Traumatic Brain Injury and Infectious Encephalopathy in Children From Four Resource-Limited Settings in Africa

Catalysing global surgery: a meta-research study on factors affecting surgical research collaborations with Africa

INTRODUCTION

In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals.

AIM

To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa.

METHODOLOGY

A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search.

RESULTS

Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge.

CONCLUSION

Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2022 CRD42022352115 .

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.

Understanding the Ghanaian Neurosurgical Literature: A Scoping Review and Bibliometric Analysis

BACKGROUND

Research serves to bolster clinical neurosurgery by critically assessing various disease pathologies, while identifying important challenges and opportunities. However, there is limited information on the landscape of the Ghanaian neurosurgical literature.

METHODS

A scoping review and bibliometric analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched from inception until December 21, 2021 for English language articles about neurosurgery in Ghana.

RESULTS

927 articles were identified and 66 were ultimately included in the analysis. A majority of them, 42.4%, were retrospective cohort studies, with 62.1% published after 2010. There were no randomized controlled or basic science studies. Most articles were published in the West African Journal of Medicine (24.2%) and non-infectious/non-traumatic spinal pathology was the most commonly discussed topic (22.7%); 66.7% of articles included only authors affiliated with Ghanaian institutions, and international collaborators frequently originated from the United States (15.9%). Only 22.7% of the manuscripts reported a funding source. Commonly reported challenges included limited sample sizes, delays in diagnosis and treatment, and lack of proper diagnostic tools and specialized care.

CONCLUSIONS

This review revealed that while the Ghanaian academic neurosurgery output has been increasing over time, these have been limited to cohort studies largely assessing spine pathology. The Ghanaian neurosurgical research environment may be bolstered by an increase in research funding, the establishment of longitudinal clinical databases, training in research methodology, increased incentives for researchers, strengthening of research collaborative networks, and increased engagement of neurosurgical trainees in research.

The epidemiology of pediatric traumatic brain injury presenting at a referral center in Moshi, Tanzania

Background

Over 95% of childhood injury deaths occur in low- and middle-income countries (LMICs). Patients with severe traumatic brain injury (TBI) have twice the likelihood of dying in LMICs than in high-income countries (HICs). In Africa, TBI estimates are projected to increase to upwards of 14 million new cases in 2050; however, these estimates are based on sparse data, which underscores the need for robust injury surveillance systems. We aim to describe the clinical factors associated with morbidity and mortality in pediatric TBI at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania to guide future prevention efforts.

Methods

We conducted a secondary analysis of a TBI registry of all pediatric (0–18 years of age) TBI patients presenting to the KCMC emergency department (ED) between May 2013 and April 2014. The variables included demographics, acute treatment and diagnostics, Glasgow Coma Scores (GCSs, severe 3–8, moderate 9–13, and mild 14–15), morbidity at discharge as measured by the Glasgow Outcome Scale (GOS, worse functional status 1–3, better functional status 4–6), and mortality status at discharge. The analysis included descriptive statistics, bivariable analysis and multivariable logistic regression to report the predictors of mortality and morbidity. The variables used in the multivariable logistic regression were selected according to their clinical validity in predicting outcomes.

Results

Of the total 419 pediatric TBI patients, 286 (69.3%) were male with an average age of 10.12 years (SD = 5.7). Road traffic injury (RTI) accounted for most TBIs (269, 64.4%), followed by falls (82, 19.62%). Of the 23 patients (5.58%) who had alcohol-involved injuries, most were male (3.6:1). Severe TBI occurred in 54 (13.0%) patients. In total, 90 (24.9%) patients underwent TBI surgery. Of the 21 (5.8%) patients who died, 11 (55.0%) had severe TBI, 6 (30.0%) had moderate TBI (GCS 9–13) and 3 (15.0%) presented with mild TBI (GCS>13). The variables most strongly associated with worse functional status included having severe TBI (OR = 9.45) and waiting on the surgery floor before being moved to the intensive care unit (ICU) (OR = 14.37).

Conclusions

Most pediatric TBI patients were males who suffered RTIs or falls. Even among children under 18 years of age, alcohol was consumed by at least 5% of patients who suffered injuries, and more commonly among boys. Patients becoming unstable and having to be transferred from the surgery floor to the ICU could reflect poor risk identification in the ED or progression of injury severity. The next steps include designing interventions to reduce RTI, mitigate irresponsible alcohol use, and improve risk identification and stratification in the ED.

A Virtual Community of Practice: An International Educational Series in Pediatric Neurocritical Care

Pediatric neurocritical care (PNCC) is a rapidly growing field. Challenges posed by the COVID-19 pandemic on trainee exposure to educational opportunities involving direct patient care led to the creative solutions for virtual education supported by guiding organizations such as the Pediatric Neurocritical Care Research Group (PNCRG). Our objective is to describe the creation of an international, peer-reviewed, online PNCC educational series targeting medical trainees and faculty. More than 1600 members of departments such as pediatrics, pediatric critical care, and child neurology hailing from 75 countries across six continents have participated in this series over a 10-month period. We created an online educational channel in PNCC with over 2500 views to date and over 130 followers. This framework could serve as a roadmap for other institutions and specialties seeking to address the ongoing problems of textbook obsolescence relating to the rapid acceleration in knowledge acquisition, as well as those seeking to create new educational content that offers opportunities for an interactive, global audience. Through the creation of a virtual community of practice, we have created an international forum for pediatric healthcare providers to share and learn specialized expertise and best practices to advance global pediatric health.

An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa

PURPOSE

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs.

METHODS

We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests.

RESULTS

Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge.

CONCLUSION

Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

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.

Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.

Survey of resources available to implement severe pediatric traumatic brain injury management guidelines in low and middle-income countries

PURPOSE

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionately high burden in low-middle income countries. Guideline implementation has been associated with mortality reduction in high-income countries (HIC), but it is not known if hospitals in low and middle-income countries possess the resources to implement the pre-hospital TBI guidelines and the guidelines for the management of severe pediatric traumatic brain injury.

METHOD

An anonymous online survey was undertaken by a range of health care professionals currently managing children with severe TBI in low to middle-income countries. A variety of international and national pediatric, intensive care, and neurological societies assisted in the survey distribution. Thirty-eight questions were included to evaluate patient care and the provider's perceptions of their resources available to implement the pre-hospital specific TBI and current pediatric severe TBI guidelines.

RESULTS

Two hundred and forty-seven hospitals were represented from 68 countries. Fifty percent of LMIC hospitals that responded had the resources to implement 13 of 15 guidelines for the pediatric component of pre-hospital management for TBI and all baseline care recommendations. First tier therapies including the intracranial pressure (ICP) and cerebral perfusion pathways (CPP), however, demonstrated low capacity for uptake with 21.5% and 38.5% of surveyed hospitals possessing sufficient resources to follow the recommended pathways.

CONCLUSION

Pediatric TBI ICP/CPP management guidelines require numerous resources not widely sourced in LMIC. The creation of international guidelines that outline recommendations of care for LMIC may benefit patient care and outcomes in these settings.

Prevalence of Children With Complex Chronic Conditions in PICUs of Argentina: A Prospective Multicenter Study

OBJECTIVES

To determine the prevalence of children with complex chronic conditions in PICUs in Argentina. To describe the demographic profile, clinical course and outcomes in PICU of children with complex chronic condition in comparison to previously healthy children.

DESIGN

Prospective, observational multicenter study.

SETTING

Nineteen PICUs located in Argentina belonging to public and private institutions.

PATIENTS

All children admitted to the participating PICUs between March 1, 2015, and February 28, 2016.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We analyzed 3,483 PICU admissions. The prevalence of complex chronic condition was 48.06% (95% CI, 46.39-49.72). Cardiovascular complex chronic condition was predominant (22.24% [421/1,893]), followed by neuromuscular complex chronic condition (18.75% [355/1,893]) and malignant disease 17.7% (335/1,893). Technologic dependence was present in 22.22% of the patients (372 of 1,674). Predominant admission diagnosis was postoperative (36.6%) and respiratory disease (28.32%). Children with complex chronic condition had higher mortality than previously healthy patients (odds ratio, 2.74; 95% CI, 2.01-3.73). The risk of prolonged stay (≥ 26 d) was also higher (odds ratio, 1.44; 95% CI, 1.10-1.89). Rate utilization of the following devices was higher in patients with complex chronic condition: mechanical ventilation (odds ratio, 1.35; 95% CI, 1.12-1.63), central venous catheter (odds ratio, 1.24; 95% CI, 1.04-1.48), and arterial monitoring (odds ratio, 1.33; 95% CI, 1.09-1.63).

CONCLUSIONS

We observed a high prevalence of patients with complex chronic condition in this sample of argentine PICUs. These patients presented higher mortality and resource use than previously healthy children. This information is valuable to understand the impact that patients with complex chronic condition have on PICU performance and enables proper planning of care.

Pattern and Outcome of Pediatric Traumatic Brain Injury at Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: Observational Cross-Sectional Study

BACKGROUND

Traumatic brain injury (TBI) is the most common cause of death/disability in children. The Glasgow coma scale and other parameters are used for treatment/follow-up of TBI. Childhood TBI data are scarce from sub-Saharan Africa. The study aimed to determine the pattern and predictors of the TBI outcome in Southern Ethiopia.

METHODS

An observational cross-sectional study was conducted from September 2017 to September 2018 at Hawassa University Hospital. Structured questionnaires were used for data collection. Significant associations were declared at a P value of <0.05.

RESULTS

There were 4,258 emergency room (ER) visits during the study period, and TBI contributed to 317 (7.4%) cases. The mean age of study subjects was 7.66 ± 3.88 years. Boys, predominantly above 5 years of age, comprise 218 (68.8%) of the study subjects with a male to female ratio of 2.2 : 1. Pedestrian road traffic accidents (RTA), 120 (37.9%), and falls, 104 (32.8%), were the commonest causes of TBI. Mild, moderate, and severe TBI were documented in 231 (72.9%), 61 (19.2%), and 25 (7.9%) of cases, respectively. Most of the TBI cases presented within 24 hrs of injury, 258 (81.4%). Recovery with no neurologic deficit, 267 (84.2%); focal neurologic deficit, 30 (9.5%); depressed mentation, 10 (3.2%); and death, 10 (3.2%), were documented. Signs of increased intracranial pressure (ICP) at admission [AOR: 1.415 (95% CI: 1.4058-9.557)], severe TBI [AOR: 2.553 (95% CI: 1.965-4.524)], presence of hyperglycemia [AOR: 2.318 (95% CI: 1.873-7.874)], and presence of contusion, diffuse axonal injury (DAI), or intracranial bleeding on the head computed tomography (CT) scan [AOR: 2.45 (95% CI: 1.811-7.952)] predicted poor TBI outcome.

CONCLUSION

TBI contributed to 7.4% of pediatric ER visits. Pedestrian RTA and falls, early presentation (<24 hours of injury), and mild form of TBI among boys were the most common documented patterns. ICP, hyperglycemia, severe TBI, and presence of contusion, DAI, or intracranial bleeding on head CT predicted poor outcome. Strategies to ensure road safety and to prevent falls and animal-related injuries and TBI follow-up for ICP and glycemic controls are recommended.

Pediatric neuroimaging at a university hospital in Rwanda: a pictorial essay

Rwanda is a country of 12 million people with 41% of its population under the age of 14 years. Despite major improvements in health care since the 1994 genocide, pediatric neuroimaging in Rwanda remains challenging. Prenatal and advanced imaging techniques, such as magnetic resonance imaging (MRI), are not widespread. As a result, many children with neurological diseases present unexpectedly as newborns or are in advanced stages of disease at diagnosis. The goal of this essay is to describe some unique features of the practice of pediatric neuroradiology in Rwanda in 2018.