Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation

BACKGROUND AND OBJECTIVES

Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking.

METHODS

The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables.

RESULTS

A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established.

CONCLUSION

The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part II): Barriers to Professional Development and Service Delivery in Neurosurgery

BACKGROUND

Strengthening health systems requires attention to workforce, training needs, and barriers to service delivery. The World Federation of Neurosurgical Societies Young Neurosurgeons Committee survey sought to identify challenges for residents, fellows, and consultants within 10 years of training.

METHODS

An online survey was distributed to various neurosurgical societies, personal contacts, and social media platforms (April-November 2018). Responses were grouped by World Bank income classification into high-income countries (HICs), upper middle-income countries (UMICs), low-middle-income countries (LMICs), and low-income countries (LICs). Descriptive statistical analysis was performed.

RESULTS

In total, 953 individuals completed the survey. For service delivery, the limited number of trained neurosurgeons was seen as a barrier for 12.5%, 29.8%, 69.2%, and 23.9% of respondents from HICs, UMICs, LMICs, and LICs, respectively (P < 0.0001). The most reported personal challenge was the lack of opportunities for research (HICs, 34.6%; UMICs, 57.5%; LMICs, 61.6%; and LICs, 61.5%; P = 0.03). Other differences by income class included limited access to advice from experienced/senior colleagues (P < 0.001), neurosurgical journals (P < 0.0001), and textbooks (P = 0.02). Assessing how the World Federation of Neurosurgical Societies could best help young neurosurgeons, the most frequent requests (n = 953; 1673 requests) were research (n = 384), education (n = 296), and subspecialty/fellowship training (n = 232). Skills courses and access to cadaver dissection laboratories were also heavily requested.

CONCLUSIONS

Young neurosurgeons perceived that additional neurosurgeons are needed globally, especially in LICs and LMICs, and primarily requested additional resources for research and subspecialty training.

The World Federation of Neurosurgical Societies Young Neurosurgeons Survey (Part I): Demographics, Resources, and Education

BACKGROUND

Providing a comprehensive and effective neurosurgical service requires adequate numbers of well-trained, resourced, and motivated neurosurgeons. The survey aims to better understand 1) the demographics of young neurosurgeons worldwide; 2) the challenges in training and resources that they face; 3) perceived barriers; and 4) needs for development.

METHODS

This was a cross-sectional study in which a widely disseminated online survey (April 2018-November 2019) was used to procure a nonprobabilistic sample from current neurosurgical trainees and those within 10 years of training. Data were grouped by World Bank income classifications and analyzed using χ2 tests because of its categorical nature.

RESULTS

There were 1294 respondents, with 953 completed responses included in the analysis. Of respondents, 45.2% were from high-income countries (HICs), 23.2% from upper-middle-income countries, 26.8% lower-middle-income countries, and 4.1% from low-income countries. Most respondents (79.8%) were male, a figure more pronounced in lower-income groups. Neuro-oncology was the most popular in HICs and spinal surgery in all other groups. Although access to computed tomography scanning was near universal (98.64%), magnetic resonance imaging access decreased to 66.67% in low-income countries, compared with 98.61% in HICs. Similar patterns were noted with access to operating microscopes, image guidance systems, and high-speed drills. Of respondents, 71.4% had dedicated time for neurosurgical education.

CONCLUSIONS

These data confirm and quantify disparities in the equipment and training opportunities among young neurosurgeons practicing in different income groups. We hope that this study will act as a guide to further understand these differences and target resources to remedy them.

Abstract P4-02-05: Indocyanine green (ICG) fluorescence mapping for sentinel lymph node (SLN) localization in early breast cancer

Background:Dual localization methods with blue dye and radioisotope are commonly employed for SLN identification but allergic reactions together with staining of skin and surgical tissues disadvantage blue dye. A previous feasibility study using blue dye, radioisotope and ICG confirmed high sensitivity of ICG fluorescence for SLN detection with three-quarters of nodes both radioactive and fluorescent.1 This follow-on study has evaluated a combination of ICG with radioisotope for SLN identification. Methods: In a prospective observational study, 79 patients with unilateral clinically node negative tumors scheduled to undergo routine SLN biopsy for core-biopsy proven invasive (n= 78) or non-invasive (n = 1) breast cancer were identified at multidisciplinary meetings [43 screen-detected; 36 symptomatic]. All patients received dual localization with radiocolloid (Technetium nanocolloid, 20MBq) and ICG (0.5%) and had pre-operative axillary ultrasound. The number of nodes was recorded numerically and whether radioactive, fluorescent or both. Lymphatic and nodal tissue were visualized with a Photodynamic Eye camera and sensitivity of individual tracers alone and in combination calculated. Institutional approval was granted for use of ICG instead of blue dye. Statistical analysis was performed using Stata (version 15.1) with student t-test for normal distribution and Mann-Whitney test for other variables. The main objective was to assess non-inferiority of fluorescent (ICG) compared with standard radioisotopic localization. This was based on a confidence interval for the difference in percentage detection rate with a non-inferiority margin of 5%. Results: A total of 162 nodes were retrieved from 79 patients with an average nodal count of 2.04 (range 1 - 4) and an overall identification rate of 98.7% (78/79). Amongst these excised nodes, 154 displayed uptake of tracer and were either fluorescent, radioactive or both (8 nodes were removed incidentally or were palpably suspicious and tracer negative). More than 90% (151/154) of nodes were fluorescent and 73.4% (113/154) were radioactive with at least 10% activity of the hottest node. These results yielded an overall concordance rate of 71.4%. Nodal detection rates for ICG alone or combined with radioisotope were 98.1% (151/154) and 73.4% (113/154) respectively whilst procedural detection rates were 97.5% (77/79) for radioisotope and 98.7% (78/79) for ICG. Metastases were present in 13 nodes (all fluorescent and hot) with 13 patients having a single positive node containing macrometastases (n= 5), micrometastases (n = 6) or isolated tumor cells (n = 2). The node positivity rate was 14.1% for macro- or micrometastases and 2.5% for isolated tumor cells. ICG was non-inferior to radioisotope for both procedural and nodal detection rates with the lower confidence interval not crossing within the pre-defined limit. No serious adverse reactions were recorded. Conclusion: ICG fluorescence imaging permits real-time visualization of lymphatics and provides an additional dimension to SLN biopsy that is safe and effective. These results confirm high sensitivity for fluorescence localization with comparable performance to the gold standard using radioisotope. ICG can reliably be employed as a sole tracer that avoids potential drawbacks of standard tracer agents including availability and costs of radioisotope.

1. Wishart GC, Jones LC, Loh S-W, Benson JR. A feasibility study (ICG-10) of indocyanine green (ICG) fluorescence mapping for sentinel lymph node detection in early breast cancer. Eur J Surg Oncol 2012; Jun 13

Citation Format: Dorin Dumitru, Sujit Gnanakumar, Elena Provenzano, John Benson. Indocyanine green (ICG) fluorescence mapping for sentinel lymph node (SLN) localization in early breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-02-05.

The use of a microscope integrated three-dimensional camera display system as a valuable aid in delivering human anatomy workshops

This article was migrated. The article was not marked as recommended. Introduction: Whole body dissection significantly improves a student's knowledge of anatomy, but the costs associated with utilising human cadavers are often prohibitive. This study introduces innovative three-dimensional (3D) anatomical image display to aid the learning process. Methods: Small-group prosection demonstrations were delivered to second year pre-clinical medical students using 3D microscope and display. Results: Students were shown different head and neck structures and their anatomical relations. Hundred and fifty students (94.3%) agreed that 3D image display was useful for learning anatomy. Difficulties in viewing 3D content were reported by 21 students (13.2%). Students highlighted the usefulness of 3D derived imaging in viewing small structures and that it helped with consolidating their spatial anatomical knowledge. Conclusion: 3D technology is becoming popular in clinical medicine, training and education. This study has shown that anatomy demonstrations delivered using innovative 3D microscope derived images are well received by undergraduate students and are valuable adjuncts to humany anatomy teaching.

Abstract P3-03-07: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Benson JR, Gnanakumar S, Dumitru D, Provenzano E. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-07.

The international health elective: a stepping stone for tomorrow's global surgeons and anaesthetists

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