Survival and Functional Outcomes at Discharge After Traumatic Brain Injury in Children versus Adults in Resource-Poor Setting

The status of pediatric surgery in Malawi: a narrative mini-review

Introduction

Pediatric surgery is essential to a well-functioning health system. Unmet surgical needs contribute to 6.7% of pediatric deaths in Malawi. Understanding the current state of pediatric surgical care in Malawi is necessary to recognize gaps and opportunities in service delivery and to develop evidence-based national planning and solutions.

Methods

This narrative mini review synthesized the literature on the state of pediatric surgery in Malawi through the pillars of the World Health Organization's Health System Building Blocks. A search of PubMed, Embase, and Scopus databases was executed to identify relevant studies and a thematic analysis was performed. Further, to ensure contextual accuracy, pediatric surgeons from Malawi were consulted and involved in this review.

Results

Twenty-six papers were identified. In Malawi's central hospitals, there are six specialist pediatric surgeons for a pediatric population of more than 8 million. There is limited pediatric surgical capacity at the district hospitals. There is little to no written evidence of the national governing and finance structures in place for pediatric surgical services.

Discussion

In countries like Malawi, where a significant portion of the population comprises children, it is crucial to recognize that pediatric services are currently inadequate and fall short of the required standards. It is crucial to prioritize the enhancement of services specifically designed for this age group. This review aims to shed light on the existing gaps within pediatric surgical services in Malawi, providing valuable insights that can inform the development of comprehensive national surgical planning strategies.

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.

Factors Affecting Death and Severe Injury in Child Motor Vehicle Passengers

Saving children from motor vehicle collisions is a high priority because the injury rate among motor vehicle passengers has been increasing in Japan. This study aimed to examine the factors that influence death and serious injury in child motor vehicle passengers to establish effective preventive measures. To identify these factors, we performed a retrospective study using a nationwide medical database. The data of child motor vehicle passengers younger than 15 years (n = 1084) were obtained from the Japanese Trauma Data Bank, registered from 2004 to 2019. Physiological variables, outcomes, and injury severity were compared between fatal and non-fatal patients and between those with and without severe injuries. Multivariate logistic regression analysis was performed to determine factors affecting fatality and severe injury. The Glasgow Coma Scale score (odds ratio (OR): 1.964), body temperature (OR: 2.578), and the Abbreviated Injury Scale score of the head (OR: 0.287) were identified as independent predictors of a non-fatal outcome. Systolic blood pressure (OR: 1.012), the Glasgow Coma Scale score (OR: 0.705), and Focused Assessment with Sonography for Trauma positivity (OR: 3.236) were identified as independent predictors of having severe injury. Decreasing the severity of head injury is the highest priority for child motor vehicle passengers to prevent fatality and severe injury.

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.

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.

Serum Substance P Concentration in Children With Traumatic Brain Injury: A First Report

OBJECTIVE

To review the clinic value and severity assessment of serum substance P (SP) concentration in children with different degrees of traumatic brain injury (TBI) through analyzing correlations with outcomes.

METHODS

One hundred thirty-nine children with TBI who were diagnosed and treated at Nanjing Medical University for longer than 72 hours between June 2017 and 2019 were analyzed. Blood samples were obtained within 24 hours after TBI to measure SP concentration. The endpoint was discharge mortality. Thirty healthy children composed the control group. Comparative analyses of differences in SP concentration were conducted for the different groups. Both the Sequential Organ Failure Assessment (SOFA) scores and Pediatric Clinical Illness Score (PCIS) were measured on admission and used in univariate and multivariate analyses.

RESULTS

The serum SP (89.10 ± 64.32) pmol/L) level in the case group was significantly higher than that in the control group (21.84 ± 2.09) pmol/L (t = 5.71, P < 0.05). The serum SP (182.81 ± 58.39) pmol/L) level in the deceased group was significantly higher than that in the survival group (59.93 ± 27.90) pmol/L (t = 16.52, P < 0.05). A negative correlation existed between serum SP concentration and Glasgow Coma Scale score in the severe, moderate, and mild groups (r = -0.72, P < 0.05). Serum SP concentration was identified as an independent risk factor for mortality (odds ratio >1, 95% confidence interval = 1.04-1.28, P < 0.01). Receiver operating characteristic curve analysis suggested that serum SP concentration had the same calibrating power as SOFA and PCIS in discriminating the risk of death of children.

CONCLUSIONS

Serum SP concentration was associated with severity in children with TBI, and extremely high levels indicated a poor prognosis.

Injury Causes and Severity in Pediatric Traumatic Brain Injury Patients Admitted to the Ward or Intensive Care Unit: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

Background: Traumatic brain injury (TBI) is the leading cause of death and disability in children. It includes a range of different pathologies that differ considerably from adult TBI. Analyzing and understanding injury patterns of pediatric TBI is essential to establishing new preventive efforts as well as to improve clinical management.

Methods: The multi-center, prospectively collected CENTER-TBI core and registry databases were screened and patients were included when younger than 18 years at enrollment and admitted to the regular ward (admission stratum) or intensive care unit (ICU stratum) following TBI. Patient demographics, injury causes, clinical findings, brain CT imaging details, and outcome (GOSE at 6 months follow-up) were retrieved and analyzed. Injury characteristics were compared between patients admitted to the regular ward and ICU and multivariate analysis of factors predicting an unfavorable outcome (GOSE 1-4) was performed. Results from the core study were compared to the registry dataset which includes larger patient numbers but no follow-up data.

Results: Two hundred and twenty seven patients in the core dataset and 687 patients in the registry dataset were included in this study. In the core dataset, road-traffic incidents were the most common cause of injury overall and in the ICU stratum, while incidental falls were most common in the admission stratum. Brain injury was considered serious to severe in the majority of patients and concurrent injuries in other body parts were very common. Intracranial abnormalities were detected in 60% of initial brain CTs. Intra- and extracranial surgical interventions were performed in one-fifth of patients. The overall mortality rate was 3% and the rate of unfavorable outcome 10%, with those numbers being considerably higher among ICU patients. GCS and the occurrence of secondary insults could be identified as independent predictors for an unfavorable outcome. Injury characteristics from the core study could be confirmed in the registry dataset.

Conclusion: Our study displays the most common injury causes and characteristics of pediatric TBI patients that are treated in the regular ward or ICU in Europe. Road-traffic incidents were especially common in ICU patients, indicating that preventive efforts could be effective in decreasing the incidence of severe TBI in children.