Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI. METHODS: A prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery. RESULTS: A total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128-0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53-0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05-16.7) and older age (continuous HR 1.03, 95% CI 1.009-1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress. CONCLUSIONS: Inpatient and postdischarge mortality remain high following admission to Uganda's main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

Central Nervous System Tumors in Uganda: Outcomes of Surgical Treatment and Complications Assessed Through Telephone Survey.

BACKGROUND: Uganda has one of the largest unmet neurosurgical needs in the world, but has seen major improvements in neurosurgery-largely centered at Mulago National Referral Hospital (MNRH). This study implements the first long-term follow-up and outcomes analysis of central nervous system tumor patients in Uganda. METHODS: Inpatient data were collected using a prospective database of patients presenting to the MNRH neurosurgical ward between 2014 and 2015. Follow-up health care status was assessed in the patient's language using phone surveys. Analysis was performed to identify which factors were associated with patient outcomes. RESULTS: The MNRH neurosurgical ward saw 112 patients with central nervous system tumors (adult N = 87, female: 70%, median age: 37 years). Meningiomas (21%) comprised the most common tumor diagnosis. In-hospital mortality (18%), 30-day mortality (22%), and 1-year mortality (35%) were high. Thirty percent of patients underwent tumor resection in-patient and had greater median overall survival (66.5 months vs. 5.1 months for nonsurgical patients, P = 0.025). For those with known pathologic diagnoses, patients with glioblastomas had decreased median overall survival (0.83 months vs. 59 months for meningiomas, P = 0.02). Phone interviews yielded an 85% response rate. Of the survivors at the time of follow-up, 55% reported a subjective return to normalcy, and 75% received follow-up care for their tumor with most returning to MNRH. CONCLUSIONS: We show evidence for improved overall survival with surgical care at MNRH. In addition, phone interviews as a method of measuring health outcomes provided an effective means of follow-up, showing that most patients do seek follow-up care.

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda.

BACKGROUND: Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed. OBJECTIVE: To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda. METHODS: Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed. RESULTS: Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04). CONCLUSION: Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.

Long-term follow-up of pediatric head trauma patients treated at Mulago National Referral Hospital in Uganda.

In Brief: This study used telephone surveys as a novel method of measuring health outcomes and tracking healthcare utilization in pediatric head trauma patients at the national referral hospital in Uganda. As the first-ever long-term follow-up of this patient population in Uganda, this work establishes a baseline of pediatric head trauma outcomes and lays the groundwork for tracking and improving outcomes for similar patients in low-resource settings.

Neural tube defects in Uganda: follow-up outcomes from a national referral hospital.

OBJECTIVE: Children with neural tube defects (NTDs) require timely surgical intervention coupled with long-term management by multiple highly trained specialty healthcare teams. In resource-limited settings, outcomes are greatly affected by the lack of coordinated care. The purpose of this study was to characterize outcomes of spina bifida patients treated at Mulago National Referral Hospital (MNRH) through follow-up phone surveys. METHODS: All children presenting to MNRH with NTDs between January 1, 2014, and August 31, 2015, were eligible for this study. For those with a documented telephone number, follow-up phone surveys were conducted with the children's caregivers to assess mortality, morbidity, follow-up healthcare, and access to medical resources. RESULTS: Of the 201 patients, the vast majority (n = 185, 92%) were diagnosed with myelomeningocele. The median age at presentation was 6 days, the median length of stay was 20 days, and the median time to surgery was 10 days. Half of the patients had documented surgeries, with 5% receiving multiple procedures (n = 102, 51%): 80 defect closures (40%), 32 ventriculoperitoneal shunts (15%), and 1 endoscopic third ventriculostomy (0.5%). Phone surveys were completed for 53 patients with a median time to follow-up of 1.5 years. There were no statistically significant differences in demographics between the surveyed and nonrespondent groups. The 1-year mortality rate was 34% (n = 18). At the time of survey, 91% of the survivors (n = 30) have received healthcare since their initial discharge from MNRH, with 67% (n = 22) returning to MNRH. Hydrocephalus was diagnosed in 29 patients (88%). Caregivers reported physical deficits in 39% of patients (n = 13), clubfoot in 18% (n = 6), and bowel or bladder incontinence in 12% (n = 4). The surgical complication rate was 2.5%. Glasgow Outcome Scale-Extended pediatric revision scores were correlated with upper good recovery in 58% (n = 19) of patients, lower good recovery in 30% (n = 10), and moderate disability in 12% of patients (n = 4). Only 5 patients (15%) reported access to home health resources postdischarge. CONCLUSIONS: This study is the first to characterize the outcomes of children with NTDs that were treated at Uganda's national referral hospital. There is a great need for improved access to and coordination of care in antenatal, perioperative, and long-term settings to improve morbidity and mortality.

Life After the Neurosurgical Ward in Sub-Saharan Africa: Neurosurgical Treatment and Outpatient Outcomes in Uganda.

BACKGROUND: In the past decade, neurosurgery in Uganda experienced increasing surgical volume and a new residency training program. Although research has examined surgical capacity, minimal data exist on the patient population treated by neurosurgery and their eventual outcomes in sub-Saharan Africa. METHODS: Patients admitted to Mulago National Referral Hospital neurosurgical ward over 2 years (2014 and 2015) were documented in a prospective database. In total, 1167 were discharged with documented phone numbers and thus eligible for follow-up. Phone surveys were developed and conducted in the participant's language to assess mortality, neurologic outcomes, and follow-up health care. RESULTS: During the study period, 2032 patients were admitted to the neurosurgical ward, 80% for traumatic brain injury. A total of 7.8% received surgical intervention. The in-hospital mortality rate was 18%. A total of 870 patients were reached for phone follow-up, a 75% response rate, and 30-day and 1-year mortality were 4% and 8%, respectively. Almost one-half of patients had not had subsequent health care after the initial encounter. Most patients had Glasgow Outcome Scale-Extended scores consistent with good recovery and mild disability, with patients experiencing trauma faring best and patients with tumor faring worst. A total of 85% felt they returned to baseline work performance, and 76% of guardians felt that children returned to baseline school performance. CONCLUSIONS: The neurosurgical service provided health care to a large proportion of nonoperative patients. Phone surveys captured data on patients in whom nearly one-half would be lost to subsequent health care. Although mortality during initial hospitalization was high, more than 90% of those discharged survived at 1-year follow up, and the vast majority returned to work and school.

A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda.

BACKGROUND: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda. METHODS: We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality. RESULTS: 563 TBI patients were enrolled from 1 June- 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours. CONCLUSIONS: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Past, Present, and Future of Neurosurgery in Uganda.

Neurosurgery in Uganda was virtually non-existent up until late 1960s. This changed when Dr. Jovan Kiryabwire spearheaded development of a neurosurgical unit at Mulago Hospital in Kampala. His work ethic and vision set the stage for rapid expansion of neurosurgical care in Uganda.At the beginning of the 2000s, Uganda was a country of nearly 30 million people, but had only 4 neurosurgeons. Neurosurgery's progress was plagued by challenges faced by many developing countries, such as difficulty retaining specialists, lack of modern hospital resources, and scarce training facilities. To combat these challenges 2 distinct programs were launched: 1 by Dr. Benjamin Warf in collaboration with CURE International, and the other by Dr. Michael Haglund from Duke University. Dr. Warf's program focused on establishing a facility for pediatric neurosurgery. Dr. Haglund's program to increase neurosurgical capacity was founded on a "4 T's Paradigm": Technology, Twinning, Training, and Top-Down. Embedded within this paradigm was the notion that Uganda needed to train its own people to become neurosurgeons, and thus Duke helped establish the country's first neurosurgery residency training program.Efforts from overseas, including the tireless work of Dr. Benjamin Warf, have saved thousands of children's lives. The influx of the Duke Program caused a dynamic shift at Mulago Hospital with dramatic effects, as evidenced by the substantial increase in neurosurgical capacity. The future looks bright for neurosurgery in Uganda and it all traces back to a rural village where 1 man had a vision to help the people of his country.

Pediatric Neurosurgical Outcomes Following a Neurosurgery Health System Intervention at Mulago National Referral Hospital in Uganda.

OBJECTIVE: Pediatric neurosurgical cases have been identified as an important target for impacting health disparities in Uganda, with over 50% of the population being less than 15 years of age. The objective of the present study was to evaluate the effects of the Duke-Mulago collaboration on pediatric neurosurgical outcomes in Mulago National Referral Hospital. METHODS: We performed retrospective analysis of all pediatric neurosurgical cases who presented at Mulago National Referral Hospital in Kampala, Uganda, to examine overall, preprogram (2005-2007), and postprogram (2008-2013) outcomes. We analyzed mortality, presurgical infections, postsurgical infections, length of stay, types of procedures, and significant predictors of mortality. Data on neurosurgical cases was collected from surgical logbooks, patient charts, and Mulago National Referral Hospital's yearly death registry. RESULTS: Of 820 pediatric neurosurgical cases, outcome data were complete for 374 children. Among children who died within 30 days of a surgical procedure, the largest group was less than a year old (45%). Postinitiation of the Duke-Mulago collaboration, we identified an overall increase in procedures, with the greatest increase in cases with complex diagnoses. Although children ages 6-18 years of age were 6.66 times more likely to die than their younger counterparts preprogram, age was no longer a predictive variable postprogram. When comparing pre- and postprogram outcomes, mortality among pediatric patients within 30 days after a neurosurgical procedure increased from 4.3% to 10.0%, mortality after 30 days increased slightly from 4.9% to 5.0%, presurgical infections decreased by 4.6%, and postsurgery infections decreased slightly by 0.7%. CONCLUSIONS: Our data show the provision of more complex neurological procedures does not necessitate improved outcomes. Rather, combining these higher-level procedures with essential pre- and postoperative care and continued efforts in health system strengthening for pediatric neurosurgical care throughout Uganda will help to address and decrease the burden throughout the country.

Building neurosurgical capacity in low and middle income countries.

Neurosurgery capacity in low- and middle-income countries is far from adequate; yet burden of neurological diseases, especially neuro-trauma, is projected to increase exponentially. Previous efforts to build neurosurgical capacity have typically been individual projects and short-term missions. Recognizing the dual needs of addressing disease burden and building sustainable, long-term neurosurgical care capacity, we describe in this paper an ongoing collaboration between the Mulago Hospital Department of Neurosurgery (Kampala, Uganda) and Duke University Medical Center (Durham, NC, USA) as a replicable model to meet the dual needs. The collaboration employs a threefold approach to building capacity: technology, twinning, and training performed together in a top-down approach. Also described are lessons learned to date by Duke Global Neurosurgery and Neurosciences (DGNN) and applicability beyond Kampala.

Distribution and characteristics of severe traumatic brain injury at Mulago National Referral Hospital in Uganda.

OBJECTIVE: Road traffic accidents are a leading cause of injury in low- and middle-income countries, where mortality rates are disproportionately higher. Patients with severe traumatic brain injury (TBI) tend to have very poor outcomes. To reduce the burden from severe TBI, we describe its distribution at Mulago National Referral Hospital (Kampala, Uganda) and identify the associations between outcomes and patient characteristics, offering insights into prevention and future research efforts to improve clinical care. METHODS: This is a single-institution, retrospective chart review including patients of all ages with a Glasgow Coma Scale (GCS) score of 8 or less (measured upon admission). A database was compiled to maximize all available clinical variables. Descriptive statistics and univariable and multivariable regression models were fitted to identify significant associations with outcome (died or discharged). RESULTS: One hundred twenty patients were identified between July 1, 2008, and June 30, 2009. The cumulative incidence of admissions is 89 per 100,000. Thirty-one patients died in the hospital, yielding a 25.8% mortality rate. Motorcycle road traffic accident was the leading mechanism of injury, and males ages 15-29 years comprised the predominant demographic (42.5% of patients). Initial GCS, change in GCS score during hospital stay, and the presence of hematoma were strongest predictors of outcome. CONCLUSIONS: Severe TBI was a common condition for injury-related hospital admissions at Mulago Hospital. The capacity for neurosurgery may have explained the relatively lower mortality rate than previously reported from Sub-Saharan Africa. Further investigations are needed. Targeted prevention programs focused on motorcycle users and helmet law enforcement should decrease the incidence of severe TBI.

Surgical capacity building in Uganda through twinning, technology, and training camps.

BACKGROUND: Neurosurgical capacity is extremely deficient in East African countries where 27 neurosurgeons serve more than 250 million people. To build capacity, the Duke University Medical Center and New Mulago Hospital in Uganda applied a two-pronged twinning approach that placed usable surplus equipment in a developing country's National Hospital, combined with dedicated comprehensive surgical training camps. METHODS: Neurosurgery, anesthesiology, nursing, and clinical engineering personnel supported three training camps. More than 21 tons of essential equipment was delivered to New Mulago Hospital in Uganda. Data was collected during the 2-year period preceding and following the initiation of the program. RESULTS: During the 2 years after the program began, neurosurgery demonstrated a significant increase (180%) in the number and complexity of cases performed (p<0.0001). Multiple cases performed in a single day increased eightfold (p<0.0001), with utilization of elective operating room days improving from 43 to 98%. There was no change in the number of hospital admissions over the 4 years (p>0.1), but there was a dramatic increase in the overall number of procedures performed by all surgical specialties (106%, p<0.0001). CONCLUSIONS: Through a twinning program combining delivery of surplus equipment and training camps, capacity building was accomplished and maintained. The program not only built overall surgical capacity, it improved the efficiency and increased the complexity of operative cases performed at the National Hospital in Uganda. This program could serve as a model for twinning, capacity building, and training in other developing countries where surgical disparities are among the greatest.

Reconstruction of the superior sagittal sinus with silicone tubing.

OBJECT: The authors conducted a study to develop a safe and effective intracranial venous sinus reconstruction for extensive clinical use. METHODS: After resecting the superior sagittal sinus (SSS), it was reconstructed in eight dogs by performing either a tube-insertion technique or end-to-end anastomosis procedure, in both of which a thin-walled silicone tube was used for repair. The patency of the SSS reconstruction was observed on digital subtraction angiography and transcranial Doppler ultrasonography, preoperatively and at 1, 2, 4, and 8 weeks postoperatively. Histological and ultrastructural changes were observed using light and electron microscopy. In five dogs the reconstructed SSS was patent, in one it was narrowed, in one it was completely occluded at the proximal site of the anastomosis, and one dog escaped from the laboratory 1 week postoperatively. The authors found no evidence of any additional neurological deficits, signs of toxicity, or side effects. Histological and ultrastructural studies generally showed vascular endothelial proliferation. No thrombosis occurred in the inner surface, at the site of anastomosis, or in the lumen of silicone tube nor in the sagittal sinus at up to 8 weeks postoperatively. CONCLUSIONS: The use of a thin-walled silicone tube as an artificial substitute for intracranial dural venous sinus reconstruction seems to be a valuable technique. The silicone tubes were found to have good biological compatibility, nonthrombogenic effects, and a high patency rate. The method was found to be simple and effective as well as practicable in the clinic for the short term (8 weeks). The authors emphasize that Phase I clinical trials involving silicone tube-assisted SSS reconstruction require further research.