Working in low- and middle-income countries: Learning from each other.

•Barriers may limit LMICs-HICs collaborations: infrastructure, equipment's lack/inadequacy, political issues, brain drain.•Local training is crucial for universal health coverage; several activities are headed by Global Neurosurgery organisations.•The â€‹EANS Global and Humanitarian Neurosurgery Committee aims to become a gateway for partnerships between HICs and LMICs.

Global neurosurgery amongst the EANS community: Where are we at?

•Awareness of Global Neurosurgery opportunities is limited in the EANS and a minority have had previous experiences with such activities.•Most training programs and job environments don't encourage participation in Global Neurosurgery and mentors are lacking.•However, most European neurosurgeons and trainees remain interested in Global Neurosurgery and are willing to participate.•Junior trainees is the group with the highest rate of interest for Global Neurosurgery.•Barriers exist that may limit participation in Global Neurosurgery, and funding is the most relevant.

Telemedicine for Neurotrauma Prevents Unnecessary Transfers: An Update from a Nationwide Program in Albania and Analysis of 590 Patients.

BACKGROUND: The telemedicine program in Albania includes a specialized teleneurotrauma program. There is only 1 national trauma center with neurosurgery capability in the capital city of Tirana. Patients with isolated head or spine injury who require consultation with neurosurgeons located at the National Trauma Center receive telemedicine consultation. The aim of this follow-up study was to evaluate the effectiveness of a nationwide teleneurotrauma network in preventing unnecessary transfers for neurotrauma. METHODS: Retrospective analysis was performed of prospectively collected data on all telemedicine consultations for isolated neurotrauma from March 2014 to February 2018. All teleconsultations were coded using the International Classification of Diseases, Tenth Revision coding system (codes S00, S01-S010). RESULTS: Of 590 teleconsultations for neurotrauma, most patients (76%) were male (median age 46.5 years; range, 1-93 years); 403 (68.31%; mean age 45.12 years) did not require a transfer to the tertiary center, and 187 (mean age 42.47 years) were transferred. An average 12.5 (monthly average range, 8.5-16) patients were seen monthly with a steady increase to a mature telemedicine program at the present time. Most teleconsultations (70.67%) occurred during business hours (8:00 am-4:30 pm); 173 (29.32%) occurred at night and on weekends. Analysis by diagnosis indicated that most cases of low severity were not transferred, whereas higher severity cases were twice as likely to be transferred (P < 0.05). CONCLUSIONS: Structured and coordinated telemedicine for neurotrauma increases access to care for neurosurgery patients in countries that do not have widespread neurosurgery services. Nearly 70% of patients may be treated locally by nonneurosurgeons.

Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients.

BACKGROUND: Use of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania. METHODS: A retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed. RESULTS: Of the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital. CONCLUSION: Telemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.

The readiness of emergency and trauma care in low- and middle-income countries: a cross-sectional descriptive study of 42 public hospitals in Albania.

BACKGROUND: Traumatic injuries have become a substantial but neglected epidemic in low- and middle-income countries (LMICs), but emergency rooms (ERs) in these countries are often staffed with healthcare providers who have minimal emergency training and experience. The aim of this paper was to describe the specialized training, available interventions, and the patient management strategies in the ERs in Albanian public hospitals. METHODS: A cross-sectional descriptive study of 42 ERs in the Republic of Albania between September 5, 2014, and December 29, 2014 was performed. Assessment subcategories included the following: (1) specialized training and/or certifications possessed by healthcare providers, (2) interventions performed in the ER, and (3) patient management strategies. RESULTS: Across the 42 ERs surveyed, less than half (37.1-42.5 %) of physicians and one third of nurses (7.1-26.0 %) working in the ERs received specialized trauma training. About half (47.9-57.1 %) of the ER physicians and one fifth of the nurses (18.3-22.9 %) possessed basic life support certification. This survey demonstrated some significant differences in the emergency medical care provided between primary, secondary, and tertiary hospitals across Albania (the significance level was set at 0.05). Specifically, these differences involved spinal immobilization (p = 0.01), FAST scan (p = 0.04), splinting (p = 0.01), closed reduction of displaced fractures (p = 0.02), and nurses performing cardiopulmonary resuscitation (CPR) (p = 0.01). Between 50.0 and 71.4 % of the facilities cited a combined lack of training and supplies as the reason for not offering interventions such as rapid sequence induction, needle thoracotomy, chest tube insertion, and thrombolysis. Mass casualty triage was utilized among 39.1 % primary hospitals, 41.7 % of secondary, and 28.6 % of tertiary. CONCLUSIONS: The emergency services in Albania are currently staffed with inadequately trained personnel, who lack the equipment and protocols to meet the needs of the population.

Access to Specialized Care Through Telemedicine in Limited-Resource Country: Initial 1,065 Teleconsultations in Albania.

OBJECTIVE: To analyze the initial experience of the nationwide clinical telemedicine program of Albania, as a model of implementation of telemedicine using "Initiate-Build-Operate-Transfer" strategy. METHODS: This was a retrospective study of prospectively collected data from teleconsultations in Albania between January 1, 2014 and August 26, 2015, delivered synchronously, asynchronously, or a combination of both methods. Patient's demographics, mode of consultation, clinical specialty, hospitals providing referral and consultation, time from initial call to completion of consultation, and patient disposition following teleconsultation were analyzed. Challenges of the newly created program have been identified and analyzed as well. RESULTS: There were 1,065 teleconsultations performed altogether during the study period. Ninety-one patients with autism managed via telemedicine were not included in this analysis and will be reported separately. Of 974 teleconsults, the majority were for radiology, neurotrauma, and stroke (55%, 16%, and 10% respectively). Asynchronous technology accounted for nearly two-thirds of all teleconsultations (63.7%), followed by combined (24.3%), and then synchronous (12.0%). Of 974 cases, only 20.0% of patients in 2014 and 22.72% of patients in 2015 were transferred to a tertiary hospital. A majority (98.5%) of all teleconsultations were conducted within the country itself. CONCLUSIONS: The Integrated Telemedicine and e-Health program of Albania has become a useful tool to improve access to high-quality healthcare, particularly in high demanding specialty disciplines. A number of challenges were identified and these should serve as lessons for other countries in their quest to establish nationwide telemedicine programs.

Telemedicine as an innovative model for rebuilding medical systems in developing countries through multipartnership collaboration: the case of Albania.

The U.S. Government and other developed nations provide billions of dollars annually in relief assistance to countries around the world. The long-term benefits of this aid, however, are often difficult to elucidate. The aim of this article is to present a model of a multipartnership collaboration among U.S. governmental, nongovernmental organizations, and academia to rebuild medical systems using telemedicine as a sustainable model of foreign aid. The International Virtual e-Hospital implemented the "initiate-build-operate-transfer" strategy to establish an effective telemedicine system in Albania that includes the National Telemedicine Center and 12 regional telemedicine centers. This nationwide telemedicine network has active clinical programs, virtual educational programs, and an electronic library that has substantially improved the access to care while advancing medical education. We propose that telemedicine is an optimal, sustainable, low-cost model for rebuilding medical systems of developing countries when implemented through a multipartnership approach.

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial.

BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919. FINDINGS: 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077). INTERPRETATION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients. FUNDING: UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation.

Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months.

MRC CRASH is a randomised controlled trial (ISRCTN74459797) of the effect of corticosteroids on death and disability after head injury. We randomly allocated 10,008 adults with head injury and a Glasgow Coma Scale score of 14 or less, within 8 h of injury, to a 48-h infusion of corticosteroid (methylprednisolone) or placebo. Data at 6 months were obtained for 9673 (96.7%) patients. The risk of death was higher in the corticosteroid group than in the placebo group (1248 [25.7%] vs 1075 [22.3%] deaths; relative risk 1.15, 95% CI 1.07-1.24; p=0.0001), as was the risk of death or severe disability (1828 [38.1%] vs 1728 [36.3%] dead or severely disabled; 1.05, 0.99-1.10; p=0.079). There was no evidence that the effect of corticosteroids differed by injury severity or time since injury. These results lend support to our earlier conclusion that corticosteroids should not be used routinely in the treatment of head injury.

Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial.

BACKGROUND: Corticosteroids have been used to treat head injuries for more than 30 years. In 1997, findings of a systematic review suggested that these drugs reduce risk of death by 1-2%. The CRASH trial--a multicentre international collaboration--aimed to confirm or refute such an effect by recruiting 20000 patients. In May, 2004, the data monitoring committee disclosed the unmasked results to the steering committee, which stopped recruitment. METHODS: 10008 adults with head injury and a Glasgow coma score (GCS) of 14 or less within 8 h of injury were randomly allocated 48 h infusion of corticosteroids (methylprednisolone) or placebo. Primary outcomes were death within 2 weeks of injury and death or disability at 6 months. Prespecified subgroup analyses were based on injury severity (GCS) at randomisation and on time from injury to randomisation. Analysis was by intention to treat. Effects on outcomes within 2 weeks of randomisation are presented in this report. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN74459797. FINDINGS: Compared with placebo, the risk of death from all causes within 2 weeks was higher in the group allocated corticosteroids (1052 [21.1%] vs 893 [17.9%] deaths; relative risk 1.18 [95% CI 1.09-1.27]; p=0.0001). The relative increase in deaths due to corticosteroids did not differ by injury severity (p=0.22) or time since injury (p=0.05). INTERPRETATION: Our results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury. The cause of the rise in risk of death within 2 weeks is unclear.