Anthony T. Fuller

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.

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.

Burden of Surgical Conditions in Uganda: A Cross-sectional Nationwide Household Survey.

Objective: To quantify the burden of surgical conditions in Uganda. Background: Data on the burden of disease have long served as a cornerstone to health policymaking, planning, and resource allocation. Population-based data are the gold standard, but no data on surgical burden at a national scale exist; therefore, we adapted the Surgeons OverSeas Assessment of Surgical Need survey and conducted a nation-wide, cross-sectional survey of Uganda to quantify the burden of surgically treatable conditions. Methods: The 2-stage cluster sample included 105 enumeration areas, representing 74 districts and Kampala Capital City Authority. Enumeration occurred from August 20 to September 12, 2014. In each enumeration area, 24 households were randomly selected; the head of the household provided details regarding any household deaths within the previous 12 months. Two household members were randomly selected for a head-to-toe verbal interview to determine existing untreated and treated surgical conditions. Results: In 2315 households, we surveyed 4248 individuals: 461 (10.6%) reported 1 or more conditions requiring at least surgical consultation [95% confidence interval (CI) 8.9%–12.4%]. The most frequent barrier to surgical care was the lack of financial resources for the direct cost of care. Of the 153 household deaths recalled, 53 deaths (34.2%; 95% CI 22.1%–46.3%) were associated with surgically treatable signs/symptoms. Shortage of time was the most frequently cited reason (25.8%) among the 11.6% household deaths that should have, but did not, receive surgical care (95% CI 6.4%–16.8%). Conclusions: Unmet surgical need is prevalent in Uganda. There is an urgent need to expand the surgical care delivery system starting with the district-level hospitals. Routine surgical data collection at both the health facility and household level should be implemented.

Epidemiology of pediatric surgical needs in low-income countries.

Objective According to recent estimates, at least 11% of the total global burden of disease is attributable to surgically-treatable diseases. In children, the burden is even more striking with up to 85% of children in low-income and middle-income countries (LMIC) having a surgically-treatable condition by age 15. Using population data from four countries, we estimated pediatric surgical needs amongst children residing in LMICs. Methods A cluster randomized cross-sectional countrywide household survey (Surgeons OverSeas Assessment of Surgical Need) was done in four countries (Rwanda, Sierra Leone, Nepal and Uganda) and included demographics, a verbal head to toe examination, and questions on access to care. Global estimates regarding surgical need among children were derived from combined data, accounting for country-level clustering. Results A total of 13,806 participants were surveyed and 6,361 (46.1%) were children (0–18 years of age) with median age of 8 (Interquartile range [IQR]: 4–13) years. Overall, 19% (1,181/6,361) of children had a surgical need and 62% (738/1,181) of these children had at least one unmet need. Based on these estimates, the number of children living with a surgical need in these four LMICs is estimated at 3.7 million (95% CI: 3.4, 4.0 million). The highest percentage of unmet surgical conditions included head, face, and neck conditions, followed by conditions in the extremities. Over a third of the untreated conditions were masses while the overwhelming majority of treated conditions in all countries were wounds or burns. Conclusion Surgery has been elevated as an “indivisible, indispensable part of health care” in LMICs and the newly formed 2015 Sustainable Development Goals are noted as unachievable without the provision of surgical care. Given the large burden of pediatric surgical conditions in LMICs, scale-up of services for children is an essential component to improve pediatric health in LMICs.

Geospatial analysis of unmet pediatric surgical need in Uganda

BACKGROUND In low- and middle-income countries (LMICs), an estimated 85% of children do not have access to surgical care. The objective of the current study was to determine the geographic distribution of surgical conditions among children throughout Uganda. METHODS Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 2176 children in 2315 households throughout Uganda. At the district level, we determined the spatial autocorrelation of surgical need with geographic access to surgical centers variable. FINDINGS The highest average distance to a surgical center was found in the northern region at 14.97km (95% CI: 11.29km-16.89km). Younger children less than five years old had a higher prevalence of unmet surgical need in all four regions than their older counterparts. The spatial regression model showed that distance to surgical center and care availability were the main spatial predictors of unmet surgical need. INTERPRETATION We found differences in unmet surgical need by region and age group of the children, which could serve as priority areas for focused interventions to alleviate the burden. Future studies could be conducted in the northern regions to develop targeted interventions aimed at increasing pediatric surgical care in the areas of most need. LEVEL OF EVIDENCE Level III.

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 Hospitals 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.

Prevalence of Surgically Untreated Face, Head, and Neck Conditions in Uganda: A Cross-Sectional Nationwide Household Survey

BACKGROUND The Surgeons OverSeas Assessment of Surgical Need tool (SOSAS) was created to evaluate the burden of surgically treatable conditions in low- and middle-income countries. The goal of our study is to describe the face, head, and neck (FHN) conditions that need surgical care in Uganda, along with barriers to that care and disability from these conditions. METHODS A 2-stage cluster randomized SOSAS survey was administered in a cross-sectional manner between August and September 2014. Participants included randomly selected persons in 105 enumeration areas in 74 districts throughout Uganda with 24 households in each cluster. The SOSAS survey collected demographic and clinical data on all respondents. Univariate and multivariate logistic models evaluated associations of demographic characteristics and clinical characteristics of the FHN conditions and outcomes of whether health care was sought or surgical care was received. RESULTS Of the 4428 respondents, 331 (7.8%) reported having FHN conditions. The most common types of conditions were injury-related wounds. Of those who reported an FHN condition, 36% reported receiving no surgical care whereas 82.5% reported seeking health care. In the multivariate model, literacy and type of condition were significant predictors of seeking health care whereas village type, literacy, and type of condition remained significant predictors of receiving surgical care. CONCLUSIONS Many individuals in Uganda are not receiving surgical care and barriers include costs, rural residency, and literacy. Our study highlights the need for targeted interventions in various parts of Uganda to increase human resources for surgery and expand surgical capacity.

Pilot Use of a Novel Tool to Assess Neurosurgical Capacity in Uganda

INTRODUCTION There is a significant burden of unmet surgical need in many low- and middle-income countries (>80% in parts of Africa). This need is even larger for specialties such as neurosurgery. Surgical capacity tools have been developed and used to assess needs and plan for resource allocation. This study piloted a new tool to assess neurosurgical capacity and describes its use. METHODS A surgical capacity tool was adapted to assess neurosurgical capacity. An expert panel of neurosurgeons and researchers reviewed the Surgeons OverSeas PIPES (personnel, infrastructure, procedures, equipment, and supplies) assessment and added additional items essential to perform common neurosurgery procedures. This tool was then piloted at 3 public hospitals in Uganda and each hospital was given a score of neurosurgical capacity. At 1 hospital, 3 respondents were asked to answer the survey to assess reliability. RESULTS The hospital with the largest neurosurgery caseload and 5 neurosurgeons scored the highest on our survey, followed by a regional hospital with 1 practicing neurosurgeon. The third hospital, without a neurosurgeon, scored the lowest on the scale. At the hospital that completed the reliability assessment, scores were varied between respondents. CONCLUSIONS NeuroPIPES survey scores were in keeping with the number of neurosurgeons and respective caseloads of each hospital. However, the variation in scores between respondents at the same hospital suggests that adaptations could be made to the tool that may improve reliability and validity. The methodology used to create NeuroPIPES may be successfully applied to a variety of other surgical subspecialties for similar assessments.