Distribution and Characteristics of Severe Traumatic Brain Injury at Mulago National Referral Hospital in Uganda

Exploring the feasibility of pupillometry training and perceptions of potential use for intracranial pressure monitoring in Uganda: A mixed methods study

INTRODUCTION

Traumatic brain injury (TBI) accounts for the majority of Uganda's neurosurgical disease burden; however, invasive intracranial pressure (ICP) monitoring is infrequently used. Noninvasive monitoring could change the care of patients in such a setting through quick detection of elevated ICP.

PURPOSE

Given the novelty of pupillometry in Uganda, this mixed methods study assessed the feasibility of pupillometry for noninvasive ICP monitoring for patients with TBI.

METHODS

Twenty-two healthcare workers in Kampala, Uganda received education on pupillometry, practiced using the device on healthy volunteers, and completed interviews discussing pupillometry and its implementation. Interviews were assessed with qualitative analysis, while quantitative analysis evaluated learning time, measurement time, and accuracy of measurements by participants compared to a trainer's measurements.

RESULTS

Most participants (79%) reported a positive perception of pupillometry. Participants described the value of pupillometry in the care of patients during examination, monitoring, and intervention delivery. Commonly discussed concerns included pupillometry's cost, understanding, and maintenance needs. Perceived implementation challenges included device availability and contraindications for use. Participants suggested offering continued education and engaging hospital leadership as implementation strategies. During training, the average learning time was 13.5 minutes (IQR 3.5), and the measurement time was 50.6 seconds (IQR 11.8). Paired t-tests to evaluate accuracy showed no statistically significant difference in comparison measurements.

CONCLUSION

Pupillometry was considered acceptable for noninvasive ICP monitoring of patients with TBI, and pupillometer use was shown to be feasible during training. However, key concerns would need to be addressed during implementation to aid device utilization.

Clinical characteristics and outcomes of traumatic brain injury in patients admitted to surgical ward of Jimma Medical Center, Southwest Ethiopia: a prospective observational follow-up study

OBJECTIVE

To assess the Clinical Characteristics and Outcomes of Traumatic Brain Injury in Patients Admitted to the Surgical Ward of Jimma Medical Center, Southwest Ethiopia from January to July 2022.

DESIGN AND SETTING

A hospital-based prospective observational study was conducted among 175 patients admitted with Traumatic Brain Injury at Jimma Medical Center from January to July 2022. Data were collected by structured questionnaires and a convenient sampling technique was used. For data entry, Epidata V.4.6.0.5 software was used and exported to Stata V.14.0.2 for analysis. The Cox regression model was fitted to evaluate the predictors of mortality and variables with a p value <0.05 at 95% CI were taken as statistically significant predictors.

RESULTS

The incidence of in-hospital mortality was 22 (12.6%). The mean length of hospital stay was 6 days. In-hospital complications were recorded in 32.0% of patients. A Glasgow Coma Scale (GCS) score of <8 on admission (adjusted HR (AHR)=6.2, 95% CI 0.75 to 51), hyperthermia (AHR: 1.7, 95% CI 1.02 to 3.05) and lack of prehospital care (AHR: 3.2, 95% CI 2.2 to 8.07) were predictors of mortality in patients with traumatic brain injury.

CONCLUSION

In-hospital mortality was recorded in over one-tenth of patients with traumatic brain injury. The GCS score of <8 on admission, hyperthermia and lack of prehospital care positively affected the outcome of patients with traumatic brain injury. Screening of patients for hyperthermia and antipsychotics should be strengthened to reduce death. However, a multicentred study is needed for further evidence. Giving priority to the patients with those predictors will decrease the number of deaths.

Incidence and Predictors of Mortality Among Patients with Traumatic Brain Injury at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study

Background

Traumatic brain injury is a major list of health and socioeconomic problems especially in low- and middle-income countries which influences productive age groups. Differences in patient characteristics, socioeconomic status, intensive care unit admission thresholds, health-care systems, and the availability of varying numbers of intensive care unit (ICU) beds among hospitals had shown to be the causes for the variation on the incidence in mortality following traumatic brain injury across different continents. The aim of this study was to assess the incidence and predictors of mortality among patients with traumatic brain injury at University of Gondar Comprehensive Specialized Hospital.

Methods

A retrospective follow-up study was conducted based on chart review and selected patient charts admitted from January, 2017 to January, 2022. Participants in the study were chosen using a simple random sample procedure that was computer generated. Data was entered with epi-data version 4.6 and analyzed using SPSS version 26. Both bivariate and multivariate logistic regression analyses were used, and in multivariate logistic regression analysis, P-value <0.05 with 95% CI was considered statistically significant.

Results

The magnitude of mortality was 28.8%. Most of the injuries were caused by assault followed by road traffic accident (RTA). About 30% of the subjects presented with severe head injuries and epidural hematoma (EDH) followed by skull fracture were the most common diagnoses on admission. The independent predictors of mortality were male sex (AOR: 6.12, CI: 1.82, 20.5), severe class injury with Glasco coma scale (GCS <9) (AOR: 5.96, CI: 2.07, 17.12), intraoperative hypoxia episode (AOR: 10.5, CI: 2.6-42.1), hyperthermia (AOR: 25, CI: 5.54, 115.16), lack of pre-hospital care (AOR: 2.64 CI: 1.6-4.2), abnormal appearance on both eyes (AOR: 13.4, CI: 5.1-34.6), in-hospital hypoxia episode and having extra-cranial concomitant injury were positively associated with mortality, while on admission, systolic blood pressure (SBP) of 100-149 (AOR: 0.086, CI: 0.016-0.46) was negatively associated with mortality.

Conclusion

The overall mortality rate was considerably high. As a result, traumatic brain injury management should be focused on modifiable factors that increase patient mortality, such as on-admission hypotension, a lack of pre-hospital care, post-operative complications, an intraoperative hypoxia episode, and hyperthermia.

Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature

Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.

Barriers and facilitators to implementation of early mobilisation of critically ill patients in Zimbabwean and South African public sector hospitals: a qualitative study

PURPOSE

Implementing early mobilisation in intensive care is challenging, and a detailed knowledge of factors that may hinder or facilitate implementation is essential for success. The study was done to explore the perceived barriers and facilitators to early mobilisation by physiotherapists in Zimbabwean and South African public sector hospital ICUs.

METHODS

A qualitative study was done in eight public sector hospitals from South Africa and four hospitals from Zimbabwe. Physiotherapists from the participating hospitals who had at least two years working experience in ICU were invited to participate in semi-structured, in-depth, face-to-face interviews. Purposive sampling was done. Data collected included interpretation of early mobilisation, perceived barriers, and facilitators to early mobilisation. Data analysis was done using the content analysis method.

FINDINGS

A total of 22 physiotherapists were interviewed. In defining the activities regarded as early mobilisation, there was diversity in relation to the specific activities and the nature of the patients in which the defined activities were suitable for. Perceived barriers which emerged included lack of professional autonomy or boundaries, motivation, and clinical skills. Perceived facilitators to early mobilisation included the availability of guidelines, good communication, adequate staff, and mobilisation equipment.

CONCLUSIONS

Barriers and facilitators to early mobilisation are multifactorial. There is need for multidisciplinary team collaboration and planning before implementing early mobilisation activities.Implications to rehabilitationProfessional roles/identity and or boundaries emerged to be a barrier that hinder implementation of early mobilisation if not clearly defined.Non-rotational physiotherapy coverage was highlighted to be important in facilitating good communication and teamwork and sustainability of services in ICU.Good communication channels and referrals between different disciplines should be employed in ICU to prevent delay in rendering services to ICU patients.

Outcomes of management of intestinal obstruction at an urban tertiary hospital in sub Saharan Africa: a cross-sectional study

Background

Intestinal obstruction (IO) is a common cause of acute abdomen globally, it remains challenging as it increases surgical financial expenditure while also causing major morbidity. Clinically it presents with nausea, vomiting, colicky abdominal pain and cessation of bowel movements or passage flatus and stool. Diagnosis, especially in resource limited settings, can be clinical but is usually confirmed radiologically. We studied the current diagnosis, management and outcomes of IO in Mulago Hospital.

Materials and methods

This was a prospective study done at all the surgical units of Mulago from January to May 2014 to assess general diagnosis and management of IO. Ethical approval was got in line with Helsinki declaration, we used pretested and validated questionnaires to collect data. Informed consent was got with eligible and consenting/assenting patients that fitted the inclusion criteria of age and presenting with suspected intestinal obstruction. Uni-variate and bi-variate variables analysis was done plus measures of association.

Results

We enrolled 135 patients, excluded 25 and recruited 110 patient. We had more males than females i.e. 71.8% males and 28.2% females. Colicky abdominal pain, abdominal distension, and vomiting were commonest symptoms, then abdominal distension, increased bowel sounds and abdominal tenderness were the commonest signs. Most patients’ (51%) were diagnosed radiologically with a lesser number clinically diagnosed. “Dilated bowel loops” was the commonest radiological sign. Surgery was the main stay of management at 72.7% while 27.3% were conservatively managed. Postoperatively the bowels opened averagely on the 3rd post-operative day (POD) with return of bowel sounds occurring on 5th POD. Most discharges (73%) occurred by the 7th POD. Unfavourable outcomes were prolonged hospital stay followed by wound sepsis (surgical site infection) and then Mortality.

Conclusion

This study noted that In Mulago we mostly diagnosed patients radiologically with most surgically managed and which is similar to regional practices. Postoperatively bowel opening happening on third POD with return of bowel sounds on fifth POD. Prolonged hospital stay followed by wound sepsis and then mortality were commonest unfavorable management outcomes.

Delays in emergency department intervention for patients with traumatic brain injury in Uganda

Background

In Sub-Saharan African countries, the incidence of traumatic brain injury (TBI) is estimated to be many folds higher than the global average and outcome is hugely impacted by access to healthcare services and quality of care. We conducted an analysis of the TBI registry data to determine the disparities and delays in treatment for patients presenting at a tertiary care hospital in Uganda and to identify factors predictive of delayed treatment initiation.

Methods

The study was conducted at the Mulago National Referral Hospital, Kampala. The study included all patients presenting to the emergency department (ED) with suspected or documented TBI. Early treatment was defined as first intervention within 4 hours of ED presentation-a cut-off determined using sensitivity analysis to injury severity. Descriptive statistics were generated and Pearson's χ² test was used to assess the sample distribution between treatment time categories. Univariable and multivariable logistic regression models with <0.05 level of significance were used to derive the associations between patient characteristics and early intervention for TBI.

Results

Of 3944 patients, only 4.6% (n=182) received an intervention for TBI management within 1 hour of ED presentation, whereas 17.4% of patients (n=708) received some treatment within 4 hours of presentation. 19% of those with one or more serious injuries and 18% of those with moderate to severe head injury received care within 4 hours of arrival. Factors independently associated with early treatment included young age, severe head injury, and no known pre-existing conditions, whereas older or female patients had significantly less odds of receiving early treatment.

Discussion

With the increasing number of patients with TBI, ensuring early and appropriate management must be a priority for Ugandan hospitals. Delay in initiation of treatment may impact survival and functional outcome. Gender-related and age-related disparities in care should receive attention and targeted interventions.

Level of evidence

Prognostic and epidemiological study; level II evidence.

Changes in Mortality Related to Traumatic Brain Injuries in the Seychelles from 1989 to 2018

Introduction: Traumatic Brain Injuries (TBIs) are a significant source of disability and mortality, which disproportionately affect low- and middle-income countries. The Republic of Seychelles is a country in the African region that has experienced rapid socio-economic development and one in which all deaths and the age distribution of the population have been enumerated for the past few decades. The aim of this study was to investigate TBI-related mortality changes in the Republic of Seychelles during 1989–2018.

Methods: All TBI-related deaths were ascertained using the national Civil Registration and Vital Statistics System. Age- and sex-standardised mortality rates (per 100,000 person-years) were standardised to the age distribution of the World Health Organisation standard population.

Results: The 30-year age-standardised TBI-related mortality rates were 22.6 (95% CI 19.9, 25.2) in males and 4.0 (95% CI 2.9, 5.1) in females. Road traffic collisions were the leading contributor to TBI-related mortality [10.0 (95% CI 8.2, 11.8) in males and 2.7 (95% CI 1.8, 3.6) in females, P > 0.05]. TBI-related mortality was most frequent at age 20–39 years in males (8.0) and at age 0–19 in females (1.4). Comparing 2004–2018 vs. 1989–2003, the age-standardised mortality rates changed in males/females by −20%/−11% (all cause mortality), −24%/+39.4% (TBIs) and +1%/+34.8% (road traffic injury-related TBI).

Conclusion: TBI-related mortality rates were much higher in males but decreased over time. Road traffic collisions were the single greatest contributor to TBI mortality, emphasising the importance of road safety measures.

The Burden of Traumatic Brain Injury in Sub-Saharan Africa: A Scoping Review

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.

Incidence and predictors of mortality among patients with head injury admitted to Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: A retrospective follow-up study

Introduction

Head injury is the leading cause of morbidity and mortality throughout the world, especially in resource-limited countries including Ethiopia. However, little is known about the mortality rate and its predictors among these patients in Ethiopia. Thus, the study aims to assess the incidence rate of mortality and its predictors among patients with head injury admitted at Hawassa University Comprehensive Specialized Hospital.

Methods

Institutional based retrospective follow-up study was conducted among 1220 randomly selected head injury patients admitted from July 2017 to July 2019. Bivariable and multivariable Cox regression models were fitted to identify the predictors of mortality. Proportionality assumption was tested by a global test based on the Schoenfeld residuals test.

Results

The incidence of the mortality rate was 2.26 (95%CI: 1.9–2.6) per 100-person day observation. The independent predictors of time to death were age above 65 years (AHR:3.49, 95%CI:1.63, 7.48), severe TBI (AHR: 8.8, 95%CI:5.13, 15.0), moderate TBI (AHR:3, 95%CI:1.73,5.31), hypotension (AHR:1.72, 95%CI: 1.11,2.66), hypoxia (AHR:1.92, 95%CI: 1.33,2.76), hyperthermia (AHR:1.8, 95%CI: 1.23,2.63) and hypoglycemic (AHR:1.94, 95%CI: 1.34, 2.81) positively associated with mortality, while underwent neurosurgery was negatively associated with mortality (AHR: 0.25, 95% CI: 0.11,0.53).

Conclusion

The incidence of mortality rate among head injury patients was high. Older age, moderate and severe TBI, hypotension and hypoxia at admission, neurosurgical procedure, and the episode of hyperthermia and hypoglycemia during hospitalization were the independent predictors of mortality among head injury patients. Therefore, intervention to reduce earlier deaths should focus on the prevention of secondary brain insults.

Epidemiology of traumatic brain injury based on clinical symptoms amongst inhabitants of the Southwest Region of Cameroon: a community-based study

BACKGROUND

The majority of studies investigating the epidemiology of traumatic brain injury (TBI) in sub-Saharan Africa are primarily hospital-based, missing fatal, mild, and other cases of TBI that do not present to formal care settings. This study aims to bridge this gap in data by describing the epidemiology of TBI in the Southwest Region of Cameroon.

METHODS

This was a cross-sectional community-based study. Using a three-stage cluster sampling, local research assistants surveyed households with a pre-tested questionnaire to identify individuals with symptoms of TBI in nine health districts in the Southwest Region of Cameroon from 2016 to 2017.

RESULTS

Data gathered on 8,065 individuals revealed 78 cases of suspected TBI. Road traffic injury (RTI) comprised 55% of subjects' mechanism of injury. Formal medical care was sought by 82.1% of subjects; three subjects died at the time of injury. Following injury, 59% of subjects reported difficulty affording basic necessities and 87.2% of subjects were unable to perform activities of their primary occupation.

CONCLUSIONS

This study postulates an incidence of TBI in Southwest Cameroon of 975.57 per 100,000 individuals, significantly greater than prior findings. A large proportion of TBI is secondary to RTI.

Traumatic Brain Injury-Related Pediatric Mortality and Morbidity in Low- and Middle-Income Countries: A Systematic Review

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.

Trends in head injury associated mortality in Malawi

BACKGROUND

To address the problem of surgical workforce deficiencies in Malawi, we partnered with local institutions to establish a surgical residency-training and educational program for local surgeons in 2009. While this program has improved trauma-associated outcomes, it is unclear whether, without additional system improvements, the management of traumatic brain injury (TBI) has similarly advanced. This study sought to describe trends of TBI-associated in-hospital trauma mortality at a tertiary trauma center in sub-Saharan Africa.

METHODS

We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi, from 2012 through 2017. Modified Poisson regression modeling was used to compare the risk ratio of TBI associated in-hospital death each year compared to the year 2012, after adjusting for relevant covariates.

RESULTS

87,295 patients were recorded into the KCH Trauma Registry. 3,393 patients with TBI were identified, and most TBI patients were young males. In 2013 (RR 0.66, 95% CI 0.48, 0.92) and 2014 (RR 0.57, 95% CI 0.41, 0.79), the adjusted risk ratio of in-hospital death decreased compared to 2012 when adjusted for age, sex, initial AVPU score, transfer status, and multisystem trauma. However, the adjusted risk ratio of mortality in 2015 (0.73, 95% CI 0.53, 1.02) plateaued, with relatively minor improvements in 2016 (0.72, 95% CI 0.54, 0.97) and 2017 (0.71, 95% CI 0.53, 0.96).

CONCLUSIONS

A decrease in TBI associated mortality was associated with the establishment of a residency and educational training program for general surgery. This program increased available surgeons, improved critical care and trauma training, and integrated some neurosurgical training. However, improvements in outcomes plateaued in the last few years of the study, despite these enhancements to surgical care. The general surgery workforce must be supplemented with improved neurosurgical services and neurocritical care to decrease TBI-related mortality.

Surgical intervention and patient factors associated with poor outcomes in patients with traumatic brain injury at a tertiary care hospital in Uganda

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.

Mapping Global Neurosurgery Research Collaboratives: A Social Network Analysis of the 50 Most Cited Global Neurosurgery Articles

Social network analysis of bibliometric data evaluates the relationships between the articles, authors, and themes of a research niche. The network can be visualized as maps composed of nodes and links. This study aimed to identify and evaluate the relationships between articles, authors, and keywords in global neurosurgery. The authors searched global neurosurgery articles on the Web of Science database from inception to June 18, 2020. The 50 most cited articles were selected and their metadata (document coupling, co-authorship, and co-occurrence) was exported. The metadata were analyzed and visualized with VOSViewer (Centre for Science and Technology Studies, Leiden University, The Netherlands). The articles were published between 1995 and 2020 and they had a median of 4.0 (interquartile range [IQR] = 5.0) citations. There were 5 clusters in the document coupling and 10 clusters in the co-authorship analysis. A total of 229 authors contributed to the articles and Kee B. Park contributed the most to articles (14 publications). Backward citation analysis was organized into 4 clusters and co-occurrence analysis into 7 clusters. The most common themes were pediatric neurosurgery, neurotrauma, and health system strengthening. The authors identified trends, contributors, and themes of highly cited global neurosurgery research. These findings can help establish collaborations and set the agenda in global neurosurgery research.

Hyperglycemia in severe traumatic brain injury patients and its association with thirty-day mortality: a prospective observational cohort study in Uganda

Background

Traumatic brain injury (TBI) is a growing public health concern that can be complicated with an acute stress response. This response may be assessed by monitoring blood glucose levels but this is not routine in remote settings. There is a paucity of data on the prevalence of hyperglycemia and variables associated with mortality after severe TBI in Uganda.

Objective

We aimed to determine the prevalence of hyperglycemia in patients with severe TBI and variables associated with 30-day mortality at Mulago National Referral Hospital in Uganda.

Methods

We consecutively enrolled a cohort 99 patients patients with severe TBI. Serum glucose levels were measured at admission and after 24 h. Other study variables included: mechanism of injury, CT findings, location and size of hematoma, and socio-demographics. The main outcome was mortality after 30 days of management and this was compared in patients with hyperglycemia more than 11.1 mmol/L to those without.

Results

Most patients (92.9%) were male aged 18-30 years (47%). Road Traffic Collisions were the most common cause of severe TBI (64.7%) followed by assault (17.1%) and falls (8.1%). Nearly one in six patients were admitted with hyperglycemia more than 11.1 mmol/L. The mortality rate in severe TBI patients with hyperglycemia was 68.8% (OR 1.47; 95% CI [0.236-9.153]; P = 0.063) against 43.7% in those without hyperglycemia. The presence of hypothermia (OR 10.17; 95% CI [1.574-65.669]; P = 0.015) and convulsions (OR 5.64; 95% CI [1.541-19.554]; P = 0.009) were significant predictors of mortality.

Conclusion

Hypothermia and convulsions at admission were major predictors of mortality in severe TBI. Early hyperglycemia following severe TBI appears to occur with a tendency towards high mortality. These findings justify routine glucose monitoring and could form the basis for establishing a blood sugar control protocol for such patients in remote settings.

Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

Introduction

Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality.

Methods

A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded.

Results

Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6).

Conclusion

Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.

Pattern and frequency of neurological and neurosurgical care of adult inpatients and outpatients at a tertiary referral hospital in Kenya

OBJECTIVE

To describe the patterns and burden of neurological and neurosurgical disorders at a national tertiary level referral hospital in western Kenya.

METHODS

We conducted a three-month period prevalence study. We recruited consecutive adult patients seeking neurological-neurosurgical care in both inpatient and outpatient settings at Moi Teaching and Referral Hospital.

RESULTS

833 participants were included. The age range was between 19 year and 99 years (mean age = 45.3 years). The most common diagnoses among neurology inpatients were meningitis (12%), ischemic stroke (11.0%) and epilepsy/seizure (6.7%). Among neurology outpatients, epilepsy (35.1%) and ischemic stroke (18.8%) were the most common diagnoses. The most common neurosurgery inpatient diagnosis was hemorrhagic stroke (16.3%) and among outpatients, the most common diagnoses were traumatic brain injury (17.4%) and hemorrhagic stroke (16.3%). Overall, 471 (56.5%) patients underwent HIV testing, of which, 89 (18.9%) were HIV positive and 382 (81.1%) were HIV negative. Thirty-one inpatient deaths (male 58%), attributable to neurological and neurosurgical disorders, occurred during the study period. Meningitis was the most common cause of death.

CONCLUSIONS

The findings suggest that meningitis, stroke, epilepsy, and traumatic brain injury were the most common diagnosis. More resources and efforts should be directed towards prevention, diagnosis and management of these conditions in the region.

A Comparison of the Predictive Value of the Glasgow Coma Scale and the Kampala Trauma Score for Mortality and Length of Hospital Stay in Head Injury Patients at a Tertiary Hospital in Uganda: A Diagnostic Prospective Study

Introduction

The prevalence rates of head injury have been shown to be as high as 25% among trauma patients with severe head injury contributing to about 31% of all trauma deaths. Triage utilizes numerical cutoff points along the scores continuum to predict the greatest number of people who would have a poor outcome, “severe” patients, when scoring below the threshold and a good outcome “non severe” patients, when scoring above the cutoff or numerical threshold. This study aimed to compare the predictive value of the Glasgow Coma Scale and the Kampala Trauma Score for mortality and length of hospital stay at a tertiary hospital in Uganda.

Methods

A diagnostic prospective study was conducted from January 12, 2018 to March 16, 2018. We recruited patients with head injury admitted to the accidents and emergency department who met the inclusion criteria for the study. Data on patient's demographic characteristics, mechanisms of injury, category of road use, and classification of injury according to the GCS and KTS at initial contact and at 24 hours were collected. The receiver operating characteristics (ROC) analysis and logistic regression analysis were used for comparison.

Results

The GCS predicted mortality and length of hospital stay with the GCS at admission with AUC of 0.9048 and 0.7972, respectively (KTS at admission time, AUC 0.8178 and 0.7243). The GCS predicted mortality and length of hospital stay with the GCS at 24 hours with AUC of 0.9567 and 0.8203, respectively (KTS at 24 hours, AUC 0.8531 and 0.7276). At admission, the GCS at a cutoff of 11 had a sensitivity of 83.23% and specificity of 82.61% while the KTS had 88.02% and 73.91%, respectively, at a cutoff of 13 for predicting mortality. At admission, the GCS at a cutoff of 13 had sensitivity of 70.48% and specificity of 66.67% while the KTS had 68.07% and 62.50%, respectively, at a cutoff of 14 for predicting length of hospital stay.

Conclusion

Comparatively, the GCS performed better than the KTS in predicting mortality and length of hospital stay. The GCS was also more accurate at labelling the head injury patients who died as severely injured as opposed to the KTS that categorized most of them as moderately injured. In general, the two scores were sensitive at detection of mortality and length of hospital stay among the study population.

An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis

OBJECTIVE

The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury.

METHODS

The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania.

RESULTS

Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI.

CONCLUSIONS

Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI.

METHODS

A prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery.

RESULTS

A total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128-0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53-0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05-16.7) and older age (continuous HR 1.03, 95% CI 1.009-1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress.

CONCLUSIONS

Inpatient and postdischarge mortality remain high following admission to Uganda's main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

Boda Bodas and Road Traffic Injuries in Uganda: An Overview of Traffic Safety Trends from 2009 to 2017

INTRODUCTION

Road traffic injuries (RTIs) are an important contributor to the morbidity and mortality of developing countries. In Uganda, motorcycle taxis, known as boda bodas, are responsible for a growing proportion of RTIs. This study seeks to evaluate and comment on traffic safety trends from the past decade.

METHODS

Traffic reports from the Ugandan police force (2009 to 2017) were analyzed for RTI characteristics. Furthermore, one month of casualty ward data in 2015 and 2018 was collected from the Mulago National Referral Hospital and reviewed for casualty demographics and trauma type.

RESULTS

RTI motorcycle contribution rose steadily from 2009 to 2017 (24.5% to 33.9%). While the total number of crashes dropped from 22,461 to 13,244 between 2010 and 2017, the proportion of fatal RTIs increased from 14.7% to 22.2%. In the casualty ward, RTIs accounted for a greater proportion of patients and traumas in 2018 compared to 2015 (10%/41% and 36%/64%, respectively).

CONCLUSIONS

Although RTIs have seen a gross reduction in Uganda, they have become more deadly, with greater motorcycle involvement. Hospital data demonstrate a rising need for trauma and neurosurgical care to manage greater RTI patient burden. Combining RTI prevention and care pathway improvements may mitigate current RTI trends.

A Systematic Review of Neurosurgical Care in Low-Income Countries

OBJECTIVE

More than 5 billion individuals lack access to essential surgical care. Neurosurgical care is especially limited in low-income countries (LICs). Studies describing neurosurgical care in LICs are critical for understanding global disparities in access to neurosurgical procedures. To better understand these disparities, we conducted a systematic review of the literature identifying neurosurgical patients in LICs.

METHODS

MEDLINE (PubMed), Embase (embase.com), and Cochrane Library (Wiley) databases were systematically searched to retrieve studies describing neurosurgical care in LICs as defined by the World Bank Country and Lending Groups income classification. All databases were searched from their inception; no date or language limits were applied. All the articles were blindly reviewed by 2 individuals. Data from eligible studies were extracted and summarized.

RESULTS

Of the 4377 citations screened, 154 studies met inclusion criteria. The number of publications substantially increased over the study period, with 49% (n = 76) of studies published in the last 5 years. Twenty-six percent (n = 40) of studies had a first author, and 30% (n = 46) had a senior author, affiliated with a country different from the LIC of study. The most common neurosurgical diagnosis was traumatic brain injury (24%, n = 37), followed by hydrocephalus (26%, n = 40), and neoplastic intracranial mass (10%, n = 16). Of LICs, 43% (n = 15/35) had no published neurosurgical literature.

CONCLUSIONS

There is a significant deficit in the literature on neurosurgical care in LICs. Efforts must focus on supporting research initiatives in LICs to improve publication bias and understand disparities in access to neurosurgical care in the lowest-resource countries.

A comparison of publication to TBI burden ratio of low- and middle-income countries versus high-income countries: how can we improve worldwide care of TBI?

OBJECTIVE

Traumatic brain injury (TBI) is a global public health problem and more than 70% of trauma-related deaths are estimated to occur in low- and middle-income countries (LMICs). Nevertheless, there is a consistent lack of data from these countries. The aim of this work is to estimate the capacity of different and heterogeneous areas of the world to report and publish data on TBI. In addition, we wanted to estimate the countries with the highest and lowest number of publications when taking into account the relative TBI burden.

METHODS

First, a bibliometric analysis of all the publications about TBI available in the PubMed database from January 1, 2008, to December 31, 2018, was performed. These data were tabulated by country and grouped according to each geographical region as indicated by the WHO: African Region (AFR), Region of the Americas (PAH), South-East Asia Region (SEAR), European Region (EUR), Eastern Mediterranean Region (EMR), and Western Pacific Region (WPR). In this analysis, PAH was further subdivided into Latin America (AMR-L) and North America (AMR-US/Can). Then a “publication to TBI volume ratio” was derived to estimate the research interest in TBI with respect to the frequency of this pathology.

RESULTS

Between 2008 and 2018 a total of 8144 articles were published and indexed in the PubMed database about TBI. Leading WHO regions in terms of contributions were AMR-US/Can with 4183 articles (51.36%), followed by EUR with 2003 articles (24.60%), WPR with 1507 (18.50%), AMR-L with 141 articles (1.73%), EMR with 135 (1.66%), AFR with 91 articles (1.12%), and SEAR with 84 articles (1.03%). The highest publication to TBI volume ratios were found for AMR-US/Can (90.93) and EUR (21.54), followed by WPR (8.71) and AMR-L (2.43). Almost 90 times lower than the ratio of AMR-US/Can were the ratios for AFR (1.15) and SEAR (0.46).

CONCLUSIONS

An important disparity currently exists between countries with a high burden of TBI and those in which most of the research is conducted. A call for improvement of data collection and research outputs along with an increase in international collaboration could quantitatively and qualitatively improve the ability of LMICs to ameliorate TBI care and develop clinical practice guidelines.

Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines

Objective

The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden.

Methods

Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes.

Results

Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01).

Conclusions

This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.

Motor vehicle accident is a risk factor for traumatic head injury among children in Abuja: analysis of the first trauma registry in Nigeria

Introduction

Pediatric traumatic injury is a major public health concern that is poorly documented in lower and middle-income countries. This study analyzed data on pediatric injuries from a unique hospital trauma registry in Abuja, Nigeria.

Methods

Data were analyzed on 220 traumatically injured patients aged 21 years/less to describe injury characteristics and to determine the association between mechanism of injury and pediatric head injuries in Abuja, Nigeria, between 2014 and 2015. Bivariate analysis using Pearson's chi-square and adjusted logistic regression were conducted to characterize the population and identify risk factors for head injury. P-values<0.05 were considered statistically significant. All statistical analyses were performed using STATA v.15.1.

Results

The majority of patients were male (60.9%) with a mean age (SD) of 12.5±6.9 years. Head injuries were most common (49.6%), followed by chest (14.1%), abdomen (12.3%) and back (7.7%). The mechanism of injury was statistically significantly associated with head injury (p=0.027) with 63% of children in a motor vehicle accident sustaining a head injury. After adjusting for covariates, the odds of head injury were 3.8 times higher for children injured in a motor vehicle accidents (MVA) compared to those with falls (95%CI 1.40-10.40).

Conclusion

This analysis reveals that motor vehicle accident is a risk factor for traumatic head injury among children in Nigeria. Therefore, efforts should be made to address motor vehicle accidents involving children. These data will help to inform age-related prevention and treatment strategies. The results of this study highlight the importance of collecting pediatric trauma data in developing countries.

Changing Demographic Profiles of Patients With Traumatic Brain Injury: An Aging Concern

Background: Trauma continues to be a common cause of mortality in Singapore. By understanding the epidemiology of Traumatic Brain Injury (TBI), healthcare professionals can be better equipped to tackle the increasing socioeconomic burden of disease, adopting better strategies in healthcare planning. Methodology: A retrospective review of 367 patients admitted with TBI to a tertiary medical institution from January to December 2014 was performed, studying demographic profiles, injury details and outcomes of these patients. Data was retrieved from the National Trauma Registry and the institution's database. Results: Two hundred thirty-four of the 367 patients included in this study fell into two age groups--19 to 40 years and ≥65 years. 58% of the TBI population were aged >60. Predominant mechanism of injuries in these groups were road traffic accidents and unwitnessed falls respectively. 39% of the Elderly group were on antiplatelet/anticoagulant agents (p < 0.001). While aggressive surgical intervention was more common in younger patients (p < 0.001), the elderly group had significantly longer lengths of hospital stay (p < 0.001). Though Glasgow Outcome Scale (GOS) scores at discharge were not significantly different between the two groups, elderly patients showed greater percentages of post-injury improvement subsequently. Conclusion: The demographics of TBI patients appears to have shifted toward an older population as compared to a decade ago, with an increased incidence of falls, highlighting a huge healthcare concern. We hope that this study will drive further nationwide studies in future, looking at the incidence and prevalence of TBI, and with the focus on tackling preventable causes of TBI.

Road safety compliance among motorcyclists in Kawempe Division, Kampala, Uganda: a cross-sectional study

Motorcyclists are vulnerable road users in Uganda and 21.7% (3912/18,016) experienced crashes in 2012. This study determined the prevalence of and factors associated with compliance to selected road safety measures (helmet use, retro-reflective jackets use, riding permit and carrying one passenger) among commercial motorcyclists in Kawempe, from April to June 2014 using interviewer administered questionnaires. Total compliance was 0.9% and 24.4% to at least 3/4 measures. Compliance by measure was; 7.6% retroreflective jackets, 28.8% riding permits, 69.4% helmet use and 86.1% carrying one passenger. The associated factors were; knowing that (training before one starts to ride prevents crashes, Adjusted-odds-ratio (AOR) = 2.38 (1.36-4.19), maintaining the motorcycle in good condition prevents crashes, AOR = 0.34 (0.15-0.77) and padding reduces impact of road traffic injury, AOR = 0.37 (0.15-0.89)). Prevalence to compliance is very low. Road safety messages should highlight the importance of all road safety measures to improve compliance.

Causes and outcomes of traumatic brain injuries in Uganda: analysis from a pilot hospital registry

Background

Traumatic brain injury (TBI) is an important cause of morbidity and mortality in low/middle-income countries. The objective was to assess causes and outcomes of unintentional and intentional TBI among patients presenting to a tertiary care hospital in Uganda.

Methods

This study was conducted at Mulago National Referral Hospital, Kampala, Uganda, for 15 months in 2016–2017. Patients of all ages, males and females, presenting to the emergency department with suspected or documented TBI were enrolled. Patient demographics, TBI causes and outcomes were recorded. The outcome of interest was unintentional and intentional TBI.

Results

Intent was known for 3749 patients, of these 69.7% were unintentional TBI and 30.3% were intentional TBI. The average age of patients in both groups was similar (28±14 years) with over 70% of patients between 19 and 45 years age group. About 80% were males in both groups. The main causes of unintentional TBI were road traffic injuries (RTI) (88.9%) and falls (11.1%). Pedestrians (42.1%) and motorcycle drivers (28.1%) were the most common road users. Among patients with unintentional TBI, about 43.6% were admitted, 34.0% were sent home. There were 73 deaths: 63 were patients with RTI and 10 had a fall. Although assault (97.1%) was the main cause of intentional TBI, those patients with self-harm were likely to be in severe Glasgow Coma Scale range (39.4%) compared with victims of assault (14.2%). Among patients with intentional TBI, 42.6% were admitted and 37.1% were sent home. There were 30 deaths: 29 were assault victims and 1 of self-harm.

Discussion

Unintentional TBI caused by RTI and intentional TBI caused by assault are common among young males attending Mulago Hospital in Kampala.

Level of evidence

Prospective observational study, level III.

Patterns of traumatic brain injury and six-month neuropsychological outcomes in Uganda

BACKGROUND

Traumatic brain injuries in Uganda are on the increase, however little is known about the neuropsychological outcomes in survivors. This study characterized patients with traumatic brain injury (TBI) and the associated six-month neuropsychological outcomes in a Ugandan tertiary hospital.

METHODS

Patients admitted at Mulago Hospital with head injury from November 2015 to April 2016 were prospectively enrolled during admission and followed up at six months after discharge to assess cognition, posttraumatic stress symptoms (PTSS), depression symptoms and physical disability. The outcomes were compared to a non-head-injury group recruited from among the caretakers, siblings and neighbours of the patients with age and sex entered as covariates.

RESULTS

One hundred and seventy-one patients and 145 non-head injury participants were enrolled. The age range for the whole sample was 1 to 69 years with the non-head injury group being older (mean age (SD) 33.34 (13.35) vs 29.34 (14.13) years of age, p = 0.01). Overall, motorcycle crashes (36/171, 38.6%) and being hit by an object (58/171, 33.9%) were the leading causes of TBI. Head injury from falls occurred more frequently in children < 18 years (13.8% vs 2.8%, p = 0.03). In adults 18 years and older, patients had higher rates of neurocognitive impairment (28.4% vs 6.6%, p < 0.0001), PTSS (43.9% vs 7.9%, p < 0.0001), depression symptoms (55.4% vs 10%, p < 0.0001) and physical disability (7.2% vs 0%, p = 0.002). Lower Glasgow Coma Score (GCS) on admission was associated with neurocognitive impairment (11.6 vs 13.1, p = 0.04) and physical disability (10 vs 12.9, p = 0.01) six months later.

CONCLUSION

This first such study in the East-African region shows that depth of coma on admission in TBI is associated with neurocognitive impairment and physical disability.

Determinants of emergency department disposition of patients with traumatic brain injury in Uganda: results from a registry

Background

Traumatic brain injuries (TBIs) are a common cause of emergency department (ED) visits and hospital admissions in Kampala, Uganda. The objective of this study was to assess determinants of ED discharge disposition based on patient demographic and injury characteristics. Four ED outcomes were considered: discharge home, hospital admission, death, and others.

Methods

This prospective study was conducted at Mulago National Referral Hospital, Kampala, Uganda, from May 2016 to July 2017. Patients of all age groups presenting with TBI were included. Patient demographics, external causes of injury, TBI characteristics, and disposition from EDs were noted. Injury severity was estimated using the Glasgow Coma Scale (GCS), Kampala Trauma Score (KTS), and the Revised Trauma Score (RTS). A multinomial logistic regression model was used to estimate conditional ORs of hospital admission, death, and other dispositions compared with the reference category “discharged home”.

Results

A total of 3944 patients were included in the study with a male versus female ratio of 5.5:1 and a mean age of 28.5 years (SD=14.2). Patients had closed head injuries in 62.9% of cases. The leading causes of TBIs were road traffic crashes (58.8%) and intentional injuries (28.7%). There was no significant difference between the four discharge categories with respect to age, sex, mode of arrival, cause of TBI, place of injury, type of head injury, transport time, and RTS (p>0.05). There were statistically significant differences between the four discharge categories for a number of serious injuries, GCS on arrival, change in GCS, and KTS. In a multinomial logistic regression model, change in GCS, area of residence, number of serious injuries, and KTS were significant predictors of ED disposition.

Discussion

This study provides evidence that ED disposition of patients with TBI is differentially affected by injury characteristics and is largely dependent on injury severity and change in GCS during ED stay.

Level of evidence

Level II.

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

BACKGROUND

Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed.

OBJECTIVE

To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda.

METHODS

Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed.

RESULTS

Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04).

CONCLUSION

Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.

A qualitative study exploring nurses' attitudes, confidence, and perceived barriers to implementing a traumatic brain injury nursing chart in Uganda

Introduction

In Africa, traumatic brain injuries frequently result from road traffic injuries and assaults. Despite limited resources and the high costs of life-saving neurosurgical interventions, secondary brain injury prevention has the potential for improving outcomes. However, nurses and other medical personnel infrequently monitor vital signs, blood sugar, and pulse oximetry and only sporadically re-assess neurological status.

Methods

In one-on-one, semi-structured interviews, 27 nurses from Mulago Hospital’s emergency centre, a tertiary care trauma hospital in Kampala, Uganda, provided feedback regarding a traumatic brain injury-focused education session and use of a nursing chart for detecting secondary brain injury. The interviews explored the nurses’ confidence and perceived barriers to long-term chart implementation and traumatic brain injury care, as well as their ideas for improving this intervention. Interviews were audio recorded, transcribed, and coded using ATLAS.ti: Qualitative Data Analysis and Research Software (Cleverbridge, Inc., Chicago, USA) and Microsoft Word and Excel (Microsoft Office, Redmond, USA) for thematic content analysis.

Results

Key findings identified in the interviews included the nurses’ attitudes toward the chart and their feelings of increased confidence in assessing and caring for these patients. The main barriers to continuous implementation included inadequate staffing and resources.

Conclusion

Nurses were receptive to the education session and nursing chart, and felt that it increased their confidence and improved their ability to care for traumatic brain injured patients. However, lack of supplies, overwhelming numbers of patients, and inadequate staffing interfered with consistent monitoring of patients. The nurses offered various suggestions for improving traumatic brain injury care that should be further investigated. More research is needed to assess the applicability of a standardised traumatic brain injury nursing education and chart in a broader context.

Neurosurgery in East Africa: Foundations

This article is the first in a series of 3 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). We review the history and evolution of neurosurgery as a clinical specialty in East Africa. We also review Kenya, Uganda, and Tanzania in some detail and highlight contributions of individuals and local and regional organizations that helped to develop and shape neurosurgical care in East Africa. Neurosurgery has developed steadily as advanced techniques have been adopted by local surgeons who trained abroad, and foreign surgeons who have dedicated part of their careers in local hospitals. New medical schools and surgical training programs have been established through regional and international partnerships, and the era of regional specialty surgical training has just begun. As more surgical specialists complete training, a comprehensive estimation of disease burden facing the neurosurgical field is important. We present an overview with specific reference to neurotrauma and neural tube defects, both of which are of epidemiologic importance as they gain not only greater recognition, but increased diagnoses and demands for treatment. Neurosurgery in East Africa is poised to blossom as it seeks to address the growing needs of a growing subspecialty.

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.

Traumatic brain injury in Uganda: exploring the use of a hospital based registry for measuring burden and outcomes

Objective

Lack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the TBI burden. This paper describes a scientific approach for hospital based systematic data collection in a low-income country. The registry is based on the evaluation framework for injury surveillance systems which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) review of the identified variables based on adopted specific, measurable, assignable, realistic, and time-related criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system.

Results

The electronic hospital-based TBI registry is designed through a collaborative approach to capture comprehensive, yet context specific, information on each TBI case, from the time of injury until death or discharge from the hospital. It includes patients’ demographics, pre-hospital and hospital assessment and care, TBI causes, injury severity, and patient outcomes. The registry in Uganda will open the opportunity to replicate the process in other similar context and contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3419-1) contains supplementary material, which is available to authorized users.

Estimating the global incidence of traumatic brain injury

OBJECTIVETraumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.METHODSOpen-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.RESULTSRelevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.CONCLUSIONSSixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Life After the Neurosurgical Ward in Sub-Saharan Africa: Neurosurgical Treatment and Outpatient Outcomes in Uganda

BACKGROUND

In the past decade, neurosurgery in Uganda experienced increasing surgical volume and a new residency training program. Although research has examined surgical capacity, minimal data exist on the patient population treated by neurosurgery and their eventual outcomes in sub-Saharan Africa.

METHODS

Patients admitted to Mulago National Referral Hospital neurosurgical ward over 2 years (2014 and 2015) were documented in a prospective database. In total, 1167 were discharged with documented phone numbers and thus eligible for follow-up. Phone surveys were developed and conducted in the participant's language to assess mortality, neurologic outcomes, and follow-up health care.

RESULTS

During the study period, 2032 patients were admitted to the neurosurgical ward, 80% for traumatic brain injury. A total of 7.8% received surgical intervention. The in-hospital mortality rate was 18%. A total of 870 patients were reached for phone follow-up, a 75% response rate, and 30-day and 1-year mortality were 4% and 8%, respectively. Almost one-half of patients had not had subsequent health care after the initial encounter. Most patients had Glasgow Outcome Scale-Extended scores consistent with good recovery and mild disability, with patients experiencing trauma faring best and patients with tumor faring worst. A total of 85% felt they returned to baseline work performance, and 76% of guardians felt that children returned to baseline school performance.

CONCLUSIONS

The neurosurgical service provided health care to a large proportion of nonoperative patients. Phone surveys captured data on patients in whom nearly one-half would be lost to subsequent health care. Although mortality during initial hospitalization was high, more than 90% of those discharged survived at 1-year follow up, and the vast majority returned to work and school.

Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey

BACKGROUND

The Surgeons OverSeas Assessment of Surgical Need tool (SOSAS) was created to evaluate the burden of surgically treatable conditions in low- and middle-income countries. The goal of our study is to describe the face, head, and neck (FHN) conditions that need surgical care in Uganda, along with barriers to that care and disability from these conditions.

METHODS

A 2-stage cluster randomized SOSAS survey was administered in a cross-sectional manner between August and September 2014. Participants included randomly selected persons in 105 enumeration areas in 74 districts throughout Uganda with 24 households in each cluster. The SOSAS survey collected demographic and clinical data on all respondents. Univariate and multivariate logistic models evaluated associations of demographic characteristics and clinical characteristics of the FHN conditions and outcomes of whether health care was sought or surgical care was received.

RESULTS

Of the 4428 respondents, 331 (7.8%) reported having FHN conditions. The most common types of conditions were injury-related wounds. Of those who reported an FHN condition, 36% reported receiving no surgical care whereas 82.5% reported seeking health care. In the multivariate model, literacy and type of condition were significant predictors of seeking health care whereas village type, literacy, and type of condition remained significant predictors of receiving surgical care.

CONCLUSIONS

Many individuals in Uganda are not receiving surgical care and barriers include costs, rural residency, and literacy. Our study highlights the need for targeted interventions in various parts of Uganda to increase human resources for surgery and expand surgical capacity.

A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda

Background

Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.

Methods

We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.

Results

563 TBI patients were enrolled from 1 June– 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3–5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.

Conclusions

The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3–82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa

BACKGROUND

Trauma accounts for 4.7 million deaths each year, with an estimated 90% of these occurring in low- and middle-income countries (LMICs). Approximately half of trauma-related deaths are caused by central nervous system injury. Because a thorough understanding of traumatic brain injury (TBI) in LMICs is essential to mitigate TBI-related mortality, we established a clinical and radiographic database to characterize TBI in our low-income setting.

METHODS

This is a review of prospectively collected data from Kamuzu Central Hospital, a tertiary care center in the capital of Malawi. All patients admitted from October 2016 through May 2017 with a history of head trauma, altered consciousness, and/or radiographic evidence TBI were included. We performed descriptive statistics, a Cox regression analysis, and a survival analysis.

RESULTS

There were 280 patients who met inclusion criteria; of these, 80.5% were men. The mean age was 28.8 ± 16.3 years. Median Glasgow Coma Scale (GCS) score was 12 (interquartile range, 8-15). Road traffic crashes constituted the most common injury mechanism (60.7%). There were 148 (52.3%) patients who received a computed tomography scan, with the most common findings being contusions (26.1%). Of the patients, 88 (33.0%) had severe TBI, defined as a GCS score ≤8, of whom 27.6% were intubated and 10.3% received tracheostomies. Overall mortality was 30.9%. Of patients who survived, 80.1% made a good recovery. Female sex was protective, and the only significant predictor of poor functional outcome was presence of severe TBI (hazard ratio, 2.98; 95% confidence interval, 1.79-4.95).

CONCLUSIONS

TBI represents a significant part of the global neurosurgical burden of disease. Implementation of proven in-hospital interventions for these patients is critical to attenuate TBI-related morbidity and mortality.

Severe Traumatic Brain Injury at a Tertiary Referral Center in Tanzania: Epidemiology and Adherence to Brain Trauma Foundation Guidelines

BACKGROUND

Severe traumatic brain injury (TBI) is a major cause of death and disability worldwide. Prospective TBI data from sub-Saharan Africa are sparse. This study examines epidemiology and explores management of patients with severe TBI and adherence to Brain Trauma Foundation Guidelines at a tertiary care referral hospital in Tanzania.

METHODS

Patients with severe TBI hospitalized at Bugando Medical Centre were recorded in a prospective registry including epidemiologic, clinical, treatment, and outcome data.

RESULTS

Between September 2013 and October 2015, 371 patients with TBI were admitted; 33% (115/371) had severe TBI. Mean age was 32.0 years ± 20.1, and most patients were male (80.0%). Vehicular injuries were the most common cause of injury (65.2%). Approximately half of the patients (47.8%) were hospitalized on the day of injury. Computed tomography of the brain was performed in 49.6% of patients, and 58.3% were admitted to the intensive care unit. Continuous arterial blood pressure monitoring and intracranial pressure monitoring were not performed in any patient. Of patients with severe TBI, 38.3% received hyperosmolar therapy, and 35.7% underwent craniotomy. The 2-week mortality was 34.8%.

CONCLUSIONS

Mortality of patients with severe TBI at Bugando Medical Centre, Tanzania, is approximately twice that in high-income countries. Intensive care unit care, computed tomography imaging, and continuous arterial blood pressure and intracranial pressure monitoring are underused or unavailable in the tertiary referral hospital setting. Improving outcomes after severe TBI will require concerted investment in prehospital care and improvement in availability of intensive care unit resources, computed tomography, and expertise in multidisciplinary care.

The effect of anatomic location of injury on mortality risk in a resource-poor setting

INTRODUCTION

Injury is a significant cause of death, with approximately 4.7 million people mortalities each year. By 2030, injury is predicted to be among the top 20 causes of death worldwide. We sought to characterize and compare the mortality probability in trauma patients in a resource-poor setting based on anatomic location of injury.

METHODS

We performed a retrospective analysis of prospectively collected data using the trauma database at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. We included all adult trauma patients (≥16years) admitted between 2011 and 2015. We stratified patients according to anatomic location of injury, and used descriptive statistics to compare characteristics and management of each group. Bivariate analysis by mortality was done to determine covariates for our adjusted model. A Cox proportional hazard model was performed, using upper extremity injury as the baseline comparator. Descriptive statistics were used to describe the trend in incidence and mortality of head and spine injuries over five years.

RESULTS

Of the 76,984 trauma patients who presented to KCH from 2011 to 2015, 49,126 (63.8%) were adults, and 8569 (17.4%) were admitted. The most common injury was to the head or spine, seen in 3712 patients (43.6%). The highest unadjusted hazard ratio for mortality was in head and spine injury patients, at 3.685 (95% CI=2.50-5.44), which increased to 4.501 (95% CI=2.78-7.30) when adjusted for age, sex, injury severity, transfer status, injury mechanism, and surgical intervention. Abdominal trauma had the second highest adjusted hazard of mortality, at 3.62 (95% CI=1.92-6.84) followed by thoracic trauma (HR=1.3621, 95% CI=0.49-3.56).

CONCLUSION

In our setting, head or spine injury significantly increases the hazard of mortality significantly compared to all other anatomic injury locations. The prioritization of timely operative and non-operative head injury management is imperative. The development of head injury units may help attenuate trauma- related mortality in resource poor settings.

Mortality-Associated Characteristics of Patients with Traumatic Brain Injury at the University Teaching Hospital of Kigali, Rwanda

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with TBI in low and middle-income countries have worse outcomes than patients in high-income countries. We evaluated important clinical indicators associated with mortality for patients with TBI at University Teaching Hospital of Kigali, Kigali, Rwanda.

METHODS

A prospective consecutive sampling of patients with TBI presenting to University Teaching Hospital of Kigali Accident and Emergency Department was screened for inclusion criteria: reported head trauma, alteration in consciousness, headache, and visible head trauma. Exclusion criteria were age <10 years, >48 hours after injury, and repeat visit. Data were assessed for association with death using logistic regression. Significant variables were included in a multivariate logistic regression model and refined via backward elimination.

RESULTS

Between October 7, 2013, and April 6, 2014, 684 patients were enrolled; 14 (2%) were excluded because of incomplete data. Of patients, 81% were male with mean age of 31 years (range, 10-89 years; SD 11.8). Most patients (80%) had mild TBI (Glasgow Coma Scale [GCS] score 13-15); 10% had moderate (GCS score 9-12) and 10% had severe (GCS score 3-8) TBI. Multivariate logistic regression determined that GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were significantly associated with death.

CONCLUSIONS

GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were associated with mortality. These findings inform future research that may guide clinicians in prioritizing care for patients at highest risk of mortality.

Epidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital

BACKGROUND

The unmet surgical need, specifically neurosurgical need, in Uganda is significant, yet only 2 public hospitals currently perform neurosurgery in the country. This study examines the epidemiology and outcomes of neurosurgical conditions presenting to 1 of 12 regional referral hospitals in Uganda, in an effort to understand the neurosurgical needs of this population.

METHODS

The study was conducted at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. Demographics, clinical characteristics, and outcomes were retrospectively collected for all patients who presented to MRRH with a neurosurgical condition between January 2012 and September 2015.

RESULTS

During the study period, 1854 patients presented to MRRH with a neurosurgical condition. More than half of the patients were between 19 and 40 years old, and the majority were males (76.1%). The overall median length of stay was 5 days (interquartile range: 2.5-10). The majority of admissions were due to trauma (87%), with almost 60% due to road traffic incidents. The overall mortality rate was 12.8%. A multivariable Cox proportional hazards model revealed that age, closed head injury, and admission Glasgow Coma Scale have a strong positive correlation with mortality while getting a diagnostic image and neurosurgical procedure were negatively correlated with mortality.

CONCLUSION

Traumatic brain injury represented the majority of neurosurgical admissions at MRRH, disproportionately affecting young males. Age, closed head injury, admission Glasgow Coma Scale, getting a diagnostic image, and neurosurgical procedure were all independent predictors of mortality. Resource appropriate interventions throughout the health system are needed to meet the demand and improve outcomes.