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Ariana S. Barkley, Laura J. Spece, Lia M. Barros, Robert H. Bonow, Ali Ravanpay, Richard Ellenbogen, Phearum Huoy, Try Thy, Seang Sothea, Sopheak Pak, James LoGerfo and Abhijit V. Lele

) instrument, 6 its neurosurgery-specific counterpart, NeuroPIPES, 16 and the Neurocritical Care (NCC) checklist recently published by NCS. 10 To inform capacity-development initiatives for TBI in an LMIC setting, we conducted a mixed-methods study to assess capacity for neurosurgical care in general, and perioperative/nonoperative TBI care in particular, at two national hospitals in Phnom Penh, Cambodia. The mixed-methods study design included administering quantitative survey instruments, together with qualitative interviews conducted with healthcare personnel at both

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Swagoto Mukhopadhyay, Maria Punchak, Abbas Rattani, Ya-Ching Hung, James Dahm, Serena Faruque, Michael C. Dewan, Sophie Peeters, Sonal Sachdev and Kee B. Park

OBJECTIVE

In 2000, the global density of neurosurgeons was estimated at 1 per 230,000 population, which remains the most recent estimate of the global neurosurgeon workforce density. In 2004, the World Health Organization (WHO) estimated that there were 33,193 neurosurgeons worldwide, including trainees. There have been no updates to this estimate in the past decade. Moreover, only WHO region–level granularity regarding neurosurgeon distribution exists; country-level estimates are limited. The neurosurgery workforce is a crucial component to meeting the growing burden of neurosurgical diseases, which not only represent high absolute incidences and prevalences, but also represent correspondingly high disability-adjusted life years affecting hundreds of millions of people worldwide. Combining the lack of knowledge about the availability of the neurosurgical workforce and the increasing demand for neurosurgical services underscores the need for a system of neurosurgical workforce density surveillance.

METHODS

This study involved 3 key steps: 1) global survey/literature review to obtain the number of working neurosurgeons per WHO-recognized country, 2) regression to interpolate any missing data, and 3) calculation of workforce densities and comparison to available historical data by WHO region.

RESULTS

Data for 198 countries were collected (158) or interpolated (40). The global total number of neurosurgeons was estimated at 49,940. Overall, neurosurgeon density ranged from 0 to 58.95 (standardized to per 1,000,000 population) with a median of 3.56 (IQR 0.29–8.26). Thirty-three countries were found to have no neurosurgeons (zero). The highest density, 58.95, was in Japan, where 7495 neurosurgeons are taking care of a population of 127,131,800.

CONCLUSIONS

In 2015, the Lancet Commission on Global Surgery estimated that 143 million additional surgical procedures are needed in low- and middle-income countries each year, and a subsequent study revealed that approximately 15% of those surgical procedures are neurosurgical. Based on our results, we can conclude that there are approximately 49,940 neurosurgeons currently, worldwide. The availability of neurosurgeons appears to have increased in all geographic regions over the past decade, with Southeast Asia experiencing the greatest growth. Such remarkable expansion should be assessed to determine factors that could play a role in other regions where the acceleration of growth would be beneficial.

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Alexandra Cutillo, Kathrin Zimmerman, Susan Davies, Avi Madan-Swain, Wendy Landier, Anastasia Arynchyna and Brandon G. Rocque

providers to identify specific strategies that are helpful to caregivers, and to design methods to teach these useful strategies to caregivers who may be using more maladaptive coping strategies, such as avoidance. The goal of this mixed-methods study is to use patient-centered qualitative techniques to determine what strategies caregivers use to cope with the stress of having a child diagnosed with and surgically treated for a brain tumor. Understanding the adaptive and maladaptive ways caregivers cope can help us design recommendations to families in the future. Methods

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Charlotte Sayer, Daniel E. Lumsden, Sarah Perides, Kylee Tustin, Sanj Bassi, Jean-Pierre Lin and Margaret Kaminska

OBJECT

Intrathecal baclofen (ITB) is an effective management option for childhood hypertonia. Given the potential complications of implanted ITB pumps, trials of ITB are usually performed as part of the workup for ITB pumps. Two methods are used for ITB trials, lumbar puncture (LP) and catheter insertion into the intrathecal space. Little has been written to date on the number of positive trials and complications in trials. This study aimed to report the outcomes and complications in ITB trials for childhood hypertonia (dystonia, spastic, or mixed).

METHODS

A retrospective case notes review was conducted of all patients who underwent ITB trials at the Evelina London Children’s Hospital between 2005 and 2012 (inclusive). Positive trials were defined as a reduction in Modified Ashworth Scale by a minimum of 1 point in at least 2 muscle groups and improvement reported by the caregivers in the areas of goals agreed upon between professionals and the families.

RESULTS

Our patient group comprised children with dystonia (n = 7), mixed spasticity/dystonia (n = 29), spasticity (n = 4), and pain (n = 1). A total of 47 trials were attempted in 41 children. Forty trials were successfully completed, with 39 being positive. Thirty-three were catheter trials, and 14 were LPs. The overall complication rate in the 47 attempted trials was 53%: 61% in catheter trials, and 36% in LP trials. This difference was not statistically significant. The most common complications were vomiting (n = 9) and CSF leak (n = 4). The most serious complication was meningitis (n = 1) in a catheter trial. No patients experienced a permanent injury.

CONCLUSIONS

There is a high risk of minor self-limiting complications with ITB trials, which needs to be factored into the decision process of progression to trials. The rate of positive trials in this study was 98%, of which 21% did not progress to pump implantation. While the authors would still advocate for ITB trials prior to ITB pump insertion to aid parental decision-making, this figure suggests that with good patient selection, ITB pumps could be placed without a preceding trial.

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Michael C. Dewan, Abbas Rattani, Graham Fieggen, Miguel A. Arraez, Franco Servadei, Frederick A. Boop, Walter D. Johnson, Benjamin C. Warf and Kee B. Park

OBJECTIVE

Worldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand.

METHODS

Results from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity.

RESULTS

Every year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases—all in low- and middle-income countries—that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.

CONCLUSIONS

Each year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.

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Kee B. Park

JG , Leather AJ , Hagander L , Alkire BC , Alonso N , Ameh EA , : Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development . Lancet 386 : 569 – 624 , 2015 25924834 10.1016/S0140-6736(15)60160-X 6 Mukhopadhyay S , Punchak M , Rattani A , Hung YC , Dahm J , Faruque S , : The global neurosurgical workforce: a mixed-methods assessment of density and growth . J Neurosurg [epub ahead of print January 4, 2019; DOI: 10.3171/2018.10.JNS171723] 30611133 7 Robertson FC , Lepard JR

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James T. Rutka

Neurosurg [epub ahead of print April 6, 2018; DOI: 10.3171/2017.10.JNS17435] 29624152 9 Mukhopadhyay S , Punchak M , Rattani A , Hung YC , Dahm J , Faruque S , : The global neurosurgical workforce: a mixed-methods assessment of density and growth . J Neurosurg [epub ahead of print January 4, 2019; DOI: 10.3171/2018.10.JNS171723] 30611133 10 Robertson FC , Lepard JR , Mekary RA , Davis MC , Yunusa I , Gormley WB , : Epidemiology of central nervous system infectious diseases: a meta-analysis and systematic review with implications

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Ghassan Awad Elkarim, Naif M. Alotaibi, Nardin Samuel, Shelly Wang, George M. Ibrahim, Aria Fallah, Alexander G. Weil and Abhaya V. Kulkarni

, Badhiwala JH , Nassiri F , Guha D , Ibrahim GM , Shamji MF , : The current use of social media in neurosurgery . World Neurosurg 88 : 619 – 624 , 624.e1–624.e7, 2016 10.1016/j.wneu.2015.11.011 26585734 3 Alotaibi NM , Samuel N , Wang J , Ahuja CS , Guha D , Ibrahim GM , : The use of social media communications in brain aneurysms and subarachnoid hemorrhage: a mixed-method analysis . World Neurosurg 98 : 456 – 462 , 2017 27890750 10.1016/j.wneu.2016.11.085 4 Barakat LP , Linney JA : Children with physical handicaps and their

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Rasheedat T. Zakare-Fagbamila, Christine Park, Wes Dickson, Tracy Z. Cheng and Oren N. Gottfried

of waiting in univariate mixed-methods regression. Dept = department; N = neurosurgery ( red dots ); O = orthopedic surgery ( blue dots ). R = −0.18, p = 0.0056. Figure is available in color online only. Access-5 Scores In univariate analysis there were no nonmodifiable characteristics that predicted Access-5 scores ( Table 3 ). Longer overall cycle times, waiting-room times, and in-room times were all significant predictors of lower Access-5 scores (p < 0.001). A 10-minute increase in waiting-room time was associated with a 9.8% absolute decrease in Access-5

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1126 2017.10.JNS17359 10.3171/2017.10.JNS17359 An estimation of global volume of surgically treatable epilepsy based on a systematic review and meta-analysis of epilepsy Kerry A. Vaughan 1, 5 MD Christian Lopez Ramos 2, 5 BS Vivek P. Buch 1 MD Rania A. Mekary 3, 4 MSc, PhD Julia R. Amundson 5, 6 MD, MPH Meghal Shah 5, 7 BS Abbas Rattani 5, 8 MBe Michael C. Dewan 5, 9 MD, MSCI Kee B. Park 5 MD 04 2019 14 09 2018 130 4 1127 1141 10.3171/2018.3.JNS171722 2018.3.JNS171722 The global neurosurgical workforce: a mixed-methods assessment of density and growth Swagoto