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

Profile of Pediatric Neurosurgery in Nigeria from 1962 to 2021: A Systematic Review

OBJECTIVE

This study aims to provide a comprehensive overview of pediatric neurosurgery in Nigeria, since 1962, by assessing epidemiological data, management strategies, and case outcomes.

METHODS

A systematic bibliometric review of Nigerian neurosurgical literature was reported with the PRISMA guidelines. The Risk of Bias Assessment Tool was applied to all nonrandomized studies, and a descriptive analysis was performed for all variables.

RESULTS

We identified 12,295 pediatric patients from 196 published studies. Most publications (72.4%) occurred in the recent 2 decades, of which 40.3% were observational case reports/series. The patients were predominantly male (57.2%) and aged 0-18 years, with the majority (66.1%) belonging to the 0-5 age range. Most patients (63.4%) presented between 1-12 months. The most common presenting feature was altered consciousness (7.7%), with computed tomography (38.8%) being the most frequently utilized diagnostic imaging modality. The diagnoses with the greatest prevalence (60.2%) were congenital abnormalities such as hydrocephalus and neural tube defects. 57.5% of cases received surgical therapy, with ventriculoperitoneal shunt placement being the most noticeable procedure performed (36.4%). Complications were identified in 9.5% of cases, with a 4.5% death rate. The Glasgow Outcome Score (95.7%) was the primary outcome measure utilized, with positive outcomes reported in 59.3% of cases.

CONCLUSIONS

This review provides significant epidemiological data which emphasizes the country's enormous burden of pediatric neurosurgical cases. The findings can help guide clinical decisions as well as future research and policy development.

Pediatric head injuries: particularities and neurosurgical experience in a lower-middle income country

PURPOSE

To the best of our knowledge, this is the first study conducted in Tunisia on the neurosurgical management of child cranial trauma. The objectives of the present work were to identify the causes of pediatric head injuries, explore epidemiological and clinical specificities, and analyze the short- and long-term postoperative evolution.

METHODS

A retrospective review was conducted on one hundred children with head injuries over a five-year period at one of the largest neurosurgery departments in Tunisia. The collected data encompassed demographic information, clinical presentation features, neuroimaging characteristics, surgical management, complications, and outcomes.

RESULTS

Over a five-year period, we have found 118 children who have undergone surgery, representing an annual incidence of twenty-four children per year. The average age was 10 years. Falls emerged as the primary cause of childhood head injuries in our series, followed by road traffic accidents. The most frequently encountered initial sign was the loss of consciousness (52%), followed by headaches (28%), vomiting (25%), and seizures (8%). The average time between the accident and admission to the operating unit was 10 h. Various neurosurgeries were performed, with the evacuation of an epidural hematoma being the most common procedure. At a median follow-up of 24 months, the outcomes were favorable in 88% of cases.

CONCLUSION

The main prognostic factors for head trauma in children included age, circumstances of the accident, association with polytrauma, the initial Glasgow Coma Scale, the nature of the initial cerebral lesions, and the timeliness and quality of initial management.

Further recommendations of the International Paediatric Brain Injury Society (IPBIS) for the post-acute rehabilitation of children with acquired brain injury

BACKGROUND

Paediatric acquired brain injury is a life-long condition which impacts on all facets of the individual's lived experience. The existing evidence base continues to expand and new fields of enquiry are established as clinicians and researchers uncover the extent of these impacts.

PRIMARY OBJECTIVE

To add to recommendations described in the International Paediatric Brain Injury Society's 2016 paper on post-acute care for children with acquired brain injury and highlight new areas of enquiry.

REVIEW OF INFORMATION

Recommendations were made based on the opinions of a group of experienced international clinicians and researchers who are current or past members of the board of directors of the International Paediatric Brain Injury Society. The importance of each recommendation was agreed upon by means of group consensus.

OUTCOMES

This update gives new consideration to areas of study including injuries which occur in pre-school children, young people in the military, medical referral, young offenders and the use of technology in rehabilitation.

Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania

BACKGROUND

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge.

OBJECTIVE

The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania.

METHODS

This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis.

RESULTS

Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up.

CONCLUSION

Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

Traumatic Brain Injury Mortality and Correlates in Low- and Middle-Income Countries: A Meta-Epidemiological Study

BACKGROUND

It is estimated that up to 69 million people per year experience traumatic brain injury (TBI) with the highest prevalence found in low- and middle-income countries (LMICs). A paucity of data suggests that the mortality rate after severe TBI is twice as high in LMICs than in high-income countries.

OBJECTIVE

To analyze TBI mortality in LMICs and to evaluate what country-based socioeconomic and demographic parameters influence TBI outcomes.

METHODS

Four databases were searched for the period January 1, 2002, to January 1, 2022, for studies describing TBI outcomes in LMICs. Multivariable analysis was performed using multivariable linear regression, with the outcome as the pooled mortality by country and the covariates as the adjusted parameters.

RESULTS

Our search yielded 14 376 records of which 101 were included in the final analysis, totaling 59 197 patients and representing 31 LMICs. The pooled TBI-related mortality was 16.7% (95% CI: 13.7%-20.3%) without significant differences comparing pediatrics vs adults. Pooled severe TBI-related mortality was significantly higher than mild. Multivariable analysis showed a significant association between TBI-related mortality and median income ( P = .04), population percentage below poverty line ( P = .02), primary school enrollment ( P = .01), and poverty head ratio ( P = .04).

CONCLUSION

TBI-related mortality in LMICs is 3-fold to 4-fold higher than that reported in high-income countries. Within LMICs, parameters associated with poorer outcomes after TBI include factors recognized as social determinants of health. Addressing social determinants of health in LMICs might expedite the quest to close the care delivery gap after TBI.

Pediatric Traumatic Brain Injury in Malawi: A Propensity-Weighted Analysis of Outcomes and Trends Over Time

BACKGROUND

Pediatric injuries contribute to substantial mortality and morbidity worldwide, particularly in sub-Saharan Africa. We aim to identify predictors of mortality and time trends for pediatric traumatic brain injuries (TBIs) in Malawi.

METHODS

We performed a propensity-matched analysis of data from the trauma registry at Kamuzu Central Hospital in Malawi from 2008 to 2021. All children ≤16 years of age were included. Demographic and clinical data were collected. Outcomes were compared between patients with and without head injuries.

RESULTS

A cohort of 54,878 patients was included, with 1755 having TBI. The mean ages of patients with and without TBI were 7.8 ± 7.8 years and 7.1 ± 4.5 years, respectively. The most common mechanism for patients with and without TBI was road traffic injury and falls, respectively (48.2% vs. 47.8%, P < 0.01). The crude mortality rate for the TBI cohort was 20.9% compared to 2.0% in the non-TBI cohort (P < 0.01). After propensity matching, patients with TBI had 4.7 higher odds of mortality (95% confidence interval 1.9-11.8). Over time, patients with TBI had an increasing predicted probability of mortality for all age categories, with the most significant increase among children younger than 1 year.

CONCLUSIONS

TBI confers a greater than 4-fold higher likelihood of mortality in this pediatric trauma population in a low-resource setting. These trends have worsened over time.

Increasing incidence of pediatric mild traumatic brain injury in Finland - a nationwide register study from 1998 to 2018

AIM

The purpose of this study is to document the annual incidence and incidence trends of pediatric traumatic brain injury (pTBI) in Finland over the course of 21 years.

METHODS

We conducted a retrospective nationwide register-based cohort study and used the Finnish Care Register and Population information statistics from 1998 to 2018. The patient group includes all patients aged <18 at the time of injury. We included all emergency department (ED) visits and subsequent inpatient admissions (meaning at least one night in the hospital) with International Classification of Diseases diagnostic code S06*. We calculated pTBI incidences per 100,000 person-years with 95% confidence intervals and the incidences were compared by incidence rate ratios (IRR), including age, diagnosis, and gender stratified analyses.

RESULTS

A total of 71,972 patients were included with 76,785 ED visits or hospitalizations for pTBI diagnoses. The annual incidence of diagnosed pTBI was 251 (CI: 241-260) per 100,000 in 1998 and 547 (CI: 533-561) per 100,000 in 2018, indicating a 118% increase in the incidence (IRR 2.18 CI: 2.09-2.28). Boys had 32% higher incidence (IRR 1.32 CI: 1.30-1.34) than girls. The highest cumulative incidence was observed among boys aged <1 years, 525 (CI: 507-543) per 100,000, and boys had higher incidences in all age groups. The most used diagnostic code was concussion, which included 92.1% of the diagnoses followed by diffuse brain injury, which included 2.3% of the diagnoses. The increase in the incidence of diagnosed pTBI was notably high after 2010. Concussion diagnoses and pTBI cases that were discharged directly from the ED had more than a two-fold increase from 2010 to 2018, whereas the incidence of inpatient admissions for pTBI increased by 53%.

CONCLUSIONS

The overall incidence of diagnosed pTBI has increased in Finland especially since 2010. Boys have higher incidence of diagnosed pTBI in all age groups. Most of the increase was due to increase in the concussion diagnoses, which may be due to the centralization of EDs into bigger units and increased diagnostic awareness of mild pTBI.

HYPERGLYCEMIA AS A PREDICTOR OF OUTCOME IN PAEDIATRIC SEVERE TRAUMATIC BRAIN INJURY PATIENTS UNDERWENT SURGERY: A SINGLE CENTER EXPERIENCE FROM EASTERN INDONESIA FROM 2017-2022

OBJECTIVE

The aim: Traumatic Brain Injury (TBI) remains a significant health burden worldwide. This study aimed to describe, determine and recommendation concerning the impact of hyperglycemia on pediatric TBI.

PATIENTS AND METHODS

Materials and methods: Paediatric trauma patients with severe TBI event were identified and admitted to our Dr. Soetomo General Hospital, Surabaya, the regional Trauma Center of East Java, Indonesia between calendar year of 2017 and 2022. Our institutions trauma database was utilized to select the patient included in this study. Patients with GCS ≤ 8 who underwent neurosurgical interventions were included to the study. Neurosurgical interventions are craniotomy for clot evacuation and decompressive craniectomy. We excluded patients with GCS > 8 and/or treated with conservative therapy (no surgery needed). Data collected for analysis as independent variables included patient age, admission GCS score and admission serum glucose score, mechanism of injury, type of intracranial lesion and type of surgery. Outcome of the patients included was examined at discharge which sub-grouped by Glasgow Outcomes Scale (GOS) score. Independent variables were entered into the logistic model in a stepwise fashion with a significant cutoff of p< 0,05.

RESULTS

Results: Patients with worse neurological outcomes (GOS score 1-2) had a mean serum glucose value of over 200 mg/dL. Patients who died (GOS score of 1) had higher mean admission glucose values (226.44 ± 62,00) than the patients who had survived with a GOS score of 3 (139.80 ± 10.87), 4 (87), or 5 (134). Patients who resulted in a vegetative state (GOS score of 2) had higher mean admission serum glucose values than patients who were discharged with a GOS score of 5 (205.14 ± 36.17 vs. 134; p = 0.003).

CONCLUSION

Conclusions: Hyperglycaemia in pediatric TBI patients that underwent neurosurgical intervention is associated with worse outcomes, even mortality. We believe that prospective evaluation of glucose normalization in the context of acute management of pediatric head injuries is both appropriate and necessary for the next study.

Global emergency medicine: A scoping review of the literature from 2021

OBJECTIVE

The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers.

METHODS

A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary.

RESULTS

The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%).

CONCLUSIONS

The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.

Management and Outcomes of Traumatic Paediatric Spinal Cord Injuries in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Traumatic spinal cord injury (TSCI) is a subset of neurotrauma, which is a significant contributor to global trauma mortality and morbidity in children. The management and outcomes of paediatric TSCI in low-and-middle income countries (LMICs) is unknown. We conducted a scoping review to characterise the methods of management and outcomes of TSCI in LMICs.

METHODS

MEDLINE, EMBASE, and Global Index Medicus were searched from database inception to February 15, 2021. Studies reporting management or outcomes of paediatric TSCI in LMICs were included. Pooled statistics were calculated using measures of central tendency and spread.

RESULTS

A total of 1171 studies were identified, of which, 5 were included. A total of 212 patients were included in our review with age of participants ranging from 2.5 to 18 years old (mean = 15.4 years). Most patients were male (n=162, 76.4%). The commonest cited cause of injury were falls (n=104/212, 49.1%). The most common level of injury was cervical (n=83, 39.2%). The majority of patients underwent surgery (n=134/212, 63.2%). The extent of injury was quantified and classified using the ASIA chart in only one paper. Long-term management data was not present in any of the included studies.

CONCLUSION

There is a scarcity of published studies reporting the management and outcome of paediatric TSCI in LMICs. The paucity of studies in this domain provides insufficient data to be compared, reducing the ability to draw a strong conclusion. This hinders the development of guidelines to inform best practice.

Non-Communicable Neurological Disorders and Neuroinflammation

Traumatic brain injury, stroke, and neurodegenerative diseases represent a major cause of morbidity and mortality in Africa, as in the rest of the world. Traumatic brain and spinal cord injuries specifically represent a leading cause of disability in the younger population. Stroke and neurodegenerative disorders predominantly target the elderly and are a major concern in Africa, since their rate of increase among the ageing is the fastest in the world. Neuroimmunology is usually not associated with non-communicable neurological disorders, as the role of neuroinflammation is not often considered when evaluating their cause and pathogenesis. However, substantial evidence indicates that neuroinflammation is extremely relevant in determining the consequences of non-communicable neurological disorders, both for its protective abilities as well as for its destructive capacity. We review here current knowledge on the contribution of neuroinflammation and neuroimmunology to the pathogenesis of traumatic injuries, stroke and neurodegenerative diseases, with a particular focus on problems that are already a major issue in Africa, like traumatic brain injury, and on emerging disorders such as dementias.

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.