Roxanna M. Garcia

BACKGROUND AND OBJECTIVES: Penetrating brain injury (PBI) is a highly lethal form of traumatic brain injury, with substantial mortality and marked differences across high-income countries and low- to middle-income countries. The aim of the Comparative Effectiveness Research in the Americas on Penetrating Brain Injury (COMPAS-PBI) study was to evaluate management variability, compare outcomes across resource settings, and assess the feasibility of real-time multinational neurocritical care data collection. METHODS: COMPAS-PBI is a multinational, multicenter observational comparative effectiveness study. It includes a retrospective cohort (2021-2025) and a prospective cohort (2026-2028) of adults aged 18 years or older with confirmed PBI, defined by radiographic evidence of dural penetration on head computed tomography, presenting within 24 hours of injury. Eleven trauma centers across 8 countries in the Americas will participate, with the University of Oklahoma Health Sciences Campus serving as the coordinating center. The principal management strategies compared are intracranial pressure monitoring vs no monitoring and neurosurgical intervention, primarily early decompressive craniectomy, vs medical management alone. Comparative analyses will use propensity score–based methods to address baseline confounding. EXPECTED OUTCOMES: The primary outcome is in-hospital mortality. Secondary outcomes include disposition at discharge, Glasgow Outcome Scale-Extended score (at discharge, 6, and 12 months), and timing of intracranial pressure monitoring and decompressive craniectomy. Feasibility outcomes will assess completeness, timeliness, and quality of prospective real-time data capture, particularly in resource-limited settings. DISCUSSION: COMPAS-PBI will generate the first multinational comparative effectiveness data sets focused on civilian PBI within the Americas. The study is expected to provide pragmatic evidence to inform context-sensitive care strategies, reduce practice differences, and support future collaborative neurotrauma research.

Background: Congenital anomalies impact 52 million infants worldwide with an estimated 94% living in low- and middle-income countries (LMICs). Approximately 200,000 children are born with a neural tube defect (NTD) in LMICs annually. Zambia is an LMIC with a high burden of myelomeningocele (MMC; a severe form of NTD). This study sought to characterize the barriers influencing access to healthcare for children born with MMC in Zambia. Methods: Two cross-sectional surveys were administered to healthcare providers at referring public health facilities and mothers of infants born with MMC undergoing surgical closure. The survey among mothers was nested in a longitudinal study evaluating surgical closure in Lusaka, Zambia from 28 May 2024 to 21 January 2025. Results: Sixty-nine mother–MMC baby dyads and 123 providers from 21 facilities were enrolled in the study. The median age at presentation for MMC was 7.5 (range 0–244) days old. Most patients were referred from rural district hospitals (51%; n = 35) and travelled greater than 250 km to access care (80%; n = 55). Seventy-seven percent (n = 53) of mothers reported receiving at least one antenatal ultrasound, with 62% (n = 43) undergoing an ultrasound after 20 weeks estimated gestational age. Of these, only 3% (n = 2) received an MMC diagnosis prior to delivery. Referring patients with MMC for further care greater than six hours after birth was reported by 59% providers (n = 73). Hospitals further away from the tertiary center were more likely to report late referrals (p < 0.001). Conclusions: There is a delay in the diagnosis and referral of infants with MMC to specialized care in Zambia, which may be attributed to inadequate in utero diagnosis capabilities and distance from the tertiary facility. Improving the accuracy of prenatal diagnosis and strengthening referral pathways to facilitate access to care among infants with MMC in Zambia are important for improving incidence and outcomes.

In 1998, the United States (US) implemented mandatory folic acid fortification of enriched cereal grain products (ECGP) to prevent neural tube defects (NTD) in newborns. NTD rates remained highest among Hispanic births. Voluntary fortification of corn masa flour was approved in 2016, without improvement in NTD rates. This review aims to understand folic acid consumption among Hispanic women in the US before and after voluntary fortification. A systematic search was conducted in PubMed, Embase, and Scopus from inception to September 2024 using the keywords folic acid, Hispanic Americans, and fortification. Study designs included descriptive, cross-sectional, and observational cohort. Studies in any language reporting the consumption of folic acid fortified foods among Hispanic women of reproductive age in the US were eligible. Study variables were compared to non-Hispanic White (NHW) women when available. Findings were summarized descriptively. Of 446 publications, eight studies (n = 20,123) met inclusion criteria. All studies reported on folic acid fortified foods, four characterized folic acid intake and acculturation factors, three quantified red blood cell (RBC) folate concentrations, and two described NTD rates. Hispanic women consumed grains, cereals, bread, flour, pasta, and corn masa flour. Most Hispanic women obtained folic acid from ECGP only. Hispanic women consumed more dietary folic acid than NHW women pre-voluntary fortification (406–456 µg (mcg) versus 349 mcg daily, p < 0.001) but less total folic acid when supplements were included (244 mcg versus 332 mcg daily, p < 0.05). Monolingual Spanish-speakers had the lowest total intake (224 mcg daily, p < 0.05). RBC folate concentrations were lower among Hispanic women compared to NHW women pre-voluntary fortification (963 nmol per liter (nmol/L) versus 1043 nmol/L) but showed no improvement post-fortification. Voluntary fortification did not significantly increase folic acid intake or reduce the proportion with inadequate intake; however, monolingual Spanish-speakers demonstrated higher intake and RBC folate concentrations. NTD rates remained similar between Hispanic (7.5/10,000 live births) and NHW women (7.1/10,000 live births) post-fortification. The certainty of evidence, assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework, ranged from low to very low across outcomes. There is a paucity of literature to describe the rate, influencing factors, and prevalence disparities in NTD among Hispanic women living in the US despite its public health importance. This review provides a current summary on the disparities in folic acid intake and NTD rates between Hispanic and NHW women, and the effectiveness of voluntary fortification targeting populations at higher risk. Research initiatives investigating the factors influencing these disparities and future targeted interventions are necessary.

Education and training are essential components of global neurosurgery because they provide a sustainable solution to address the workforce deficits in the neurosurgical burden of disease. Neurosurgery training programs and opportunities exist in most areas of the world, but some countries still lack formal mechanisms to train future generations. In this special article, we review the neurosurgical workforce deficit, characterize factors influencing the absence or inadequacy of neurosurgical training, and identify strategies that could facilitate global efforts in building a stronger workforce. We summarize the key neurosurgical training models worldwide and the factors influencing the standardization of neurosurgical education by region. In addition, we evaluate the “brain drain” issue in the larger context of the healthcare workforce and propose solutions to mitigate this phenomenon in neurosurgical practice. Future generations of neurosurgical trainees depend on our efforts to intensify and expand education and training in this new virtual era. As we look to the future, we must prioritize education to strengthen the future neurosurgeons who will lead and shape the frontiers of our field.

The future of global neurosurgery should focus on addressing the unmet neurosurgical need from a health system approach should we hope to achieve sustainable and ethical change. In this article, we review the global building blocks, as defined by the World Health Organization, and use this framework to propose strategies to strengthen neurosurgical care on the global frontier. The targets for Universal Healthcare Coverage by 2030, as outlined by the United Nations Sustainable Development Goals, are reviewed, and the role of neurosurgeons in addressing the global targets is discussed. Surgical indicators according to the Lancet Commission on Global Surgery are also reviewed, and neurosurgical indicators are proposed according to the 6 surgical indicators of the commission. The execution of these global targets and indicators within the context of health system strengthening will be a persistent challenge, given the complexity of health system and its components. The neurosurgical community must continue to support, promote, and diversify collaborations, especially among deserts of neurosurgical care across the world. Innovative technology and education are essential to this global dilemma.

Advocacy, one of the five domains of global neurosurgery, represents a powerful avenue to influence public policy to expand access to safe, timely, and affordable neurosurgical care. In this manuscript, we characterize advocacy in global neurosurgery, describe specific neurosurgeon-led initiatives, and delineate how neurosurgeons can become involved in global neurosurgery advocacy efforts. Advocacy in global neurosurgery involves working together in organized neurosurgery with organizations focused on clinical provisions, training, and policy initiatives. Effective advocacy uses a data-driven approach with myriad facilitators, including collaboration and approach strategies for sharing information and a variety of contextual, ideological, and practical barriers. The main action fronts for global neurosurgery include identifying needs, broadening access, and assuring quality. Neurosurgery-led initiatives transforming public policy have occurred on regional and global scales and accelerated since 2019. Folate fortification of staple foods to prevent neural tube defects represents a recent and notably successful area of advocacy and remains in progress. Neurosurgeons who aspire to become involved in advocacy efforts must obtain competencies and skills distinct from, yet complementary to, the traditional neurosurgical training curriculum.

In the following article, we define the practice of global neurosurgery and review the major historical events defining this movement within the larger context of global surgery. The current state of the neurosurgical workforce, disease burden, and ongoing collaborative efforts are highlighted. Ethical practice leading the sustainability is discussed, as well as future targets for the global community as we look beyond the next decade of opportunities to affect the neurosurgical burden of disease.

Objective: To comprehensively describe the epidemiology and morbidity of spina bifida in Hispanic Americans and identify risk factors associated with the increased prevalence of spina bifida. Design: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources: Three databases (MEDLINE, Embase and Scopus) were searched between inception of the database and June 2023. Study designs included case–control, descriptive, cross-sectional and databases. Eligibility criteria: Observational and experimental analytical studies reporting epidemiology or morbidity of spina bifida in Hispanic Americans or Latinx individuals were eligible. Data extraction and synthesis: Data were extracted independently by authors. Descriptive analysis was used to summarise findings. Results: Of 392 publications, 32 studies met inclusion criteria. Study periods ranged from 1955 to 2020. A total of 50 382 patients with spina bifida were included and 13 209 identified as Hispanic American (26.2%). Five studies report higher prevalence of spina bifida at birth per 10 000 births in Hispanic Americans compared with non-Hispanic white individuals, while one reported no significant difference (2.11 vs 2.24). Risk factors associated with spina bifida included prenatal exposures, sociodemographic factors and maternal clinical characteristics. Lower levels of maternal education, age and income were associated with an increased risk of spina bifida. Eleven papers found spina bifida had high morbidity among Hispanic Americans resulting in high financial, physical and socioeconomic impacts. There was high study heterogeneity that can be explained by the varying time periods and geographical distribution. Conclusion: Increased prevalence and morbidity of spina bifida in Hispanic Americans are due to a variety of inter-related factors relating to existing health disparities. High heterogeneity across the studies suggests a need for future studies and increased standardisation of reporting guidelines.