Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review protocol.

INTRODUCTION: Neurotrauma is an important global health problem. This 'silent epidemic' is a major cause of death and disability in adolescents and young adults, with significant societal and economic impacts. Globally, the largest cause of neurotrauma is road traffic collisions (RTCs). Neurotrauma and RTCs are largely preventable, and many preventative strategies and interventions have been established and implemented over the last decades, particularly in high-income countries. However, these approaches may not be applicable globally, due to variations in environment, resources, population, culture and infrastructure. This paper outlines the protocol for a scoping review, which seeks to map the evidence on strategies and interventions in neurotrauma and RTCs prevention globally, and to ascertain contextual factors that influence their implementation. METHODS AND ANALYSIS: This scoping review will use the established methodology by Arksey and O'Malley. Eligible studies will be identified from five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health/EBSCO and Cochrane Database of Systematic Reviews) and grey literature sources. We will also carry out bibliographical and citation searching of included studies. A two-stage selection process, which involves screening of titles and abstracts, followed by full-text screening, will be used to determine eligible studies which will undergo data abstraction using a customised, piloted data extraction sheet. The extracted data will be presented using evidence mapping and a narrative summary. ETHICS AND DISSEMINATION: Ethical approval is not required for this scoping review, which is the first step in a multiphase public health research project on the global prevention of neurotrauma. The final review will be submitted for publication to a scientific journal, and results will be presented at appropriate conferences, workshops and meetings. Protocol registered on 5 April 2019 with Open Science Framework (https://osf.io/s4zk3/)

Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review

Abstract: Background: Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs. Methods: A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Results: A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions. Conclusions: There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs

Pediatric neurosurgical-oncology scope and management paradigms in Sub-Saharan Africa: a collaboration among 7 referral hospitals on the subcontinent

BackgroundUnderstanding of the epidemiology and biology of pediatric CNS tumors has advanced dramatically over the last decade; however there remains a discrepancy in the understanding of epidemiologic data and clinical capacity between high- and lower-income countries.ObjectiveWe collected and analyzed hospital-level burden and capacity-oriented data from pediatric neurosurgical oncology units at 7 referral hospitals in Sub-Saharan Africa (SSA).MethodsA cross sectional epidemiological survey was conducted using REDCap at the 7 SSA sites, capturing 3-month aggregate data for patients managed over a total of 9 months. Descriptive statistical analyses for the aggregate data were performed.ResultsAcross the neurosurgical spectrum, 15% of neurosurgery outpatient and 16% of neurosurgery operative volume was represented by pediatric neuro-oncology across the 7 study sites. Eighty-six percent and 87% of patients who received surgery underwent preoperative CT scan and/or MRI respectively. Among 312 patients evaluated with a CNS tumor, 211 (68%) underwent surgery. Mean surgery wait time was 26.6 ± 36.3 days after initial presentation at the clinic. The most common tumor location was posterior fossa (n=94, 30%), followed by sellar/suprasellar region (n=56, 18%). Histopathologic analysis was performed for 189 patients (89%). The most common pathologic diagnosis was low grade glioma (n=43, 23%), followed by medulloblastoma (n=37, 20%), and craniopharyngioma (n=31, 17%). Among patients for whom adjuvant therapy was indicated, only 26% received chemotherapy and 15% received radiotherapy.ConclusionThe histopathologic variety of pediatric brain and spinal tumors managed across 7 SSA referral hospitals was similar to published accounts from other parts of the world. About two-thirds of patients received a tumor-directed surgery with significant inter-institutional variability. Less than a third of patients received adjuvant therapy when indicated. Multi-dimensional capacity building efforts in neuro-oncology are necessary to approach parity in the management of children with brain and spinal tumors in SSA

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study.

BackgroundTraumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.MethodsWe did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.FindingsOur study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).InterpretationPatients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.FundingNational Institute for Health Research Global Health Research Group

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury

Abstract: Background: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction

The Use of IV-Tubing as a Closed-Suction Drainage System During Neurosurgical Cases in Tanzania.

Commercial closed-suctions drainage systems are commonly used in the United States and many other countries for use in neurosurgical cases. However, in Tanzania and other developing nations with fewer resources, these are not available. This report explores another option for a closed-system drainage system utilizing inexpensive supplies found commonly in hospitals around the world. Sterile IV-tubing is cut, inserted into the wound, and brought out through an adjacent puncture incision. For suction, an empty plastic bottle can be attached to the tubing. The IV-tubing closed-suction drainage system was applied in both cranial and spinal neurosurgical procedures, including as subdural, subgaleal, epidural, and suprafacial drains. It maintained suction and was an adequate substitute when commercial drains are unavailable. This report illustrates how sterile IV-tubing can be adapted for use as a closed-drainage system. It utilizes inexpensive supplies commonly found in many hospitals throughout the world and can be applied to both cranial and spinal neurosurgical procedures

Evaluating the feasibility and outcomes of a scoliosis surgical camp in a resource-limited setting in sub-saharan Africa

Background: In sub-Saharan Africa, the estimated prevalence of scoliosis ranges from 3.3% to 5.5%. The management of these deformities is restricted due to lack of infrastructure and access to deformity spine surgeons. Utilizing surgical camps has been demonstrated to be efficient in transferring skills to low-resource environments; however, this has not been documented concerning deformity surgery. Methods: We conducted a cross-sectional study. The scoliosis camp was held at a major referral spine center in East Africa. We documented information about the organization of the course. We also collected clinical and demographic patient data. Finally, we assessed the knowledge and confidence among surgeon participants on the management scoliosis. Results: The camp lasted 5 days and consisted of lectures and case discussions, followed by casting and surgical sessions. Five patients were operated during the camp. All the patients in the study were diagnosed with AIS, except one with a congenital deformity. The primary curve in the spine was in the thoracic region for all patients. Six months postoperative Scoliosis Research Society-22R Scoring System (SRS-22R) score ranged from 3.3–4.5/5. 87.5% of the participants found the course content satisfactory. Conclusions: To the best of our knowledge, this is the first time an African scoliosis camp has been established. The study highlights the difficulty of conducting such a course and illustrates the feasibility of executing these complex surgeries in a resource-limited environment

Pressure ulcers after traumatic spinal injury in East Africa: risk factors, illustrative case, and low-cost protocol for prevention and treatment

Study design Retrospective, case-control study. Objectives In a traumatic spinal injury (TSI) cohort from Tanzania, we sought to: (1) describe potential risk factors for pressure ulcer development, (2) present an illustrative case, and (3) propose a low-cost outpatient protocol for prevention and treatment. Setting Tertiary referral hospital. Methods All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, time to hospital, injury characteristics, operative management, length of hospitalization, and mortality. Pressure ulcer development was the primary outcome. Regressions were used to report potential predictors, and international guidelines were referenced to construct a low-cost outpatient protocol. Results Of 267 patients that met the inclusion criteria, 51 developed a pressure ulcer. Length of stay was greater for patients with pressure ulcers compared with those without (45 vs. 30 days, p \u3c 0.001). Potential predictors for developing pressure ulcers were: increased days from injury to hospital admission (p = 0.036), American Spinal Injury Association Impairment Scale grade A upon admission (p \u3c 0.001), and thoracic spine injury (p = 0.037). The illustrative case described a young male presenting ~2 months after complete thoracic spinal cord injury with a grade IV sacral pressure ulcer that lead to septic shock and death. Considering the dramatic consequences of pressure ulcers in lower- and middle-income countries (LMICs), we proposed a low-cost protocol for prevention and treatment targeting support surfaces, repositioning, skin care, nutrition, follow-up, and dressing. Conclusions Pressure ulcers after TSI in LMICs can lead to increased hospital stays and major adverse events. High-risk patients were those with delayed presentation, complete neurologic injuries, and thoracic injuries. We recommended aggressive prevention and treatment strategies suitable for resource-constrained settings

Cervical Spine Trauma in East Africa: Presentation, Treatment, and Mortality

Background: Cervical spine trauma (CST) leads to devastating neurologic injuries. In a cohort of CST patients from a major East Africa referral center, we sought to (a) describe presentation and operative treatment patterns, (b) report predictors of neurologic improvement, and (c) assess predictors of mortality. Methods: A retrospective, cohort study of CST patients presenting to a tertiary hospital in Dar Es Salaam, Tanzania, was performed. Demographic, injury, and operative data were collected. Neurologic exam on admission/discharge and in-hospital mortality were recorded. Univariate/multivariate logistic regression assessed predictors of operative treatment, neurologic improvement, and mortality. Results: Of 101 patients with CST, 25 (24.8%) were treated operatively on a median postadmission day 16.0 (7.0-25.0). Twenty-six patients (25.7%) died, with 3 (12.0%) in the operative cohort and 23 (30.3%) in the nonoperative cohort. The most common fracture pattern was bilateral facet dislocation (26.7%). Posterior cervical laminectomy and fusion and anterior cervical corpectomy were the 2 most common procedures. Undergoing surgery was associated with an injury at the C4-C7 region versus occiput-C3 region (odds ratio [OR] 6.36, 95% confidence interval [CI] 1.71-32.28, P = .011) and an incomplete injury (OR 3.64; 95% CI 1.19-12.25; P = .029). Twelve patients (15.8%) improved neurologically, out of the 76 total patients with a recorded discharge exam. Having a complete injury was associated with increased odds of mortality (OR 11.75, 95% CI 3.29-54.72, P \u3c .001), and longer time from injury to admission was associated with decreased odds of mortality (OR 0.66, 95% CI 0.48-0.85, P = .006). Conclusions: Those most likely to undergo surgery had C4-C7 injuries and incomplete spinal cord injuries. The odds of mortality increased with complete spinal cord injuries and shorter time from injury to admission, probably due to more severely injured patients dying early within 24-48 hours of injury. Thus, patients living long enough to present to the hospital may represent a self-selecting population of more stable patients. These results underscore the severity and uniqueness of CST in a less-resourced setting

A scoping review protocol to map the evidence on strategies and interventions in neurotrauma and road traffic collisions prevention globally

This protocol describes the methodology for a scoping review that seeks to identify,quantify and summarize the existing evidence-base on preventative strategies and interventions in neurotrauma, particularly for road traffic collisions