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Covell MM, Naik A, Shaffer A, Cramer SW, Alan N, Shabani HK, Rabiel H, Rosseau G, Arnold PM. Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study. Neurosurgery 2023:00006123-990000000-00960. [PMID: 37962339 DOI: 10.1227/neu.0000000000002765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs. METHODS A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction). RESULTS Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up. CONCLUSION This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Annabelle Shaffer
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Samuel W Cramer
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Nima Alan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Happiness Rabiel
- Department of Neurosurgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gail Rosseau
- Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Paul M Arnold
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois, USA
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Abstract
The article describes the rehabilitation services provided at Christian Medical College Vellore, a tertiary care medical college hospital in South India. The department was started by Dr Mary Verghese, who on completion of her medical training sustained spinal cord injury with resulting paraplegia. Following a section on the initial beginnings of the department, the current status of the department offering comprehensive rehabilitation by the multidisciplinary team is highlighted. The article ends with the challenges faced, including limitations in providing affordable solutions, architectural and attitudinal barriers, and inadequate number of rehabilitation physicians and comprehensive rehabilitation centers in the country.
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Affiliation(s)
- Raji Thomas
- Department of Physical Medicine and Rehabilitation, Christian Medical College Vellore, Vellore, Tamil Nadu, India.
| | - George Tharion
- Department of Physical Medicine and Rehabilitation, Christian Medical College Vellore, Vellore, Tamil Nadu, India
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Survival in 222 Patients With Severe CSCI: An 8-Year Epidemiologic Survey in Western China. Arch Phys Med Rehabil 2019; 100:1872-1880. [PMID: 30684486 DOI: 10.1016/j.apmr.2018.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/03/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the survival and the predictors of mortality in patients with severe cervical spinal cord injuries (CSCI). DESIGN Retrospective study. PARTICIPANTS From January 1, 2010, to May 31, 2018, patients who suffered from severe CSCIs in Western China were enrolled in this study (N=222). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Survival rates and mortality risk factors. Measures were calculated by the product-limit method (Kaplan-Meier) and the Cox model. RESULTS The overall 1-year, 3-year, 5-year, and 8-year postoperative mortalities were 24.4%, 30.6%, 33.3%, 36.2%, and 39.0%, respectively. Most deaths occurred within 36 months after the injury. According to the Cox proportional hazards model, the significant predictors of survival were as follows: (1) age; (2) neurologic level; (3) treatment options (surgical or conservative); (4) ventilator support (P<.05). The 8-year mortality for older patients (>50y) was 50.2%, which was significantly higher than that for younger patients (32.4%, <50y). The risk of death was 2.053 times higher in higher levels of injury (C1-C4) than in lower levels of injury (C5-C8) (P<.05). Compared with conservative treatment, patients who received surgical treatment (either anterior or posterior decompression) had a lower risk of death (P<.05). No significant difference was detected in the risk of death between early surgery (<3d) and mid-term surgery (3-7d) (P>.05). However, patients who received late-term surgery (>7d) had a higher mortality risk (P<.05). The overall 8-year mortality risk of patients who needed ventilator support was much higher than those who did not need ventilator support (P<.05). CONCLUSIONS Age, neurologic level, ventilator dependence, treatment options, and timing to surgery were main risk factors for mortality in patients with severe CSCIs. Better understanding of the predictors for survival could possibly contribute to the improvement of survival rates.
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Hossain MS, Harvey LA, Islam MS, Rahman MA, Glinsky JV, Herbert RD. A prediction model to identify people with spinal cord injury who are at high risk of dying within 5 years of discharge from hospital in Bangladesh. Spinal Cord 2018; 57:198-205. [DOI: 10.1038/s41393-018-0211-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/03/2018] [Accepted: 10/08/2018] [Indexed: 11/09/2022]
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Post-discharge mortality in patients with traumatic spinal cord injury in a Brazilian hospital: a retrospective cohort. Spinal Cord 2018; 57:134-140. [PMID: 30089892 DOI: 10.1038/s41393-018-0183-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/24/2018] [Accepted: 07/03/2018] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate the survival outcomes in patients with traumatic spinal cord injury (TSCI). SETTING A teaching hospital in Brazil. METHODS A total of 434 patients diagnosed with TSCI (2004-2014) were included. Overall survival, standardized mortality ratios (SMR), and causes of death were assessed by Student's t-test, χ2 test, Kaplan-Meier analysis, and Cox proportional-hazards regression. RESULTS The mean follow-up was 4.8 years (±3.3 years). Individuals with tetraplegia had a median survival of 11 years, with participants in the paraplegia group not reaching median survival. The overall mortality rate was 37 per 1000 person-years. Age-adjusted SMR was 28.8 (95% CI: 22.8-36). There were 77 deaths with 56 defined causes, of which pneumonia was the most frequent (35.7%). Combined infectious etiologies caused 55.3% of deaths. Multivariate analysis revealed higher mortality among individuals with tetraplegia vs. paraplegia in the first 2 years post injury (HR = 8.28, 95% CI: 2.76-24.80), after 2 years post injury (HR = 2.35, 95% CI: 1.31-4.24), and in all years combined (HR = 3.36, 95% CI: 2.04-5.52). CONCLUSION Mortality among patients with TSCI was 28.8 times higher than in the reference population. In more than half of the cases, the cause of death was linked to infectious diseases. Pneumonia caused two times more deaths in individuals with tetraplegia than in individuals with paraplegia, with a higher impact in the first 2 years post injury. Reported findings indicate the need for a surveillance and prevention program with emphasis on vaccination and respiratory rehabilitation.
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Hossain MS, Harvey LA, Liu H, Islam MS, Rahman MA, Muldoon S, Biering-Sorensen F, Cameron ID, Chhabra HS, Lindley RI, Jan S. Protocol for process evaluation of CIVIC randomised controlled trial: Community-based InterVentions to prevent serIous Complications following spinal cord injury in Bangladesh. BMJ Open 2018; 8:e024226. [PMID: 30012798 PMCID: PMC6082451 DOI: 10.1136/bmjopen-2018-024226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/14/2018] [Accepted: 06/25/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION People with spinal cord injuries in low-income and middle-income countries are highly vulnerable to life-threatening complications in the period immediately after discharge from hospital. We are conducting a randomised controlled trial in Bangladesh to determine whether all-cause mortality at 2 years can be reduced if health professionals regularly ring and visit participants in their homes following discharge. We will conduct a process evaluation alongside the trial to explain the trial results and determine the feasibility of scaling this intervention up in low-income and middle-income countries if it is found to be effective. METHODS AND ANALYSIS Our process evaluation is based on the Realist and Reach, Effectiveness, Adoption, Implementation and Maintenance frameworks. We will use a mixed methods approach that uses both qualitative and quantitative data. For example, we will audit a sample of telephone interactions between intervention participants and the healthcare professionals, and we will conduct semistructured interviews with people reflective of various interest groups. Quantitative data will also be collected to determine the number and length of interactions between the healthcare professionals and participants, the types of issues identified during each interaction and the nature of the support and advice provided by the healthcare professionals. All quantitative and qualitative data will be analysed iteratively before the final analysis of the trial results. These data will then be triangulated with the final results of the primary outcome. ETHICS AND DISSEMINATION Ethics approval was obtained from the institutional ethics committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval and the relevant regulatory bodies. The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER ACTRN12615000630516.
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Affiliation(s)
- Mohammad Sohrab Hossain
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Hueiming Liu
- George Institute for Global Health, Sydney, New South Wales, Australia
| | | | | | | | | | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
| | | | - Richard I Lindley
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Stephen Jan
- George Institute for Global Health, Sydney, New South Wales, Australia
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Azarhomayoun A, Aghasi M, Mousavi N, Shokraneh F, Vaccaro AR, Haj Mirzaian A, Derakhshan P, Rahimi-Movaghar V. Mortality Rate and Predicting Factors of Traumatic Thoracolumbar Spinal Cord Injury; A Systematic Review and Meta-Analysis. Bull Emerg Trauma 2018; 6:181-194. [PMID: 30090812 PMCID: PMC6078479 DOI: 10.29252/beat-060301] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective To estimate the summation of mortality rate and the contributing factors in patients with traumatic thoracolumbar spinal cord injuries (TLSCI). Methods A systematic search of observational studies that evaluated the mortality associated with TLSCI in MEDLINE and EMBASE was conducted. The study quality was evaluated using a modified quality assessment tool previously designed for observational studies. Results Twenty-four observational studies involving 11,205 patients were included, published between January 1, 1997, and February 6, 2016. Ten studies were of high quality, thirteen were of moderate quality, and one study was of low quality. Seventeen reports described risk factors for mortality and eleven of these studies used a multiple regression models to adjust for confounders. The reported mortality rate ranged from 0 to 37.7% overall and between 0 and 10.4% in-hospital. The sum of mortality for in-hospital, 6-month, and 12-month were 5.2%, 26.12%, 4.3%, respectively. The mortality at 7.7 years follow-up was 10.07% and for 14 years follow-up reports ranged from 13.47% to 21.46%. Associated data such as age at injury, male to female ratio, pre-existing comorbidities, concomitant injuries, duration of follow-up, and cause of death have been underreported in studies investigating the mortality rate after TLSCI. Conclusion There is no study was found that accurately assessed mortality in the thoracolumbar spine, while there is general agreement that traumatic thoracolumbar spinal cord injuries are important.
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Affiliation(s)
- Amir Azarhomayoun
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Aghasi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Najmeh Mousavi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Shokraneh
- Division of Psychiatry and Clinical Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Alexander R Vaccaro
- Departments of Orthopaedic Surgery and Neurological Surgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, PA, USA
| | - Arvin Haj Mirzaian
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pegah Derakhshan
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Student Research Committee, Faculty of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Hossain MS, Rahman MA, Herbert RD, Quadir MM, Bowden JL, Harvey LA. Two-year survival following discharge from hospital after spinal cord injury in Bangladesh. Spinal Cord 2015; 54:132-6. [PMID: 26078229 DOI: 10.1038/sc.2015.92] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/23/2015] [Accepted: 04/26/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Mixed retrospective-prospective cohort study. OBJECTIVES To determine 2-year survival following discharge from hospital after spinal cord injury in Bangladesh. SETTING Bangladesh. METHODS Medical records were used to identify all patients admitted in 2011 with a recent spinal cord injury to the Centre for Rehabilitation of the Paralysed, a large Bangladeshi hospital that specialises in care of people with spinal cord injury. Patients or their families were subsequently visited or contacted by telephone in 2014. Vital status and, where relevant, date and cause of death were determined by verbal autopsy. RESULTS 350 of 371 people admitted with a recent spinal cord injury in 2011 were discharged alive from hospital. All but eleven were accounted for two years after discharge (97% follow-up). Two-year survival was 87% (95% CI 83% to 90%). Two-year survival of those who were wheelchair-dependent was 81% (95% CI 76% to 86%). The most common cause of death was sepsis due to pressure ulcers. CONCLUSION In Bangladesh, approximately one in five people with spinal cord injury who are wheelchair-dependent die within two years of discharge from hospital. Most deaths are due to sepsis from potentially preventable pressure ulcers.
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Affiliation(s)
- M S Hossain
- Centre for Rehabilitation of the Paralysed, Savar, Bangladesh
| | - M A Rahman
- Centre for Rehabilitation of the Paralysed, Savar, Bangladesh
| | - R D Herbert
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
| | - M M Quadir
- Centre for Rehabilitation of the Paralysed, Savar, Bangladesh
| | - J L Bowden
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - L A Harvey
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Sydney Medical School/Northern, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales, Australia
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