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Buh FC, Sumbele IUN, Maas AIR, Motah M, Pattisapu JV, Youm E, Meh BK, Kobeissy FH, Wang KW, Hutchinson PJA, Taiwe GS. Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1558. [PMID: 37763678 PMCID: PMC10535664 DOI: 10.3390/medicina59091558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023]
Abstract
Background and Objective: About 14 million people will likely suffer a traumatic brain injury (TBI) per year by 2050 in sub-Saharan Africa. Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma centre in Cameroon. Materials and Methods: Data on demographics, causes, clinical aspects, and discharge status were collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality-of-Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes six months after TBI. Comparisons between two categorical variables were done using Pearson's chi-square test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years was most represented (78%). Males were more affected (90%). A low educational level was seen in 122 (76%) cases. Road traffic incidents (RTI) (85%), assaults (7.5%), and falls (2.5%) were the main causes of TBI, with professional bike riders being frequently involved (27%). Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% of cases, and intracranial traumatic abnormalities were identified in 64% of cases. Financial constraints (93%) was the main reason for not performing a CT scan. Forty-six (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) and high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only four patients received post-injury physical therapy services. Conclusions: TBI in Cameroon mainly results from RTIs and commonly affects young adult males. Lack of pre-hospital care, financial constraints limiting both CT scanning and medical care, and a lack of acute physiotherapy services likely influenced care and outcomes adversely.
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Affiliation(s)
- Franklin Chu Buh
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
| | - Irene Ule Ngole Sumbele
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, University of Antwerp, 2000 Edegem, Belgium;
| | - Mathieu Motah
- Department of Surgery, Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala P.O. Box 2701, Cameroon;
| | - Jogi V. Pattisapu
- Department of Pediatric Neurosurgery, University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA;
| | - Eric Youm
- Holo Healthcare, Nairobi 00400, Kenya;
| | - Basil Kum Meh
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
| | - Firas H. Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Riad El-Solh, Beirut P.O. Box 11-0236, Lebanon
| | - Kevin W. Wang
- Center for Neurotrauma, Multiomics & Biomarkers (CNMB), Department of Neurobiology, Neuroscience Institute, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30310-1458, USA;
| | | | - Germain Sotoing Taiwe
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea P.O. Box 63, Cameroon (B.K.M.)
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Nguembu S, Kenfack YJ, Sadler S, Zolo Y, Figuim B, Sebopelo LA, Tétinou F, Kanmounye US. Factors Associated with Adverse Outcomes in Cameroonian Patients with Traumatic Brain Injury: A Cross-Sectional Study. World Neurosurg 2023; 172:e62-e67. [PMID: 36481439 DOI: 10.1016/j.wneu.2022.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries. In Cameroon, the estimated annual incidence rate is 572 cases per 100,000 people. This study investigated factors associated with adverse outcomes in the management of Cameroonian patients with TBI. METHODS This cross-sectional study included all patients with TBI treated between January 1 and December 31, 2018, at 2 Cameroonian referral hospitals. Sociodemographic and clinical data were extracted from patient charts and admission registries and analyzed with SPSS v.26. Independent t tests, odds ratios, and cumulative mortality hazard rates were computed. A P-value <0.05 was considered statistically significant. Also, binomial regression analyses were calculated. RESULTS One hundred seventy-one patients aged 38.63 ± 20.46 years old received treatment for TBI. Most patients were male (78.9%), Cameroonian (98.2%), from urban areas (75.4%), and uninsured (88.8%). The average admission length was 11.23 ± 10.71 days, during which 27.5% of patients received surgical treatment while 72.5% received non-surgical (conservative) management. From postdischarge day 12 onwards, surgically-treated patients had a greater cumulative mortality hazard rate than conservatively-treated patients. By 28 days postdischarge, 66.1% of patients had recovered completely [Glasgow Outcome Scale (GOS) = 5], 23.4% had a disability (GOS = 2-4), and 10.5% expired (GOS = 1). Complete recovery was associated with the absence of severe TBI (B = -1.42, standard error [SE] = 0.52, P = 0.006), disability was associated with increased injury-to-admission delay (B = -1.27, SE = 0.48, P = 0.009), and death was associated with severe TBI (B = 3.16, SE = 0.73, P < 0.001). CONCLUSIONS We identified factors associated with unfavorable outcomes among Cameroonian patients with TBI. These results can inform triage and referral practices and aid policymakers in developing context-specific prehospital guidelines.
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Affiliation(s)
- Stéphane Nguembu
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Yves Jordan Kenfack
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Yvan Zolo
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Bello Figuim
- Department of Surgery, Neurosurgery Unit, Yaounde Central Hospital, Yaounde, Cameroon
| | | | - Francklin Tétinou
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
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Buh FC, Taiwe GS, Maas AI, Motah M, Youm E, Wanyu BY, Wang KW, Hutchinson PJ, Sumbele IUN. Demographics, Causes, and Outcome of Traumatic Brain Injury among Trauma Cases in Cameroon: A Multi-Center Five Year's Retrospective Study. Neurotrauma Rep 2022; 3:569-583. [PMID: 36711440 PMCID: PMC9879018 DOI: 10.1089/neur.2022.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Traumatic brain injury (TBI) is a huge public health challenge worldwide. Epidemiological monitoring is important to inform healthcare policy. We aimed at determining the prevalence, outcome, and causes of TBI in Cameroon by conducting a 5-year retrospective study in three referral trauma centers. Data on demographics, causes, injury mechanisms, clinical aspects, and discharge status were recorded. Comparisons between two categorical variables were done using Pearson's chi-square test or Fisher's exact test. A total of 6248 cases of TBI were identified of 18,151 trauma cases, yielding a prevalence of 34%. The number of TBI cases increased across the years (915 in 2016, 1406 in 2020). Demographic data and causes of TBI were available for 6248 subjects and detailed data on clinical characteristics on 2178 subjects. Median age was 30.0 (24.0, 41.0) years. Males were more affected (80%). Road traffic incidents (RTIs; 75%) was the main cause of TBI, with professional bike riders being more affected (17%). Computed tomography (CT) imaging was performed in 67.7% of cases. Of the 597 (27.4%) cases who did not undergo neuroimaging, 311 (52.1%) did not have neuroimaging performed because of financial constraints, among which 7% were severe TBI cases. A total of 341 (19.6%) patients were discharged against medical advice, of which 83% had financial limitations. Mortality was 10.3% (225 of 2178) in the overall population, but disproportionately high in patients with severe TBI (55%) compared to those in high-income settings (27%). TBI occurrence is high in Cameroon, and RTIs are the main causes. Disparities in care provision were identified as attributable to financial constraints regarding CT scanning and continuation of care. The data presented can inform preventive interventions to improve care provision and transport policies. Implementation of a universal health insurance may be expected to improve hospital care and reduce the adverse effects of TBI among Cameroonians.
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Affiliation(s)
- Franklin Chu Buh
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea, Cameroon
- Panafrican Hospital Center-Douala, Buea, Cameroon
| | - Germain Sotoing Taiwe
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea, Cameroon
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Mathieu Motah
- Department of Surgery, Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | - Bertrand Yuwong Wanyu
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea, Cameroon
| | - Kevin W. Wang
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
| | - Peter J.A. Hutchinson
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Irene Ule Ngole Sumbele
- Department of Animal Biology and Conservation, Faculty of Science, University of Buea, Buea, Cameroon
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Traumatic intracranial haemorrhage in Cameroon: Clinical features, treatment options and outcome. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Spears CA, Adil SM, Kolls BJ, Muhumza ME, Haglund MM, Fuller AT, Dunn TW. Surgical intervention and patient factors associated with poor outcomes in patients with traumatic brain injury at a tertiary care hospital in Uganda. J Neurosurg 2021; 135:1569-1578. [PMID: 33770754 DOI: 10.3171/2020.9.jns201828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate whether neurosurgical intervention for traumatic brain injury (TBI) is associated with reduced risks of death and clinical deterioration in a low-income country with a relatively high neurosurgical capacity. The authors further aimed to assess whether the association between surgical intervention and acute poor outcomes differs according to TBI severity and various patient factors. METHODS Using TBI registry data collected from a national referral hospital in Uganda between July 2016 and April 2020, the authors performed Cox regression analyses of poor outcomes in admitted patients who did and did not undergo surgery for TBI, with surgery as a time-varying treatment variable. Patients were further stratified by TBI severity using the admission Glasgow Coma Scale (GCS) score: mild TBI (mTBI; GCS scores 13-15), moderate TBI (moTBI; GCS scores 9-12), and severe TBI (sTBI; GCS scores 3-8). Poor outcomes constituted Glasgow Outcome Scale scores 2-3, deterioration in TBI severity between admission and discharge (e.g., mTBI to sTBI), and death. Several clinical and demographic variables were included as covariates. Patients were observed for outcomes from admission through hospital day 10. RESULTS Of 1544 patients included in the cohort, 369 (24%) had undergone surgery. Rates of poor outcomes were 4% (n = 13) for surgical patients and 12% (n = 144) among nonsurgical patients (n = 1175). Surgery was associated with a 59% reduction in the hazard for a poor outcome (HR 0.41, 95% CI 0.23-0.72). Age, pupillary nonreactivity, fall injury, and TBI severity at admission were significant covariates. In models stratifying by TBI severity at admission, patients with mTBI had an 80% reduction in the hazard for a poor outcome with surgery (HR 0.20, 95% CI 0.04-0.90), whereas those with sTBI had a 65% reduction (HR 0.35, 95% CI 0.14-0.89). Patients with moTBI had a statistically nonsignificant 56% reduction in hazard (HR 0.44, 95% CI 0.17-1.17). CONCLUSIONS In this setting, the association between surgery and rates of poor outcomes varied with TBI severity and was influenced by several factors. Patients presenting with mTBI had the greatest reduction in the hazard for a poor outcome, followed by those presenting with sTBI. However, patients with moTBI had a nonsignificant reduction in the hazard, indicating greater variability in outcomes and underscoring the need for closer monitoring of this population. These results highlight the importance of accurate, timely clinical evaluation throughout a patient's admission and can inform decisions about whether and when to perform surgery for TBI when resources are limited.
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Affiliation(s)
- Charis A Spears
- 1Duke University Division of Global Neurosurgery and Neurology, Durham
- 2Duke University School of Medicine, Durham, North Carolina
| | - Syed M Adil
- 1Duke University Division of Global Neurosurgery and Neurology, Durham
- 2Duke University School of Medicine, Durham, North Carolina
| | - Brad J Kolls
- 1Duke University Division of Global Neurosurgery and Neurology, Durham
- 3Department of Neurology
| | | | - Michael M Haglund
- 1Duke University Division of Global Neurosurgery and Neurology, Durham
- 2Duke University School of Medicine, Durham, North Carolina
- 5Department of Neurosurgery, Duke University Medical Center, Durham
- 6Duke University Global Health Institute, Durham
| | - Anthony T Fuller
- 1Duke University Division of Global Neurosurgery and Neurology, Durham
- 2Duke University School of Medicine, Durham, North Carolina
- 5Department of Neurosurgery, Duke University Medical Center, Durham
- 6Duke University Global Health Institute, Durham
| | - Timothy W Dunn
- 1Duke University Division of Global Neurosurgery and Neurology, Durham
- 5Department of Neurosurgery, Duke University Medical Center, Durham
- 7Duke Forge, Duke University School of Medicine, Durham; and
- 8Department of Statistical Science, Duke University, Durham, North Carolina
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Adegboyega G, Zolo Y, Sebopelo LA, Dalle DU, Dada OE, Mbangtang CB, Tetinou F, Kanmounye US, Alalade AF. The Burden of Traumatic Brain Injury in Sub-Saharan Africa: A Scoping Review. World Neurosurg 2021; 156:e192-e205. [PMID: 34520864 DOI: 10.1016/j.wneu.2021.09.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the growing incidence of traumatic brain injury (TBI) in Sub-Saharan Africa, there is yet to be a study to map the current burden of the disease on the continent. This scoping review aims to outline the literature on TBI. METHODS This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews. A search string was developed to identify studies relating to TBI epidemiology, management, and outcomes. The search was applied to Medline, Embase, and Global Medicus Index. RESULTS In total, 107 studies were included in the final analysis. More than one half originated from South Africa. Seventy-five studies were published in 2013 or later. Studies recruited a median of 115 patients: 83.5 male and 31 female. TBI affected all age groups (range = 0-105 years) and sexes but was more common among young males aged 20-40. Road traffic accidents caused TBI in a median of 71 patients. Other major causes included assault (median = 39.5) and falls (median = 12.5). Craniectomies were the most commonly reported surgical treatment (18.7%) followed by burr holes (7.5%). Four studies (3.7%) reported delays in seeking neurotrauma care, with delays in reaching a neurotrauma facility and delays in receiving care being reported in 15 studies (14%) each. Glasgow Outcome Scale score was reported in 28 (26.1%) studies, whereas quality of life measures were reported in 2 (1%). Younger age was associated with favorable outcomes. CONCLUSIONS There is an increased need for TBI research, education, and training in Sub-Saharan Africa. This will aid stakeholders in optimizing patient management and outcome.
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Affiliation(s)
- Gideon Adegboyega
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon.
| | - Yvan Zolo
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | - David Ulrich Dalle
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | | | - Francklin Tetinou
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
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Traumatic Brain Injury-Related Pediatric Mortality and Morbidity in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2021; 153:109-130.e23. [PMID: 34166832 DOI: 10.1016/j.wneu.2021.06.077] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The burden of pediatric traumatic brain injury (pTBI) in low- and middle-income countries (LMICs) is unknown. To fill this gap, we conducted a review that aimed to characterize the causes of pTBI in LMICs, and their reported associated mortality and morbidity. METHODS A systematic review was conducted. MEDLINE, Embase, Global Health, and Global Index Medicus were searched from January 2000 to May 2020. Observational or experimental studies on pTBI of individuals aged between 0 and 16 years in LMICs were included. The causes of pTBI and morbidity data were descriptively analyzed, and case fatality rates were calculated. PROSPERO ID CRD42020171276. RESULTS A total of 136 studies were included. Fifty-seven studies were at high risk of bias. Of the remaining studies, 170,224 cases of pTBI were reported in 32 LMICs. The odds of having a pTBI were 1.8 times higher (95% confidence interval, 1.6-2.0) in males. The odds of a pTBI being mild were 4.4 times higher (95% confidence interval, 1.9-6.8) than a pTBI being moderate or severe. Road traffic accidents were the most common cause (n = 16,275/41,979; 39%) of pTBIs. On discharge, 24% of patients (n = 4385/17,930) had a reduction in their normal mental or physical function. The median case fatality rate was 7.3 (interquartile range, 2.1-7.7). CONCLUSIONS Less than a quarter (n = 32) of all LMICs have published high-quality data on the volume and burden of pTBI. From the limited data available, young male children are at a high risk of pTBIs in LMICs, particularly after road traffic accidents.
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Takoukam R, Kanmounye US, Robertson FC, Zimmerman K, Nguembu S, Lartigue JW, Park KB, Figuim B, Esene I. Prehospital Conditions and Outcomes After Craniotomy for Traumatic Brain Injury Performed Within 72 Hours in Central Cameroon: A Cross-Sectional Study. World Neurosurg 2020; 142:e238-e244. [PMID: 32599210 DOI: 10.1016/j.wneu.2020.06.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the most common neurosurgical condition globally. In Cameroon, there are 572 cases of TBI per 100,000 people, but <40% of Cameroonians live within 4 hours of a neurosurgical facility. We sought to understand the clinical outcomes at a neurosurgical center in Central Cameroon. METHODS This cross-sectional study was conducted at the largest neurosurgical center of Cameroon, the Yaounde Central Hospital. Data included 100 consecutive patients undergoing an intervention 72 hours after their injury from February 1, 2015 to February 1, 2019. Patients with missing data or undergoing surgery >72 hours after injury were excluded. Analyses of covariance were performed, and a P value >0.05 was considered significant. A Kaplan-Meier survival curve was computed. RESULTS The patients had a mean age of 31.3 ± 17.4 years, with a male predominance of 91.0%, and the principal mechanism of injury was road traffic accidents (68.0%). Only 11% arrived via ambulance, and 36.0% were admitted <3 hours after the traumatic event. The postoperative mortality was 15.0%, mean survival was 25.0 postoperative days (95% confidence interval, 23.42-26.52), and the mean Glasgow Outcome Scale score at 28 days was 3.9 ± 1.4. CONCLUSIONS Most patients with TBI undergoing neurosurgery 72 hours after injury in Cameroon arrive at the hospital late and have a high mortality risk during the first postoperative week. Investments in prehospital care should be made to improve surgical outcomes.
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Affiliation(s)
- Régis Takoukam
- Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon; Department of Neurosurgery, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire; Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Ulrick Sidney Kanmounye
- Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon; Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.
| | - Faith C Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathrin Zimmerman
- Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA; School of Medicine, University of Alabama at Birminghssam, Birmingham, Alabama, USA
| | - Stéphane Nguembu
- Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon; Department of Research, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Jean W Lartigue
- Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Neurosurgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Bello Figuim
- Department of Neurosurgery, Yaounde Central Hospital, Yaounde, Cameroon
| | - Ignatius Esene
- Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon; Department of Neurosurgery, Garoua Regional Hospital, Garoua, Cameroon
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Laeke T, Tirsit A, Debebe F, Girma B, Gere D, Park KB, Azazh A. Profile of Head Injuries: Prehospital Care, Diagnosis, and Severity in an Ethiopian Tertiary Hospital. World Neurosurg 2019; 127:e186-e192. [DOI: 10.1016/j.wneu.2019.03.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 01/01/2023]
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