Neurosurgical training and global health education: systematic review of challenges and benefits of in-country programs in the care of neural tube defects

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The recognition that neurosurgeons harbor great potential to advocate for the care of individuals with neural tube defects (NTDs) globally has sounded as a clear call to action; however, neurosurgical care and training in low- and middle-income countries (LMICs) present unique challenges that must be considered. The objective of this study was to systematically review publications that describe the challenges and benefits of participating in neurosurgery-related training programs in LMICs in the service of individuals with NTDs.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Using MEDLINE (PubMed), the authors conducted a systematic review of English- and Spanish-language articles published from 1974 to 2019 that describe the experiences of in-country neurosurgery-related training programs in LMICs. The inclusion criteria were as follows—1) population/exposure: US residents, US neurosurgeons, and local in-country medical staff participating in neurosurgical training programs aimed at improving healthcare for individuals with NTDs; 2) comparison: qualitative studies; and 3) outcome: description of the challenges and benefits of neurosurgical training programs. Articles meeting these criteria were assessed within a global health education conceptual framework.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Nine articles met the inclusion criteria, with the majority of the in-country neurosurgical training programs being seen in subregions of Africa (8/9 [89%]) and one in South/Central America. US-based residents and neurosurgeons who participated in global health neurosurgical training had increased exposure to rare diseases not common in the US, were given the opportunity to work with a collaborative team to educate local healthcare professionals, and had increased exposure to neurosurgical procedures involved in treating NTDs. US neurosurgeons agreed that participating in international training improved their own clinical practices but also recognized that identifying international partners, travel expenses, and interference with their current practice are major barriers to participating in global health education. In contrast, the local medical personnel learned surgical techniques from visiting neurosurgeons, had increased exposure to intraoperative decision-making, and were given guidance to improve postoperative care. The most significant challenges identified were difficulties in local long-term retention of trained fellows and staff, deficient infrastructure, and lower compensation offered for pediatric neurosurgery in comparison to adult care.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The challenges and benefits of international neurosurgical training programs need to be considered to effectively promote the development of neurosurgical care for individuals with NTDs in LMICs. In this global health paradigm, future work needs to investigate further the in-country professionals’ perspective, as well as the related outcomes.</jats:p></jats:sec>

Neonatal ten-year retrospective study on neural tube defects in a second level University Hospital

“…The ongoing genomic revolution will indeed offer the possibility to carry out genomic projects, with the aim of identifying new variants implicated in the biologic basis of NTDs [16][17][18]. The low rate of NTDs observed in our case series, even more marked than that currently found in HICs [8,[19][20][21], may be explained by some plausible factors: a likely high number of prenatal diagnoses and abortions in our setting, and the phenomenon of health emigration (from Sicily to central-northern Italian regions), that may have contributed to the reduction/underestimation of our cases.…”

“…These unfavorable outcomes are still highly prevalent also in HICs [9,19]. Thus, despite the achievement of advanced standards of care and the improvements in neonatological management and surgical techniques [8,25,26], they have been observed also in some of our patients.…”

“…Infants with anencephaly are mostly stillborn, or die shortly after birth, while those with spina bifida and encephalocele may survive, although suffering from physical and developmental disabilities of various degrees of severity [7]. Worldwide average incidence is 1.8/1000 births (more than 300,000 affected infants born every year), with significant geographic (ethnic, environmental, socioeconomic) variations (> 1 to around 10/1000 births in middle and lowincome countries (LMICs) and decreasing incidence in high-income countries (HICs, 0.6/1000 in USA) in the recent decades [8,9].…”

“…NTDs are among the main causes of childhood mortality and disability worldwide, with higher rates in LMICs for limited access to specialized neonatological/ pediatric and surgical care [8][9][10]. Moreover, inequities in the access to high quality care affect pregnant/childbearing age women [11], in relation to low rate of prenatal diagnosis and prevention tools (preconception folic acid supplement), thus explaining the higher prevalence of NTDs at birth.…”

Open Neural Tube Defects: A Case Presentation of 30-year-old Secundigravida with Spina Bifida of the Fetus

“…An occurrence frequency of the disease is 1 case per 1,000 births [3,4] and each year nearly 300,000 infants with Neural Tube Defects (NTDs) are born, further resulting in death or lifelong disabilities [1,5]. Therefore, socioeconomic cost associated with NTD patients is very high due to the increased morbidity and premature mortality [4,6,7]. Around 17% of cases are presented with spina bifida occulta with better prognosis for the developing fetus, due to lack of central nervous system involvement [8,9].…”