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Enicker B, Aldous C. The Landscape of Pediatric Hydrocephalus in the Province of KwaZulu-Natal: A Comparative Analysis of the Referral Pattern, Etiology, and Management Outcomes in 4 Distinct 5-Year Periods. World Neurosurg 2024; 189:e498-e518. [PMID: 38914134 DOI: 10.1016/j.wneu.2024.06.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Pediatric hydrocephalus is a significant health burden globally, particularly in low- and middle-income countries. Data from specific regions such as KwaZulu-Natal, South Africa, are lacking. This study aimed to investigate pediatric hydrocephalus by comparing 4 distinct 5-year periods. METHODS Data were collected retrospectively (2003-2007, 2008-2012, and 2013-2017) and prospectively (2018-2022). Children (≤18 years old) treated for hydrocephalus were included. Data on demographics, referral patterns, etiology, treatment modalities, and outcomes were collected and analyzed. RESULTS A total of 3325 children were treated. The peak period was 2008-2012 (35.3%). Most children (51.4%) were from rural areas (P = 0.013), and 47.9% were referred from regional hospitals (P < 0.001). Boys (56.4%) and infants (60.2%) were predominant groups (P < 0.001). Postinfectious etiology (32.7%) was predominant (P < 0.001), particularly tuberculous meningitis (54.1%). Ventriculoperitoneal shunts were the mainstay treatment (84.2%), with notable complication rates (20.4%), including infections (9.6%). Human immunodeficiency virus co-infection was diagnosed in 2.5% of cases. Weekend procedures were associated with ventriculoperitoneal shunt complications (hazard ratio [HR] = 1.3, 95% confidence [CI]1.03-1.66, P = 0.03). Mortality rate was 7.9%, and age ≥1 year (HR = 2.43, 95% CI 1.87-3.17, P < 0.001), tertiary hospital referral (HR = 1.48, 95% CI 1.06-2.04, P = 0.019), ventriculoperitoneal shunt infection (HR = 3.63, 95% CI 2.66-4.95, P < 0.001), acute abdomen (HR = 2.17, 95% CI 1.11-4.25, P = 0.024), and pneumonia (HR = 7.32, odds ratio = 4.84-11.06, P < 0.001) were associated with mortality. CONCLUSIONS This study provides comprehensive insights into pediatric hydrocephalus in KwaZulu-Natal. Monitoring temporal trends and predictors of outcomes will guide future interventions to mitigate the burden of pediatric hydrocephalus in the region.
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Affiliation(s)
- Basil Enicker
- Department of Neurosurgery, Inkosi Albert Luthuli Central Hospital, Durban, KwaZulu-Natal, South Africa; Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa.
| | - Colleen Aldous
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Flocks Monaghan C, Pittalis C, Byrne E, Hussein I, Chilunjika T, Nandi B, Borgstein E, Gajewski J. The status of pediatric surgery in Malawi: a narrative mini-review. Front Pediatr 2023; 11:1195691. [PMID: 37484773 PMCID: PMC10357470 DOI: 10.3389/fped.2023.1195691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
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.
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Affiliation(s)
- Celina Flocks Monaghan
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elaine Byrne
- Centre for Positive Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Israa Hussein
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tiyamike Chilunjika
- Department of Surgery, University of Malawi College of Medicine, Zomba, Malawi
| | - Bip Nandi
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Eric Borgstein
- Department of Surgery, University of Malawi College of Medicine, Zomba, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
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Dahir S, Cotache-Condor C, Grimm A, Mohamed M, Rice H, Smith E, Ismail EA. Delays in care for hydrocephalus and spina bifida at a tertiary hospital in Somaliland. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000472. [PMID: 38328393 PMCID: PMC10848631 DOI: 10.1136/wjps-2022-000472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/16/2022] [Indexed: 01/22/2023] Open
Abstract
Background Childhood neurosurgical conditions such as hydrocephalus and spina bifida represent a significant burden of death and disability worldwide, particularly in low and middle-income countries. However, there are limited data on the disease prevalence and delays in care for pediatric neurosurgical conditions in very low-resource settings. This study aims to characterize the delays in access to care for pediatric neurosurgical conditions in Somaliland. Methods We performed a retrospective review of all children with congenital hydrocephalus and spina bifida admitted to the Edna University Hospital (EAUH) in Somaliland between 2011 and 2018. Patient demographics were analyzed with descriptive statistics and χ2 test statistics. We defined delays in care for each condition based on standard care in high-income settings. Univariate and multivariate logistic regression were performed to evaluate predictors of delay in care. Statistical significance was set at p<0.05. Results A total of 344 children were admitted to EAUH with neurosurgical conditions from 2011 to 2018. The most common condition was congenital hydrocephalus (62%). Delays in care were found for 90% of patients and were associated with the type of diagnosis and region. The longest delay among children with spina bifida was 60 months, while the longest delay for children with congenital hydrocephalus was 36 months. Children with congenital hydrocephalus or spina bifida traveling from foreign countries had the highest waiting time to receive care, with a median delay of 8 months (IQR: 5-11 months) and 4 months (IQR: 3-7 months), respectively. Conclusion We found significant delays in care for children with neurosurgical conditions in Somaliland. This country has an urgent need to scale up its surgical infrastructure, workforce, and referral pathways to address the needs of children with hydrocephalus and spina bifida.
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Affiliation(s)
- Shukri Dahir
- Edna Adan University Hospital, Hargeisa, Somaliland
| | | | - Andie Grimm
- Department of Public Health, Baylor University, Waco, TX, USA
| | | | - Henry Rice
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Surgery, Duke School of Medicine, Durham, North Carolina, USA
| | - Emily Smith
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Surgery, Duke School of Medicine, Durham, North Carolina, USA
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Chimaliro S, Hara C, Kamalo P. Mortality and complications 1 year after treatment of hydrocephalus with endoscopic third ventriculostomy and ventriculoperitoneal shunt in children at Queen Elizabeth Central Hospital, Malawi. Acta Neurochir (Wien) 2023; 165:61-69. [PMID: 36282428 DOI: 10.1007/s00701-022-05392-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 10/11/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Over the past two decades, the management of hydrocephalus has witnessed the addition of endoscopic third ventriculostomy with or without choroid plexus cauterization (ETV ± CPC) to the traditional methods including ventriculoperitoneal shunt insertion (VPSI). We conducted this study to assess mortality and complications with surgical implications associated with the two procedures in children with hydrocephalus. METHODS We reviewed our operating theater registry to identify children below 17 years old who underwent hydrocephalus surgery for the first time in 2016. The patients were followed for up to 1 year from the date of the initial operation. Their vital status was confirmed by follow-up visits by a community nurse. Descriptive analyses were used to describe the characteristics of the patients and evaluate the study outcomes (i.e., mortality and complications). RESULTS One hundred fifty-three patients were eligible for the study; 56% were males and 73.2% had primary ETV ± CPC. Complete 1-year follow-up data was available for 79 patients, and 73.4% of these had ETV ± CPC. One-year success (event-free) rates for ETV and VPSI were similar at 67.4% and 66.7%, respectively. ETVs in infants under 6 months performed poorly; failing in half the infants, who were subsequently converted to VPS. Shunt sepsis was very high, 21.4% (95% CI 10.3-36.8). The majority of surgical complications (81.8%) occurred within 3 months of surgery. CONCLUSION ETV ± CPC and VPSI carry a similar frequency of mortality and complications in our setting, and therefore, both should be considered as a treatment option for patients with hydrocephalus. As VP shunt is still used for managing most of the patients, there is still a need to prioritize measures to reduce shunt infections.
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Affiliation(s)
- S Chimaliro
- Blantyre Institute of Neurosurgical Sciences, Chipatala Avenue, P O Box 1052, Blantyre, Malawi
| | - C Hara
- Blantyre Institute of Neurosurgical Sciences, Chipatala Avenue, P O Box 1052, Blantyre, Malawi.
| | - P Kamalo
- Blantyre Institute of Neurosurgical Sciences, Chipatala Avenue, P O Box 1052, Blantyre, Malawi
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Aukrust, Mphil CG, Parikh K, Smart LR, Mdala I, Fjeld HE, Lubuulwa J, Makene AM, Härtl R, Winkler AS. Pediatric Hydrocephalus in Northwest Tanzania: a descriptive cross-sectional study of clinical characteristics and early surgical outcomes from the Bugando Medical Centre. World Neurosurg 2022; 161:e339-e346. [PMID: 35134579 DOI: 10.1016/j.wneu.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES In this study, we present data from a neurosurgical training program in Tanzania for the treatment of pediatric hydrocephalus. The objectives of the study were to identify the demographics and clinical characteristics of pediatric patients with hydrocephalus who were admitted to Bugando Medical Centre in Mwanza, Tanzania, as well as to describe their surgical treatment and early clinical outcomes. METHODS This cross-sectional study included 38 pediatric patients. Physical examinations were conducted pre- and postoperatively, and their mothers completed a questionnaire providing demographic and clinical characteristics. RESULTS There was a slight preponderance of male sex (21/38; 55.3%) with median age at the time of admission of 98.5 days. The majority of patients were surgically treated (33/38; 86.8%). Among those surgically treated, most received a ventriculoperitoneal shunt (23/33; 69.7%), whereas 7 were treated with an endoscopic third ventriculostomy (7/33; 21.2%). At the time of admission, the majority of patients (86%) had head circumferences that met criteria for macrocephaly. The median time between admission and surgery was 23 days (2-49 days). Overall, 5 patients (13.2%) died, including 2 who did not receive surgical intervention. CONCLUSIONS We found that in our population, pediatric patients with hydrocephalus often present late for treatment with additional significant delays prior to receiving any surgical intervention. Five patients died, of whom 2 had not undergone surgery. Our study reinforces that targeted investments in clinical services are needed to enable access to care, improve surgical capacity, and alleviate the burden of neurosurgical disease from pediatric hydrocephalus in sub-Saharan Africa.
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Rush J, Paľa A, Kapapa T, Wirtz CR, Mayer B, Micah-Bonongwe A, Gladstone M, Kamalo P. Assessing neurodevelopmental outcome in children with hydrocephalus in Malawi. A pilot study. Clin Neurol Neurosurg 2021; 212:107091. [PMID: 34922292 DOI: 10.1016/j.clineuro.2021.107091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Congenital and infantile hydrocephalus are assumed to be major contributors to pediatric morbidity, mortality and functional disability in low-income countries. Despite this, epidemiologic data and the overview of neurodevelopmental outcomes in these regions is very limited. We aimed to pilot the use of a wide range of more locally suitable tools to assess neurodevelopment to understand whether they were feasible for use and could provide estimates of developmental delay and poor functioning in a population of children with hydrocephalus in Malawi. METHODS We conducted a prospective observational cohort study, at the tertiary neurosurgery clinic in Blantyre, Malawi in 2018, recruiting consecutive children with congenital and infantile hydrocephalus who were previously treated with ventriculoperitoneal shunts and endoscopic third ventriculostomy (ETV) in the neurosurgery unit of the hospital. We assessed demographic details, and gained information on children's functioning using the Liverpool Outcome Score (LOS), and the Eating and Drinking Ability Classification System as well as full anthropometric assessment and child development with the Malawi Developmental Assessment Tool (MDAT). RESULTS All tools were feasible for use, easy to train on, could be used for assessing children with hydrocephalus and were suitable to adapt for our environment. We evaluated 41 children, aged 2-60 months with a mean age of 22.6 months (interquartile range [IQR] = 8.3 months -36.5 months). Functional assessment using the Liverpool Outcome Score showed the majority of children 92.7% (CI 80.1-98.5, n = 38) had severe sequelae from the hydrocephalus and were dependent on their parents or caregivers. Only 27 children (65.9%, CI 49.4, 80.0) had full or expected control of their bowel and bladder and 6 children (14.6%, CI 5.6, 29.2), had a recent history of seizures. About two thirds (63.4% CI 45.0-77.9, n = 26/41) of children were able to eat and to drink safely and efficiently. Over two thirds of the children (70.7%, CI 56.8, 84.6, n = 29) were stunted and almost half of the cohort underweight (43.9%,(CI 28.5, 60.3, n = 18). Almost half 48.8% (CI 32.9, 64.9, n = 20/41) had developmental delay on MDAT with 41.5% (CI 26.4, 56.6, n = 17/41) graded as severely delayed (-<2sd on developmental age z score). We found significant associations between dependence identified by the LOS and developmental delay according to the MDAT (p = 0.014, Pearson's chi-squared test). CONCLUSION This pilot study demonstrates that the assessment tools we used identified a high proportion of children with hydrocephalus as having functional difficulties, stunted growth and developmental delay, in Malawi. Use of these tools can now be scaled up and will be helpful to support research in understanding what factors contribute to poor functioning, growth and development in these cohorts and help us to investigate what strategies may prevent and support children with hydrocephalus in African settings.
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Affiliation(s)
- James Rush
- Liverpool School of Tropical Medicine, University of Liverpool, Pembroke Pl, Liverpool L3 5QA, UK
| | - Andrej Paľa
- University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
| | - Thomas Kapapa
- University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Christian Rainer Wirtz
- University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Benjamin Mayer
- Liverpool School of Tropical Medicine, University of Liverpool, Pembroke Pl, Liverpool L3 5QA, UK; University Hospital Ulm, Department of Neurosurgery, Albert-Einstein-Allee 23, 89081 Ulm, Germany; Blantyre Institute of Neurological Surgery, Queen Elizabeth Central Hospital, Department of Neurosurgery, Chipatala Road, Blantyre, Malawi; Institute of Translational Medicine, University of Liverpool, Department of Women's and Children's Health University Department, First Floor, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Annie Micah-Bonongwe
- Blantyre Institute of Neurological Surgery, Queen Elizabeth Central Hospital, Department of Neurosurgery, Chipatala Road, Blantyre, Malawi
| | - Melissa Gladstone
- Institute of Translational Medicine, University of Liverpool, Department of Women's and Children's Health University Department, First Floor, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, UK
| | - Patrick Kamalo
- Blantyre Institute of Neurological Surgery, Queen Elizabeth Central Hospital, Department of Neurosurgery, Chipatala Road, Blantyre, Malawi
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Reynolds RA, Bhebhe A, Garcia RM, Zhao S, Lam S, Sichizya K, Shannon CN. Pediatric hydrocephalus outcomes in Lusaka, Zambia. J Neurosurg Pediatr 2020; 26:624-635. [PMID: 32916646 PMCID: PMC7947024 DOI: 10.3171/2020.5.peds20193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia. METHODS This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications. RESULTS A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001). CONCLUSIONS Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.
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Affiliation(s)
- Rebecca A. Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
| | - Arnold Bhebhe
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Roxanna M. Garcia
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Shilin Zhao
- Vanderbilt Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandi Lam
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Kachinga Sichizya
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Chevis N. Shannon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
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