Clinical spectrum of paediatric head injury: A prospective study from tribal region

Introduction: Traumatic Brain injury is considered as a major health problem which causes frequent deaths and disabilities in paediatric population with special concern to tribal regions of developing countries like India where etiology of traumatic brain injury in the paediatric population fall from height dominant over the road traffic accident as a major. Aim and objective: The aim is to analyse the epidemiology, mechanism, clinical presentation, severity and outcome of paediatric head injury in the tribal region of northern India that could help to make preventive policies to improve their care. Material methods: It is a prospective observational study of 345 children of up to 18 years of age admitted under Department of Neurosurgery from October 2017 to April 2019. Results: The study population comprised of 345 paediatric patients. Mean age was 9.25 years.36.81% patients were in 1-6-year age group and male to female ratio was 2.45. The most common cause for trauma was fall from height in 179(52%) cases followed by RTA in 141(41%) cases. The most common radiological finding was depressed skull fractures in 97(50%) cases. There was 35% mortality in severe head injury patients. Conclusion: This study through some light on the different scenario of head injury in Tribal regions of Developing country and will help to formulate effective strategies for prevention and better care of the patients

Clinical spectrum of paediatric head injury. A prospective study from tribal region

Introduction: Traumatic brain injury is considered as a major health problem which causes frequent deaths and disabilities in the paediatric population with special concern to tribal regions of developing countries like India where aetiology of traumatic brain injury in the paediatric population fall from height dominant over the road traffic accident as a major. Aim & Objective: The aim is to analyse the epidemiology, mechanism, clinical presentation, severity and outcome of paediatric head injury in the tribal region of northern India that could help to make preventive policies to improve their care. Material Methods: It is a prospective observational study of 345 children of up to 18 years of age admitted under Department of Neurosurgery from October 2017 to April 2019. Results: The study population comprised of 345 paediatric patients. Mean age was 9.25 years.36.81% patients were in 1-6-year age group and male to female ratio was 2.45. The most common cause for trauma was fall from height in 179(52%) cases followed by RTA in 141(41%) cases. The most common radiological finding was depressed skull fractures in 97(50%) cases. There was 35% mortality in severe head injury patients. Conclusion: This study through some light on the different scenario of head injury in Tribal regions of Developing country and will help to formulate effective strategies for prevention and better care of the patients

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt for treatment of hydrocephalus in infants in a tribal population in India: A single centre experience

Study design: Prospective long term follow-up study Background: Hydrocephalus remains a common cause of admission in pediatric neurosurgery units. Of the two prevalent modalities of treatment for hydrocephalus in infants, i.e. endoscopic third ventriculostomy and ventriculoperitoneal shunt, which one is a better option, especially in a tribal setting, is a matter of debate. Aim: To determine and compare the effectiveness of endoscopic third ventriculostomy versus ventriculoperitoneal shunt for the treatment of infants in a tribal population. Methods: A prospective follow-up study was carried out on 70 patients of hydrocephalus with age less than or equal to 12 months during a period of 7 years from August 2014 to June 2021. A detailed history, physical examination, and computed tomography scan were done in all the cases. Based on patient condition, aetiology and parents choice, 30 patients were treated by Endoscopic third ventriculostomy and 40 patients were treated by ventriculoperitoneal shunt. At enrolment, baseline clinical data were collected. Postoperative data were collected, including assessments of complications and treatment failures.   Results: A total of 70 infants with hydrocephalus were enrolled in the study and out of them, 30 (42.86%) underwent ETV and 40 (57.14%) underwent VP shunt for the initial treatment of their hydrocephalus. The mean age of patients was 6.4±1.2 months with a range of 18 days to 342 days. Clinical improvement was shown in 76.67% and 70% in ETV and VP shunt groups respectively. No significant difference (p=0.53) was observed in clinical outcomes in both groups. In the 1 to 6 months of age group, 07 (30.43%) clinically improved patients were from the ETV group, while in the VP shunt group, 10 (35.71%) patients showed improvement. In the 7 to 12 months age group, 16 (69.57%) clinically improved patients were from the ETV group and 18 (64.29%) patients were from the VP shunt group (p=0.69). Association of treatment success with gender, term of gestation and aetiology of hydrocephalus was not statistical significant (p>0.05). Out of 70 patients with hydrocephalus, postoperative complications such as infection, CSF leak, haemorrhage and blockage was found in 09 (12.86%), 08 (11.43%), 05 (7.14%) and 08 (11.43%) patients respectively. A significant higher proportion of infection (p=0.043) and blockage (p=0.023) was found in the VP shunt group than in the ETV group. Conclusion: Treatment success was high in both procedures. VP shunt was found to be more successful than ETV in terms of clinical outcome in both age groups. However, the results were statistically insignificant. A significantly higher proportion of complications was found with VP shunt than ETV therefore greater benefits can be achieved using ETV. Thus for a tribal population, where patient compliance is poor and healthcare accessibility, as well as regular follow-up, is difficult, a procedure like ETV can be considered better than VP shunt

Bilateral chronic subdural hematoma: clinical presentation, outcome and review literature. : A single centre experience from India

Study design: Prospective hospital-based study. Background: Annual incidence of bilateral chronic subdural hematoma (CSDH) is increasing due to an increase in the ageing population, associated medical comorbidities such as haemodialysis, anticoagulant and/or antiplatelet therapy. Objectives: 1. To determine the socio-demographic and clinical profile of bilateral CSDH patients. 2. To determine treatment outcome and its association with the socio-demographic profile. Method: A prospective hospital-based study was carried out on 100 confirmed patients of bilateral CSDH. Information of patients such as socio-demographic profile, clinical presentation and laboratory investigation, along with treatment and outcome were recorded and analysed. Results: Among 100 patients, male and female were 74% and 26%. The mean age of patients was 63.03±13.57 years. A history of head injury was reported by 49% of patients. The mean Glasgow coma scale (GCS) was 12.14±2.38. Common presenting symptoms were hemiparesis (69%), headache (58%), aphasia (18%) and complete loss of consciousness (16%). Clinical improvement was observed in 81% while 09% had no change, 06% shows clinical deterioration and 04% of patients die during treatment. Conclusion: Bilateral CSDH is common in the elderly and prognosis is poor with increasing age however gender has no association with poor outcomes. More than 80% of patients recover with timely interventions.  Key message: Surgery leads to achieving good outcomes in cases of bilateral chronic SDH, but not all such patients will recover completely. Similarly, good functional outcomes can also be achieved in those presented early after symptom onset when managed promptly

Posterior fossa extradural hematoma - clinical presentation and outcome: A single centre experience from India

Background: Posterior Fossa Extra Dural Hematoma (PFEDH) is a rare entity but certain crucial structures are supposed to be injured. Because of limited space in the posterior fossa, a clinical small volume of hematoma can deteriorate patients. Therefore timely diagnosis and prompt intervention are required. Objective: This study is done to analyse factors like demographic profile, mode of injury, clinical features in relation to PFEDH and its management and how they influence the outcome. Materials & methods: This is a retrospective analysis of patients who presented with PFEDH from July 2016 to July 2021 at RNT Medical College and M.B. group of Hospitals Udaipur, India. Patients were evaluated on the basis of demographic profile, mode of injuries, GCS on admission & discharge, and associated radiological findings. Result: A total of 25 patients with PFEDH were included in this study. Amongst these, 18 (72%) were males, and10 (40%) were less than 18 years of age. On admission 19 (76%) had GCS 13-15.22 (88%) patients underwent surgery and 3 (12%) were planned for conservative management. At 6-month follow-up, 22 (88%) patients had good outcomes with GOS 3-5 and 1 was lost to follow up while 2 (8%) had poor outcomes with GOS 1-2. Conclusion: GCS on admission is a good predictor of outcome. The volume of EDH was one of the key factors in deciding the line of management. PFEDH can sometimes be rapidly fatal due to expansion of hematoma and compression of posterior cranial fossa space which leads to brain stem compression therefore time management is the most important factor for a good outcome

Paediatric brain abscesses in tribal region of India

Introduction: Brain parenchymal abscesses are relatively infrequent but potentially serious infections in the paediatric population. Surgical intervention in addition to a prolonged administration of antibiotics is generally appropriate management. Aims and objective: We performed this study to assess the clinical profile, aetiology and outcome of paediatric brain abscess which are treated surgically only by aspiration in the tribal region of Rajasthan. Material and method: A single-centre retrospective study was conducted over a 5 year period (2014–2019) in the department of neurosurgery in RNT medical college, Udaipur, Rajasthan. We treated approx 60 patients of which 25 patients treated conservatively and 5 patient treated by craniotomy and abscess excision. So only 30 patient included in our study in which abscess treated by aspiration only. Patients<18 years of age with a confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess location, microbiology results, Clinical features, Surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. Result: 11 patients had an abscess in the temporal lobe and Streptococcus was the most common causative micro-organism (n¼15). 25 patients (80%) had an identifiable source which included: ENT infections, congenital cardiac malformations, recent dental surgery and meningitis. The most common symptom is fever f/b headache, seizure and vomiting. But despite previous studies seizure (10/30) presentation is comparatively more. All 30 patients underwent aspiration. Conclusion: In tribal regions of India ENT infections are a more common source of brain abscess because of poor hygiene and illiteracy and their ignorance of ENT infections and also not taking seriously to fever, headache and other health issues. But at present, there are also decreasing trends of brain abscess by ENT infections and rising trends by congenital heart disease which is a good sign that the health and educational infrastructure is strengthening in the tribal region also

Long term clinical outcome following decompressive surgery for Cauda Equina Syndrome

Study design: Retrospective study with prospective long-term clinical follow-up. Background: Cauda equina syndrome (CES) is a neurosurgical emergency, mostly caused by herniated lumbar disc for which urgent surgical decompression is indicated. Data on long-term clinical outcome of bladder, bowel & sexual function following decompression are elusive. Aim: To evaluate the effectiveness of surgical decompression on recovery of CES symptoms at long-term follow-up & role of timing of surgery on the outcome. Methods: Records of 35 CES patients who underwent surgical decompression for herniated lumbar disc during a five years period retrospectively analysed & patients called for follow-up visits. Outcome measures comprised of history & clinical examination pertinent to bladder, bowel & sexual function. Results: Twenty-four patients (68.5%) were included for final evaluation who attended follow-up visits, with a minimum follow-up period of one year. Most common complaint at presentation was bladder dysfunction (100%) with urinary retention in 16 patients (66.6%), faecal incontinence in 11 (45.8%), saddle anaesthesia in 22 (91.6%) & erectile dysfunction in 6 patients (out of 15 males). Only four patients underwent surgery within 48 hours of CES symptom onset, rest cases after 48 hours duration. At follow-up, bladder dysfunction present in 33.3% with urinary retention in 16.6%. Faecal incontinence persisted in 4 patients (16.6%) & saddle anaesthesia in 7 (29.1%). Sexual dysfunction was the most persistent complaint. Conclusion: Long-term follow-up shows significant recovery of sphincteric function in CES patients after surgical decompression. Urinary & bowel dysfunction improve significantly. Timing to surgery didn’t affect the long-term outcome

Long term clinical outcome following decompressive surgery for Cauda Equina Syndrome: A single centre experience from India

Study design: Retrospective study with prospective long-term clinical follow-up. Background: Cauda equina syndrome (CES) is a neurosurgical emergency, mostly caused by herniated lumbar disc for which urgent surgical decompression is indicated. Data on long-term clinical outcome of bladder, bowel &amp; sexual function following decompression are elusive. Aim: To evaluate the effectiveness of surgical decompression on recovery of CES symptoms at long-term follow-up &amp; role of timing of surgery on the outcome. Methods: Records of 35 CES patients who underwent surgical decompression for herniated lumbar disc during a five years period retrospectively analysed &amp; patients called for follow-up visits. Outcome measures comprised of history &amp; clinical examination pertinent to bladder, bowel &amp; sexual function. Results: Twenty-four patients (68.5%) were included for final evaluation who attended follow-up visits, with a minimum follow-up period of one year. Most common complaint at presentation was bladder dysfunction (100%) with urinary retention in 16 patients (66.6%), faecal incontinence in 11 (45.8%), saddle anaesthesia in 22 (91.6%) &amp; erectile dysfunction in 6 patients (out of 15 males). Only four patients underwent surgery within 48 hours of CES symptom onset, rest cases after 48 hours duration. At follow-up, bladder dysfunction present in 33.3% with urinary retention in 16.6%. Faecal incontinence persisted in 4 patients (16.6%) &amp; saddle anaesthesia in 7 (29.1%). Sexual dysfunction was the most persistent complaint. Conclusion: Long-term follow-up shows significant recovery of sphincteric function in CES patients after surgical decompression. Urinary &amp; bowel dysfunction improve significantly. Timing to surgery didn’t affect the long-term outcome

Paediatric brain abscesses in tribal region of India: A single centre experience

Introduction: Brain parenchymal abscesses are relatively infrequent but potentially serious infections in the paediatric population. Surgical intervention in addition to a prolonged administration of antibiotics is generally appropriate management. Aims and objective: We performed this study to assess the clinical profile, aetiology and outcome of paediatric brain abscess which are treated surgically only by aspiration in the tribal region of Rajasthan. Material and method: A single-centre retrospective study was conducted over a 5 year period (2014–2019) in the department of neurosurgery in RNT medical college, Udaipur, Rajasthan. We treated approx 60 patients of which 25 patients treated conservatively and 5 patient treated by craniotomy and abscess excision. So only 30 patient included in our study in which abscess treated by aspiration only. Patients&lt;18 years of age with a confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess location, microbiology results, Clinical features, Surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. Result: 11 patients had an abscess in the temporal lobe and Streptococcus was the most common causative micro-organism (n¼15). 25 patients (80%) had an identifiable source which included: ENT infections, congenital cardiac malformations, recent dental surgery and meningitis. The most common symptom is fever f/b headache, seizure and vomiting. But despite previous studies seizure (10/30) presentation is comparatively more. All 30 patients underwent aspiration. Conclusion: In tribal regions of India ENT infections are a more common source of brain abscess because of poor hygiene and illiteracy and their ignorance of ENT infections and also not taking seriously to fever, headache and other health issues. But at present, there are also decreasing trends of brain abscess by ENT infections and rising trends by congenital heart disease which is a good sign that the health and educational infrastructure is strengthening in the tribal region also

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

Background: Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. Methods: We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. Findings: The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1–65·8), 17·4% (7·7–28·4), and 59·5% (34·2–86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. Interpretation: By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health. Funding: Bill & Melinda Gates Foundation