The feasibility, appropriateness, and usability of mobile neuro clinics in addressing the neurosurgical and neurological demand in Uganda.

INTRODUCTION: Uganda has a high demand for neurosurgical and neurological care. 78% of the over 50 million population reside in rural and remote communities where access to neurosurgical and neurological services is lacking. This study aimed to determine the feasibility, appropriateness, and usability of mobile neuro clinics (MNCs) in providing neurological care to rural and remote Ugandan populations. METHODS: Neurosurgery, neurology, and mobile health clinic providers participated in an education and interview session to assess the feasibility, appropriateness, and usability of the MNC intervention. A qualitative analysis of the interview responses using the constructs in the updated Consolidated Framework for Implementation Research was performed. Providers' opinions were weighted using average sentiment scores on a novel sentiment-weighted scale adapted from the CFIR. A stakeholder analysis was also performed to assess the power and interest of the actors described by the participants. RESULTS: Twenty-one healthcare providers completed the study. Participants discussed the potential benefits and concerns of MNCs as well as potential barriers and critical incidents that could jeopardize the intervention. Of the five CFIR domains evaluated, variables in the implementation process domain showed the highest average sentiment scores, followed by the implementation climate constructs, inner setting, innovation, and outer setting domains. Furthermore, many interested stakeholders were identified with diverse roles and responsibilities for implementing MNCs. These findings demonstrate that MNC innovation is feasible, appropriate, and usable. CONCLUSION: The findings of this study support the feasibility, appropriateness, and usability of MNCs in Uganda. However, integration of this innovation requires careful planning and stakeholder engagement at all levels to ensure the best possible outcomes.

Demographics, referral patterns, and outcome of patients with neural tube defects in southwestern Uganda.

OBJECTIVE: In Uganda, the burden of neural tube defects (NTDs) poses a serious neurosurgical and public health challenge; however, published data on this patient population are lacking. The authors sought to characterize the population of patients with NTDs, maternal characteristics, and referral patterns of these patients, and to quantify the burden of NTDs in southwestern Uganda. METHODS: A retrospective neurosurgical database at a referral hospital was reviewed to identify all patients with NTDs treated between August 2016 and May 2022. Descriptive statistics were used to characterize the patient population and maternal risk factors. A Wilcoxon rank-sum test and chi-square test were used to determine the association between demographic variables and patient mortality. RESULTS: A total of 235 patients were identified (121 male, 52%). The median age at presentation was 2 days (IQR 1-8 days). A total of 87% of patients with NTDs presented with spina bifida (n = 204) and 31 presented with encephalocele (13%). The most common location of dysraphism was lumbosacral (n = 180, 88%). Of all patients, 80% were delivered vaginally (n = 188). Overall, 67% of patients were discharged (n = 156) and 10% died (n = 23). The median length of stay was 12 days (IQR 7-19 days). The median maternal age was 26 years (IQR 22-30 years). The majority of mothers received only primary education (n = 100, 43%). The majority of mothers reported prenatal folate use (n = 158, 67%) and regular antenatal care (n = 220, 94%), although only 23% underwent an antenatal ultrasound (n = 55). Mortality was associated with younger age at presentation (p = 0.01), need for blood transfusion (p = 0.016) and oxygen supplementation (p < 0.001), and maternal education level (p = 0.001). CONCLUSIONS: To the authors' knowledge, this is the first study to describe the population of patients with NTDs and their mothers in southwestern Uganda. A prospective case-control study is necessary to identify unique demographic and genetic risk factors associated with NTDs in this region.

Cognitive impairment following traumatic brain injury in Uganda: Prevalence and associated factors.

BACKGROUND: As the burden of dementia continues to rise in sub-Saharan Africa, it is crucial to develop an evidence base for potentially modifiable risk factors such as Traumatic Brain Injury (TBI). Cognitive impairment may result from TBI and since it is an established prodromal form of dementia, we investigated the burden of cognitive impairment and associated factors in persons with a history of TBI in southwestern Uganda. METHODS: This was a community-based quantitative study with a cross-sectional design among 189 persons with a history of TBI in southwestern Uganda. Data were collected by the research team in March and June 2022 and entered into Kobo Toolbox before being transferred to RStudio version 4.1.0 for cleaning and analysis. Data were analyzed at a 5% level of significance. RESULTS: Most study participants had some form of cognitive impairment (56.1%), with 43.1% of the participants having mild cognitive impairment (MCI). Cognitive impairment was associated with older age (p-value<0.001); loss of consciousness following the TBI (p-value = 0.019) and a history of tobacco use (p-value = 0.003). As a measure of severity of the TBI, loss of consciousness (aOR = 4.09; CI = 1.57-11.76; p<0.01) and older age (aOR = 1.04; CI = 1.01-1.07; p<0.01) were identified as risk factors for cognitive impairment. CONCLUSION: There is a high burden of cognitive impairment among individuals with a history of TBI in southwestern Uganda, and most associated risk factors are potentially modifiable. Long-term follow-up of TBI patients would enable early identification of some risks. Patients with TBI could benefit from behavioural modifications such as restriction of alcohol intake and tobacco use to slow down the progression into dementia.

An Attitude Survey and Assessment of the Feasibility, Acceptability, and Usability of a Traumatic Brain Injury Decision Support Tool in Uganda.

BACKGROUND: Traumatic brain injury (TBI) prognostic models are potential solutions to severe human and technical shortages. Although numerous TBI prognostic models have been developed, none are widely used in clinical practice, largely because of a lack of feasibility research to inform implementation. We previously developed a prognostic model and Web-based application for in-hospital TBI care in low-resource settings. In this study, we tested the feasibility, acceptability, and usability of the application with potential end-users. METHODS: We performed our feasibility assessment with providers involved in TBI care at both a regional and national referral hospital in Uganda. We collected qualitative and quantitative data on decision support needs, application ease of use, and implementation design. RESULTS: We completed 25 questionnaires on potential uses of the app and 11 semistructured feasibility interviews. Top-cited uses were informing the decision to operate, informing the decision to send the patient to intensive care, and counseling patients and relatives. Participants affirmed the potential of the application to support difficult triage situations, particularly in the setting of limited access to diagnostics and interventions, but were hesitant to use this technology with end-of-life decisions. Although all participants were satisfied with the application and agreed that it was easy to use, several expressed a need for this technology to be accessible by smartphone and offline. CONCLUSIONS: We elucidated several potential uses for our app and important contextual factors that will support future implementation. This investigation helps address an unmet need to determine the feasibility of TBI clinical decision support systems in low-resource settings.

Estimating prognosis for traumatic brain injury patients in a low-resource setting: how do providers compare to the CRASH risk calculator?

OBJECTIVE: Traumatic brain injury (TBI), a burgeoning global health concern, is one condition that could benefit from prognostic modeling. Risk stratification of TBI patients on presentation to a health facility can support the prudent use of limited resources. The CRASH (Corticosteroid Randomisation After Significant Head Injury) model is a well-established prognostic model developed to augment complex decision-making. The authors' current study objective was to better understand in-hospital decision-making for TBI patients and determine whether data from the CRASH risk calculator influenced provider assessment of prognosis. METHODS: The authors performed a choice experiment using a simulated TBI case. All participant doctors received the same case, which included a patient history, vitals, and physical examination findings. Half the participants also received the CRASH risk score. Participants were asked to estimate the patient prognosis and decide the best next treatment step. The authors recruited a convenience sample of 28 doctors involved in TBI care at both a regional and a national referral hospital in Uganda. RESULTS: For the simulated case, the CRASH risk scores for 14-day mortality and an unfavorable outcome at 6 months were 51.4% (95% CI 42.8%, 59.8%) and 89.8% (95% CI 86.0%, 92.6%), respectively. Overall, participants were overoptimistic when estimating the patient prognosis. Risk estimates by doctors provided with the CRASH risk score were closer to that score than estimates made by doctors in the control group; this effect was more pronounced for inexperienced doctors. Surgery was selected as the best next step by 86% of respondents. CONCLUSIONS: This study was a novel assessment of a TBI prognostic model's influence on provider estimation of risk in a low-resource setting. Exposure to CRASH risk score data reduced overoptimistic prognostication by doctors, particularly among inexperienced providers.

Patterns and treatment outcomes of anorectal malformations in Mbarara Regional Referral Hospital, Uganda.

BACKGROUND/PURPOSE: Anorectal malformation (ARM) is a common condition. Owing to scarcity of pediatric surgery services in Uganda, however, relatively little is known about this condition. METHODS: This was a retrospective review of medical records of all patients admitted to Mbarara Regional Referral Hospital (MRRH) from January 2014 to May 2016. MRRH serves 3-8 million people in southwest Uganda. We also enrolled patients prospectively from June 2016 to December 2016. RESULTS: 78 patients were enrolled in the study. 63.38% had delayed diagnosis (presenting >48 h after birth), and most of these were self-referrals from home. The most common malformation was a vestibular fistula. Associated congenital anomalies were seen in 20% of patients, and this was associated with increased mortality. These anomalies included limb, eye, ear and genitourinary anomalies as well as ventricular septal defects, patent ductus arteriosus, spina bifida and tracheoesophageal fistula. Posterior sagittal anorectoplasty (PSARP) was the definitive surgery used. It was performed in 58.97% of the patients. Median age of patients who underwent PSARP was 11 months. 73.91% of PSARP patients had their colostomies closed and 62.5% of these who were ≥3 years old had good continence outcomes. Overall mortality rate was 8.97%. CONCLUSION: The majority of patients are diagnosed late. Vestibular fistula is the overall most common type of ARM. In males, however, rectourethral fistula is the most common type. Definitive surgery at MRRH is performed late. Continence outcomes are good and comparable to other countries with more resources. LEVEL OF EVIDENCE: III.

Trends in neurosurgical care in Western Uganda: an interrupted time series analysis.

OBJECTIVE: In addition to the rising burden of surgical disease globally, infrastructure and human resources for health remain a great challenge for low- and middle-income countries, especially in Uganda. In this study, the authors aim to explore the trends of neurosurgical care at a regional referral hospital in Uganda and assess the long-term impact of the institutional collaboration between Mulago National Referral Hospital and Duke University. METHODS: An interrupted time series is a quasi-experimental design used to evaluate the effects of an intervention on longitudinal data. The authors applied this design to evaluate the trends in monthly mortality rates for neurosurgery patients at Mbarara Regional Referral Hospital (MRRH) from March 2013 to October 2015. They used segmented regression and autoregressive integrated moving average models for the analysis. RESULTS: Over the study timeframe, MRRH experienced significant increases in referrals received (from 117 in 2013 to 211 in 2015), neurosurgery patients treated (from 337 in 2013 to 625 in 2015), and operations performed (from 61 in 2013 to 173 in 2015). Despite increasing patient volumes, the hospital achieved a significant reduction in hospital mortality during 2015 compared to prior years (p value = 0.0039). CONCLUSIONS: This interrupted time series analysis study showed improving trends of neurosurgical care in Western Uganda. There is a steady increase in volume accompanied by a sharp decrease in mortality through the years. Multiple factors are implicated in the significant increase in volume and decrease in mortality, including the addition of a part-time neurosurgeon, improvement in infrastructure, and increased experience. Further in-depth prospective studies exploring seasonality and long-term outcomes are warranted.

Causes, clinical presentation, management, and outcomes of chronic subdural hematoma at Mbarara Regional Referral Hospital.

OBJECTIVE: Causes, clinical presentation, management, and outcomes of chronic subdural hematoma (CSDH) in low- and middle-income countries are not well characterized in the literature. Knowledge regarding these factors would be beneficial in the development and implementation of effective preventive and management measures for affected patients. The authors conducted a study to gain a better understanding of these factors in a low-income setting. METHODS: This prospective study was performed at Mbarara Regional Referral Hospital (MRRH) in Uganda between January 2014 and June 2017. Patients of any age who presented and were diagnosed with CSDH during the aforementioned time period were included in the study. Variables were collected from patients' files at discharge and follow-up clinic visits. The primary outcome of interest was death. Secondary outcomes of interest included discharge Glasgow Coma Scale (GCS) score, ICU admission, wound infection, and CSDH recurrence. RESULTS: Two hundred five patients, the majority of whom were male (147 [72.8%]), were enrolled in the study. The mean patient age was 60.2 years (SD 17.7). Most CSDHs occurred as a result of motor vehicle collisions (MVCs) and falls, 35.6% (73/205) and 24.9% (51/205), respectively. The sex ratio and mean age varied depending on the mechanism of injury. Headache was the most common presenting symptom (89.6%, 173/193), whereas seizures were uncommon (11.5%, 23/200). Presenting symptoms differed by age. A total of 202 patients underwent surgical intervention with burr holes and drainage, and 22.8% (46) were admitted to the ICU. Two patients suffered a recurrence, 5 developed a postoperative wound infection, and 18 died. Admission GCS score was a significant predictor of the discharge GCS score (p = 0.004), ICU admission (p < 0.001), and death (p < 0.001). CONCLUSIONS: Trauma from an MVC is the commonest cause of CSDH among the young. For the elderly, falling is common, but the majority have CSDH with no known cause. Although the clinical presentation is broad, there are several pronounced differences based on age. Burr hole surgery plus drainage is a safe and reliable intervention. A low preoperative GCS score is a risk factor for ICU admission and death.

Mechanism of Pediatric Traumatic Brain Injury in Southwestern Uganda: A Prospective Cohort of 100 Patients.

BACKGROUND: Road traffic incidents (RTIs), falls, and violence contribute to more than two thirds of pediatric traumatic brain injuries in sub-Saharan Africa. In this study, we sought to assess mechanisms of pediatric traumatic brain injury in an effort to propose interventions for more effective pediatric head injury prevention. METHODS: A cohort of 100 patients who were <18 years treated at Mbarara Regional Referral Hospital between November 2016 and June 2017 were enrolled in the study. Information on etiology of injury was obtained via a questionnaire administered to patient caretakers at the time of admission. RESULTS: The mean age was found to be 7.5 years (standard deviation 5.2) and 38% were female. In our sample, 61% had computed tomography imaging done, of whom 88.5% had a positive finding. A majority of patients presented with a mild head injury (55%). RTIs were the predominant mechanism of injury across age groups (75%). Across all age groups, falls were responsible for a greater proportion of injuries in children aged 10-14 years (13.3%), whereas the greatest proportion of intentional injuries was reported in age group 10-14 and 15-17 years, 20% and 31.3%, respectively. Patients involved in pedestrian RTIs were significantly younger compared with those injured in nonpedestrian RTIs. Most parents (87.9%) were not with their children at the time of a pedestrian RTI. CONCLUSIONS: In Southwestern Uganda, the majority of pediatric neurotrauma patients are injured pedestrians, with no adult supervision at the time of the injury. Conducting a public awareness and education campaign on the necessity of child supervision is critical to decreasing pediatric head injuries in Uganda.

Pediatric traumatic brain injury at Mbarara Regional Referral Hospital, Uganda.

BACKGROUND: In Uganda, TBI constitute the majority of neurosurgical admissions and deaths specially in the pediatric population. This study aims to determine the factors associated with poor outcome among pediatric TBI cases at a major referral hospital in western Uganda. METHODS: This study was conducted at Mbarara Regional Referral Hospital (MRRH) in western Uganda. All pediatric neurosurgical cases between 2012 and 2015 were reviewed. In-hospital mortality and discharge GCS were the main outcomes of interest. Multivariable logistic regression with backward elimination was used to determine the factors significantly associated with outcome. RESULTS: A total of 381 pediatric TBI patients were admitted to MRRH between 2012 and 2015. The mean age was 8.6 (SD 5.6) with a male predominance (62.0%). The most common mechanism of injury overall was RTI, which was responsible for 71% of all TBI cases. In the multivariable logistic regression model, admission GCS < 13 was a strong predictor of poor outcome and in-hospital mortality compared to admission GCS ≥ 13, with patients demonstrating an odds ratio of 30 (95%CI: 7-132) and OR of 18 (95%CI: 4-79), respectively. CONCLUSION: Given the lack of published literature on pediatric TBI in LMICs, this study was the first to describe and evaluate risk factors associated with TBI severity among pediatric patients at a major referral hospital in western Uganda. Injury severity on admission was the only variable found to be significantly associated with discharge outcome. This study ultimately highlights the need for more effective preventative measures to decrease admission severity.

Role of Conventional Myelography in Diagnosis and Treatment of Degenerative Spine Disease in Low-Income Communities: Prospective Study.

INTRODUCTION: Chronic back pain is a common problem, and imaging is crucial for effective diagnosis and treatment. In low-resource settings conventional myelography is a cheap alternative to magnetic resonance imaging and computed tomography. This study was conducted to reexamine the diagnostic reliability, effectiveness for surgical decision making, and safety of conventional myelography. METHODS: The study was conducted at Tenwek Mission Hospital during June 2009 and March 2010. New patients who presented with features of radiculopathy and/or myelopathy were eligible. Standard anteroposterior views were taken; oblique views were obtained from patients with radiculopathy. Cervical and lumbosacral myelography was performed using iohexol contrast. Patients were observed for complications. Those with surgically remediable lesions underwent operation. Patients were monitored for symptom improvement and complication postoperatively. RESULTS: Fifty-one patients underwent diagnostic myelography and 39 of them (77.8%) were positive. Lesions at levels L4/5 were the most common, occurring in 23 patients (59%). Of those with cervical lesions, 11 of them (73.3%) had a positive myelography compared with 28 patients (77.8%) with lumbosacral lesions. Patients presenting with claudication were more likely to have a positive myelography, compared with those with other symptoms. There were 16 patients (41%) with partial spinal canal block, 6 patients (15.4%) with total block, and 17 patients (43.6%) with recess compression. Thirty-eight (38) patients had surgery, and recess decompression was the most common procedure (n = 24, 63.2%). Following surgery, symptoms due to degenerative spine disease improved in the majority of patients. CONCLUSIONS: Conventional myelography is a reliable and safe diagnostic test. Appropriate and sound surgical decisions can be made following conventional myelography tests.

Epidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital.

BACKGROUND: The unmet surgical need, specifically neurosurgical need, in Uganda is significant, yet only 2 public hospitals currently perform neurosurgery in the country. This study examines the epidemiology and outcomes of neurosurgical conditions presenting to 1 of 12 regional referral hospitals in Uganda, in an effort to understand the neurosurgical needs of this population. METHODS: The study was conducted at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. Demographics, clinical characteristics, and outcomes were retrospectively collected for all patients who presented to MRRH with a neurosurgical condition between January 2012 and September 2015. RESULTS: During the study period, 1854 patients presented to MRRH with a neurosurgical condition. More than half of the patients were between 19 and 40 years old, and the majority were males (76.1%). The overall median length of stay was 5 days (interquartile range: 2.5-10). The majority of admissions were due to trauma (87%), with almost 60% due to road traffic incidents. The overall mortality rate was 12.8%. A multivariable Cox proportional hazards model revealed that age, closed head injury, and admission Glasgow Coma Scale have a strong positive correlation with mortality while getting a diagnostic image and neurosurgical procedure were negatively correlated with mortality. CONCLUSION: Traumatic brain injury represented the majority of neurosurgical admissions at MRRH, disproportionately affecting young males. Age, closed head injury, admission Glasgow Coma Scale, getting a diagnostic image, and neurosurgical procedure were all independent predictors of mortality. Resource appropriate interventions throughout the health system are needed to meet the demand and improve outcomes.

Building a global surgery initiative through evaluation, collaboration, and training: the Massachusetts General Hospital experience.

OBJECTIVE: The Massachusetts General Hospital (MGH) Department of Surgery established the Global Surgery Initiative (GSI) in 2013 to transform volunteer and mission-based global surgery efforts into an educational experience in surgical systems strengthening. The objective of this newly conceived mission is not only to perform advanced surgery but also to train surgeons beyond MGH through international partnerships across disciplines. At its inception, a clear pathway to achieve this was not established, and we sought to identify steps that were critical to realizing our mission statement. SETTING: Massachusetts General Hospital, Boston, MA, USA and Mbarara Regional Referral Hospital, Mbarara, Uganda PARTICIPANTS: Members of the MGH and MRRH Departments of Surgery including faculty, fellows, and residents RESULTS: The MGH GSI steering committee identified 4 steps for sustaining a robust global surgery program: (1) administer a survey to the MGH departmental faculty, fellows, and residents to gauge levels of experience and interest, (2) catalog all ongoing global surgical efforts and projects involving MGH surgical faculty, fellows, and residents to identify areas of overlap and opportunities for collaboration, (3) establish a longitudinal partnership with an academic surgical department in a limited-resource setting (Mbarara University of Science and Technology (MUST) at Mbarara Regional Referral Hospital (MRRH)), and (4) design a formal curriculum in global surgery to provide interested surgical residents with structured opportunities for research, education, and clinical work. CONCLUSIONS: By organizing the collective experiences of colleagues, synchronizing efforts of new and former efforts, and leveraging the funding resources available at the local institution, the MGH GSI hopes to provide academic benefit to our foreign partners as well as our trainees through longitudinal collaboration. Providing additional financial and organizational support might encourage more surgeons to become involved in global surgery efforts. Creating a partnership with a hospital in a limited-resource setting and establishing a formal global surgery curriculum for our residents allows for education and longitudinal collaboration. We believe this is a replicable model for building other academic global surgery endeavors that aim to strengthen health and surgical systems beyond their own institutions.

Myelography as a stand-alone diagnostic procedure for degenerative spine disease in developing nations.

The use of "stand-alone" contrast myelography (i.e., without computed tomography) has a proven track record in developing nations where few patients have access to magnetic resonance imaging, whether on the basis of prohibitive cost or the absence of such a modality altogether. To substantiate the author's 12-year experience with more than 300 myelograms performed in 16 different countries (plus some 1500 studies during 30 years of practice in the United States), a prospective pilot study was undertaken over 1 month in a community-based neurosurgical setting in western Kenya. Forty patients underwent cervical or lumbar myelography at Tenwek Hospital under the auspices of the Neurosurgery Training Program for East, Central, and South Africa (NSTP-ECSA) following failure of conservative measures to treat spine-related pathology. Thirty-five of the forty patients (88%) came to definitive surgery on the basis of a positive study that correlated with their clinical history and physical examination. There were no significant complications from the procedures, and no false-positive studies, with virtually all patients returning to normal activity and/or gainful employment within 3 weeks of their surgery. Myelography as a stand-alone diagnostic procedure is a sensitive, specific, and cost-effective means of diagnosing symptomatic degenerative spine disorders. Accordingly, its use should be encouraged at every NSTP-ECSA training site to address such ubiquitous pathology.