BACKGROUND: Most articles describing the effect of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical services have been from developed countries. We report our experience in carrying out neurosurgical services at Dr. Sardjito General Hospital, Yogyakarta, Indonesia, during the time of the pandemic.

OBJECTIVEEducating future neurosurgeons is of paramount importance, and there are many aspects that must be addressed within the process. One of the essential issues is the disproportion in neurosurgical care, especially in low- and middle-income countries (LMICs). As stated in their report “Global Surgery 2030,” The Lancet Commission on Global Surgery has emphasized that the availability of adequate neurosurgical care does not match the burden of neurosurgical disease. A strong partnership with the local and national government is very desirable to improve the way everyone addresses this issue. In addition, international collaborative effort is absolutely essential for the transfer of knowledge and technology from a developed country to an LMIC. This paper shows what the authors have done in Yogyakarta to build an educational model that helps to improve neurosurgical care distribution in Indonesia and reduce the inequity between provinces.METHODSThe authors gathered data about the number of neurosurgical procedures that were performed in the sister hospital by using data collected by their residents. Information about the distribution of neurosurgeons in Indonesia was adapted from the Indonesian Society of Neurological Surgeons.RESULTSThe data show that there remains a huge disparity in terms of distribution of neurosurgeons in Indonesia. To tackle the issue, the authors have been able to develop a model of collaboration that can be applied not only to the educational purpose but also for establishing neurosurgical services throughout Indonesia. Currently they have signed a memorandum of understanding with four sister hospitals, while an agreement with one sister hospital has come to an end. There were more than 400 neurosurgical procedures, ranging from infection to trauma, treated by the authors’ team posted outside of Yogyakarta.CONCLUSIONSIndonesia has a high level of inequality in neurological surgery care. This model of collaboration, which focuses on the development of healthcare providers, universities, and related stakeholders, might be essential in reducing such a disparity. By using this model, the authors hope they can be involved in achieving the vision of The Lancet Commission on Global Surgery, which is “universal access to safe, affordable surgical and anesthesia care when needed.”

BACKGROUND: Shunt infection is one of the dreaded and serious complications following ventriculoperitoneal shunt (VP shunt) insertion, especially in a pediatric population. Numerous risk factors have been identified, particularly in developing countries, indicating that age may play an essential element in the pathogenesis of shunt infection, typically in patients <1-year-old. However, a few research demonstrate the inverse result. AIM: The purpose of this was to determine the relationship between age and shunt infection so that it can be taken into consideration when performing VP shunt insertion. METHODS: From January 2017 to December 2019, 98 pediatric patients with hydrocephalus who underwent VP shunt insertion were retrospectively reviewed to determine the relationship between age and shunt infection. We evaluated the microbiology results and management of shunt infection in patients with shunt infection. RESULTS: Fifteen (15.15%) of 98 patients developed shunt infection. Patients aged >3–6 months had a significantly increased risk of shunt infection (p = 0.04; RR = 4.15; CI 95% = 1.19–14.45). Staphylococcus aureus was the most frequently encountered pathogen in pediatric patients with shunt infection (53.3%), and the most common management for shunt infection was complete removal of the shunt and systemic antibiotics followed by re-insertion of the shunt after the cerebrospinal fluid was sterile (46.6%). CONCLUSION: We conclude that age, especially those aged >3–6 months, has a significantly higher risk of shunt infection in pediatric patients.

Kasus hidrosefalus pada bayi dan anak, merupakan salah satu kasus yang sering terjadi dan mempunyai komplikasi yang bervariasi. Penanganan hidrosefalus adalah dilakukan pemasangan pirau ventrikuloperitoneal. Tindakan tersebut sering ditemukan komplikasi, diantaranya adalah malfungsi. Faktor yang mempengaruhi terjadinya malfungsi tersebut, salah satunya berupa karakteristik pasien, cara persalinan, analisa CSS, tipe dan tekanan pirau ventrikuloperitoneal, jenis hidrosefalus, dan etiologi hidrosefalus. Penulis dalam kesempatan ini akan menganalisa faktor – faktor yang berpengaruh terhadap kejadian malfungsi pirau ventrikuloperitoneal. Penelitian ini adalah penelitian analitik dengan desain cohort retrospective, yaitu dengan cara mengambil sampel pasien hidrosefalus pada bayi dan anak yang telah dilakukan pemasangan pirau ventrikuloperitoneal pada periode Januari 2015 sampai dengan Desember 2016. Jumlah sampel yang akan diteliti adalah sebesar 124 sampel. Data dianalisis dengan Chi square yang selanjutnya dilakukan analisis multivariat dengan regresi logistik. Total sampel penelitian 124 pasien hidrosefalus pada bayi dan anak yang sesuai dengan kriteria inklusi. Dilakukan pengambilan sampel secara total. Pada penelitian ini terdapat 8 faktor risiko yang dapat mempengaruhi kejadian malfungsi pirau ventrikuloperitoneal pada pasien hidrosefalus bayi dan anak Pada analisis multivariat terpilih 3 faktor risiko yang dapat mempengaruhi kejadian malfungsi pirau ventrikuloperitoneal, yaitu usia kehamilan, usia kehamilan, tipe pirau ventrikuloperitoneal, dan analisa jumlah sel CSS. Faktor risiko yang dominan dan berpengaruh terhadap kejadian malfungsi pirau ventrikuloperitoneal pada pasien hidrosefalus bayi dan anak adalah usia kehamilan preterm, yaitu sebanyak 6 sampel (66,7%) dari 9 sampel dengan nilai p = 0,010 yang artinya nilai p < 0,05 dan dengan Odds Ratio (OR) paling besar yaitu 7,156 dengan IK 95% (1,627-31,476), sedangkan jumlah sel CSS yang meningkat  sebesar 8 sampel (38,1%) dari 21 sampel dan nilai p = 0,406 dan OR 1,646 dengan IK 95% (0,509-5,328). Untuk tipe pirau ventrikuloperitoneal mempunyai nilai p = 0,161 dan OR 0,727 dengan IK 95% (0,466-1,136). Usia kehamilan preterm pada pasien hidrosefalus bayi dan anak merupakan faktor risiko yang dapat mempengaruhi kejadian malfungsi pirau ventrikuloperitoneal di RSUP Dr. Sardjito.

Healthcare facilities are "soft targets." The "Run-Hide-Fight" mantra can be easily assimilated by the average learner in generic "active shooter" educational programs. However, healthcare professionals, confronting an active shooter situation, must reconcile conflicting goals: personal, staff, and their patient's safety. Indecisiveness may lead to catastrophe. Targeted education addressing these concerns can be explored in medical simulations. Methods: A case-based simulation medical program (four hours weekly) is included within an emergency medical clerkship involving multidisciplinary students and faculty. At the start of their rotation, students receive "active shooter" educational material including the hospital protocol. While managing a typical ED simulated patient (varying levels of criticality), an "active shooter" component is added. Students must reconcile "Run-Hide-Fight" within the context of patient care. Debriefings follow. Results: Sessions are held twice monthly in a no-threat environment with approval and assistance from university police trained in "active shooter" education. Within a span of ninety minutes, students manage a case into which one active shooter scenario is added. Depending on shooter location and patient condition, students must decide to run (with what and whom) or hide (barricade techniques) and fight (improvisational weapons). Debriefing emphasizes no right answer. Each situation is unique. Lifesaving strategies and tactics emphasize the improvised barricades and weapons that are uniquely found in a patient's room. Over 100 students have gone through this program since its inception. Conclusion: Incorporating active shooter scenarios in medical simulations is accomplished in a no-threat, no-consequence environment. Regular training of healthcare and public health students through simulation of typical and atypical scenarios in healthcare facilities provides experience and sharpens mental "muscle memory"allowing them to make wise decisions quickly during an actual active shooter incident.