Neurosurgeons' experiences of conducting and disseminating clinical research in low- and middle-income countries: a qualitative study protocol

External validation of the Glasgow coma scale-pupils in low- to middle-income country patients with traumatic brain injury: Could “motor score-pupil” have higher prognostic value?

Background:

The objective of this study is to validate the admission Glasgow coma scale (GCS) associated with pupil response (GCS-P) to predict traumatic brain injury (TBI) patient’s outcomes in a low- to middle-income country and to compare its performance with that of a simplified model combining the better motor response of the GCS and the pupilar response (MS-P).

Methods:

This is a prospective cohort of patients with TBI in a tertiary trauma reference center in Brazil. Predictive values of the GCS, GCS-P, and MS-P were evaluated and compared for 14 day and in-hospital mortality outcomes and length of hospital stay (LHS).

Results:

The study enrolled 447 patients. MS-P demonstrated better discriminative ability than GCS to predict mortality (AUC 0.736 × 0.658; P < 0.001) and higher AUC than GCS-P (0.736 × 0.704, respectively; P = 0.073). For hospital mortality, MS-P demonstrated better discrimination than GCS (AUC, 0.750 × 0.682; P < 0.001) and higher AUC than GCS-P (0.750 × 0.714; P = 0.027). Both scores were good predictors of LHS (r2 = 0.084 [GCS-P] × 0.079 [GCS] × 0.072 [MS-P]).

Conclusion:

The predictive value of the GCS, GCS-P, and MS-P scales was demonstrated, thus contributing to its external validation in low- to middle-income country.

Rubiano A, G. Kolias A, Silva Paiva W. Evaluation of Computed Tomography Scoring Systems in the Prediction of Short-Term Mortality in Traumatic Brain Injury Patients from a Low- to Middle-Income Country

The present study aims to evaluate the accuracy of the prognostic discrimination and prediction of the short-term mortality of the Marshall computed tomography (CT) classification and Rotterdam and Helsinki CT scores in a cohort of TBI patients from a low- to middle-income country. This is a post hoc analysis of a previously conducted prospective cohort study conducted in a university-associated, tertiary-level hospital that serves a population of >12 million in Brazil. Marshall CT class, Rotterdam and Helsinki scores, and their components were evaluated in the prediction of 14-day and in-hospital mortality using Nagelkerk's pseudo-R² and area under the receiver operating characteristic curve. Multi-variate regression was performed using known outcome predictors (age, Glasgow Coma Scale, pupil response, hypoxia, hypotension, and hemoglobin values) to evaluate the increase in variance explained when adding each of the CT classification systems. Four hundred forty-seven patients were included. Mean age of the patient cohort was 40 (standard deviation, 17.83) years, and 85.5% were male. Marshall CT class was the least accurate model, showing pseudo-R² values equal to 0.122 for 14-day mortality and 0.057 for in-hospital mortality, whereas Rotterdam CT scores were 0.245 and 0.194 and Helsinki CT scores were 0.264 and 0.229. The AUC confirms the best prediction of the Rotterdam and Helsinki CT scores regarding the Marshall CT class, which presented greater discriminative ability. When associated with known outcome predictors, Marshall CT class and Rotterdam and Helsinki CT scores showed an increase in the explained variance of 2%, 13.4%, and 21.6%, respectively. In this study, Rotterdam and Helsinki scores were more accurate models in predicting short-term mortality. The study denotes a contribution to the process of external validation of the scores and may collaborate with the best risk stratification for patients with this important pathology.

Neurosurgeons' experiences of conducting and disseminating clinical research in low-income and middle-income countries: a reflexive thematic analysis

OBJECTIVES

Low-income and-middle-income countries (LMICs) are increasing investment in research and development, yet there remains a paucity of neurotrauma research published by those in LMICs. The aim of this study was to understand neurosurgeons' experiences of, aspirations for, and ability to conduct and disseminate clinical research in LMICs.

DESIGN

This was a two-stage inductive qualitative study situated within the naturalistic paradigm. This study committed to an interpretivist way of knowing (epistemology), and considered reality subjective and multiple (ontology). Data collection used online methods and included a web-based survey tool for demographic data, an asynchronous online focus group and follow-up semistructured interviews. Data were analysed using Braun and Clarke's Reflexive Thematic Analysis supported by NVivo V.12.

SETTING

LMICs.

PARTICIPANTS

In April-July 2020, 26 neurosurgeons from 11 LMICs participated in this study (n=24 in the focus groups, n=20 in follow-up interviews).

RESULTS

The analysis gave rise to five themes: The local landscape; creating capacity; reach and impact; collaborative inquiry; growth and sustainability. Each theme contained an inhibitor and stimulus to neurosurgeons conducting and disseminating clinical research, interpreted as 'the neurosurgical research potential in LMICs'. Mentorship, education, infrastructure, impact and engagement were identified as specific accelerators. Whereas lack of generalisability, absence of dissemination and dissemination without peer review may desensitise the impact of research conducted by neurosurgeons.

CONCLUSION

The geographical, political and population complexities make research endeavour challenging for neurosurgeons in LMICs. Yet in spite of, and because of, these complexities LMICs provide rich opportunities to advance global neurosurgery. More studies are required to evaluate the specific effects of accelerators of research conducted by neurosurgeons and to understand the effects of desensitisers on high-quality, high-impact clinical research.