Timing of ventriculoperitoneal shunt insertion following spina bifida closure in Kenya

A Proposed Protective Protocol Predicting Reduction of Shunt Infection

OBJECTIVE

To identify the best protective interventions against shunt infection and, hence, to find an appropriate protocol assumed to be associated with reduction of infection rates.

METHODS

A combined prospective-retrospective cohort study was conducted over a period of 5 years in 3 referral hospitals. Twelve interventions against infection practiced by blinded surgeons during ventriculoperitoneal shunt operations were surveyed and their association with the outcome of interest (i.e., shunt infection) was tested. Interventions proved to be associated with the outcome entered a multivariate logistic regression to identify the protective interventions.

RESULTS

Among a total of 392 cases, shunt infection was diagnosed in 11.5% with a median onset of 55 days. Patients' demographics, etiology of hydrocephalus, shunt-related factors, and type of preoperative antibiotics were not associated with shunt infection. Two-thirds of infected shunts revealed Staphylococcus species. Among the tested interventions, double-gloving and device and wound irrigation using vancomycin solution and the use of incision adhesive drapes proved to exhibit a significant protective effect against shunt infection, whereas operative time <40 minutes revealed a marginal protective benefit.

CONCLUSIONS

Shunt infection is a significant complication that occurs early during the first 2 months after surgery. According to the study findings, an appropriate protocol against shunt infection is assumed to be composed of double-gloving, device and wound irrigation using vancomycin solution, and the use of incision adhesive drapes. Reduced operative time had a beneficial effect against shunt infection, although it was of marginal significance in the current study.

Global Surgery Indicators and Pediatric Hydrocephalus: A Multicenter Cross-Country Comparative Study Building the Case for Health System Strengthening

Objective: The aim of this study is to compare specific three-institution, cross-country data that are relevant to the Global Surgery indicators and the functioning of health systems. Methods: We retrospectively reviewed the clinical and socioeconomic characteristics of pediatric patients who underwent cerebrospinal fluid (CSF) diversion surgery for hydrocephalus in three different centers: the University of Tsukuba Hospital in Ibaraki, Japan (HIC), the Jose R. Reyes Memorial Medical Center in Manila, Philippines [low-to-middle-income country (LMIC)], and the Federal Neurosurgical Center in Novosibirsk, Russia (UMIC). The outcomes of interest were the timing of CSF diversion surgery and mortality. Statistical tests included descriptive statistics, Cox proportional hazards model, and logistic regression. Nation-level data were also obtained to provide the relevant socioeconomic contexts in discussing the results. Results: In total, 159 children were included, where 13 are from Japan, 99 are from the Philippines, and 47 are from the Russian Federation. The median time to surgery at the specific neurosurgical centers was 6 days in the Philippines and 1 day in both Japan and Russia. For the cohort from the Philippines, non-poor patients were more likely to receive CSF diversion surgery at an earlier time (HR = 4.74, 95% CI 2.34-9.61, p <0.001). In the same center, those with infantile or posthemorrhagic hydrocephalus (HR = 3.72, 95% CI 1.70-8.15, p = 0.001) were more likely to receive CSF diversion earlier compared to those with congenital hydrocephalus, and those with postinfectious (HR = 0.39, 95% CI 0.22-0.70, p = 0.002) or myelomeningocele-associated hydrocephalus (HR = 0.46, 95% CI 0.22-0.95, p = 0.037) were less likely to undergo surgery at an earlier time. For Russia, older patients were more likely to receive or require early CSF diversion (HR = 1.07, 95% CI 1.01-1.14, p = 0.035). External ventricular drain (EVD) insertion was found to be associated with mortality (cOR 14.45, 95% CI 1.28-162.97, p = 0.031). Conclusion: In this study, Filipino children underwent late time-interval of CSF diversion surgery and had mortality differences compared to their Japanese and Russian counterparts. These disparities may reflect on the functioning of the health systems of respective countries.

Myelomeningocele-associated hydrocephalus: nationwide analysis and systematic review

OBJECTIVE

Myelomeningocele (MMC), the most severe form of spina bifida, is characterized by protrusion of the meninges and spinal cord through a defect in the vertebral arches. The management and prevention of MMC-associated hydrocephalus has evolved since its initial introduction with regard to treatment of MMC defect, MMC-associated hydrocephalus treatment modality, and timing of hydrocephalus treatment.

METHODS

The Nationwide Inpatient Sample (NIS) database from the years 1998-2014 was reviewed and neonates with spina bifida and hydrocephalus status were identified. Timing of hydrocephalus treatment, delayed treatment (DT) versus simultaneous MMC repair with hydrocephalus treatment (ST), and treatment modality (ETV vs ventriculoperitoneal shunt [VPS]) were analyzed. Yearly trends were assessed with univariable logarithmic regression. Multivariable logistic regression identified correlates of inpatient shunt failure. A PRISMA systematic literature review was conducted that analyzed data from studies that investigated 1) MMC closure technique and hydrocephalus rate, 2) hydrocephalus treatment modality, and 3) timing of hydrocephalus treatment.

RESULTS

A weighted total of 10,627 inpatient MMC repairs were documented in the NIS, 8233 (77.5%) of which had documented hydrocephalus: 5876 (71.4%) were treated with VPS, 331 (4.0%) were treated with ETV, and 2026 (24.6%) remained untreated on initial inpatient stay. Treatment modality rates were stable over time; however, hydrocephalic patients in later years were less likely to receive hydrocephalus treatment during initial inpatient stay (odds ratio [OR] 0.974, p = 0.0331). The inpatient hydrocephalus treatment failure rate was higher for patients who received ETV treatment (17.5% ETV failure rate vs 7.9% VPS failure rate; p = 0.0028). Delayed hydrocephalus treatment was more prevalent in the later time period (77.9% vs 69.5%, p = 0.0287). Predictors of inpatient shunt failure included length of stay, shunt infection, jaundice, and delayed treatment. A longer time between operations increased the likelihood of inpatient shunt failure (OR 1.10, p < 0.0001). However, a meta-analysis of hydrocephalus timing studies revealed no difference between ST and DT with respect to shunt failure or infection rates.

CONCLUSIONS

From 1998 to 2014, hydrocephalus treatment has become more delayed and the number of hydrocephalic MMC patients not treated on initial inpatient stay has increased. Meta-analysis demonstrated that shunt malfunction and infection rates do not differ between delayed and simultaneous hydrocephalus treatment.

Neurosurgery in East Africa: Innovations

In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.

Access to health care for children with neural tube defects: Experiences of mothers in Zambia

INTRODUCTION

In Zambia, all children born with neural tube defects requiring surgery need to be referred to a tertiary level hospital in Lusaka, the capital city, where the specialists are based. The aim of this study was to explore the experiences of mothers accessing health care who had recently given birth to a child with a neural tube defect.

METHODS AND ANALYSIS

In-depth interviews were conducted with a purposively selected sample of 20 mothers at the tertiary level hospital. The interviews were audiotaped, transcribed verbatim and translated. Content analysis was used to identify codes, which were later collapsed into categories and themes.

FINDINGS

Five themes emerged: access to health care, access to transport, access to information, concerns about family and support needs.

DISCUSSION

Barriers to access to health care included geographical barriers and barriers linked to availability. Geographical barriers were related to distance between home and the health centre, and referral between health facilities. Barriers to availability included the lack of specialist health workers at various levels, and insufficient hospital vehicles to transport mothers and children to the tertiary level hospital. The main barrier to affordability was the cost of transport, which was alleviated by either family or government support. Acceptability of the health services was affected by a lack of information, incorrect advice, the attitude of health workers and the beliefs of the family.

CONCLUSION

Access to health care by mothers of children with neural tube defects in Zambia is affected by geographical accessibility, availability, affordability and acceptability. The supply-side barriers and demand-side barriers require different interventions to address them. This suggests that health policy is needed which ensures access to surgery and follow-up care.

Challenges in the Management of Hydrocephalic Children in Northern Mozambique

BACKGROUND

Hydrocephalus in sub-Saharan Africa, including Mozambique, is still a significant health care problem.

METHODS

Retrospective data from a previous study were used to determine patient provenance, referral patterns, and lost to follow-up rates.

RESULTS

Many children with hydrocephalus in this region are not taken to health care facilities for treatment. Reasons include poverty, difficult access, lack of transportation, and erroneous cultural interpretations. Resource limitations in terms of poorly equipped health care facilities and a lack of trained health professionals also contribute.

CONCLUSIONS

Efforts to improve prevention, early diagnosis, treatment, and follow-up are of utmost importance in Mozambique.

Hydrocephalus in children less than 1 year of age in northern Mozambique

Background:

In developed countries, the incidence of neonatal hydrocephalus ranges from 3 to 5 cases per 1000 live births, but little is known about the frequency of hydrocephalus in Africa. In Mozambique, there is no primary information related to this disorder, but using the above data, the expected incidence of neonatal hydrocephalus would range from 2900 to 4800 cases per year.

Methods:

This study is based on 122 children younger than 1 year with neonatal hydrocephalus, followed up between January 2010 and December 2012, their origin and treatment, and aims to evaluate difficulties with diagnosis, treatment, and follow-up in northern Mozambique.

Results:

Identified cases were mainly less than 6 months old (77%), with severe macrocephaly and the classic stigmata of this condition. A high rate of follow-up loss (44.3%) was detected, particularly among children from more distant locations. Our findings contrast with the expected 1000-1700 cases that would occur in the area during the study period, being considerably lower.

Conclusions:

Hydrocephalus is a serious problem in sub-Saharan Africa, whose effects can be minimized by a better organization of the health system in hydrocephalus prevention, referral, and follow-up. New management alternatives to provide treatment to more children with this disorder and reduction of the follow-up difficulties caused due to geographical reasons for the children undergoing treatment are essential.

Targeting a zero blood transfusion rate in the repair of craniospinal dysraphism: outcome of a surgical technique for developing countries

OBJECTIVES

In Africa and other developing countries, the financial cost of the in-hospital acute surgical treatment of children with open neural tube defects (NTD) is often beyond the reach of the parents. Surgery-related blood transfusion requirements sometimes add to the concerns. Here, we present a surgical technique used in our practice to mitigate the blood transfusion issue.

METHODS

First, we present the technical report of our near-bloodless technique for targeting zero blood transfusion rate during the surgical repair of open cranial and spinal dysraphism. The technique is based on the generous use of the Bovie electrocautery in the initial phase of the surgical dissection. We also carried out an outcome analysis of its use in a prospective consecutive cohort of patients operated on over a 24-month period.

RESULTS

There were 48 NTDs in children aged 2-372 days. The widest diameter of the dysraphic lesions ranged from 3 to 14 cm (mean 5.8 ± 2.6); six were occipital encephalocoeles and the rest were spinal dysraphisms, 79.2% lumbosacral. The operative time ranged from 25 to 105 minutes (mean 59.6 ± 20.4); surgical blood loss was <10% of calculated total blood volume in 92% of the children, and none needed blood replacement. With only few minor wound issues recorded, healing of the surgical wound was by primary intention in 92%. There was no other unusual occurrence of postoperative neurological limb or sphincteric deficits.

CONCLUSION

This surgical technique greatly reduces the need for operative blood replacement in the surgical repair of open craniospinal dysraphisms, and has acceptable rates of postoperative wound and neurological complications.

Multidisciplinary approach to cerebrospinal fluid shunt infection with an appeal for attention to details in assessment and standardization in reporting

OBJECT

The goal of this study was to evaluate the problems encountered in monitoring CSF shunt infection, including the collection, analysis, and reporting of data. The authors propose a system that would produce more accurate, and hence more meaningful, information on shunt infection than do the methodologies and customs now in common use.

METHODS

The authors reviewed and analyzed 19 years of quarterly records of a committee that has addressed CSF shunt infection in an ongoing manner.

RESULTS

There are strong incentives, political and otherwise, to identify low rates of CSF shunt infection. Details of the composition and operation of a multidisciplinary approach to CSF shunt infection are summarized. Many factors affect the occurrence of shunt infection and its accurate assessment and reporting. Easily accessible sources for the identification of cases of shunt infections and for the assessment of an at-risk population often contain discrepancies in significant numbers.

CONCLUSIONS

Multidisciplinary oversight of the entire matter of CSF shunt infection enhances the chances for collecting accurate data, identifying causes of infection, and developing effective preventative strategies. Valid data require a mechanism for finding all individuals within the at-risk pool; the accurate identification of patients who had shunt infections; standard, pragmatic, and robust criteria for diagnosis of shunt infection; and multidisciplinary oversight of the entire process.