Profile of Head Injuries: Prehospital Care, Diagnosis, and Severity in an Ethiopian Tertiary Hospital

Temporal Delays in the Management of Traumatic Brain Injury: A Comparative Meta-Analysis of Global Literature

OBJECTIVE

A meta-analysis was conducted to compare: 1) time from traumatic brain injury (TBI) to the hospital, and 2) time within the hospital to intervention or surgery, by country-level income, World Health Organization region, and healthcare payment system.

METHODS

A comprehensive literature search was conducted and followed by a meta-analysis comparing duration of delays (prehospital and intrahospital) in TBI management. Means and standard deviations were pooled using a random effects model and subgroup analysis was performed using R software.

RESULTS

Our analysis comprised 95,554 TBI patients from 45 countries.

BY COUNTRY-LEVEL INCOME

From 23 low- and middle-income countries, a longer mean time from injury to surgery (862.53 minutes, confidence interval [CI]: 107.42-1617.63), prehospital (217.46 minutes, CI: -27.34-462.25), and intrahospital (166.36 minutes, 95% CI: 96.12-236.60) durations were found compared to 22 high-income countries.

BY WHO REGION

African Region had the greatest total (1062.3 minutes, CI: -1072.23-3196.62), prehospital (256.57 minutes [CI: -202.36-715.51]), and intrahospital durations (593.22 minutes, CI: -3546.45-4732.89).

BY HEALTHCARE PAYMENT SYSTEM

Multiple-Payer Health Systems had a greater prehospital duration (132.62 minutes, CI: 54.55-210.68) but greater intrahospital delays were found in Single-Payer Health Systems (309.37 minutes, CI: -21.95-640.69).

CONCLUSION

Our study concludes that TBI patients in low- and middle-income countries within African Region countries face prolonged delays in both prehospital and intrahospital management compared to high-income countries. Additionally, patients within Single-Payer Health System experienced prolonged intrahospital delays. An urgent need to address global disparities in neurotrauma care has been highlighted.

Extended tests for evaluating post-traumatic brain injury deficits in resource-limited settings: methods and pilot study data

Introduction

Traumatic brain injury (TBI) is one of the leading causes of all injury-related deaths and disabilities in the world, especially in low to middle-income countries (LMICs) which also suffer from lower levels of funding for all levels of the health care system for patients suffering from TBI. These patients do not generally get comprehensive diagnostic workup, monitoring, or treatment, and return to work too quickly, often with undiagnosed post-traumatic deficits which in turn can lead to subsequent incidents of physical harm.

Methods

Here, we share methods and results from our research project to establish innovative, simple, and scientifically based practices that dramatically leverage technology and validated testing strategies to identify post-TBI deficits quickly and accurately, to circumvent economic realities on the ground in LMICs. We utilized paper tests such as the Montreal cognitive assessment (MoCA), line-bisection, and Bell's test. Furthermore, we combined modifications of neuroscience computer tasks to aid in assessing peripheral vision, memory, and analytical accuracies. Data from seventy-one subjects (51 patients and 20 controls, 15 females and 56 males) from 4 hospitals in Ethiopia are presented. The traumatic brain injury group consists of 17 mild, 28 moderate, and 8 severe patients (based on the initial Glasgow Comma Score). Controls are age and education-matched subjects (no known history of TBI, brain lesions, or spatial neglect symptoms).

Results

We found these neurophysiological methods can: 1) be implemented in LMICs and 2) test impairments caused by TBI, which generally affect brain processing speed, memory, and both executive and cognitive controls.

Discussion

The main findings indicate that these examinations can identify several deficits, especially the MoCA test. These tests show great promise to assist in the evaluation of TBI patients and support the establishment of dedicated rehabilitation centers. Our next steps will be expansion of the cohort size and application of the tests to other settings.

Profile of Patients Receiving Computed Tomography Scans for Mild Traumatic Brain Injury in a Tertiary Care Hospital in Ethiopia

BACKGROUND

Traumatic brain injury (TBI) is a leading contributor to emergency department (ED) mortalities in Ethiopia. Mild TBI patients comprise half of all TBI patients presenting for care in Ethiopia and have a high potential for recovery. As such, context-specific care-improving strategies may be highly impactful for this group of patients.

OBJECTIVE

This study examines the presentation and disposition of mTBI patients who received a computed tomography scan of the head upon arrival at the largest teaching hospital in Ethiopia.

METHODS

A retrospective cohort study was conducted from 2018 to2021 including patients >13 years old with a head injury and a Glasgow Coma Score of 13-15 who obtained a computed tomography scan of the head. Variables were collected from medical charts and single and multivariable analyses assessed outcomes of clinically important TBI (ciTBI) requiring a neurosurgical procedure or admission.

RESULTS

A total of 193 patients were included. They were predominantly young men with no comorbidities, injured in road traffic accidents or by assault, had stable vital signs and were treated in lower-acuity ED areas. A minority demonstrated focal deficits, and 29.5% of patients had ciTBI. Most patients were discharged from the ED, but 13% were taken for operative neurosurgical procedures and 10.4% were admitted to the neurosurgery ward for observation. ED stays ranged from 8 hours to 10 days, as patients waited for CT availability, neurosurgical decision, or transportation. Female sex was independently protective of ciTBI. Self-referral status was independently protective against operative intervention. Female sex and self-referral status were independently protective of a disposition of admission and/or going to the operating room.

CONCLUSIONS

This study characterizes the mTBI subgroup of head injury patients in Ethiopia's busiest ED: predominantly healthy young men with low-acuity presentations and only a fraction with abnormal neurological examinations. Nonetheless, about one-third had ciTBI and a minority were taken for neurosurgical procedures or admission, with female sex and self-referral identified as protective factors. Meanwhile, many patients stayed in the ED for days due to social or other nonmedical reasons. As TBI care in Ethiopia continues to improve, optimizing care for the mTBI subgroup is tantamount given their high recovery potential. This care will benefit from efficiently identifying those who need intervention or hospital level of care, and discharging those who do not.

Management of traumatic brain injury in Africa: challenges and opportunities

Traumatic brain injury (TBI) is a major public health concern globally, with significant implications for morbidity, mortality, and long-term disability. While extensive research has been conducted on TBI management in high-income countries, limited attention has been given to the specific challenges and opportunities faced by healthcare systems in sub-Saharan Africa (SSA). This perspective study aims to provide a comprehensive overview of the current status of TBI management in SSA, focusing on the unique challenges and potential opportunities for improvement. The findings highlight several key challenges faced by SSA healthcare systems in managing TBIs, including limited resources, inadequate infrastructure, and a shortage of trained healthcare professionals. Furthermore, social and cultural factors, such as ignorance of driving laws, financial constraints, and limited access to modern technology services. However, the study also identifies potential opportunities for improving TBI management in SSA. These include strengthening healthcare infrastructure, enhancing pre-hospital care and transportation systems, and increasing public awareness and education about TBI. This perspective study emphasizes the urgent need for tailored interventions and strategies to address the unique challenges faced by SSA in managing TBIs. Addressing the challenges and opportunities in brain injury management in SSA requires a comprehensive approach which can be through investing in health infrastructure, addressing socio-economic inequalities, implementing prevention strategies, and fostering evidence-based research collaboration. Through this, the region can significantly improve TBI care and outcomes, thereby improving the well-being of people affected by TBI in SSA.

Neurotrauma from fall accidents in Ethiopia

Background

Ethiopia is a fast-growing economy with rapid urbanization and poor occupational safety measures. Fall injuries are common and frequently result in traumatic brain injury (TBI) or spinal cord injury (SCI).

Methods

We prospectively included fall victims who were hospital-treated for neurotrauma or forensically examined in 2017 in Addis Ababa, Ethiopia. We registered sociodemographic factors, fall types, injuries, treatment, and outcome.

Results

We included 117 treated and 51 deceased patients (median age 27 vs. 40 years). Most patients were injured at construction sites (39.9%) and only one in three used protective equipment. TBI (64.7%) and SCI (27.5%) were the most common causes of death among the deceased patients, of which most died at the accident site (90.2%). Many patients suffered significant prehospital time delays (median 24 h). Among treated patients, SCI was more frequent than TBI (50.4% vs. 39.3%), and 10.3% of the patients had both SCI and TBI. Most SCIs were complete (49.3%), whereas most TBIs were mild (55.2%). Less than half of TBI patients and less than one in five SCI patients were operated. There were twice as many deaths among TBI patients as SCI patients. Among those discharged alive, at a median of 33 weeks, 50% of TBI patients had a good recovery whereas 35.5% of SCI patients had complete injuries.

Conclusion

Falls at construction sites with inadequate safety measures were common causes of SCI and TBI resulting in severe disability and death. These results support further development of prevention strategies and neurotrauma care in Ethiopia.

Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs.

METHODS

A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively.

RESULTS

A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified.

CONCLUSIONS

Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.

Incidence and predictors of mortality among traumatic brain injury patients admitted to Amhara region Comprehensive Specialized Hospitals, northwest Ethiopia, 2022

INTRODUCTION

Traumatic brain injury is a substantial cause of mortality and morbidity with a higher burden in low and middle-income countries due to healthcare systems that are unable to deliver effectively the acute and long-term care the patients require. Besides its burden, there is little information on traumatic brain injury-related mortality in Ethiopia, especially in the region. Therefore, this study aimed to assess the incidence and predictors of mortality among traumatic brain injury patients admitted to comprehensive specialized hospitals in the Amhara region, northwest Ethiopia, 2022.

METHODS

An institution-based retrospective follow-up study was conducted among 544 traumatic brain injury patients admitted from January 1, 2021, to December 31, 2021. A simple random sampling method was used. Data were extracted using a pre-tested and structured data abstraction sheet. Data were entered, coded, and cleaned into EPi-info version 7.2.0.1 software and exported to STATA version 14.1 for analysis. The Weibull regression model was fitted to determine the association between time to death and covariates. Variables with a P-value < 0.05 were declared statistically significant.

RESULTS

The overall incidence of mortality among traumatic brain injury patients was 1.23 per 100 person-day observation [95% (CI: 1.0, 1.5)] with a median survival time of 106 (95% CI: 60, 121) days. Age [AHR: 1.08 (95% CI; 1.06, 1.1)], severe traumatic brain injury [AHR: 10 (95% CI; 3.55, 28.2)], moderate traumatic brain injury [AHR: 9.2 (95% CI 2.97, 29)], hypotension [AHR: 6.9 (95% CI; 2.8, 17.1)], coagulopathy [AHR: 2.55 (95% CI: 1.27, 5.1)], hyperthermia [AHR: 2.79 (95% CI; 1.4, 5.5)], and hyperglycemia [AHR: 2.28 (95% CI; 1.13, 4.6)] were positively associated with mortality while undergoing neurosurgery were negatively associated with mortality [AHR: 0.47 (95% CI; 0.27-0 0.82)].

CONCLUSION

The overall incidence of mortality was found to be high. Age, severe and moderate traumatic brain injury, hypotension at admission, coagulopathy, presence of associated aspiration pneumonia, undergoing a neurosurgical procedure, episode of hyperthermia, and hyperglycemia during hospitalization were the independent predictors of time to death. Therefore, interventions to reduce mortality should focus on the prevention of primary injury and secondary brain injury.

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.

Prehospital emergency medical service utilization and associated factors among critically ill COVID-19 patients treated at centers in Addis Ababa, Ethiopia

The majority of populations in developing countries are living in areas of no access or limited access to prehospital emergency medical services (EMS). In Addis Ababa, the reported prehospital EMS utilization were ranging from zero to thirty-eight percent. However, there is limited research on reasons for the low utilization of prehospital resources in Ethiopia. This study aimed to assess factors associated with prehospital EMS utilization among critically ill COVID-19 patients in Addis Ababa, Ethiopia. A hospital-based cross-sectional study was conducted to collect primary data from 421 COVID-19 patients in Addis Ababa between May and July 2021. Logistic regression was used to identify factors associated with prehospital service utilization. Andersen's Behavioral Model was implemented to address independent variables, including predisposing, enabling, need, and health behaviors-related variables. The level of prehospital care utilization was 87.6%. Being married [AOR 2.6(95%; CI:1.24-5.58)], belief that self-transport is quicker than the ambulance [AOR 0.13(95%; CI: 0.05-0.34)], and perceptions that ambulance provides transportation service only [AOR 0.14(95%; CI:0.04-0.45)] were predisposing factors associated with prehospital service utilization while the source of referrals [AOR 6.9(95%; CI: 2.78-17.30)], and prior knowledge on the availability of toll-free ambulance calling numbers [AOR 0.14(95%; CI: 0.04-0.45)] were identified as enabling factors. Substantial proportions of critically ill COVID-19 patients used prehospital services to access treatment centers. Prehospital EMS utilization in this study varies by predisposing and enabling factors, particularly: marital status, source of referral, prior knowledge on the availability of toll-free ambulances, belief that self-transport is quicker than ambulances, and perceptions that ambulance provides transportation service only. Our findings call for further actions to be taken by policymakers including physical and media campaigns focusing on the identified factors.

Factors Associated with Willingness to Call Emergency Medical Services for Worsening Symptoms of COVID-19 in Addis Ababa, Ethiopia

Background

In response to the COVID-19 pandemic, the Ethiopian Ministry of Health has established ambulances and dispatch centers specifically designed to transport COVID-19 patients to city medical centers. Due to a lack of evidence in this area, it is critical to assess the factors that influence the willingness to call for emergency medical services.

Methods

A community-based cross-sectional study was conducted from June to July 2021 in Addis Ababa. The data were gathered through use of a pretested questionnaire and analyzed using SPSS 25. Logistic regression was used to calculate odds ratios with and without confounding variable controls, and significant associations were declared at (0.05). For the variables that show significant associations in bivariate and multivariate analyses, a 95% confidence interval is provided.

Results

Three-quarters of those surveyed said they would call ambulance if they experienced worsening COVID-19 symptoms. The individual’s language was associated with the willingness to call EMS for worsening COVID-19 symptoms [AOR 0.51(95% CI: 0.28–0.92)].; awareness of the availability of toll-free ambulance services [AOR 3.4(95% CI: 1.92–5.95)]; recalling an EMS number [AOR 4.3(95% CI: 1.71–10.67)]; ambulance crew quality of care perception [AOR 3.6(95% CI: 2.09–6.10)]; ambulance service adequacy and accessibility perception [AOR 0.25(95% CI: 0.11–0.55)].

Conclusion

The study showed significant portion of the Addis Ababa community recognized the need to call EMS due to worsening COVID-19 symptoms. The individual’s language, awareness of toll-free ambulance; ability to recall an ambulance number, perception of the ambulance crew’s quality of care and adequacy and accessibility of service in the city influence the decision to call an ambulance. The finding highlights the significance of addressing problems through various media outlet, for advocacy and public awareness. More research, including qualitative studies, is needed to investigate the factors that encourage people to seek EMS.

The effect of transfer status on trauma outcomes in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

Injuries are a leading cause of disability and death worldwide, and low- and middle-income countries (LMICs) are disproportionately burdened by trauma. Prior studies have shown that transfer status (direct transfer from injury scene to a referral hospital versus indirect transfer from another facility to a referral hospital) may affect patient outcomes. The purpose of this study is to evaluate the relationship between transfer status and trauma patient outcomes in LMICs by conducting a systematic review and meta-analysis.

METHODS

We performed a systematic search to identify studies from LMICs that evaluated the relationship between transfer status and trauma patient outcomes. We extracted data on study country, design, patient characteristics, and outcomes. We report results in the form of a narrative summary stratified by type of outcome. We also performed a meta-analysis of studies that reported mortality by transfer status. We calculated a pooled odds ratio of mortality among indirectly transferred (IT) versus directly transferred (DT) patients using random-effects modeling.

RESULTS

We included 17 observational studies from 9 LMICs in this systematic review. Outcomes assessed were time from injury to arrival at a referral hospital, post-trauma functional status, hospital length of stay, and mortality. IT patients took between 0.6 and 37.9 h longer to arrive at referral hospitals than DT patients. Hospital length of stay was up to 6 days longer for IT patients than DT patients. The pooled odds ratio of mortality among IT patients compared to DT patients was 1.55 (95% CI 1.12 - 2.15; p = 0.009).

CONCLUSION

Trauma patients in LMICs who are indirectly transferred to referral hospitals have significantly higher mortality rates than patients who present directly to referral hospitals. These results conflict with findings from HICs and reflect the relative immaturity of trauma systems in LMICs. Strategies to narrow the mortality gap between IT and DT patients include improving prehospital and primary hospital care and developing more efficient transfer protocols.

The status of prehospital care delivery for COVID-19 patients in Addis Ababa, Ethiopia: The study emphasizing adverse events occurring in prehospital transport and associated factors

BACKGROUND

COVID-19 patients may require emergency medical services for emergent treatment and/or transport to a hospital for further treatment. However, it is common for the patients to experience adverse events during transport, even the shortest transport may cause life-threatening conditions. Most of the studies that have been done on prehospital care of COVID-19 patients were conducted in developed countries. Differences in population demographics and economy may limit the generalizability of available studies. So, this study was aimed at investigating the status of prehospital care delivery for COVID-19 patients in Addis Ababa focusing on adverse events that occurred during transport and associated factors.

METHODS

A total of 233 patients consecutively transported to Saint Paul's Hospital Millennium Medical College from November 6 to December 31, 2020, were included in the study. A team of physicians and nurses collected the data using a structured questionnaire. Descriptive statistics were used to summarize data, and ordinal logistic regression was carried out to assess the association between explanatory variables and the outcome variable. Results are presented using frequency, percentage, chi-square, crude and adjusted odds ratios (OR) with 95% confidence intervals.

RESULTS

The overall level of adverse events in prehospital setting was 44.2%. Having history of at least one chronic medical illness, [AOR3.2 (95%; CI; 1.11-9.53)]; distance traveled to reach destination facility, [AOR 0.11(95%; CI; 0.02-0.54)]; failure to recognize and administer oxygen to the patient in need of oxygen, [AOR 15.0(95%; CI; 4.0-55.7)]; absent or malfunctioned suctioning device, [AOR 4.0(95%; CI; 1.2-13.0)]; patients handling mishaps, [AOR 12.7(95%; CI; 2.9-56.8)] were the factors associated with adverse events in prehospital transport of COVID-19 patients.

CONCLUSIONS

There were a significant proportion of adverse events in prehospital care among COVID-19 patients. Most of the adverse events were preventable. There is an urgent need to strengthen prehospital emergency care in Ethiopia by equipping the ambulances with essential and properly functioning equipment and trained manpower. Awareness creation and training of transport staff in identifying potential hazards, at-risk patients, adequate documentation, and patient handling during transport could help to prevent or minimize adverse events in prehospital care.

Clinical Outcomes and Prognostic Determinants of Surgically Treated Depressed Skull Fracture in Addis Ababa University Neurosurgical Teaching Hospitals: A Prospective Multicenter Observational Study

BACKGROUND

Depressed skull fracture is one of the most common neurosurgical emergencies in Ethiopia. The clinical outcome after surgical management and what factors predict the outcome are not well studied. Our study aimed to assess the outcome and identify predictors of the outcome in surgically treated adult patients.

METHODS

A prospective, multicenter, observational study was undertaken on 197 cases, at 4 selected neurosurgical teaching hospitals in Ethiopia. Relevant data were collected and analyzed using Statistical Package for the Social Sciences software (IBM, Armonk, New York, USA). The outcome was assessed by the extended Glasgow Outcome Scale. Multivariate analysis was done to identify independent predictors of the outcome.

RESULTS

The outcome was favorable in 81.2%. The mean age was 27. The mode of injury was violence in 79.7%. Motor deficit witnessed in 24.4%. Based on the Glasgow Coma Scale, 92.2% of patients had mild traumatic brain injury. Associated intracranial lesions were identified in 87.3%. The median hospital stay was 4.7 days. Reoperation and mortality rates were 4.1% and 0.5%, respectively. Five factors were statistically significant independent predictors of unfavorable outcome in multivariate analysis: motor deficit (adjusted odds ratio [AOR] 13.8, 95% confidence interval [CI]: 4.13-46.17, P = 0.000), Glasgow Coma Scale ≤13 (AOR 10.36, 95% CI: 1.93-55.56, P = 0.006), pneumocephalus (AOR 12.93, 95% CI: 3.12-53.52, P = 0.000), hospital stay for ≥3 days (AOR 4.39, 95% CI: 1.18-16.3, P = 0.027), and reoperation (AOR 6.92, 95% CI: 1.09-43.97, P = 0.04).

CONCLUSIONS

The overall outcome was favorable. The presence of motor deficit, postresuscitation Glasgow Coma Scale ≤13, pneumocephalus, reoperation, and hospital stays for ≥3 days were independent predictors of an unfavorable outcome.

Neurosurgery in Ethiopia: A New Chapter and Future Prospects

BACKGROUND

Inequitable access to surgical care is most conspicuous in low-income countries (LICs), such as Ethiopia, where infectious diseases, malnutrition, and other maladies consume the lion's share of the available health resources. The aim of this article was to provide an update on the current state of neurosurgery in Ethiopia and identify targets for future development of surgical capacity as a universal health coverage component in this East African nation.

METHODS

Publicly available data included in this report were gathered from resources published by international organizations. A PubMed search was used for a preliminary bibliometric analysis of scholarly output of neurosurgeons in Ethiopia and other low-income countries. Statistical analysis was used to determine the correlation between the number of neurosurgeons and academic productivity.

RESULTS

Neurosurgeon density has increased >20-fold from 0.0022 to 0.045 neurosurgeons per 100,000 population between 2006 and 2020. The increase in neurosurgeons was strongly correlated with an increase in total publications (P < 0.001) and the number of new publications per year (P = 0.003). Despite recent progress, the availability of neuroimaging equipment remains inadequate, with 38 computed tomography scanners and 11 magnetic resonance imaging machines for a population of 112.07 million. The geographic distribution of neurosurgical facilities is limited to 12 urban centers.

CONCLUSIONS

Ethiopian neurosurgery exemplifies the profound effect of international partnerships for training local surgeons on progress in low-income countries toward improved neurosurgical capacity. Collaborations that focus on increasing the neurosurgical workforce should synchronize with efforts to enhance the availability of diagnostic and surgical equipment necessary for basic neurosurgical care.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Surgical Procedures, Complications, and Postoperative Outcomes

BACKGROUND

Traumatic brain injury (TBI) is an important cause of trauma-related mortality and morbidity in Ethiopia. There are significant resource limitations along the entire continuum of care, and little is known about the neurosurgical activity and patient outcomes.

METHODS

All surgically treated TBI patients at the 4 teaching hospitals in Addis Ababa, Ethiopia were prospectively registered from October 2012 to December 2016. Data registration included surgical procedures, complications, reoperations, discharge outcomes, and mortality.

RESULTS

A total of 1087 patients were included. The most common procedures were elevation of depressed skull fractures (49.5%) and craniotomies (47.9%). Epidural hematoma was the most frequent indication for a craniotomy (74.7%). Most (77.7%) patients were operated within 24 hours of admission. The median hospital stay for depressed skull fracture operations or craniotomies was 4 days. Decompressive craniectomy was only done in 10 patients. Postoperative complications were seen in 17% of patients, and only 3% were reoperated. Cerebrospinal fluid leak was the most common complication (7.9%). The overall mortality was 8.2%. Diagnosis, admission Glasgow Coma Scale (GCS) score, surgical procedure, and complications were significant predictors of discharge GCS score (P < 0.01). Age, admission GCS score, and length of hospital stay were significantly associated with mortality (P ≤ 0.005).

CONCLUSIONS

The injury panorama, surgical activity, and outcome are significantly influenced by patient selection due to deficits within both prehospital and hospital care. Still, the neurosurgical services benefit a large number of patients in the greater Addis region and are qualitatively comparable with reports from high-income countries.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Trauma Causes, Injury Types, and Clinical Presentation

BACKGROUND

Traumatic brain injury (TBI) is a public health problem in Ethiopia. More knowledge about the epidemiology and neurosurgical management of TBI patients is needed to identify possible focus areas for quality improvement and preventive efforts.

METHODS

This prospective cross-sectional study (2012-2016) was performed at the 4 teaching hospitals in Addis Ababa, Ethiopia. All surgically treated TBI patients were included, and data on clinical presentation, injury types, and trauma causes were collected.

RESULTS

We included 1087 patients (mean age 29 years; 8.7% females; 17.1% <18 years old). Only 15.5% of TBIs were classified as severe (Glasgow Coma Scale score 3-8). Depressed skull fracture (44.9%) and epidural hematoma (39%) were the most frequent injuries. Very few patients had polytrauma (3.1%). Assault was the most common injury mechanism (69.9%) followed by road traffic accidents (15.8%) and falls (8.1%). More than 80% of patients came from within 200 km of the hospitals, but the median time to admission was 24 hours. Most assault victims (80.4%) were injured >50 km from the hospitals, whereas 46% of road traffic accident victims came from the urban area. Delayed admission was associated with higher Glasgow Coma Scale scores and nonsevere TBI (P < 0.01).

CONCLUSIONS

The injury panorama, delayed admission, and small number of operations performed for severe TBI are linked to a substantial patient selection bias both before and after hospital admission. Our results also suggest that there should be a geographical framework for tailored guidelines, preventive efforts, and development of prehospital and hospital services.

A Comparison of Reported Outcomes of Anterior Cervical Spinal Surgery Among Neurosurgeons in Africa and North America

BACKGROUND

Neurosurgical practice in some African countries has significant differences in patient load and resource availability compared with North America. We designed a survey to determine reported differences in outcome of anterior cervical decompression and fusion surgery, including blood loss, length of stay, and follow-up time, among physicians on different continents. We expected outcomes in all categories to be pronounced between respondents in Africa compared with North America due to a multitude of factors.

METHODS

The survey consisted of 7 questions and was sent to 352 neurosurgeons practicing on the continents of North America, Africa, or Other.

RESULTS

A total of 62 surgeons responded, 44 from Africa, 15 from North America, and 3 from Other. A greater percentage of respondents in Africa reported an average follow-up time within 2 weeks compared with respondents practicing in North America (63.6% and 40%, respectively). On blood loss, 56% of surgeons in Africa reported >50 mL of intraoperative blood loss compared with 6.67% for respondents in North America. Over 90% reported length of stay of 2 or more days in Africa, compared with 6.67% in North America.

CONCLUSIONS

Our findings demonstrate greater advances in reported surgical outcomes for patients in Africa than we expected, but still highlight key areas for improvement, almost certainly due to lack of resources.

Patterns of injury at an Ethiopian referral hospital: Using an institutional trauma registry to inform injury prevention and systems strengthening

Background

Data about injury patterns and clinical outcomes are essential to address the burden of injury in low- and middle-income countries. Institutional trauma registries (ITRs) are a key tool for collecting epidemiologic data about injury. This study uses ITR data to describe the demographics and patterns of injury of trauma patients in Addis Ababa, Ethiopia in order to identify opportunities for injury prevention, systems strengthening and further research.

Methods

This is an analysis of prospectively collected data from a sustainable ITR at Menelik II Specialized Hospital, a public teaching hospital with trauma expertise. All patients presenting to the hospital with serious injuries requiring intervention or admission over a 13 month period were included. Univariable and bivariable analyses were performed for patient demographics and injury characteristics.

Results

A total of 854 patients with serious injuries were treated during the study period. Median age was 33 years and 74% were male. The most common mechanisms of injury were road traffic injuries (RTI) (37%), falls (30%) and blunt assault (17%). Over half of RTI victims were pedestrians. Median delay in presentation was 2 h; 17% of patients presented over 6 h after injury. 58% of patients were referred from another hospital or a clinic, and referrals accounted for 84% of patients arriving by ambulance. Median emergency center length of stay was 2 h and 62% of patients were discharged from the emergency center.

Conclusion

This study highlights the utility of institutional trauma registries in collecting crucial injury surveillance data. In Addis Ababa, road safety is an important target for injury prevention. Our findings suggest that the most severely injured patients may not be making it to the referral centers with the capacity to treat their injuries, thus efforts to improve prehospital care and triage are needed.

African relevance

Injury is a public health priority in Africa. Institutional trauma registries play a crucial role in efforts to improve trauma care by describing injury epidemiology to identify targets for injury prevention and systems strengthening efforts. In our context, pedestrian safety is a key target for injury prevention. Improving prehospital care and developing referral networks are goals for systems strengthening.