the use of DP in this study. DP has the potential to quantify patient behavior and recovery objectively and with minimal patient burden.
Chronic kidney disease (CKD) affects 37 million adults in the United States, and for patients with CKD, hypertension is a key risk factor for adverse outcomes, such as kidney failure, cardiovascular ...events, and death.
To evaluate a computerized clinical decision support (CDS) system for the management of uncontrolled hypertension in patients with CKD.
This multiclinic, randomized clinical trial randomized primary care practitioners (PCPs) at a primary care network, including 15 hospital-based, ambulatory, and community health center-based clinics, through a stratified, matched-pair randomization approach February 2021 to February 2022. All adult patients with a visit to a PCP in the last 2 years were eligible and those with evidence of CKD and hypertension were included.
The intervention consisted of a CDS system based on behavioral economic principles and human-centered design methods that delivered tailored, evidence-based recommendations, including initiation or titration of renin-angiotensin-aldosterone system inhibitors. The patients in the control group received usual care from PCPs with the CDS system operating in silent mode.
The primary outcome was the change in mean systolic blood pressure (SBP) between baseline and 180 days compared between groups. The primary analysis was a repeated measures linear mixed model, using SBP at baseline, 90 days, and 180 days in an intention-to-treat repeated measures model to account for missing data. Secondary outcomes included blood pressure (BP) control and outcomes such as percentage of patients who received an action that aligned with the CDS recommendations.
The study included 174 PCPs and 2026 patients (mean SD age, 75.3 0.3 years; 1223 60.4% female; mean SD SBP at baseline, 154.0 14.3 mm Hg), with 87 PCPs and 1029 patients randomized to the intervention and 87 PCPs and 997 patients randomized to usual care. Overall, 1714 patients (84.6%) were treated for hypertension at baseline. There were 1623 patients (80.1%) with an SBP measurement at 180 days. From the linear mixed model, there was a statistically significant difference in mean SBP change in the intervention group compared with the usual care group (change, -14.6 95% CI, -13.1 to -16.0 mm Hg vs -11.7 -10.2 to -13.1 mm Hg; P = .005). There was no difference in the percentage of patients who achieved BP control in the intervention group compared with the control group (50.4% 95% CI, 46.5% to 54.3% vs 47.1% 95% CI, 43.3% to 51.0%). More patients received an action aligned with the CDS recommendations in the intervention group than in the usual care group (49.9% 95% CI, 45.1% to 54.8% vs 34.6% 95% CI, 29.8% to 39.4%; P < .001).
These findings suggest that implementing this computerized CDS system could lead to improved management of uncontrolled hypertension and potentially improved clinical outcomes at the population level for patients with CKD.
ClinicalTrials.gov Identifier: NCT03679247.
Nonoperative management of odontoid fractures can result in solid fusion, unstable nonunion, and fibrous nonunion. Odontoid fractures with fibrous nonunion will not demonstrate dynamic instability on ...imaging studies. However, the safety of accepting this outcome has been debated. We have provided, to the best of our knowledge, the first systematic review of the existing literature to explore the safety of allowing fibrous nonunion as an acceptable outcome for odontoid fractures.
The PubMed and Embase databases were searched in January 2022. The outcomes were extracted and categorized according to the mortality, neurologic sequelae, pain, neck disability index, and satisfaction.
Of a total of 700 abstracts screened, the full text of 79 reports was assessed, with 13 studies included. Of the included patients, 141 had had a fibrous nonunion, all described in observational studies. The follow-up ranged from 0.6 to 5.8 years. None of the 141 patients had experienced a neurologic event. One patient had died of trauma-related issues; however, causality was not reported. Most of the studies had reported good to excellent pain scores. Most of the neck disabilities reported had ranged from mild to moderate in severity. However, 1 study of 5 patients had reported severe disability. All the patients reported good or excellent satisfaction.
The evidence we found supports that it is safe to forgo surgery for carefully selected patients with nonunited odontoid fractures when near-anatomic alignment is present, dynamic instability is lacking on imaging studies, the neurologic examination findings are normal, and the risk of neck injury is low. Further study is needed to define the full natural history of fibrous nonunion of odontoid fractures.
To assess the impact of virtual education programming for patients with acromegaly.
We conducted a mixed methods study to evaluate patient attitudes, examine if patient-centered educational forums ...change these attitudes, and determine the role of virtual education as a means to learn about patients' unmet needs, self-reported outcomes, and educational priorities.
The study included 653 total virtual program registrants. Of these, 78 patients with acromegaly were included in the analysis. The programs consisted of patient-centered livestream education by a multidisciplinary team of pituitary experts and patient presenters. Multiple-choice questions were used to assess attitudes before and after the event, and short answer surveys were used to collect care goals and unmet needs related to treatment.
Attendance included participants from 37 countries. The number of patients who responded that they had no hope for improvement, had no choice in their treatment, and felt alone living with acromegaly each decreased significantly pre- to post-event (P < 0.05). The number of patients who felt anxious about their acromegaly diagnosis remained unchanged. 'Quality of life/mental health' was the most common personal care goals concern followed by 'medical therapies/tumor control.' Perceived acromegaly unmet needs were evenly distributed, with five of six categories reported by over 20% of patients.
Our findings indicate that virtual education may have a significant positive effect on acromegaly patients' perceptions of their disease. The lessons learned from these virtual programs may be used to inform future virtual education programming for acromegaly and other rare diseases.
Background
Focused ultrasound (FUS) shows promise for enhancing drug delivery to the brain by temporarily opening the blood–brain barrier (BBB), and it is increasingly used in the clinical setting to ...treat brain tumours. It remains however unclear whether FUS is being introduced in an ethically and methodologically sound manner. The IDEAL-D framework for the introduction of surgical innovations and the SYRCLE and ROBINS-I tools for assessing the risk of bias in animal studies and non-randomized trials, respectively, provide a comprehensive evaluation for this.
Objectives and methods
A comprehensive literature review on FUS in neuro-oncology was conducted. Subsequently, the included studies were evaluated using the IDEAL-D framework, SYRCLE, and ROBINS-I tools
.
Results
In total, 19 published studies and 12 registered trials were identified. FUS demonstrated successful BBB disruption, increased drug delivery, and improved survival rates. However, the SYRCLE analysis revealed a high risk of bias in animal studies, while the ROBINS-I analysis found that most human studies had a high risk of bias due to a lack of blinding and heterogeneous samples. Of the 15 pre-clinical stage 0 studies, only six had formal ethical approval, and only five followed animal care policies. Both stage 1 studies and stage 1/2a studies failed to provide information on patient data confidentiality. Overall, no animal or human study reached the IDEAL-D stage endpoint.
Conclusion
FUS holds promise for enhancing drug delivery to the brain, but its development and implementation must adhere to rigorous safety standards using the established ethical and methodological frameworks. The complementary use of IDEAL-D, SYRCLE, and ROBINS-I tools indicates a high risk of bias and ethical limitations in both animal and human studies, highlighting the need for further improvements in study design for a safe implementation of FUS in neuro-oncology.
Traumatic subarachnoid hemorrhage (tSAH) is a common consequence of head trauma. Treatment of patients with tSAH commonly involves serial computed tomography (CT) scans to assess for expansile ...hemorrhage. However, growing evidence suggests that these patients rarely deteriorate or require neurosurgical intervention. We assessed the utility of repeat CT scans in adult patients with isolated tSAH and an intact initial neurological examination.
Patients presenting to Mass General Brigham hospitals with tSAH between 2000 and 2021 were eligible for inclusion in this retrospective cohort study. Patients were excluded if subarachnoid hemorrhage was nontraumatic, they experienced another form of intracerebral hemorrhage, or they had a documented Glasgow Coma Scale score of ≤12 and/or poor presenting neurological examination. Univariate and multivariate regression models were used for statistical analysis.
Overall, 405 patients were included (191 male). The most common mechanism of trauma was fall from standing (58%). The mean number of total CT scans for all patients was 2.3, with 329 patients (80%) receiving ≥2 scans. In 309 patients, no significant neurological symptoms were present. No patients developed acute neurological deterioration or required neurosurgical intervention related to their bleed, although 5 patients had mild hemorrhagic expansion on follow-up imaging.
In this study, repeat imaging rarely demonstrated meaningful hemorrhagic expansion in this cohort of neurologically intact patients with isolated tSAH. In these patients with mild traumatic brain injury, excessive CT scans are perhaps unlikely to affect patient management and may present unnecessary burden to patients and hospital systems.
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