| Year | Title | Country | Primary Author | Publication | ||
|---|---|---|---|---|---|---|
| 2022 | Post infective bone gap management of the lower extremity | Ethiopia | Nunn, T. | Pediatric Musculoskeletal Infections | AbstractThe development of a bone gap as a sequela of chronic osteomyelitis (COM) in childhood is uncommon. The factors that lead to such an occurrence are related to the type of infecting organism and toxins produced and the stability of the segments. A critical factor for gap development in childhood is the type and extent of injury to the periosteum. The treatment of bone defects follows principles of enhancing the bone’s biological and mechanical environments whilst eliminating the infective process. Many different techniques can be successfully employed to achieve the same primary goal of bony continuity, particularly in the management of smaller defects. Long-term outcome following restoration of bony continuity in chronic osteomyelitis bone gaps is mostly predicated on other factors of the disease process such as physeal and adjacent joint destruction. |
Nunn, T., Patwardhan, S., Hosny, G. A., |
| 2022 | Pediatric foot infections | Ethiopia | Wicks, L. | Pediatric Musculoskeletal Infections | AbstractSuperficial infections in the foot and ankle, such as those associated with ingrown toenails, are relatively common and easily diagnosed. A number of common and superficial foot infections do not require surgical intervention. However, deeper foot and ankle infections in children may present with non-specific symptoms, such as difficulty in weight-bearing, and little in the way of clinical signs. Foot infections should therefore always be considered in a limping child, especially when other causes are not found. Calcaneal osteomyelitis is an uncommon cause for limp in childhood. The infection is different from other sites of osteomyelitis because of a paucity of systemic and local findings in the early stages combined with a high likelihood of normal parameters such as white blood cell count and C-reactive protein (CRP). The diagnosis is often delayed resulting in chronicity and sequelae. Imaging modalities may be needed to localise infection before commencing treatment. Broad spectrum and specific antibiotics, usually combined with trepanation, are the first line of treatment. Late cases may require drainage, debridement sequestrectomy and antibiotic-loaded beads. Calcanectomy and talectomy may be required for salvage. Foot and ankle tuberculosis (TB) also usually presents with a limp and is rare. It forms a differential diagnosis in a child with subacute or chronic arthritis of the foot and ankle, a single or multiple radiological bony or joint lesions in the ankle and foot, associated with diffuse osteoporosis. A high index of suspicion should be entertained and confirmation obtained by biopsy and culture. Antituberculous drug therapy is the mainstay of treatment. Selective surgical intervention is indicated for neglected lesions, deformities, or joint and foot architecture collapse. The goal is disease control, and to achieve and maintain a stable painless foot. Severe infections are not common in developed countries but in low- and middle-income countries, more advanced pathologies may be seen. This chapter will therefore aim to cover conditions from the mildest, including non-surgical conditions, through to more destructive pathologies, such as tuberculosis and Madura foot. |
Wicks, L., Madhuri, V., Gardner, R., |
| 2021 | Effects of velopharyngeal insufficiency on quality of life of adults with repaired cleft palate in Kenyatta National Hospital, Nairobi, Kenya | Kenya | Bundi, I. G. | Journal of Humanities And Social Science | AbstractThe purpose of this study was to evaluate the effects of Velopharyngeal Insufficiency (VPI) on quality of life of adults with repaired cleft palate. Cleft palate is one of the most prevalent birth defects around the world. The study evaluated the effect of VPI on the quality of life among adults with repaired cleft palate in order to; to establish the effect of VPI on functional ability. The study targeted adults, both males and females with repaired cleft palate at Kenyatta Hospital, Nairobi City County. The study adopted a case study research design. 22 adults with repaired cleft palate, 2 maxillofacial surgeons and 1 speech and language therapist were purposively sampled for the study. The researcher used stratified random sampling to avoid gender bias. The pilot study was carried out at Kijabe Hospital to ensure that different subjects are involved other than those in the actual study. The data was collected using questionnaires, and review of patients’ clinical notes in the maxillofacial clinic at Kenyatta National Hospital. The data was analyzed with the use of Statistical Package for Social Sciences version 21 for quantitative data. Categorical data was summarized using frequency tables and proportions. The findings showed that in assessing VPI severity and functional ability, there was a statistically significant association between VPI severity and air coming out of the nose when the respondents talk. There was also a significant association between VPI severity and perception of own speech being different from others, there was significant association between VPI severity and trouble to understand others when they cannot see their face. The results show that most of the persons with VPI after cleft palate repair had challenges of air coming out of the nose and speech difficulties. The level of accessibility of speech therapists is still very low. The study recommends that improving personal belief and self-identify among persons with VPI after cleft palate repair would be essential in improving on how they perceive many things such as functional ability. Also, ensuring that speech therapy services are available for all patients is important in improving functional ability among persons with VPI after cleft palate repair. |
Bundi, I. G. , Karia, M., Abuom, T., |
| 2021 | What matters to children with lower limb deformities: an international qualitative study guiding the development of a new patient-reported outcome measure | Ethiopia | Chhina, H. | Journal of Patient Reported Outcomes | AbstractBackgroundLower limb deformities include conditions such as leg length discrepancy, lower limb deficiency and associated angular and rotational deformities of the hips, knees, ankles and feet. Children with lower limb deformities often have physical limitations due to gait irregularities and pain. The differences in the appearance and function of their lower limbs can discourage participation in social, recreational and leisure activities, which may result in behavioural, emotional, psychological and social adjustment problems. The health-related quality of life (HRQL) of these children is often impacted due to the factors discussed above, as well as by the complex surgical procedures. Surgical treatment options for limb deformities in children vary from limb lengthening and reconstruction to amputation. The lack of evidence demonstrating superiority of either treatment options and their effect on HRQL limits the ability of healthcare providers to counsel families on the best evidence-based treatment option for them. This manuscript describes the international qualitative study which guided the development of a new patient-reported outcome measure (PROM). Individual semi-structured face-to-face interviews with children with lower limb deformities and their parents were conducted at five sites: Canada (2 sites), Ethiopia, India and the USA.ResultsSeventy-nine interviews were conducted at five international sites. Five main themes emerged from the qualitative interviews and formed the basis of the conceptual framework. These themes were: 1) appearance, 2) physical health, 3) psychological health 4) school and 5) social health.ConclusionsLower limb deformities have a substantial impact on the HRQL of children. The concepts of interest identified in our study were similar across children from all countries. The conceptual framework guided the development of outcome scales specific to these patients. The information about the impact of various treatment options on the HRQL of children with lower limb deformities, collected using this new PROM, could be used to inform parents and children about outcomes (physical, social, psychological) associated with specific treatment options. This information could supplement other objective outcome information (e.g., complication rates, how the leg will look, etc.) to help families to come to a more informed decision on a child’s course of treatment. |
Chhina, H., Klassen, A. F., Kopec, J. A., Oliffe, J., Iobst, C., Dahan-Oliel, N., Aggarwal, A., Nunn, T., Cooper, A. P., |
| 2020 | Social stigma and cultural beliefs associated with cleft lip and/or palate: parental perceptions of their experience in Kenya | Kenya | Gichuhi Kimotho, S. | Humanities and Social Sciences Publications | Abstract
Cleft lip with or without cleft palate (CL/P)—a condition associated with speech, hearing, feeding, and dental problems, as well as anomalies of the bone and soft tissue around the mouth—is a common birth defect around the globe. The prevalence of this condition varies widely across different countries and regions, and is apparently highest among Asians and lowest among Africans. A review of literature reveals that there exists a dearth of information on experiences of parents of children with CL/P and stigma communication, as well as cultural beliefs associated with CL/P in Africa. To fill this gap, we conducted a descriptive qualitative study examining the experiences of parents of children with CL/P, stigma communication, and cultural beliefs associated with CL/P in Kenya. Twenty four in-depth interviews were done involving purposefully sampled parents of children born with CL/P at AIC CURE International Hospital in Nairobi, Kenya. Five overarching themes emerged under the lived experiences of parents of children with CL/P: Emotional experiences; relational experiences; burden of care and concerns; reaction by the public and friends; and source of social support. The stigma messages and beliefs associated with CL/P further exacerbated the stigma. The study revealed that stigma communication associated with CL/P remains a significant source of social and psychological anguish to parents and guardians of children with CL/P. These findings have critical implications for the management of stigma communication associated with CL/P. They point to the need for public awareness campaigns on CL/P to demystify the condition, its causes and treatment. The study shows that raising public awareness of CL/P would go a long way towards addressing the stigma associated with the condition. It underscores the need for open communication and engagement with all stakeholders to manage stigma communication associated with CL/P through culturally appropriate anti-stigma campaigns.
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Gichuhi Kimotho, S., Nduta Macharia, F., |
| 2020 | Strategic choice and performance of mission hospitals in Kiambu County, Kenya | Kenya | Wangui Njuguna, M. | European Scientific Journal | AbstractThe modern business environment is highly dynamic and the management of every firm is compelled to make effective decisions for the company to remain relevant. Strategic choice is a critical element in the process of formulating a strategy. As a result of the threats that organizations are exposed to, organizations are adopting strategic choices to enhance performance. Despite the challenges that mission hospitals in Kiambu County encounter in the health industry, they are still luring away clients from public hospitals. Therefore, this study’s main objective was to establish the influence of strategic choice on performance of mission hospitals in Kiambu County. Specifically, the study embarked on four objectives; to establish the influence of organizational structure on the performance of mission hospitals in Kiambu County; to determine the influence of technology on performance of mission hospitals in Kiambu County; to determine the influence of leadership on the performance of mission hospitals in Kiambu County; and to establish the effect of resource acquisition on performance of mission hospitals in Kiambu County. The theories that guided this study were the agency theory, open systems theory, contingency theory, and the resource based theory. This study adopted a descriptive design. The study targeted the big four mission hospitals Africa Inland Church Kijabe Mission Hospital; Africa Inland Church cure International Hospital; Presbyterian Church of East Africa. Kikuyu Hospital; and Nazareth Hospital) in Kiambu County. The target population was 80 senior, middle, and operational managers and a census was employed. A semistructured questionnaire was utilized for data collection. Regression results revealed that organizational structure, technology, leadership and resource acquisition were highly significant on the performance of mission hospitals in Kiambu County in Kenya. The study recommended that mission hospitals in Kiambu County should create organizational structures which are in line with the goals being pursued by the mission hospitals. On technology the study recommended for effective management and use of technology infrastructure planning, on leadership, the researcher recommends that leadership development be cascaded to all level of employees/management. This is to help the mission hospitals achieve its objectives on service delivery. On resource acquisition the study recommends that managers should look for ways of motivating human resource in the organization for better performance. Mission hospitals should encourage more training and development of employees to enhance knowledge and skills if they want to sustain performance. |
Wangui Njuguna, M., Muathe, S., |
| 2020 | Labio-palatal clefts: epidemiological, clinical, therapeutic, and progressive profiles: about 285 cases in Niger | Niger | Moussa, M. | The Journal of Biomedical Sciences: Health Sciences & Disease | AbstractAim:To describe the clinical presentation, surgical management and outcome of labio-palatal clefts (LBF) in Niger.Patients and Methods:This was a cross-sectional descriptive retrospective study that was carried out from January 1, 2011, to January 31, 2013. Patients were recruited in the odonto-stomatology department of the Niamey National Hospital and in the pediatric ward of the Niamey Children’s Cure Hospital. Our study parameters were as follows: gender, age, clinical features, management and outcome.Results:Out of 2333 patients who consulted during the study period, 285 (0.12%) with cleft lip and palate were recruited. There were 160 male (56.10%) and 125 female (43.85%). Their mean age was 8.13 years (range: 6 – 47 years). The age group of 6 to 10 years was the most represented with 136 patients (47.70%). There were complete forms 166 patients (58.24%). Sucking and phonation disorders were the main complaints associated with the malformation. Surgery was the sole treatment option, using cheiloplasty and palatoplasty. For 112 patients (41.20%), we used the surgical technique of Millard. The immediate and late aftermath of surgery was simple.Conclusion:Labio-palatal clefts are more common in boys than in girls. The mean age at consultation is 8 years. Sucking and phonation disorders are the main complaints associated with the malformation. Despite the late definitive management, the aftermath of surgery is simple and the overall prognosis is good. |
Moussa, M., Abba Kaka, H.Y., Roufai, L., Eboungabeka Trigo, E.R., Bancole Pognon, S.A., Negrini, J.P., |
| 2020 | Management of neglected traumatic hip dislocation in children | Ethiopia | Gardner, R.O.E. | Journal of Pediatric Orthopaedics | AbstractBackground:Neglected traumatic hip dislocation in children is uncommon and there is no consensus on appropriate management. Previous studies report varied operative management with high rates of avascular necrosis and postoperative subluxation/dislocation. We report a series of 7 consecutive cases who underwent operative reduction after neglected hip dislocation and describe our technique for treatment.Methods:All 7 children sustained posterior dislocations and had no treatment before presentation at our institution. An associated marginal acetabular fracture was present in 2 cases. One additional patient was excluded from the study due to complete loss of articular cartilage that precluded open reduction. The mean time before surgical intervention was 13.1 months (4 to 36 mo) with a mean age of 7 years (5.3 to 10.8 y). All children underwent preoperative skeletal traction for 10 to 14 days. A postero-lateral approach was used in all cases. The acetabulum was cleared of scar tissue and a femoral shortening performed as required (5 cases). Minor erosion of the articular cartilage of the posterior aspect of the femoral head was noted in 3/6 cases. After reduction, a posterior capsulorrhaphy was performed and the patient immobilized in a hip spica for 6 to 12 weeks.Results:The mean follow-up was 44 months (33 to 56 mo). The majority of children (86%) could walk and run without a limp, could squat, and had no pain. One child had mild pain and a limp. Mean Harris Hip Score was 98.9. No hip subluxed or dislocated postoperatively. The radiographs at latest follow-up showed no evidence of growth disturbance in 29% of cases, coxa magna in 57%, and partial femoral head collapse in 1 case (14%). Of note, those patients managed within 8 months of injury had none or minimal evidence of growth disturbance.Conclusions:At medium-term follow-up, open reduction with a postero-lateral approach, posterior capsulorrhaphy, and femoral shortening (as required) produces a satisfactory outcome with a stable, congruent reduction. Good clinical function can be expected with a low incidence of avascular necrosis. |
Gardner, R.O.E., Worku, N., Nunn, T.R., Zerfu, T.T., Kassahun, M.E., |
| 2020 | Impact of musculoskeletal impairment on the lives of school-aged children in Ethiopia: a prospective mixed-methods study | Ethiopia | Tewodros, T.Z. | East and Central African Journal of Surgery | AbstractBackground:WHO estimates that more than a billion people live with some form of disability and most of them live in the developing countries. The American Community Survey states that 5.6% of children between the ages of 5-17 live with disability. The situation in Ethiopia is not studied and most of the data on disability comes from the population census conducted every ten years. In this study we report on the impact of musculoskeletal (MSI) on the lives of school age children in Ethiopia.Methods:This was a prospective mixed qualitative and quantitative research. The study was conducted at CURE Ethiopia Children’s hospital which is a specialized pediatric orthopedic hospital that provides free orthopedic care for children. The research was approved by the CURE IRB and a written consent was obtained from the participants. Children between 5 and 14 with acquired or congenital musculoskeletal impairment were interviewed using pretested questionnaires. We also conducted two focus group discussions conducted at a rural as well as an urban setting which were all recorded and translated to English.Results:A total of 55 children with MSI were interviewed and 37 parents, 3 teachers and a physiotherapist were involved in the focus group discussions. These families spend a significant amount of their income for transport to the hospital and 68.3% reported getting that money was difficult. A third of these children do not go to school or have dropped out but the number goes to 69.2% when it comes to children with mobility problems. Over 80% of these children also reported abuse from peers. The three most important challenges that stood out during the focus group discussion were indignity and exclusion, financial struggles, and challenges in schools.Conclusions:This study highlights the most important challenges of children with musculoskeletal impairments are indignity and exclusion, financial struggles at home and challenges in school. Ethiopia is one of the countries that have legally committed themselves to delivering comprehensive rehabilitation services for people living with disabilities. The issues identified in our study can be considered as part of the comprehensive rehabilitation services and they need to be addressed properly with the concerned parties in order to improve the life and future of children with musculoskeletal impairments and their families. |
Tewodros, T.Z., Mesfin, E., Nunn, T., Gardner, R., |
| 2019 | Sustainable orthopaedic surgery residency training in East Africa: A 10-year experience in Kenya | Kenya | Gokcen, E. | American Association of Orthopedic Surgeons | AbstractLow- and middle-income countries (LMICs) have continued to lag behind high-income countries in all measurable outcomes of health care. As concluded by the World Health Organization during the 2013 Global Forum on Human Resources for Health, an adequate healthcare workforce is mandatory to provide universal health coverage. Despite efforts to increase the numbers of healthcare workers, an extreme deficit in highly trained surgeons remains. Several options exist to provide training for surgeons in LMICs, including local training by local surgeons, sending local surgeons abroad for training, or local training by short-term or long-term visiting surgeons from high-income countries. This article further discusses the benefits and challenges of each option and reviews the 10-year outcomes of the Orthopaedic Surgery Residency Program at the CURE Kenya Hospital in Kijabe, Kenya. The program has graduated nine orthopaedic surgeons who are all practicing in Africa, five of which are full-time attending consultants in residency training programs. An additional eight residents are currently in the program. Sustainable orthopaedic training can be accomplished in LMICs as demonstrated by the ongoing success of the CURE Kenya Orthopaedic Surgery Residency Program. Additional efforts to expand and replicate this model may assist in providing improved access to high-quality universal healthcare in LMICs. |
Gokcen, E., |
| 2019 | The incidence of postoperative seizures following treatment of postinfectious hydrocephalus in Ugandan Infants: A post hoc comparison of endoscopic treatment vs shunt placement in a randomized controlled trial | Uganda | Punchak, M. | Journal of Neurosurgery | AbstractBackground:There are currently no published data directly comparing postoperative seizure incidence following endoscopic third ventriculostomy (ETV),with/without choroid plexus cauterization (CPC), to that for ventriculoperitoneal shunt (VPS) placement. OBJECTIVE: To compare postoperative epilepsy incidence for ETV/CPC and VPS in Ugandan infants treated for postinfectious hydrocephalus (PIH).Methods:We performed an exploratory post hoc analysis of a randomized trial comparing VPS and ETV/CPC in 100 infants (<6 mo old) presenting with PIH. Minimum follow-up was 2 yr. Variables associated with and the incidence of postoperative epilepsy were compared (intention-to-treat) using a bivariate analysis. Time to first seizure was compared using the Kaplan–Meier method, and the relative risk for the 2 treatments was determined using Mantel-Haenszel hazard ratios.Results:Seizure incidence was not related to age (P = .075), weight (P = .768), sex (P=.151), head circumference(P=.281),time from illness to hydrocephalus onset (P=.973), or hydrocephalus onset to treatment (P = .074). Irritability (P = .027) and vision deficit (P = .04) were preoperative symptoms associated with postoperative seizures. Ten (10%) patients died, and 20 (20%) developed seizures over the follow-up period. Overall seizure incidence was 9.4 per 100 person-years (9.4 and 9.5 for ETV/CPC and VPS, respectively; P =.483), with no significant difference in seizure risk between groups (hazard ratio, 1.02; 95%CI:0.42,2.45; P=.966).Meantimetoseizureonsetwas8.5moforETV/CPCand11.2mo for VPS (P=.464).As-treated, per-protocol, and attributable-intervention analyses yielded similar results.Conclusion:Postoperative seizure incidence following treatment of PIH was 20% within 2 yr, regardless of treatment modality. |
Punchak, M., Mbabazi Kabachelor, E., Ogwal, M., Nalule, E., Nalwoga, J., Ssenyonga, P., Mugamba, J., Rattani, A., Dewan, M. C., Kulkarni, A. V., Schiff, S. J., Warf, B., |
| 2019 | Pediatric Hydrocephalus in the Developing World | Uganda | Muir, R. T. | Pediatric Hydrocephalus | AbstractHydrocephalus in children has been inadequately recognized as an important cause of death and disability in developing countries. In addition to the expected congenital causes, for which high birth rates increase prevalence, neonatal infection and neural tube defects are especially important, and potentially preventable, causes. Research and public health policy have the potential to diminish the burden for both of these etiologies through prevention. The inadequate number of centers trained and equipped to treat hydrocephalus is a ubiquitous barrier to care for these children throughout the developing world. Relative to the treatment of other conditions, hydrocephalus treatment is very cost-effective; yet, poverty and insufficient health system support remain as significant obstacles to treatment. The lack of access to emergency neurosurgical care also renders shunt dependence more dangerous in these contexts. This provides a compelling argument for promoting primary endoscopic treatment whenever possible. In some regions, infants with hydrocephalus are not recognized as having a treatable medical condition, which can delay or prevent referral for neurosurgical treatment. A number of organized efforts in recent decades have made progress by providing treatment, training, research, and public education. But there is far more to be done. |
Muir, R. T., Wang, S., Warf, B. C., |
| 2019 | Factors associated with non-compliance to bracing in clubfoot among mothers of children under five years with clubfoot in African Inland Church CURE International Children’s Hospital, Kijabe, Kenya | Kenya | Muinde, W. N. | Journal of Health, Medicine, and Nursing | AbstractPurpose:The study sought to determine factors associated with non-compliance to bracing in clubfoot management among children under five years in AIC Cure International Children’s Hospital, Kijabe, Kenya.Methodology:The study adopted a cross-sectional descriptive design. It was carried out at AIC Cure International Children’s Hospital, Kijabe, Kenya between April and August 2018. Both qualitative and quantitative methods were employed using a sample size of 174 participants. A semi-structured pre-tested questionnaire was used to collect data. Further, two focused group discussions were conducted, comprising of mothers with different characteristics. Quantitative data was entered for analysis using SPSS version 23.0. Descriptive, bivariate for example Chi square and multivariate for example regression statistical analysis was performed. Qualitative data from questionnaires was analysed through textual summaries was categorized and coded to match specific relevant research questions while data from FGDs was analysed using verbatim and a three-stage thematic approach. Presentation was done through frequencies, percentages, tables and charts.Results:The proportion of non-compliance to bracing was 16.8%, and the cases of non-compliance to bracing were mostly reported in male children (89.3%), and mostly among children aged between 1-2 years of age (35.7%). Majority of the mothers (92.9%) received support from health professionals during the treatment. Gender of the child had a significant association with non-compliance with mothers of male children having 89.3% non-compliance as opposed to 10.7% non-compliance of mothers with female children. Majority of those who did not comply to bracing (81.2%) had college/university education and above. Distance to health facility, inability to meet transport costs and gender of the child had significant association with non-compliance to bracing.Unique contribution to Theory, Practice and Policy:There is need to empower local facilities that is level 1 and level 2 to be able to manage conditions like clubfoot in order to avoid relapse or even permanent disability due to non-compliance. There is also need for detailed parent education on clubfoot bracing and importance of parent compliance. |
Muinde, W. N., Kikuvi, G. M., Mutai, D. J., |
| 2019 | Treatment outcomes of congenital pseudarthrosis of the tibia at Beit CURE International Hospital in Blantyre, Malawi | Malawi | Akaro, I. L. | East and Central African Journal of Surgery | AbstractBackground:Congenital pseudarthrosis of the tibia (CPT) is a rare condition. The natural history of CPT includes persistent instability and progressive deformity. Several CPT treatment methods have been practiced, however, in Africa where there is scarce information on the modalities of treatment available and their outcomes. Methods: A retrospective cross-sectional study which was conducted among patients with CPT at Beit Cure International Hospital (BCIH), Malawi. Forty-four patients were recruited in this study and their treatment modalities and outcomes were analyzed. Results: Out of 44 patients recruited in this study, majority (63.6%) were male. The majority of cases were stage 4 congenital tibia pseudarthrosis by Crawford classification. Most patients were treated by more than one surgical modality; however, surgical excision and intramedullary rodding was commonly used (54.7%). The outcomes of treatment were good in 5%, fair in 30%, with amputation in 45% and poor outcomes in 20% of the patients. Complications developed in 60% of patients, predominated by limb length discrepancy. The foot and ankle status were rated by Oxford Foot and Ankle scoring system (OxFAQ). Conclusions: Congenital pseudarthrosis of the tibia is a complex congenital disorder with multiple modalities of treatment. Majority of the patients were treated by more than one operation. Some patients ended up with amputation or poor outcome. Limb length discrepancy, deep infection and pin tract infection are among the common complications. |
Akaro, I. L., James. K., Chokotho, L., Burgess, D., Mkandawire, N., Samoyo, P. T. K., |
| 2018 | Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2-10 | Ethiopia | Nunn, T.R. | Strategies in Trauma and Limb Reconstruction | Abstract
The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2-10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2-10, comprising 100 clubfeet (64 patients). Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1-20, 21-45 and > 45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2-4, 5-7 and 8-10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau = 0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.
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Nunn, T.R., Etsub, M., Tilahun, T., Gardner, R.O.E., Allgar, V., Wainwright, A.M., Lavy, C.B.D., |
| 2018 | Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems | Uganda | Dewan, M. C. | Journal of Neurosurgery | AbstractThere is inadequate pediatric neurosurgical training to meet the growing burden of disease in low- and middle-income countries (LMIC). Subspecialty expertise in the management of hydrocephalus and spina bifida—two of the most common pediatric neurosurgical conditions—offers a high-yield opportunity to mitigate morbidity and avoid unnecessary death. The CURE Hydrocephalus and Spina Bifida (CHSB) fellowship offers an intensive subspecialty training program designed to equip surgeons from LMIC with the state-of-the-art surgical skills and equipment to most effectively manage common neurosurgical conditions of childhood. Prospective fellows and their home institution undergo a comprehensive evaluation before being accepted for the 8-week training period held at CURE Children’s Hospital of Uganda (CCHU) in Mbale, Uganda. The fellowship combines anatomy review, treatment paradigms, a flexible endoscopic simulation lab, daily ward and ICU rounds, radiology rounds, and clinic exposure. The cornerstone of the fellowship is the unique operative experience that includes a high volume of endoscopic third ventriculostomy with choroid plexus cauterization, myelomeningocele closure, and ventriculoperitoneal shunting, among many other procedures performed at CCHU. Upon completion, fellows return to their home institution to establish or rejuvenate a robust pediatric practice as part of a worldwide network of CHSB trainees committed to the care of underserved children. To date, the fellowship has graduated 33 surgeons from 20 different LMIC who are independently performing thousands of hydrocephalus and spina bifida operations each year. |
Dewan, M. C., Onen, J., Bow, H., Ssenyonga, P., Howard, C., Warf, B. C., |
| 2018 | Renal outcomes in children with operated spina bifida in Uganda | Uganda | Sims-Williams, H. J. | International Journal of Nephrology | AbstractBackground:To describe the extent of renal disease in Ugandan children surviving at least ten years after spina bifida repair and to investigate risk factors for renal deterioration in this cohort.Patients and Method:Children who had undergone spina bifida repair at CURE Children’s Hospital of Uganda between 2000 and 2004 were invited to attend interview, physical examination, renal tract ultrasound, and a blood test (creatinine). Medical records were retrospectively reviewed. The following were considered evidence of renal damage: elevated creatinine, hypertension, and ultrasound findings of hydronephrosis, scarring, and discrepancy in renal size >1cm. Female sex, previous UTI, neurological level, mobility, detrusor leak point pressure, and adherence with clean intermittent catheterisation (CIC) were investigated for association with evidence of renal damage.Results:65 of 68 children aged 10–14 completed the assessment. The majority (83%) reported incontinence. 17 children (26%) were performing CIC. One child had elevated creatinine. 25 children (38%) were hypertensive. There was a high prevalence of ultrasound abnormalities: hydronephrosis in 10 children (15%), scarring in 42 (64%), and >1cm size discrepancy in 28 (43%). No children with lesions at S1 or below had hydronephrosis (p = 0.025), but this group had comparable prevalence of renal size discrepancy, scarring, and hypertension to those children with higher lesions.Conclusions:Incontinence, ultrasound abnormalities, and hypertension are highly prevalent in a cohort of Ugandan children with spina bifida, including those with low neurological lesions. These findings support the early and universal initiation of CIC with anticholinergic therapy in a low-income setting. |
Sims-Williams, H. J., Sims-Williams, H. P., Mbabazi Kabachelor, E., Warf, B. C., |
| 2018 | Learning based segmentation of CT brain images: application to post-operative hydrocephalic scans | Uganda | Cherukuri, V. | IEEE Transactions on Biomedical Engineering | AbstractObjective:Hydrocephalus is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the brain. Segmentation of brain imagery into brain tissue and CSF [before and after surgery, i.e., preoperative (pre-op) versus postoperative (post-op)] plays a crucial role in evaluating surgical treatment. Segmentation of pre-op images is often a relatively straightforward problem and has been well researched. However, segmenting post-op computational tomographic (CT) scans becomes more challenging due to distorted anatomy and subdural hematoma collections pressing on the brain. Most intensity- and feature-based segmentation methods fail to separate subdurals from brain and CSF as subdural geometry varies greatly across different patients and their intensity varies with time. We combat this problem by a learning approach that treats segmentation as supervised classification at the pixel level, i.e., a training set of CT scans with labeled pixel identities is employed.
Methods:Our contributions include: 1) a dictionary learning framework that learns class (segment) specific dictionaries that can efficiently represent test samples from the same class while poorly represent corresponding samples from other classes; 2) quantification of associated computation and memory footprint; and 3) a customized training and test procedure for segmenting post-op hydrocephalic CT images.
Results:Experiments performed on infant CT brain images acquired from the CURE Children’s Hospital of Uganda reveal the success of our method against the state-of-the-art alternatives. We also demonstrate that the proposed algorithm is computationally less burdensome and exhibits a graceful degradation against a number of training samples, enhancing its deployment potential. |
Cherukuri, V., Ssenyonga, P., Warf, B. C., Kulkarni, A. V., Monga, V., Schiff, S. J., |
| 2018 | Children with spina bifida in Eastern Uganda report a reasonable quality of life relative to their healthy school-attending peers | Uganda | Sims-Williams, H. J. | Archives of Disease in Childhood (BMJ) | Sims-Williams, H. J., Sims-Williams, H. P., Mbabazi Kabachelor, E., Magombe, J., Warf, B. C., | |
| 2018 | Neurosurgery in East Africa: Innovations | Uganda | Budohoski, K. P. | World Neurosurgery | AbstractIn the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service. |
Budohoski, K. P., Ngerageza, J. G., Austard, B., Fuller, A., Galler, R., Haglund, M., Lett, R., Lieberman, I. H., Mangat, H. S., March, K., Olouch-Olunya, D., Piquer, J., Qureshi, M., Santos, M. M., Schöller, K., Shabani, H. K., Trivedi, R. A., Young, P., Zubkov, M. R., Härtl, R., Stieg, P .E., |
| 2018 | Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis | Uganda | Dewan, M. C. | Journal of Neurosurgery | AbstractObjective:Hydrocephalus is one of the most common brain disorders, yet a reliable assessment of the global burden of disease is lacking. The authors sought a reliable estimate of the prevalence and annual incidence of hydrocephalus worldwide.Methods:The authors performed a systematic literature review and meta-analysis to estimate the incidence of congenital hydrocephalus by WHO region and World Bank income level using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. A global estimate of pediatric hydrocephalus was obtained by adding acquired forms of childhood hydrocephalus to the baseline congenital figures using neural tube defect (NTD) registry data and known proportions of posthemorrhagic and postinfectious cases. Adult forms of hydrocephalus were also examined qualitatively.Results:Seventy-eight articles were included from the systematic review, representative of all WHO regions and each income level. The pooled incidence of congenital hydrocephalus was highest in Africa and Latin America (145 and 316 per 100,000 births, respectively) and lowest in the United States/Canada (68 per 100,000 births) (p for interaction < 0.1). The incidence was higher in low- and middle-income countries (123 per 100,000 births; 95% CI 98–152 births) than in high-income countries (79 per 100,000 births; 95% CI 68–90 births) (p for interaction < 0.01). While likely representing an underestimate, this model predicts that each year, nearly 400,000 new cases of pediatric hydrocephalus will develop worldwide. The greatest burden of disease falls on the African, Latin American, and Southeast Asian regions, accounting for three-quarters of the total volume of new cases. The high crude birth rate, greater proportion of patients with postinfectious etiology, and higher incidence of NTDs all contribute to a case volume in low- and middle-income countries that outweighs that in high-income countries by more than 20-fold. Global estimates of adult and other forms of acquired hydrocephalus are lacking.Conclusions:For the first time in a global model, the annual incidence of pediatric hydrocephalus is estimated. Low- and middle-income countries incur the greatest burden of disease, particularly those within the African and Latin American regions. Reliable incidence and burden figures for adult forms of hydrocephalus are absent in the literature and warrant specific investigation. A global effort to address hydrocephalus in regions with the greatest demand is imperative to reduce disease incidence, morbidity, mortality, and disparities of access to treatment. |
Dewan, M. C., Rattani, A., Mekary, R., Glancz, L. J., Yunusa, I., Baticulon, R. E., Fieggen, G., Wellons, J. C., III, Park, K. B., Warf, B. C., |
| 2018 | Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change | Uganda | Dewan, M. C. | Journal of Neurosurgery | AbstractObjective:Worldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand.Methods:Results from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity.Results:Every year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases—all in low- and middle-income countries—that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.Conclusions:Each year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease. |
Dewan, M. C., Rattani, A., Fieggen, G., Arraez, M. A., Servadei, F., Boop, F. A., Johnson, W. D., Warf, B. C., Park, K. B., |
| 2018 | Total hip replacement surgery in Ethiopia | Ethiopia | Gokcen, E.C. | East and Central African Journal of Surgery | AbstractBackground:Total hip replacement (THR) surgery has evolved over years to the point that it has been considered as “the operation of the century”. For developed countries, arthroplasty is well established for the management of various joint disorders and has completely revolutionised the treatment of the arthritic hip. The story is different in developing nations. Expensive implant costs and lack of trained orthopaedic surgeons are the main constraints; poverty has caused African countries to remain behind from enjoying the benefits of this medical breakthrough. In this study, we report our first and largest series of 50 such surgeries performed at the CURE Hospital in Addis Ababa. We believe that this is the first consecutive case series from Ethiopia and wanted to share our experience.Methods:Prospectively, all consecutive patients that underwent THR at CURE Hospital from October 2009 to October 2013 were followed for over 3 years using clinical assessments and hip scores. The hip implant used was a Stryker Omnifit Uncemented HA-coated prosthesis. The Visual Analog Scale (VAS) for pain and the Modified Oxford Hip Score were used to assess outcomes. Variables recorded for each patient included sociodemographic information, diagnosis, comorbidity, surgical approach, duration of surgery, estimated blood loss, implant sizes for Ethiopian hips, complications, sequelae, hip scores, and final patient satisfaction. These were analysed using SPSS version 16. Patterns and learning points were observed.Results:Of the 50 consecutive THR patients, 26 were male. Mean age was 48 years (range 14-85). In 30 hips, the right side was operated on, and 2 were bilaterally treated. Primary osteoarthritis (OA) and avascular necrosis (AVN) were the leading diagnoses requiring THR. Previous partial hip replacement (PHR, hemiarthroplasty) was converted to THR in 6 patients. The commonest comorbidities were diabetes mellitus and hypertension. There were 4 hips that dislocated after THR and 1 needed revision surgery. There was 1 persistent infection, 1 case of deep vein thrombosis (DVT), and 1 death. Mean EBL was approximately 1 L and only 5 patients needed transfusion. The most common sizes for Ethiopian hips were a 28 mm+0 head, 52 mm acetabular shell, and 140 mm #8 stem. The VAS and Modified Oxford Hip scores both improved significantly, and the results were comparable with international standards.Conclusions:THR is a viable, safe, and effective option in Ethiopia. Appropriate staff training, careful patient selection, continuous supply chain of implants, and establishing a dedicated joint replacement centre will reliably sustain THR surgery. |
Gokcen, E.C., Wamisho, B.L., |
| 2018 | Economic burden of neonatal sepsis in sub-Saharan Africa | Uganda | Ranjeva, S. L. | BMJ Global Health | AbstractBackground and Significance:The third Sustainable Development Goal for child health, which aims to end preventable deaths of newborns and children less than 5 years of age by 2030, cannot be met without substantial reduction of infection-specific neonatal mortality in the developing world. Neonatal infections are estimated to account for 26% of annual neonatal deaths, with mortality rates highest in sub-Saharan Africa (SSA). Reliable and comprehensive estimates of the incidence and aetiology surrounding neonatal sepsis in SSA remain incompletely available. We estimate the economic burden of neonatal sepsis in SSA.Methods:Data available through global health agencies and in the medical literature were used to determine population demographics in SSA, as well as to determine the incidence, disease burden, mortality and resulting disabilities associated with neonatal sepsis. The disability-adjusted life years (DALY) associated with successful treatment or prevention of neonatal sepsis in SSA for 1 year were calculated. The value of a statistical life (VSL) methodology was estimated to evaluate the economic burden of untreated neonatal sepsis in SSA.Results:We conservatively estimate that 5.29–8.73 million DALYs are lost annually in SSA due to neonatal sepsis. Corresponding VSL estimates predict an annual economic burden ranging from $10 billion to $469 billion.Conclusions:Our results highlight and quantify the scope of the public health and economic burden posed by neonatal sepsis in SSA. We quantify the substantial potential impact of more successful treatment and prevention strategies, and we highlight the need for greater investment in strategies to characterise, diagnose, prevent and manage neonatal sepsis and its long-term sequelae in SSA. |
Ranjeva, S. L., Warf, B. C., Schiff, S. J., |
| 2017 | Endoscopic treatment versus shunting for infant hydrocephalus in Uganda | Uganda | Kulkarni, A. V. | The New England Journal of Medicine | AbstractBackground:Postinfectious hydrocephalus in infants is a major health problem in sub-Saharan Africa. The conventional treatment is ventriculoperitoneal shunting, but surgeons are usually not immediately available to revise shunts when they fail. Endoscopic third ventriculostomy with choroid plexus cauterization (ETV–CPC) is an alternative treatment that is less subject to late failure but is also less likely than shunting to result in a reduction in ventricular size that might facilitate better brain growth and cognitive outcomes. Methods:We conducted a randomized trial to evaluate cognitive outcomes after ETV–CPC versus ventriculoperitoneal shunting in Ugandan infants with postinfectious hydrocephalus. The primary outcome was the Bayley Scales of Infant Development, Third Edition (BSID-3), cognitive scaled score 12 months after surgery (scores range from 1 to 19, with higher scores indicating better performance). The secondary outcomes were BSID-3 motor and language scores, treatment failure (defined as treatment-related death or the need for repeat surgery), and brain volume measured on computed tomography. Results:A total of 100 infants were enrolled; 51 were randomly assigned to undergo ETV–CPC, and 49 were assigned to undergo ventriculoperitoneal shunting. The median BSID-3 cognitive scores at 12 months did not differ significantly between the treatment groups (a score of 4 for ETV–CPC and 2 for ventriculoperitoneal shunting; Hodges–Lehmann estimated difference, 0; 95% confidence interval [CI], −2 to 0; P=0.35). There was no significant difference between the ETV–CPC group and the ventriculoperitoneal-shunt group in BSID-3 motor or language scores, rates of treatment failure (35% and 24%, respectively; hazard ratio, 0.7; 95% CI, 0.3 to 1.5; P=0.24), or brain volume (z score, −2.4 and −2.1, respectively; estimated difference, 0.3; 95% CI, −0.3 to 1.0; P=0.12). Conclusions:This single-center study involving Ugandan infants with postinfectious hydrocephalus showed no significant difference between endoscopic ETV–CPC and ventriculoperitoneal shunting with regard to cognitive outcomes at 12 months. |
Kulkarni, A. V., Schiff, S. J., Mbabazi Kabachelor, E., Mugamba, J., Ssenyonga, P., Donnelly, R., Levenbach, J., Monga, V., Peterson, M., MacDonald, M., Cherukuri, V., Warf, B. C., |
| 2017 | Validation and reliability of the Chichewa translation of the EQ-5D quality of life questionnaire in adults with orthopedic injuries in Malawi | Malawi | Chokotho, L. | Malawi Medical Journal | AbstractBackground:The EQ-5D is a standardised instrument that measures health-related quality-of-life and explores cost-effectiveness of treatments. Malawi is a low-resource country that would benefit from assessment of quality-of-life among individuals living with chronic conditions. Chichewa is the official native language of Malawi. The Chichewa version of the EQ-5D-3L developed by EuroQoL group has not been validated with Chichewa speakers. The purpose of this study was to evaluate the clinimetric properties of the Chichewa EQ-5D-3L.Methods:Patients with orthopaedic conditions were recruited in the outpatient orthopaedic clinics and wards at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifty-three patients with various musculoskeletal problems were administered the Chichewa EQ-5D-3L and World Health Organization quality of life (WHO-QOL) questionnaires. To assess repeatability, a separate test–retest population of 20 patients were also selected from orthopaedic clinics and wards to fill out the questionnaire twice.Results:Convergence validity was determined, with each of the WHO-QOL domains and the EQ-5D descriptive index and visual analogue scale (VAS) having good to moderate correlation (r = 0.3–0.7). Internal consistency was measured for the descriptive index, and the Cronbach’s alpha was 0.7. The ceiling effect for the descriptive index and the VAS were 9.4% and 0%, respectively. No respondents reached floor effect for the descriptive index or the VAS. The test retest intraclass correlation coefficient reliability at 14 days was 0.984 for the VAS and 1 for the descriptive index, with all 20 respondents providing the same responses.Conclusions:The EuroQoL translated version of the Chichewa EQ-5D-3L was found to demonstrate adequate validity, internal consistency, floor/ ceiling effects, and reliability. |
Chokotho, L., Mkandawire, N., Conway, D., Wu, H. H., Shearer, D. D., Hallan, G., Gjertsen, J. E., Young, S., Lau, B. C., |
| 2017 | Trauma care in Malawi: a call to action | Malawi | Mulwafu, W. | Malawi Medical Journal | AbstractInjuries are a global public health concern because most are preventable yet they continue to be a major cause of death and disability, especially among children, adolescents, and young adults. This enormous loss of human potential has numerous negative social and economic consequences. Malawi has no formal system of prehospital trauma care, and there is limited access to hospital-based trauma care, orthopaedic surgery, and rehabilitation. While some hospitals and research teams have established local trauma registries and quantified the burden of injuries in parts of Malawi, there is no national injury surveillance database compiling the data needed in order to develop and implement evidence-based prevention initiatives and guidelines to improve the quality of clinical care. Studies in other low- and middle-income countries (LMICs) have demonstrated cost-effective methods for enhancing prehospital, in-hospital, and postdischarge care of trauma patients. We encourage health sectors leaders from across Malawi to take action to improve trauma care and reduce the burden from injury in this country. |
Mulwafu, W., Chokotho, L., Mkandawire, N., Pandit, H., Deckelbaum, D. L., Lavy, C., Jacobsen, K. H., |
| 2017 | Growing brains: How adapting to Africa advanced the treatment of infant hydrocephalus | Uganda | Warf, B. C. | Journal of Neurosurgery | Warf, B. C., | |
| 2017 | Quality of life among children with spina bifida in Uganda | Uganda | Sims-Williams, H. J. | Archives of Disease in Childhood (BMJ) | AbstractBackground:Children surviving after spina bifida repair often have significant disability, the consequences of which may be more profound in low-income countries. The aim of this cross-sectional study was to measure quality of life (QOL) reported by children with spina bifida in Uganda, and to define factors associated with QOL.Methods:QOL was measured using both the Health Utilities Index (HUI3) Tool and a visual analogue scale (VAS) marked from 0 to 10. In keeping with the WHO definition of QOL, further analysis was conducted using subjective QOL scores (using the VAS). Multivariate regression was used to investigate the association between VAS scores and prespecified variables: age, sex, hydrocephalus, mobility, urinary continence, school attendance and family size.Results:Sixty two of 68 surviving children aged 10–14 were able to complete all aspects of the assessment. There was poor correlation between the VAS and HUI3 Tool (Pearson correlation 0.488). On multivariate regression, the following variables were associated with a significant change in the 10-point VAS (change in score; 95% CI): male sex (−1.45; −2.436 to −0.465), urinary continence (1.681; 0.190 to 3.172), large family size (−1.775; −2.773 to −0.777) and hydrocephalus (−1.382; −2.374 to −0.465).Conclusions:Urinary continence and family size are potentially modifiable, the former by simple and inexpensive medical management. Enhanced investment in community-based rehabilitation and support is urgently needed. Delivery of family planning services is a national priority in Uganda, and should be discussed with families as part of holistic care. |
Sims-Williams, H. J., Sims-Williams, H. P., Mbabazi Kabachelor, E., Warf, B. C., |
| 2017 | Past, present, and future of neurosurgery in Uganda | Uganda | Haglund, M. M. | Journal of Neurosurgery | Abstract
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.
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Haglund, M. M., Warf, B., Fuller, A., Freischlag, K., Muhumuza, M., Ssenyonjo, H., Mukasa, J., Mugamba, J., Kiryabwire, J., |
| 2017 | The burden of trauma at a district hospital in Malawi | Malawi | Jaffry, Z. | Tropical Doctor | AbstractTrauma disproportionately affects low- and middle-income countries, many of which do not have the surveillance systems required to design effective prevention and treatment strategies. This study aimed to establish such a system at a district hospital in Malawi in order to decrease the number of preventable injuries in the country. The most common cause was falls (53.2%), and 94.8% of patients were treated and sent home. Study recommends for preventative interventions specifically targeting this group of the population |
Jaffry, Z., Chokotho, L. C.,, Harrison, W. J., Mkandawire, N. C., |
| 2017 | Improving hospital-based trauma care for road traffic injuries in Malawi | Malawi | Chokotho, L. | World Journal of Emergency Medicine | AbstractBackground:The mortality rate from road traffic injuries has increased in sub-Saharan Africa as the number of motor vehicles increase. This study examined the capacity of hospitals along Malawi’s main north-south highway to provide emergency trauma care. Methods:Structured interviews and checklists were used to evaluate the infrastructure, personnel, supplies, and equipment at all four of Malawi’s central hospitals, ten district hospitals, and one mission hospital in 2014. Most of these facilities are along the main north-south highway that spans the country. Results:Between July 2013 and March 2014, more than 9 200 road traffic injuries (RTIs) and 100 RTI deaths were recorded by the participating hospitals. All of the hospitals reported staff shortages, especially during nights and weekends. Few clinicians had completed formal training in emergency trauma management, and healthcare workers reported gaps in knowledge and skills, especially at district hospitals. Most central hospitals had access to the critical supplies and medications necessary for trauma care, but district hospitals lacked some of the supplies and equipment needed for diagnosis, treatment, and personal protection. Conclusion:The mortality and disability burden from road traffic injuries in Malawi (and other low-income countries in sub-Saharan Africa) can be reduced by ensuring that every central and district hospital has a dedicated trauma unit with qualified staff who have completed primary trauma care courses and have access to the equipment necessary to save lives. |
Chokotho, L., Mulwafu, W., Singini, I., Njalale, Y., Jacobsen, K. H., |
| 2016 | Global surgery for pediatric hydrocephalus in the developing world, a review of the history, challenges, and future directions | Uganda | Muir, R. T. | Journal of Neurosurgery | AbstractObjective:Pediatric hydrocephalus is one of the most common neurosurgical conditions and is a major contributor to the global burden of surgically treatable diseases. Significant health disparities exist for the treatment of hydrocephalus in developing nations due to a combination of medical, environmental, and socioeconomic factors. This review aims to provide the international neurosurgery community with an overview of the current challenges and future directions of neurosurgical care for children with hydrocephalus in low-income countries.Methods:The authors conducted a literature review around the topic of pediatric hydrocephalus in the context of global surgery, the unique challenges to creating access to care in low-income countries, and current international efforts to address the problem.Results:Developing countries face the greatest burden of pediatric hydrocephalus due to high birth rates and greater risk of neonatal infections. This burden is related to more general global health challenges, including malnutrition, infectious diseases, maternal and perinatal risk factors, and education gaps. Unique challenges pertaining to the treatment of hydrocephalus in the developing world include a preponderance of postinfectious hydrocephalus, limited resources, and restricted access to neurosurgical care. In the 21st century, several organizations have established programs that provide hydrocephalus treatment and neurosurgical training in Africa, Central and South America, Haiti, and Southeast Asia. These international efforts have employed various models to achieve the goals of providing safe, sustainable, and cost-effective treatment.Conclusions:Broader commitment from the pediatric neurosurgery community, increased funding, public education, surgeon training, and ongoing surgical innovation will be needed to meaningfully address the global burden of untreated hydrocephalus. |
Muir, R. T., Wang, S., Warf, B. C., |
| 2016 | Ten-year survival of Ugandan infants after myelomeningocele closure | Uganda | Sims-Williams, H. J. | Journal of Neurosurgery | AbstractObjective:Myelomeningocele (MM) is a neural tube defect complicated by neurological deficits below the level of the spinal lesion and, in many cases, hydrocephalus. Long-term survival of infants treated for MM in a low- and middle-income country has never been reported. This retrospective cohort study reports 10-year outcomes and factors affecting survival for infants undergoing MM repair at CURE Children’s Hospital of Uganda.Methods:Patients were traced by telephone or home visit. Survival was estimated using the Kaplan-Meier method. Multivariate survival was analyzed using the Cox proportional hazards model, investigating the following variables: sex, age at surgery, weight-for-age at surgery, motor level, and presence and management of hydrocephalus.Results:A total of 145 children underwent MM repair between 2000 and 2004; complete data were available for 133 patients. The probability of 10-year survival was 55%, with 78% of deaths occurring in the first 5 years. Most of the deaths were not directly related to MM; infection and neglect were most commonly described. Lesions at motor level L-2 or above were associated with increased mortality (HR 3.176, 95% CI 1.557–6.476). Compared with repair within 48 hours of birth, surgery at 15–29 days was associated with increased mortality (HR 9.091, 95% CI 1.169–70.698).Conclusions:Infants in low- and middle-income countries with MM can have long-term survival with basic surgical intervention. Motor level and age at surgery were significant factors influencing outcome. Education of local health care workers and families to ensure both urgent referral for initial treatment and subsequent access to basic medical care are essential to survival. |
Sims-Williams, H. J., Sims-Williams, H. P., Mbabazi Kabachelor, E., Fotheringham, J., Warf, B. C., |
| 2016 | Microbiological isolates of chronic suppurative otitis media at the University Teaching Hospital and Beit Cure Hospital in Lusaka, Zambia | Zambia | Phiri, H. | University of Nairobi | AbstractBackground:Chronic Suppurative Otitis Media (CSOM) is a common cause of hearing loss and many complications such as meningitis. Many approaches to treatment of CSOM have been unsatisfactory because CSOM microbiological isolates as well as their sensitivity patterns vary from place to place.Objectives:To determine the pattern of microbiological isolates of CSOM and the demographic characteristics of patients with CSOM at the University Teaching Hospital, (UTH) and Beit Cure Hospital (BCH) in Lusaka, Zambia.Study design:The study was a hospital-based Cross sectional descriptive study. Study Setting: The study was conducted at the ENT outpatient clinics of UTH and BCH in Lusaka, Zambia.Methodology:100 CSOM patients were included in the study. Quantitative data on the participants’ demographic details and clinical features were obtained using structured questionnaires. The middle ear discharge was aseptically collected using a sterile cotton swab. In the laboratory, samples were inoculated on agar media to isolate microorganisms and antibiotic susceptibility testing was done using Kirby Bauer method as per CLSI guidelines.Results:Out of the 100 CSOM patients studied, 33(33%) were children below 18yrs and 67(67%) were adults. 59(59%) of the patients had unilateral CSOM while 41 had bilateral CSOM which gave a total of 141 ears that were analyzed. 119(84.4%) had pure cultures, 20(14.2%) had mixed cultures and 2(1.4%) had no growth. Of the 169 microbiological isolates, the most frequent isolates were Proteus mirabilis 49(29.0%), Pseudomonas aeruginosa, 32(18.9%), coagulase negative Staphylococcus 18(10.7%) and klebsiella pneumonie 17(10.1%). High sensitivity rates were revealed to Gentamycin (64-100%), meropenem (68-100%), ceftazidime (85-100%), ceftriaxone (64-80%), and ciprofloxacin (66- 88%). High resistance rates were recorded to Amoxicillin-clavulanate (as high as 100%), ampicillin (as high as 100%), tetracycline (as high as 91.2%) and cotrimoxazole (as high as 100%) and penicillin (as high as 100%).Conclusion:Proteus mirabilis was the most dominant microbiological isolate followed by Pseudomonas aureginosa. The isolated microorganisms had high susceptibility rates to gentamycin, meropenem, ceftazidime, ceftriaxone and ciprofloxacin. There were high resistance rates to amoxicillin-clavulanate, ampicillin, tetracycline, cotrimoxazole and penicillin. |
Phiri, H., Ayugi, J., Omutsani, M., Froeschl, U., Mwaba, J. , |
| 2016 | Pattern of distribution of patients presenting with osteogenesis imperfecta at A.I.C. Cure Children’s International Hospital, Kijabe | Kenya | Mwangi, G. C. | East African Orthopaedic Journal | AbstractObjective:The study was carried out to determine the tribal and geographical distribution of patients with osteogenesis imperfecta in Kenya.Design:This was a 14 year retrospective review study.Setting:Cure Hospital, Kenya.Materials and Methods:The medical charts of all patients admitted with Osteogenesis Imperfecta (OI) over a period of 14 years [2000 to 2014] were reviewed.Results:A total of 80 patients with osteogenesis imperfecta were seen. Fifty seven point five percent of the patients with OI were males and 42.5% were females. Thirty seven point five percent were of Kamba origin while 28.8% were from the Kikuyu tribe. Majority of these patients came from Eastern region of Kenya with 26.25% coming from Machakos and 30 out of the total of 80 patients were from Kamba tribe.Conclusions:Most of these patients come from Eastern region of Kenya. Majority of patients with OI were of Kamba origin followed by the Kikuyu tribe. A larger epidemiological study needs to be carried out to more conclusively determine the relative prevalence and genetic patterns of osteogenesis imperfecta in Kenya. |
Mwangi, G. C., Macharia, J. T., |
| 2015 | Prioritisation of surgery in the national health strategic plans of Africa: a systematic review | Malawi | Citron, I. | World Journal of Surgery | AbstractIntroduction:Disease amenable to surgical intervention accounts for 11–15 % of world disability and there is increasing interest in surgery as a global public health issue. National Health Strategic Plans (NHSPs) reflect countries’ long-term health priorities, plans and targets. These plans were analysed to assess the prioritisation of surgery as a public health issue in Africa.Methods:NHSPs of 43 independent Sub-Saharan African countries available in the public domain in March 2014 in French or English were searched electronically for key terms: surg*, ortho*, trauma, cancer, appendic*, laparotomy, HIV, tuberculosis, malaria. They were then searched manually for disease prevalence, targets, and human resources.Results:19 % of NHSPs had no mention of surgery or surgical conditions. 63 % had five or less mentions of surgery. HIV and malaria had 3772 mentions across all the policies, compared to surgery with only 376 mentions. Trauma had 239 mentions, while the common surgical conditions of appendicitis, laparotomy and hernia had no mentions at all. Over 95 % of NHSPs specifically mentioned the prevalence of HIV, tuberculosis, malaria, infant mortality and maternal mortality. Whereas, the most commonly mentioned surgical condition for which a prevalence was given was trauma, in only 47 % of policies. All NHSPs had plans and measurable targets for the reduction of HIV and tuberculosis. Of the total 4064 health targets, only 2 % were related to surgical conditions or surgical care. 33 % of policies had no surgical targets.Discussion:NHSPs are the best available measure of health service and planning priorities. It is clear from our findings that surgery is poorly represented and that surgical conditions and surgical treatment are not widely recognised as a public health priority. Greater prioritisation of surgery in national health strategic policies is required to build resilient surgical systems. |
Citron, I., Chokotho, L., Lavy, C., |
| 2015 | Ethnic pattern of origin of children with spina bifida managed at the University Teaching Hospital and Beit CURE Hospital, Lusaka, Zambia 2001-2010 | Zambia | Mweshi, M. M. | Science Journal of Public Health | AbstractThe incidence of spina bifida (SB) is known to differ among regions. Very little has been reported about the relationship between the incidence of SB and ethnic patterns of origin in Zambia except for the general impression that it is prevalent. The aim of the study was to establish the ethnic pattern of origin of children with SB in Zambia. It was a retrospective cross sectional study. Using a checklist, data was collected from clinical files of children with SB from the University Teaching Hospital (UTH) and Beit Cure Hospital (BCH) from 2001-2010. Descriptive statistical analysis was done in SPSS version 17. A total of 253 children with SB were identified of whom 88 (35%) of them originally came from the Southern Province of the country while the lowest province was the North-Western Province with 7 (3%). Further, a total of 77 (30%) children were referred from the Southern Province of the country and the lowest province that was represented was the North-Western Province with 5 (2%). Observed is the evidence that SB is very prevalent in the Southern Province of the country. With the presence of Uranium in the Southern Province of Zambia, a serious study ought to be done to investigate the possible link of the pollutant with the prevalence of SB in the region. It is essential that the government looks seriously at Uranium Mines being operated in the Province. |
Mweshi, M. M., Amosun, S. L., Shilalukey-Ngoma, M. P., Munalula-Nkandu, E., |
| 2015 | A review of existing trauma and musculoskeletal impairment (TMSI) care capacity in East, Central, and Southern Africa | Malawi | Chokotho, L. | Injury | AbstractBackground:We conducted an assessment of orthopaedic surgical capacity in the following countries in East, Central, and Southern Africa: Burundi, Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Methods:We adapted the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care with questions specific to trauma and orthopaedic care. In May 2013–May 2014, surgeons from the College of Surgeons of East, Central and Southern Africa (COSECSA) based at district (secondary) and referral (tertiary) hospitals in the region completed a web-based survey. COSECSA members contacted other eligible hospitals in their country to collect further data. Findings:Data were collected from 267 out of 992 (27%) hospitals, including 185 district hospitals and 82 referral hospitals. Formal accident and emergency departments were present in 31% of hospitals. Most hospitals had no general or orthopaedic surgeons or medically-qualified anaesthetists on staff. Functioning mobile C-arm X-ray machines were available in only 4% of district and 27% of referral hospitals; CT scanning was available in only 3% and 26%, respectively. Closed fracture treatment was offered in 72% of the hospitals. While 20% of district and 49% of referral hospitals reported adequate instruments for the surgical treatment of fractures, only 4% and 10%, respectively, had a sustainable supply of fracture implants. Elective orthopaedic surgery was offered in 29% and Ponseti treatment of clubfoot was available at 42% of the hospitals. Interpretation:The current capacity of hospitals in sub-Saharan Africa to manage traumatic injuries and orthopaedic conditions is significantly limited. In light of the growing burden of trauma and musculoskeletal impairment within this region, concerted efforts should be made to improve hospital capacity with equipment, trained personnel, and specialist clinical services. |
Chokotho, L., Jacobsen, K. H., Burgess, D., Labib, M., Le, G., Peter, N., Lavy, C. B. D., Pandit, H., |
| 2015 | The Beit CURE classification of childhood chronic haematogenous osteomyelitis—a guide to treatment | Malawi | Stevenson, A. J. | Journal of Orthopaedic Surgery and Research | AbstractBackground:The Beit CURE (BC) classification is a radiographic classification used in childhood chronic haematogenous osteomyelitis. The aim of this study is to assess correlation between this classification and the type and extent of treatment required.Methods:We present a retrospective series of 145 cases of childhood chronic haematogenous osteomyelitis classified using the BC classification. Variables measured include age, sex, bone involved, number of admissions, length of stay, type/number of operations and microbiology.Results:The most commonly affected bone was the tibia (46 %), followed by femur (26 %) and humerus (10 %). Bone defects were most common in the tibia. Staphylococcus aureus was the most commonly isolated organism. Type B, sequestrum type, was the most common (88 %), followed by type C, sclerotic type, (7 %) and type A, Brodie’s abscess (5 %). Types A and B1 had the shortest length of hospitalisation (11 days), type B4 had the longest (87 days). Types A and B1 had the fewest infection control operations. Type B4 had the greatest total number of operations. |
Stevenson, A. J., Jones, H. W., Chokotho, L. C., Beckles, V. L. L., Harrison, W. J., |
| 2015 | Trauma and orthopedic capacity of 267 hospitals in east central and southern Africa | Malawi | Chokotho, L. | The Lancet | AbstractBackground:Trauma and road traffic accidents are predicted to increase significantly in the next decade in low-income and middle-income countries. The College of Surgeons of East, Central, and Southern Africa (COSECSA) covers Ethiopia, Kenya, Tanzania, Uganda, Rwanda, Burundi, Mozambique, Malawi, Zimbabwe, and Zambia. Ministry of Health websites for these ten countries show that 992 hospitals are covering an estimated 318 million people.
Methods:The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used with added questions relevant to trauma and orthopaedic care. A web-based survey platform was used and hospitals were contacted via COSECSA representatives. Consent to share data was requested, anonymised for country and hospital.
Findings:267 (27%) of 992 hospitals completed the survey. 185 were district level hospitals and 82 were referral or tertiary level hospitals. Formal accident and emergency departments were present in only 29% of district hospitals (95% CI 22·5–35·5) and 35% (24·7–45·3) of referral or tertiary level hospitals. The mean number (SD) of surgeons was 1·4 (3·0) in district hospitals and 2·6 (4·6) in referral or tertiary level hospitals. The mean number (SD) of orthopaedic surgeons was 0·3 (0·9) in district hospitals and 0·5 (0·9) in referral or tertiary level hospitals. Medically qualified anaesthetists were available in 16% (95% CI 10·7–21·3) of district hospitals and 20% (11·4–28·6) of referral or tertiary level hospitals. C arm radiography was available in 3% (95% CI 0·5–5·5) of district hospitals and 32% (21·9–42·1) of referral or tertiary level hospitals. CT scanning was available in 6% (95% CI 2·6– 9·4) of district hospitals and 21% (12·2–29·8) of referral or tertiary level hospitals. Closed fracture treatment was offered in 75% (95% CI 68·8– 81·2) of district hospitals and 82% (73·7–90·3) of referral or tertiary level hospitals. 37% (95% CI 30·1–43·9) of district hospitals and 40% (29·4–50·6) of referral or tertiary level hospitals had adequate instruments for the surgical treatment of fractures, but only 7% (3·4–10·6) of district hospitals and 8% (2·1–13·9) of referral or tertiary level hospitals had a sustainable supply of fracture implants. Elective orthopaedic surgery took place in 30% (95% 23·4– 36·6) of district hospitals and 34% (23·8–44·2) of referral or tertiary level hospitals. Ponseti treatment of clubfoot was available at 46% (95% 38·8–53·2) of district hospitals and 44% (33·3–54·7) of referral or tertiary level hospitals.
Interpretation:This study has limitations in that only 27% of eligible hospitals completed the survey, and it is certainly possible that there could be bias in that the less well resourced institutions could also be less likely to cooperate with data collection. Thus, it is possible that the figures we present overestimate the resources available in the region as a whole. However, despite the limitations in data quality, it is clear that current capacity to treat trauma and orthopaedic conditions is very limited, with particular areas of concern being manpower, training, facilities, and equipment. COSECSA will use these data as a baseline for further surveys and to develop a strategy to improve trauma and orthopaedic care in the region.
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Chokotho, L., Jacobsen, K. H., Burgess, D., Labib, M., Le, G., Lavy, C. B. D., Pandit, H., |
| 2015 | Finding surgery’s place on the global health agenda | Uganda | Huber, B. | The Lancet | AbstractBillions of people worldwide do not have access to even the simplest surgical procedures. But a new global initiative has launched that hopes to change the situation. Bridget Huber reports. Joshua Bukenya was barely a week old when he started having convulsions in March, 2014. His worried parents took him to be prayed over at a church near their home in eastern Uganda’s Buyende district. At first, it seemed to work, said his mother, Mera. But, with time, it became clear that the child’s head was growing abnormally large. In November, his mother brought him to the CURE Children’s Hospital in the city of Mbale for treatment. There, doctors explained that he had infant hydrocephalus, a life-threatening accumulation of fluid in the brain, in his case likely caused by the infection that was also responsible for his seizures. Joshua was luckier than most African children with hydrocephalus. His family lives close enough to a charity hospital that has pioneered a new treatment for the condition and provides the neurosurgery regardless of a family’s ability to pay. But in sub-Saharan Africa, most children in need of such surgery for hydrocephalus-an estimated 250 000 each year—don’t get it, and their prospects are dim. About half will die, in pain, by 2 years of age and most of those who survive will be severely disabled. Even people who need a simple operation often go without; globally, about 5 billion people have no access to surgical care, according to the Commission on Global Surgery published on April 27. That means conditions that could be treated surgically, like obstructed labour or appendicitis, can become a death sentence. And something as simple as a broken bone can disable a person for life. Scaling up basic surgical services in low-income and middle-income countries could save an estimated 1·5 million lives per year in these countries, according to the most recent edition of Disease Control Priorities. |
Huber, B., |
| 2015 | Reopening of an obstructed third ventriculostomy: long-term success and factors affecting outcome in 215 infants | Uganda | Marano, P. J. | Journal of Neurosurgery | AbstractObject:The role of reopening an obstructed endoscopic third ventriculostomy (ETV) as treatment for ETV failure is not well defined. The authors studied 215 children with ETV closure who underwent successful repeat ETV to determine the indications, long-term success, and factors affecting outcome.Methods:The authors retrospectively reviewed the CURE Children’s Hospital of Uganda database from August 2001 through December 2012, identifying 215 children with failed ETV (with or without prior choroid plexus cauterization [CPC]) who underwent reopening of an obstructed ETV stoma. Treatment survival according to sex, age at first and second operation, time to failure of first operation, etiology of hydrocephalus, prior CPC, and mode of ETV obstruction (simple stoma closure, second membrane, or cisternal obstruction from arachnoid scarring) were assessed using the Kaplan-Meier survival method. Survival differences among groups were assessed using log-rank and Wilcoxon methods and a Cox proportional hazards model.Results:There were 125 boys and 90 girls with mean and median ages of 229 and 92 days, respectively, at the initial ETV. Mean and median ages at repeat ETV were 347 and 180 days, respectively. Postinfectious hydrocephalus (PIH) was the etiology in 126 patients, and nonpostinfectious hydrocephalus (NPIH) in 89. Overall estimated 7-year success for repeat ETV was 51%. Sex (p = 0.46, log-rank test; p = 0.54, Wilcoxon test), age (< vs > 6 months) at initial or repeat ETV (p = 0.08 initial, p = 0.13 repeat; log-rank test), and type of ETV obstruction (p = 0.61, log-rank test) did not affect outcome for repeat ETV (p values ≥ 0.05, Cox regression). Those with a longer time to failure of initial ETV (> 6 months 91%, 3–6 months 60%, < 3 months 42%, p < 0.01; log-rank test), postinfectious etiology (PIH 58% vs NPIH 42%, p = 0.02; log-rank and Wilcoxon tests) and prior CPC (p = 0.03, log-rank and Wilcoxon tests) had significantly better outcome.Conclusions:Repeat ETV was successful in half of the patients overall, and was more successful in association with later failures, prior CPC, and PIH. Obstruction of the original ETV by secondary arachnoid scarring was not a negative prognostic factor, and should not discourage the surgeon from proceeding. Repeat ETV may be a more durable solution to failed ETV/CPC than shunt placement in this context, especially for failures at more than 3 months after the initial ETV. Some ETV closures may result from an inflammatory response that is less robust at the second operation. |
Marano, P. J., Stone, S. S. D., Mugamba, J., Ssenyonga, P., Warf, E. B., Warf, B. C., |
| 2014 | Effectiveness of caudal epidural block using bupivacaine with neostgmine for pediatric lower extremity orthopedic surgery in CURE Ethiopia Children’s Hospital | Ethiopia | Ataro, G. | Journal of Anesthesia and Clinical Research | AbstractBackground:This study was conducted to assess analgesia and side effects of neostgmine administered with caudal bupivacaine for pediatric lower extremity orthopedic surgeries in routine clinical practice.Methods:In this blinded effectiveness trial, we studied 86 children aged 1-12 years undergoing lower extremity orthopedic surgeries. After induction of general anesthesia, 43 children in Group-B received 1 ml/kg of 0.25% bupivacaine and the other 43 in Group-BN received 1 ml/kg of 0.25% bupivacaine with 2.5 mic/kg neostgmine caudally. Demographic data, hemodynamic data before and after caudal, ASA status, duration of general anesthesia, duration of surgery, episode of post-operative nausea and vomiting (PONV), frequency of rescue analgesics per 24 hour, pain score and sedation score were recorded. Analgesic duration was defined as time from caudal injection to first rescue analgesic administration. Mann-Whitney test to compare median values and chi-square test for nominal data were used. A value “P<0.05” was considered as statistically significant.Result:The median analgesic duration in Group-B was 5.8 ± 2.3 hr and 8.7 ± 5.3 hrs in Group-BN (p=0.003). Number of patients who required rescue analgesic drug doses within 24 hr twice, four times and more than four times were significantly different among the groups (p<0.05). There was no difference among the groups regarding pain and sedation scores. The PONV incidence was observed in Group-B (4.6%) and Group-BN (13.9%) which is not statistically significant (p>0.05) across the groups.Conclusion:In routine clinical practice, addition of neostgmine to caudally administered bupivacaine prolongs analgesic duration without significant difference in PONV. It also decreases rescue analgesic consumption within 24 hours. |
Ataro, G., Bernard, M., |
| 2014 | Ponseti clubfoot management: Experience with the Steenbeek foot abduction brace | Kenya | Mang’oli, P. | Paediatrics & Child Health | AbstractClubfoot is one of the most common congenital deformities, with an incidence of one in 1000 live births worldwide. In Kenya, approximately 1200 infants are born with clubfoot every year. Left untreated, clubfoot leads to painful, disabling deformity and social stigmatization. Bracing is an integral part of the internationally accepted standard of care, and the Ponseti method of clubfoot management with compliance with bracing is considered to be the key to a successful outcome (1). This has brought the type of brace under scrutiny, with newer ‘child-friendly’ braces recommended over the traditional Dennis Brown brace (Figure 1), which has been associated with high rates of noncompliance. However, these child-friendly braces are expensive (USD$300) and out of reach for most families of affected children in Kenya and other developing countries. The Steenbeek foot abduction brace (SFAB) is made locally in Kenya at a cost of <USD$10 (Figure 2). The SFAB has been in use since the inception of the Clubfoot Care for Kenya (CCK) program in 2005. Therefore, we performed a study investigating SFAB acceptance, tolerability, compliance, complications and outcomes in the CCK program. |
Mang’oli, P., Theuri, J., Kollmann, T., MacDonald, N. E., |
| 2014 | Three steps forward and 2 steps back: the Echternach Procession toward optimal hydrocephalus treatment | Uganda | Warf, B. C. | Neurosurgery | AbstractThe dancing procession in Echternach, a small town in Luxembourg, is a centuries-old religious procession to the shrine of St. Willibrord that has taken various forms over time. At one point in history, the celebrants took three steps forward and two steps backward, thus taking five steps to make one step of progress. This , I think, provides a good analogy for the last 100 years of progress in our understanding and treatment of hydrocephalus. I joined this procession when my family and I moved to Uganda in 2000 to work with CURE International, a non-profit Christian organization, in founding a pediatric neurosurgery hospital for the region. When the hospital was opened, it quickly became apparent that infant hydrocephalus was the most overwhelming problem, and we subsequently found that the majority (60%) of these cases were secondary to neonatal ventriculitis. We has subsequently reported the enormous burden of infant hydrocephalus in sub-Saharan Africa and the long-term outcome for these postinfectious hydrocephalus cases. We were soon treating >500 new infants for hydrocephalus at the CURE Children’s Hospital of Uganda each year. Creating shunt dependence was more problematic in sub-Saharan Africa than in developed countries and begged the question as to what the best treatment for hydrocephalus would be in that particular context. However, I suggest that we do not yet know the correct answer to that question for this or any other context because we have an incomplete understanding of both cerebrospinal fluid (CSF), physiology, and hydrocephalus. The problem is compounded by often not recognizing our unfounded assumptions. |
Warf, B. C., |
| 2014 | Back-carrying infants to prevent developmental hip dysplasia and its sequelae: Is a new public health initiative needed? | Malawi | Graham, S. | Journal of Pediatric Orthopaedics | AbstractBackgroundDevelopmental dysplasia of the hip (DDH) is rarely encountered in the native sub-Saharan African population. We present a retrospective review of the incidence of symptomatic DDH in Malawi and a systematic review of the role of back-carrying as a potential influence of prevalence in this population group.
MethodsWe retrospectively reviewed the diagnosis and management of all infants seen at the Beit CURE International Hospital, Malawi and its mobile clinics, from November 2002 to September 2012. In addition, methodical review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist and algorithm was performed.
ResultsA total of 40,683 children aged less than 16 years were managed at our institute over a 10-year period, of which 9842 children underwent surgery. No infant presented with, or underwent surgical intervention, for symptomatic DDH.
ConclusionsThe majority of mothers in Malawi back-carry their infants during the first 2 to 24 months of life, in a position that is similar to that of the Pavlik harness. We believe this to be the prime reason for the low incidence of DDH in the country. In addition, there is established evidence indicating that swaddling, the opposite position to back-carrying, causes an increase in the incidence of DDH. There is a need for the establishment of a large clinical trial into back-carrying and prevention of DDH in non-African population groups.
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Graham, S., Manara, J., Chokotho, L., Harrison, W. J, |
| 2014 | Total hip replacement in HIV-positive patients | Malawi | Graham, S. M. | The Bone & Joint Journal | AbstractWe report the short-term follow-up, functional outcome and incidence of early and late infection after total hip replacement (THR) in a group of HIV-positive patients who do not suffer from haemophilia or have a history of intravenous drug use. A total of 29 patients underwent 43 THRs, with a mean follow-up of three years and six months (five months to eight years and two months). There were ten women and 19 men, with a mean age of 47 years and seven months (21 years to 59 years and five months). No early (< 6 weeks) or late (> 6 weeks) complications occurred following their THR. The mean pre-operative Harris hip score (HHS) was 27 (6 to 56) and the mean post-operative HHS was 86 (73 to 91), giving a mean improvement of 59 points (p = < 0.05, Student’s t-test). No revision procedures had been undertaken in any of the patients, and none had any symptoms consistent with aseptic loosening. This study demonstrates that it is safe to perform THR in HIV-positive patients, with good short-term functional outcomes and no apparent increase in the risk of early infection. |
Graham, S. M., Lubega, N., Mkandawire, N., Harrison, W. J., |
| 2014 | Effectiveness of the bactiseal universal shunt for reducing shunt infection in a sub-Saharan African context: a retrospective cohort study in 160 Ugandan children | Uganda | Lane, J. D. | Journal of Neurosurgery |
Object: |
Lane, J. D., Mugamba, J., Ssenyonga, P., Warf, B. C., |
| 2014 | Use of antibiotic cement spacers/beads in treatment of musculoskeletal infections at A.I.C. Kijabe Hospital | Kenya | Mwangi, G. C. | East African Orthopaedic Journal | AbstractObjective:The study was done to determine outcome of treatment of chronic musculoskeletal infections involving bone after use of local antibiotic impregnated cement and report the microbiological patterns of these infections in our hospital.Setting:A.I.C. Kijabe Hospital, Kenya.Patients and Methods:The medical charts of all patients treated with antibiotic cement were reviewed over the period of one year [September 2012 to September 2013]. The cohort consisted of 80% males and 20% females. The patterns of cultures for infections were reviewed and the procedure of antibiotic impregnated cement placement described.Results:Twenty patients charts were reviewed, 4 (20%) were females and 16 (80%) males with ages ranging between 4 years and 62 years. Of these 40% had infected non unions of tibiae and femur, 25% open fractures, 25% chronic osteomyelitis. Culture results revealed 25% mixed infections, 20% staphylococcus aureus. All patients had initial debridement and antibiotic impregnated bone cement. Infection was cleared in 95% of the patients with 75% having radiological evidence of healing. Forty percent had bone transport of between 4 and 6 cm. A 100% of the patients had negative cultures at the time of antibiotic cement spacers removal.Conclusions:Use of antibiotic impregnated bone cement could be used in treating chronic musculoskeletal infections. |
Mwangi, G. C., Macharia, J. T., |
| 2013 | Presentation, pathology, and treatment outcome of brain tumors in 172 consecutive children at CURE Children’s Hospital of Uganda. The predominance of visible diagnosis and the uncertainties of epidemiology in sub-Saharan Africa. | Uganda | Stagno, V. | Child’s Nervous System | AbstractObject:This study reviews the first operative series of pediatric brain tumors from Uganda, the largest series from Sub-Saharan Africa, and explores the challenges to progress in pediatric neuro-oncology in the region.Methods:This is a retrospective operative series of brain tumors in 172 children at Cure Children’s Hospital of Uganda over 10 years. Demographics, clinical presentation, lesion location, histopathology, operative management, and outcome were investigated. Survival was assessed using Kaplan–Meier method. Log-rank test and p value with Bonferroni correction were used to determine significance of survival differences.Results:There were 103 males (59.9 %) and 69 females (40.1 %; mean age at diagnosis 6.5 years with 29 % < 2 years). The most common histologic types were pilocytic astrocytoma (23.2 %), ependymoma (16.3 %), craniopharyngioma (9.9 %), choroid plexus papilloma (9.3 %), and medulloblastoma (8.1 %). Supratentorial tumors (62.2 %) were more common. Symptomatic hydrocephalus predominated at presentation (66.9 %). In 71 (41.3 %), the presentation was macrocephaly or a visible mass. Estimated 5-year survival was 60 %.Conclusions:The majority of pediatric brain tumors in the region likely go unrecognized. Most that do come to attention have a “visible diagnosis.” Unlike operative series from developed countries, information about the incidence, prevalence, and overall burden of disease for different tumor types cannot be deduced from the various operative series reported from limited resource countries because of the selection bias that is unique to this context. Delayed presentation and poor access to adjuvant therapies were important contributors to the high mortality. The epidemiology of pediatric brain tumors in sub-Saharan Africa is obscure. |
Stagno, V., Mugamba, J., Ssenyonga, P., Nsubuga Kaaya, B., Warf, B. C., |
| 2013 | Effects of honey and sugar dressings on wound healing | Malawi | Mphande, A. N. G. | Journal of Wound Care | AbstractObjective:To investigate whether there is a difference between the efficacy of honey and sugar as wound dressings. Method:Patients with open or infected wounds were randomised to receive either honey or sugar dressings. Bacterial colonisation, wound size, wound ASEPSIS score and pain were assessed at the start of treatment and at weekly intervals until full healing occurred. Results:Forty patients were enrolled; 18 received sugar dressings and 22 honey dressings. In the honey group, 55% of patients had positive wound cultures at the start of treatment and 23% at one week, compared with 52% and 39% respectively in the sugar group. The median rate of healing in the first two weeks of treatment was 3.8cm2/week for the honey group and 2.2cm2/week for the sugar group. After three weeks of treatment 86% of patients treated with honey had no pain during dressing changes, compared with 72% treated with sugar. Conclusion:Honey appears to be more effective than sugar in reducing bacterial contamination and promoting wound healing, and slightly less painful than sugar during dressing changes and motion. |
Mphande, A. N. G., Killowe, C., Phalira, S., Wynn Jones, H., Harrison, W. J., |
| 2013 | Avascular necrosis of the femoral head in HIV positive patients-an assessment of risk factors and early response to surgical treatment | Malawi | Chokotho, L. | Malawi Medical Journal | Abstract26 consecutive patients (37 hips) with avascular necrosis (AVN) of the femoral head treated surgically at our institution from 1999 to 2008 were reviewed . The aims of the study were to evaluate the risk factors associated with AVN in HIV positive and HIV negative individuals, and assess early response to total hip replacement (THR) surgery in HIV positive and negative patients. There were 15 male and 11 female patients in total. The mean age for all patients was 47.1± 8.0 years (range, 33 to 66 years). 12 patients were HIV positive, 11 patients were HIV negative and 3 patients had unknown HIV status. Excessive alcohol intake was the most common risk factor for developing AVN .15 patients (58%) had more than one risk factor for AVN and only 2/12 (17%) HIV positive patients had no other risk factor apart from HIV infection. There were no early postoperative complications in 34 arthroplasties in both HIV positive and negative patients. The aetiology of AVN seems often to be multifactorial, even in the presence of HIV infection. Early response to arthroplasty surgery in AVN of the femoral head is equally good irrespective of the HIV serostatus of the patients. |
Chokotho, L., Harrison, W. J., Lubega, N., Mkandawire, N. C., |
| 2013 | Assessing quality of existing data sources on road traffic injuries (RTIs) and their utility in informing injury prevention in the Western Cape Province, South Africa | Malawi | Chokotho, L. C. | Traffic Injury Prevention | AbstractObjectives:This study assessed whether the quality of the available road traffic injury (RTI) data was sufficient for determining the burden of RTIs in the Western Cape Province and for implementing and monitoring road safety interventions.Methodology:Underreporting was assessed by comparing data reported by the South African Police Services (SAPS) in 2008 with data from 18 provincial mortuaries. Completeness of the driver death subset of all RTIs was assessed using the capture–recapture method.Results:The mortuary and police data sets comprised 1696 and 860 fatalities respectively for the year 2008. The corresponding provincial road traffic mortality rates were as follows: 32.2 deaths/100,000 population per year (95% confidence interval [CI]: 30.7–33.8) and 16.3 deaths/100,000 population per year (95% CI: 15.3–17.5). The police data set contained 820,960 crashes, involving 196,889 persons, indicating substantial duplication of crash events. There were varying proportions of missing data for demographic and other identifying variables, with age missing in nearly half of the cases in the police data set. The estimated total number of driver deaths/year was 588.6 (95% CI: 544.4–632.8), yielding estimated completeness of the mortuary and police data sets of 57.6 and 46.4 percent separately and 77.3 percent combined.Conclusion:This study found extensive data quality problems, including missing data, duplication, and significant underreporting of traffic injury deaths in the police data. Not all assumptions underlying the use of capture–recapture method were met in this study; hence, the estimates provided by this analysis should be interpreted with caution. There is a need to address the problems highlighted by this study in order to improve data utility for informing road safety policies. |
Chokotho, L. C., Matzopoulos, R., Myers, J. E., |
| 2013 | Educate one to save a few. Educate a few to save many | Uganda | Warf, B. C. | World Neurosurgery | AbstractRoughly one-third of the world’s nearly 7 billion people are covered by approximately 1/20 of its neurosurgeons. Neurosurgeons in the more developed countries have a moral obligation to increase access to neurosurgical care for the rest of the world. This can be achieved most effectively through neurosurgical education. Many neurosurgeons have already contributed greatly in this regard. Because of insufficient access to neurosurgical care, most children with hydrocephalus in Africa go untreated. Possibly as many as 2000 infants per neurosurgeon per year will develop hydrocephalus in sub-Saharan Africa. We have adopted a disease-specific strategy for training and equipping centers to provide evidence-based endoscopic treatment of hydrocephalus to save lives while avoiding the danger of shunt dependence, which is magnified in this context. In Uganda, we have successfully educated one to save a relative few. Our aim is to educate a few to save many. Such a disease-specific approach may provide a useful strategy for increasing access to care for other common, treatable neurosurgical conditions in resource-poor settings. |
Warf, B. C., |
| 2012 | Shunt survival after failed endoscopic treatment of hydrocephalus | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:It is not known whether previous endoscopic third ventriculostomy (ETV) affects the risk of shunt failure. Different epochs of hydrocephalus treatment at the CURE Children’s Hospital of Uganda (CCHU)—initially placing CSF shunts in all patients, then attempting ETV in all patients, and finally attempting ETV combined with choroid plexus cauterization (CPC) in all patients—provided the opportunity to assess whether prior endoscopic surgery affected shunt survival.Methods:With appropriate institutional approvals, the authors reviewed the CCHU clinical database to identify 2329 patients treated for hydrocephalus from December 2000 to May 2007. Initial ventriculoperitoneal (VP) shunt placement was performed in 900 patients under one of three circumstances: 1) primary nonselective VP shunt placement with no endoscopy (255 patients); 2) VP shunt placement at the time of abandoned ETV attempt (with or without CPC) (370 patients); 3) VP shunt placement subsequent to a completed but failed ETV (with or without CPC) (275 patients). We analyzed time to shunt failure using the Kaplan-Meier method to construct survival curves, Cox proportional hazards regression modeling, and risk-adjusted analyses to account for possible confounding differences among these groups.Results:Shunt failure occurred in 299 patients, and the mean duration of follow-up for the remaining 601 was 28.7 months (median 18.8, interquartile range 4.1–46.3). There was no significant difference in operative mortality (p = 0.07 by log-rank and p = 0.14 by Cox regression adjusted for age and hydrocephalus etiology) or shunt infection (p = 0.94, log-rank) among the 3 groups. There was no difference in shunt survival between patients treated with primary shunt placement and those who underwent shunt placement at the time of an abandoned ETV attempt (adjusted hazard ratio [HR] 1.14, 95% CI 0.86–1.51, p = 0.35). Those who underwent shunt placement after a completed but failed ETV (with or without CPC) had a lower risk of shunt failure (p = 0.008, log-rank), with a hazard ratio (adjusted for age at shunting and etiology) of 0.72 (95% CI 0.53–0.98), p = 0.03, compared with those who underwent primary shunt placement without endoscopy; but this was observed only in patients with postinfectious hydrocephalus (PIH) (adjusted HR 0.55, 95% CI 0.36–0.85, p = 0.007), and no effect was apparent for hydrocephalus of noninfectious etiologies (adjusted HR 0.98, 95% CI 0.64–1.50, p = 0.92). Improved shunt survival after failed ETV in the PIH group may be an artifact of selection arising from the inherent heterogeneity of ventricular damage within that group, or a consequence of the timing of shunt placement. The anticipated benefit of CPC in preventing future ventricular catheter obstruction was not observed.Conclusions:A paradigm for infant hydrocephalus involving intention to treat by ETV with or without CPC had no adverse effect on mortality or on subsequent shunt survival or infection risk. This study failed to demonstrate a positive effect of prior ETV or CPC on shunt survival. |
Warf, B. C., Bhai, S., Kulkarni, A. V., Mugamba, J., |
| 2011 | Costs and benefits of neurosurgical intervention for infant hydrocephalus in sub-Saharan Africa | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:Evidence from the CURE Children’s Hospital of Uganda (CCHU) suggests that treatment for hydrocephalus in infants can be effective and sustainable in a developing country. This model has not been broadly supported or implemented due in part to the absence of data on the economic burden of disease or any assessment of the cost and benefit of treatment. The authors used economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at CCHU. These results were then extrapolated to the potential economic impact of treating all cases of hydrocephalus in infants in sub-Saharan Africa (SSA).Methods:The authors conducted a retrospective review of all children initially treated for hydrocephalus at CCHU via endoscopic third ventriculostomy or shunt placement in 2005. A combination of data and explicit assumptions was used to determine the number of times each procedure was performed, the cost of performing each procedure, the number of disability-adjusted life years (DALYs) averted with neurosurgical intervention, and the economic benefit of the treatment. For CCHU and SSA, the cost per DALY averted and the benefit-cost ratio of 1 year’s treatment of hydrocephalus in infants were determined.Results:In 2005, 297 patients (median age 4 months) were treated at CCHU. The total cost of neurosurgical intervention was $350,410, and the cost per DALY averted ranged from $59 to $126. The CCHU’s economic benefit to Uganda was estimated to be between $3.1 million and $5.2 million using a human capital approach and $4.6 million–$188 million using a value of a statistical life (VSL) approach. The total economic benefit of treating the conservatively estimated 82,000 annual cases of hydrocephalus in infants in SSA ranged from $930 million to $1.6 billion using a human capital approach and $1.4 billion–$56 billion using a VSL approach. The minimum benefit-cost ratio of treating hydrocephalus in infants was estimated to be 7:1.Conclusions:Untreated hydrocephalus in infants exacts an enormous price from SSA. The results of this study suggest that neurosurgical intervention has a cost/DALY averted comparable to other surgical interventions that have been evaluated, as well as a favorable benefit-cost ratio. The prevention and treatment of hydrocephalus in SSA should be recognized as a major public health priority. |
Warf, B. C., Alkire, B. C., Bhai, S., Hughes, C., Schiff, S. J., Vincent, J. R., Meara, J. G., |
| 2011 | Five-year survival and outcome of treatment for postinfectious hydrocephalus in Ugandan infants | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:Neonatal infection is the most common cause of infant hydrocephalus in Uganda. Postinfectious hydrocephalus (PIH) is often accompanied by primary brain injury from the original infection. Since 2001, ETV (with or without choroid plexus cauterization) has been our primary treatment for PIH. The long-term outcome in these children is unknown.Methods:We studied the 5-year outcome in a cohort of 149 infants treated for PIH from 2001 to 2005 and who lived in 4 districts close to the hospital. Survival analysis was performed using the Kaplan-Meier method. Statistical significance was determined using the Fisher, Breslow, and log-rank tests.Results:The patients’ mean age at presentation was 9.5 months (median 3.0 months). Eighty-four patients (56.4%) were successfully treated without a shunt. Operative mortality was 1.2% for ETV and 4.4% for shunt placement (p = 0.3). Five-year survival was 72.8% in the non–shunt-treated group and 67.6% in the shunt-treated group, with no difference in survival (log rank p = 0.43, Breslow p = 0.46). Of 43 survivors assessed at 5–11 years, those with shunts had significantly worse functional outcomes (p = 0.003–0.035), probably reflecting treatment selection bias since those with the worst sequelae of ventriculitis were more likely to be treated with shunt placement.Conclusions:Nearly one-third of treated infants died within 5 years, and at least one-third of the survivors were severely disabled. There was no survival advantage for non–shunt-treated patients at 5 years. A randomized trial of endoscopic third ventriculostomy versus shunt placement for treating PIH may be indicated. Public health measures that prevent these infections are urgently needed. |
Warf, B. C., Dagi, A. R., Kaaya, B. N., Schiff, S. J., |
| 2011 | Management of Dandy-Walker complex–associated infant hydrocephalus by combined endoscopic third ventriculostomy and choroid plexus cauterization | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:Dandy-Walker complex (DWC) is a continuum of congenital anomalies comprising Dandy-Walker malformation (DWM), Dandy-Walker variant (DWV), Blake pouch cyst, and mega cisterna magna (MCM). Hydrocephalus is variably associated with each of these, and DWC-associated hydrocephalus has mostly been treated by shunting, often with 2-compartment shunting. There are few reports of management by endoscopic third ventriculostomy (ETV). This study is the largest series of DWC or DWM-associated hydrocephalus treated by ETV, and the first report of treatment by combined ETV and choroid plexus cauterization (ETV/CPC) in young infants with this association.Methods:A retrospective review of the CURE Children’s Hospital of Uganda clinical database between 2004 and 2010 identified 45 patients with DWC confirmed by CT scanning (25 with DWM, 17 with DWV, and 3 with MCM) who were treated for hydrocephalus by ETV/CPC. Three were excluded because of other potential causes of hydrocephalus (2 postinfectious and 1 posthemorrhagic).Results:The median age at treatment was 5 months (88% of patients were younger than 12 months). There was a 2.4:1 male predominance among patients with DWV. An ETV/CPC (ETV only in one) was successful with no further operations in 74% (mean and median follow-up 24.2 and 20 months, respectively [range 6–65 months]). The rate of success was 74% for DWM, 73% for DWV, and 100% for MCM; 95% had an open aqueduct, and none required posterior fossa shunting.Conclusions:Endoscopic treatment of DWC-associated hydrocephalus should be strongly considered as the primary management in place of the historical standard of creating shunt dependence. |
Warf, B. C., Dewan, M., Mugamba, J., |
| 2011 | Hydrocephalus associated with neural tube defects: characteristics, management, and outcome in sub-Saharan Africa | Uganda | Warf, B. C. | Child’s Nervous System | AbstractObjective:The past decade has provided new insights into the causes and optimal treatment of infant hydrocephalus in sub-Saharan Africa. Here, I review what we have learned in East Africa about the characteristics, management, and outcomes of hydrocephalus associated with neural tube defects, with particular emphasis on its primary treatment by endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV/CPC).Methods:New data from an updated review of the CURE Children’s Hospital clinical database is combined with previously published observations to summarize what we have learned to date.Results:Hydrocephalus associated with myelomeningocele (MM) accounted for 11.8% of 2,780 new cases of hydrocephalus reviewed, and that associated with encephalocele (EC) accounted for 0.5%. Treatment for hydrocephalus was required in 51% of infants with MM and 32% of those with EC. Aqueductal stenosis or obstruction was observed in 82.7% of patients with MM and 71% of those with EC. ETV/CPC successfully treated hydrocephalus without any further surgery in 76% of infants with MM and 80% of those with EC, and was superior to shunting in regard to the incidence of treatment failure, operative mortality, and infection. Shunting in MM infants has no apparent developmental advantage. Although 5-year mortality for infants with neural tube defects in Uganda is significantly greater than their unaffected peers, this appears to be dramatically reduced by the “observer effect” of community-based rehabilitation.Conclusions:Primary management by ETV/CPC avoids the increased danger of shunt dependence in sub-Saharan Africa for most infants with hydrocephalus associated with neural tube defects. |
Warf, B. C., |
| 2011 | Association of bacteria with hydrocephalus in Ugandan infants | Uganda | Li, L. | Journal of Neurosurgery | AbstractObject:Infantile hydrocephalus in East Africa is predominantly postinfectious. The microbial origins remain elusive, since most patients present with hydrocephalus after antecedent neonatal sepsis (NS) has resolved.Methods:To characterize this syndrome in Ugandan infants, the authors use polymerase chain reaction targeting bacterial16S ribosomal DNA from CSF to determine if bacterial residue from recent infections were detectable. Bacteria were identified based on the relationship of genetic sequences obtained with reference bacteria in public databases. The authors evaluated samples from patients presenting during dry and rainy seasons and performed environmental sampling in the villages of patients.Results:Bacterial DNA was recovered from 94% of patients. Gram-negative bacteria in the phylum Protobacteria were the most commonly detected. Within the phylum, Gammaprotcobacteria dominated in patients presenting after infections during the rainy season, and Betaprotcobacteria was most common following infections during the dry season. Acinetobacter species were identified in the majority of patients admitted after rainy season infection.Conclusions:Postinfectious hydrocephalus in Ugandan infants appears associated with predominantly enteric gram-negative bacteria. These findings highlight the need for linking these cases with antecedent NS to develop more effective treatment and prevention strategies. |
Li, L., Padhi, A., Ranjeva, S. L., Donaldson, S. C., Warf, B. C., Mugamba, J., Johnson, D., Opio, Z., Jayarao, B., Kapur, V., Poss, M., Schiff, S. J., |
| 2011 | Factors affecting the survival of infants myelomeningocele in southeastern Uganda | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:The survival of infants treated for myelomeningocele (MM) and hydrocephalus in Uganda is unknown. This study investigated 5-year survival and the factors that influenced death in these patients.Methods:All 140 children from 16 contiguous districts in southeastern Uganda presenting to CURE Children’s Hospital of Uganda for repair of MM prior to 6 months of age between December 2000 and December 2004 comprised the study cohort. Nine patients died within 1 month (6.4% operative mortality) and were excluded from further analysis. Sixty-seven (51%) required treatment for hydrocephalus. Survival status could not be determined for 3 patients (2%). Circumstances of death were ascertained by hospital record or interview. The Kaplan-Meier method was used for survival analysis. Association between survival and district of origin, age at MM closure, MM lesion level, presence of hydrocephalus, and method of hydrocephalus treatment were investigated.Results:The median follow-up was 86 months. Seventy-three children (56%) were alive at the time of the study, and 81 (63%) had survived more than 5 years. The under-5 mortality rate was 37% (2.5 times greater than the general population). Only 4 deaths appeared directly related to hydrocephalus or MM. There was no significant association between survival and age at MM closure, MM lesion level, presence of hydrocephalus, or its method of treatment. Mortality was lower, approaching that for their unaffected peers, in districts with community-based rehabilitation programs (p = 0.001).Conclusions:Community-based support following surgical interventions for MM and hydrocephalus appears essential to the continued survival of these children in Africa. |
Warf, B. C., Wright, E. J., III, Kulkarni, A. V., |
| 2011 | Encephalocele in Uganda: ethnic distinctions in lesion location, endoscopic management of hydrocephalus, and survival in 110 consecutive children | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:This study characterizes the first clinical series of encephalocele (EC) from East or Central Africa, and is the largest reported from the African continent. The authors explored survival, the efficacy of primary endoscopic management of associated hydrocephalus, and ethnic differences in EC location.Methods:One hundred ten consecutive children presented to CURE Children’s Hospital of Uganda for treatment of EC over a 9-year period. Clinical data, including patient demographic information, birth date, lesion type (sincipital, parietal, or occipital), operative data, and subsequent course had been entered prospectively into a clinical database. Home visits to update the status of those lost to follow-up were done when possible. With appropriate institutional approvals, the database was reviewed for this retrospective study. Two-tailed probability values calculated using the Fisher exact test were used to assess the significance of differences among groups, with p < 0.05 being considered significant. The Kaplan-Meier method was used for analysis of survival and treatment success probabilities.Results:There were 53 (48%) occipital, 33 (30%) sincipital, and 24 (22%) parietal lesions. Occipital lesions were significantly more common among children of Bantu origin (p = 0.02). Nilotes demonstrated a roughly equal distribution among sincipital, parietal, and occipital locations. The female/male ratio was 1.2, with no difference between EC types (range 1.0–1.4, p = 0.6–0.8). Of 110 patients, 108 (98%) underwent surgical repair at a median age of 1 month (mean 15.7 months), whereas 2 had treatment for hydrocephalus only. Wound revision was required in 13% of cases. Surgery-related mortality was 3%. One-year and 5-year survival rates were 87% (95% CI 0.79–0.93) and 61% (95% CI 0.51–0.70), respectively. Hydrocephalus required treatment in 32%, and was equally common among the 3 EC types. Thirteen patients were treated with combined endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC) and 2 with ETV alone, whereas 18 patients received primary shunt placement. Predicted treatment success at 1 year was 79% for ETV or ETV/CPC (95% CI 0.50–0.94) and 47% for shunt placement (95% CI 0.24–0.71).Conclusions:Analysis of this first EC series from this region suggests that sincipital lesions are 3 times more common in East than in West Africa. Occipital lesions predominate in patients of Bantu origin, but not among those of Nilotic descent. Hydrocephalus incidence was equally common among different EC types, and endoscopic treatment was more successful (79%) than shunting (47%) at 1 year. The 5-year mortality rate was similar to that for infants with myelomeningocele in Uganda, and more than twice that for their unaffected peers. |
Warf, B. C., Stagno, V., Mugamba, J., |
| 2010 | Hydrocephalus treatment and outcome in African infants with myelomeningocele: What we have learned so far | Uganda | Warf, B. C. | Cerebrospinal Fluid Research | AbstractWe estimate that around 2000 infants in Uganda develop hydrocephalus (HC) each year. Post-infectious hydrocephalus (PIH) accounts for 60% of all cases, and several lines of investigation are underway to determine the pathogens and their mode of transmission. HC associated with myelomeningocele (MM) is the second most common etiology, accounting for 15% of cases.
Access to treatment for hydrocephalus in Africa is inhibited by poverty, politics, poor infrastructure, and a paucity of neurosurgeons. These also present obstacles to follow up and emergency care for treatment failure, making death from future shunt malfunction a serious enduring threat.
We explored the role of endoscopic treatment for hydrocephalus in African infants, and found that combined endoscopic third ventriculostomy and bilateral choroid plexus cauterization (ETV/CPC) was significantly more successful than ETV alone in those less than one year of age. Infants with myelomeningocele benefitted the most from this approach, with a 76% success rate. In contrast to shunt failure, nearly all ETV/CPC failures become evident within 6 months of surgery. We have demonstrated factors that are independently predictive of ETV/CPC outcome, and have generated a new outcome prediction score (the Uganda Score) that is currently being evaluated across several centers in Africa.
In addition to safety and long-term efficacy of ETV/CPC in the myelomeningocele population, we also demonstrated that those treated in this way performed as well or better on the Bayley Scales of Infant Development over the course of their early childhood development than those who were shunted. Furthermore, we found no correlation between performance and ventricle size. We recently investigated whether the presence of HC or its method of treatment affected 5 year survival in these children, and were surprised to find no difference. Importantly, the most important determinant of survival was involvement in a community-based rehabilitation program. The five year mortality for these children was close to that of their unaffected peers (16%); whereas the mortality for those with no access to such a program was more than triple (50%). Deaths were mostly from causes not directly related to the underlying neurological conditions.
ETV/CPC is a safe and effective alternative to shunt-dependence in children with myelomeningocele. In Africa, any long-term survival advantage of shunt-independence may be obscured by diseases of poverty and neglect. “Life-saving surgery” in these children must be wedded to community-based support programs that promote their access to adequate health care and nutrition.
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Warf, B. C., |
| 2010 | Surgery for Hydrocephalus in sub-Saharan Africa versus developed nations: a risk-adjusted comparison of outcome | Uganda | Kulkarni, A. V. | Child’s Nervous System | AbstractPurpose:Surgery for children in developing nations is challenging. Endoscopic third ventriculostomy (ETV) is an important surgical treatment for childhood hydrocephalus and has been performed in developing nations, but with lower success rates than in developed nations. It is not known if the lower success rate is due to inherent differences in prognostic factors.Methods:We analyzed a large cohort of children (≤20 years old) treated with ETV in developed nations (618 patients from Canada, Israel, United Kingdom) and developing nations of sub-Saharan Africa (979 patients treated in Uganda). Risk-adjusted survival analysis was performed.Results:The risk of an intra-operative ETV failure (an aborted procedure) was significantly higher in Uganda regardless of risk adjustment (hazard ratio (HR), 95% confidence interval (CI), 11.00 (6.01 to 19.84) P < 0.001). After adjustment for patient prognostic factors and technical variation in the procedure (the use of choroid plexus cauterization), there was no difference in the risk of failure for completed ETVs (HR, 95% CI, 1.04 (0.83 to 1.29), P = 0.74).Conclusions:Three factors account for all significant differences in ETV failure between Uganda and developed nations: patient prognostic factors, technical variation in the procedure, and intra-operatively aborted cases. Once adjusted for these, the response to completed ETVs of children in Uganda is no different than that of children in developed nations. |
Kulkarni, A. V., Warf, B. C., Drake, J. M., Mallucci, C. L., Sgouros, S., Costantini, S., the Canadian Pediatric Neusorugery Study Group, |
| 2010 | Pediatric hydrocephalus in East Africa: prevalence, causes, treatments, and strategies for the future | Uganda | Warf, B. C. | World Neurosurgery | AbstractThe burden of infant hydrocephalus in East Africa is significant, with more than 6000 new cases estimated per year. The majority is caused by neonatal infection, and should thus be preventable. With about 1 neurosurgeon per 10,000,000 people in East Africa, initial treatment for hydrocephalus is often unavailable. This also renders shunt dependence more dangerous in East Africa than in the developed world. Endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV/CPC) has proven effective in avoiding shunt dependence in the majority of infants. Unlike shunts, most failures of endoscopic treatment are evident in the early months after surgery, with later failures being rare. Easily accessible clinical parameters can be used to predict the likelihood of success in a given patient. There appears to be no developmental advantage to shunt dependence compared to treatment by ETV/CPC. Cooperative efforts such as the East African Neurosurgical Research Collaboration are needed to broaden the scope of research and training needed to significantly reduce the morbidity and mortality of this disease. |
Warf, B. C., East African Neurosurgical Research Collaboration, , , |
| 2010 | Measuring the health status of children with hydrocephalus by using a new outcome measure | Uganda | Kulkarni, A. V. | Journal of Neurosurgery | AbstractObject:In the setting of a developing country where preoperative imaging may be limited, the authors wished to determine whether cisternal scarring or aqueduct patency at the time of surgery was sufficiently predictive of the failure of endoscopic third ventriculostomy (ETV) to justify shunt placement at the time of the initial operation.Methods:The status of the prepontine cistern and aqueduct at the time of ventriculoscopy was prospectively recorded in 403 children in whom an ETV had been completed. Kaplan-Meier methods were used to construct survival curves. A Cox proportional hazards model was used to provide estimates of HRs for the time to ETV failure. Several independent variables were tested in a single multivariable model, including those previously shown to be associated with ETV survival, that is, age, hydrocephalus etiology, and extent of choroid plexus cauterization (CPC). In addition, intraoperative variables of particular interest were included in the analysis: status of the aqueduct at surgery (closed vs open) and status of the prepontine cistern at surgery (scarred vs clean/unscarred). Multicollinearity was not a concern since the variance inflation factors for all variables were < 2. The examination of stratified survival curves confirmed the appropriateness of the proportional hazards assumption for each variable.Results:Overall actuarial 3-year success was 57%. Consistent with previous results, age, hydrocephalus etiology, and extent of CPC were significantly associated with ETV success. A closed aqueduct and an unscarred cistern were each independently associated with significantly better ETV success (HRs of 0.66 and 0.44, respectively). The presence of cisternal scarring more than doubled the risk of ETV failure, and an open aqueduct increased the risk of failure by 50%.Conclusions:Intraoperative observations of the aqueduct and prepontine cistern are independent predictors of the risk of ETV failure and can be used to further refine outcome predictions based on age, hydrocephalus etiology, and extent of CPC. Further studies will test validity in several African centers and determine what threshold of failure risk should prompt shunt placement at the initial operation. |
Kulkarni, A. V., Drake, J. M., Rabin, D., Dirks, P. B., Humphreys, R. P., Rutka, J. T., |
| 2010 | Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus in Uganda: report of a scoring system that predicts success | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:In Uganda, childhood hydrocephalus is common and difficult to treat. In some children, endoscopic third ventriculostomy (ETV) can be successful and avoid dependence on a shunt. This can be especially beneficial in Uganda, because of the high risk of infection and long-term failure associated with shunting. Therefore, the authors developed and validated a model to predict the chances of ETV success, taking into account the unique characteristics of a large sub-Saharan African population.Methods:All children presenting with hydrocephalus at CURE Children’s Hospital of Uganda (CCHU) between 2001 and 2007 were offered ETV as first-line treatment and were prospectively followed up. A multivariable logistic regression model was built using ETV success at 6 months as the outcome. The model was derived on 70% of the sample (training set) and validated on the remaining 30% (validation set).Results:Endoscopic third ventriculostomy was attempted in 1406 patients. Of these, 427 were lost to follow-up prior to 6 months. In the remaining 979 patients, the ETV was aborted in 281 due to poor anatomy/visibility and in 310 the ETV failed during the first 6 months. Therefore, a total of 388 of 979 (39.6% and [55.6% of completed ETVs]) procedures were successful at 6 months. The mean age at ETV was 12.6 months, and 57.8% of cases were postinfectious in origin. The authors’ logistic regression model contained the following significant variables: patient age at ETV, cause of hydrocephalus, and whether choroid plexus cauterization was performed. In the training set (676 patients) and validation set (303 patients), the model was able to accurately predict the probability of successful ETV (Hosmer-Lemeshow p value > 0.60 and C statistic > 0.70). The authors developed the simplified CCHU ETV Success Score that can be used in the field to predict the probability of ETV success.Conclusions:The authors’ model will allow clinicians to accurately identify children with a good chance of successful outcome with ETV, taking into account the unique characteristics and circumstances of the Ugandan population. |
Warf, B. C., Mugamba, J., Kulkarni, A. V., |
| 2010 | Intraoperative assessment of cerebral aqueduct patency and cisternal scarring: impact on the success of endoscopic third ventriculostomy in 403 African children | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:In the setting of a developing country where preoperative imaging may be limited, the authors wished to determine whether cisternal scarring or aqueduct patency at the time of surgery was sufficiently predictive of the failure of endoscopic third ventriculostomy (ETV) to justify shunt placement at the time of the initial operation.Methods:The status of the prepontine cistern and aqueduct at the time of ventriculoscopy was prospectively recorded in 403 children in whom an ETV had been completed. Kaplan-Meier methods were used to construct survival curves. A Cox proportional hazards model was used to provide estimates of HRs for the time to ETV failure. Several independent variables were tested in a single multivariable model, including those previously shown to be associated with ETV survival, that is, age, hydrocephalus etiology, and extent of choroid plexus cauterization (CPC). In addition, intraoperative variables of particular interest were included in the analysis: status of the aqueduct at surgery (closed vs open) and status of the prepontine cistern at surgery (scarred vs clean/unscarred). Multicollinearity was not a concern since the variance inflation factors for all variables were < 2. The examination of stratified survival curves confirmed the appropriateness of the proportional hazards assumption for each variable.Results:Overall actuarial 3-year success was 57%. Consistent with previous results, age, hydrocephalus etiology, and extent of CPC were significantly associated with ETV success. A closed aqueduct and an unscarred cistern were each independently associated with significantly better ETV success (HRs of 0.66 and 0.44, respectively). The presence of cisternal scarring more than doubled the risk of ETV failure, and an open aqueduct increased the risk of failure by 50%.Conclusions:Intraoperative observations of the aqueduct and prepontine cistern are independent predictors of the risk of ETV failure and can be used to further refine outcome predictions based on age, hydrocephalus etiology, and extent of CPC. Further studies will test validity in several African centers and determine what threshold of failure risk should prompt shunt placement at the initial operation. |
Warf, B. C., Kulkarni, A. V., |
| 2009 | Neurocognitive outcome and ventricular volume in children with myelomeningocele treated for hydrocephalus in Uganda | Uganda | Warf, B. | Journal of Neurosurgery | AbstractObject:Despite lower failure and infection rates compared with shunt placement, it has not been known whether endoscopic third ventriculostomy/choroid plexus cauterization (ETV/CPC) might be inferior in regard to neurocognitive development. This study is the first to describe neurocognitive outcome and ventricle volume in infants with hydrocephalus due to myelomeningocele that was treated primarily by ETV/CPC.Methods:The modified Bayley Scales of Infant Development (BSID-III) test was administered to 93 children with spina bifida who were 5–52 months of age. Fifty-five of these children had been treated by ETV/CPC, 19 received ventriculoperitoneal (VP) shunts, and 19 had required no treatment for hydrocephalus. Raw scores were converted to scaled scores for comparison with age-corrected norms. Ventricular volume was assessed by frontal/occipital horn ratio (FOR) calculated from late postoperative CT scans. The mean values between and among groups of patients were compared using independent samples t-test and ANOVA. The comparison of mean values to population normal means was performed using the single-sample t-test. Linear regression analyses were performed using BSID scores as the dependent variables, with treatment group and ventricular size (FOR) as the independent variables. Probability values < 0.05 were considered significant.Results:. There was no significant difference in mean age at assessment among groups (p = 0.8). The mean scale scores for untreated patients were no different from normal (all p > 0.27) in all portions of the BSID (excluding gross motor), and were generally significantly better than those for both VP shunt–treated and ETV/CPC groups. The ETV/ CPC-treated patients had nonsignificantly better mean scores than patients treated with VP shunts in all portions of the BSID (all p > 0.06), except receptive communication, which was significantly better for the ETV/CPC group (p = 0.02). The mean FOR was similar among groups, with no significant difference between the untreated group and either the VP shunt or ETV/CPC groups. The FOR did not correlate with performance.Conclusions:The ETV/CPC and VP shunt groups had similar neurocognitive outcomes. Neurocognitive outcomes for infants not requiring treatment for hydrocephalus were normal and significantly better than in those requiring treatment. The mean ventricular volume was similar among all 3 groups, and significantly larger than normal. There was no association between FOR and performance. Stable mild-to-moderate ventriculomegaly alone should not trigger intervention in asymptomatic infants with spina bifida. |
Warf, B., Ondoma, S., Kulkarni, A., Donnelly, R., Ampeire, M., Akona, J., Kabachelor, C. R., Mulondo, R., Kaaya Nsubuga, B., |
| 2009 | Results of surgical treatment of quadriceps femoris/contracture in children | Kenya | Muteti, E. N. | East African Orthopaedic Journal | AbstractBackground:The child presenting with quadriceps femoris/contracture that is resistant to serial manipulation and plaster casting and the older child with a fixed contracture of the quadriceps is treated surgically at the African Inland Church-Cure International Children’s Hospital. The surgery involves soft tissue release and lengthening of the quadriceps tendon. Open reduction of the knee and femoral osteotomy is done as indicated.Objective:To analyze the outcome of surgical treatment of quadriceps femoris contracture in children. Setting: AIC-CURE International Children’s Hospital in Kijabe, Kenya.Methodology:This is a review of files of children in our hospital treated surgically for quadriceps fibrosis over a period of three years (January 2005 to December 2007).Results:There were fifty one cases of quadriceps fibrosis in thirty six patients treated surgically over the study period. Thirty one cases were excluded due to incomplete records or patients lost to follow-up. Consequently, the remaining twenty cases were analyzed. The pre-operative range of motion of the knee was grouped as follows: two cases had dislocated knees, three had hyperextension contractures, thirteen (0-30 degrees) and two (31-60 degrees). The final post-operative range of motion was grouped as follows: three (0-30 degrees), four (13-60 degrees), three (61-90 degrees), one (91-120 degrees) and nine (full range of flexion). Gain in flexion ranged from minus forty degrees to positive 140 degrees. The average gain in flexion was 94.7 degrees. Five patients underwent a second procedure to improve flexion. Soft tissue complications developed in four cases.Conclusion:Quadriceps femoris/contracture responds well to surgical treatment with an expected gain in flexion of 94.7 degrees. The commonest complication is skin breakdown |
Muteti, E. N., Theuri, J. T., Mead, T. C., Gokcen, E. C., |
| 2009 | Surgery for pharmacoresistant epilepsy in the developing world: a pilot study | Uganda | Boling, W. | Epilepsia | AbstractEpilepsy prevalence in the developing world is many fold that found in developed countries. For individuals whose conditions failed to respond to pharmacotherapy, surgery is the only opportunity for cure. In Uganda, we developed a center for treatment of intractable temporal lobe epilepsy (iTLE) that functions within the technologic and expertise constraints of a severely low resource area. Our model relies on partnership with epilepsy professionals and training of local staff. Patients were prescreened at regional clinics for iTLE. Individuals meeting inclusion criteria were referred to the treating Ugandan hospital (CURE Children’s’ Hospital of Uganda, CCHU) for video-EEG (electroencephalography), computed tomography (CT) imaging, and neuropsychological evaluation. Data were transferred to epilepsy experts for analysis and treatment recommendations. Ten patients were diagnosed with iTLE and surgically treated at CCHU. Six (60%) were seizure free, and there was no neurologic morbidity or mortality. Our model for surgical treatment of pharmacoresistant TLE has functioned successfully in a true developing world low resource setting. |
Boling, W., Palade, A., Wabulya, A., Longoni, N., Warf, B., Nestor, S., Alpitsis, R., Bittar, R., Howard, C., Andermann, F., |
| 2008 | Combined endoscopic third ventriculostomy and choroid plexus cauterization as primary treatment of hydrocephalus for infants with myelomeningocele: long-term results of a prospective intent-to-treat study in 115 East African infants | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:Shunt dependence is more dangerous for children in less developed countries. Combining endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) was previously shown to treat hydrocephalus more effectively than ETV alone in infants < 1 year of age. The goal of this prospective study was to evaluate the effectiveness of ETV-CPC as primary treatment of hydrocephalus in infants with myelomeningocele.Methods:One hundred fifteen consecutive East African infants with myelomeningocele requiring treatment for hydrocephalus were intended for primary management using ETV-CPC. Patient information was prospectively entered into a database. Outcomes were evaluated by life table analysis. Potential predictors for treatment failure were evaluated using multivariate logistic regression.Results:Ninety-three patients had a completed ETV-CPC with > 1 month of follow-up. The ETV-CPC procedure was successful in 71 patients (76%), with a mean and median follow-up of 19.0 months. Treatment failures occurred before 6 months in 86% of the patients, and none occurred after 10 months. The operative mortality rate was 1.1%, and there were no infections. Life table analysis suggested that 72% of the patients would be successfully treated using a single ETV-CPC and 78% would remain shunt-independent with reopening of a closed ETV stoma. Multivariate logistic regression showed scarring of the cistern (p = 0.021) or choroid plexus (p = 0.026) as predictors of failure, but age at the time of surgery was not a significant predictor.Conclusions:Using ETV-CPC appears to successfully provide a more durable primary treatment of hydrocephalus for infants with spina bifida than does shunt placement. These results support ETV-CPC as the better treatment option for these children in developing countries. |
Warf, B. C., Campbell, J. W., |
| 2007 | Pin-track infection in HIV-positive and HIV-negative patients with open fractures treated by external fixation | Malawi | Norrish, A. R. | The Journal of Joint and Bone Surgery | AbstractPatients infected with HIV presenting with an open fracture of a long bone are difficult to manage. There is an unacceptably high rate of post-operative infection after internal fixation. There are no published data on the use of external fixation in such patients. We compared the rates of pin-track infection in HIV-positive and HIV-negative patients presenting with an open fracture. There were 47 patients with 50 external fixators, 13 of whom were HIV-positive (15 fixators). There were significantly more pin-track infections requiring pharmaceutical or surgical intervention (Checketts grade 2 or greater) in the HIV-positive group (t-test, p = 0.001). The overall rate of severe pin-track infection in the HIV-positive patients requiring removal of the external-fixator pins was 7%. This contrasts with other published data which have shown higher rates of wound infection if open fractures are treated by internal fixation. |
Norrish, A. R., Lewis, C. P., Harrison, W. J., |
| 2005 | Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:The aim of this prospective study was to determine whether, and in which patients, the outcome for bilateral choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) was superior to ETV alone.Methods:A total of 710 children underwent ventriculoscopy as candidates for ETV as the primary treatment for hydrocephalus. The ETV was accomplished in 550 children: 266 underwent a combined ETV—CPC procedure and 284 underwent ETV alone. The mean and median ages were 14 and 5 months, respectively, and 443 patients (81%) were younger than 1 year of age. The hydrocephalus was postinfectious (PIH) in 320 patients (58%), nonpostinfectious (NPIH) in 152 (28%), posthemorrhagic in five (1%), and associated with myelomeningocele in 73 (13%). The mean follow up was 19 months for ETV and 9.2 months for ETV—CPC. Overall, the success rate of ETV—CPC (66%) was superior to that of ETV alone (47%) among infants younger than 1 year of age (p < 0.0001). The ETV—CPC combined procedure was superior in patients with a myelomeningocele (76% compared with 35% success, p = 0.0045) and those with NPIH (70% compared with 38% success, p = 0.0025). Although the difference was not significant for PIH (62% compared with 52% success, p = 0.1607), a benefit was not ruled out (power = 0.3). For patients at least 1 year of age, there was no difference between the two procedures (80% success for each, p = 1.0000). The overall surgical mortality rate was 1.3%, and the infection rate was less than 1%.Conclusions:The ETV—CPC was more successful than ETV alone in infants younger than 1 year of age. In developing countries in which a dependence on shunts is dangerous, ETV—CPC may be the best option for treating hydrocephalus in infants, particularly for those with NPIH and myelomeningocele. |
Warf, B. C., |
| 2005 | HIV/AIDS in trauma and orthopedic surgery | Malawi | Harrison, W. J. | The Journal of Joint and Bone Surgery | AbstractImmune deficiency associated with pneumocystis carinii pneumonia and Kaposi’s sarcoma was first recognised in the United States in 1981. The causative virus, now known as the human immunodeficiency virus (HIV), was identified in 1983 by Barre-Sinoussi, Montagnier and colleagues at the Institut Pasteur, Paris.1,2 The resulting disease has been known as acquired immune deficiency syndrome (AIDS). In 1983 Bayley3 described aggressive cases of Kaposi’s sarcoma in Zambia. In the same hospital in Lusaka, Jellis4 highlighted the musculoskeletal manifestations of HIV-AIDS. The author’s interest in the relation of HIV to the practice of orthopaedic and trauma surgery began during post-graduate training in Bulawayo, Zimbabwe in 1994, and has continued in Blantyre, Malawi since 1999. HIV is a retrovirus which encodes its genome in RNA and transcribes genome copies in DNA using the enzyme reverse transcriptase. This occurs within host cells such as the human CD4 (T helper) lymphocyte. HIV is marked by a fall in the CD4 cell count with an associated decrease in immunity, particularly in humoral immunity. Antiretroviral therapies such as nucleoside analogues and protease inhibitors reduce the viral load in the host serum and restore the numbers of host CD4 cells. The infected individual is not cured but their immunity is at least partially restored. |
Harrison, W. J., |
| 2005 | Comparison of 1-year outcomes for the Chhabra and Codman-Hakim Micro Precision shunt systems in Uganda: a prospective study in 195 children | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObjectThe author investigated the 1-year outcomes for shunt treatment of hydrocephalic children in Uganda, comparing the results using the inexpensive Chhabra shunt ($35 US dollars), widely used in East Africa, with those using the Codman-Hakim Micro Precision Valve shunt ($650).MethodsThe results in 195 consecutive children (mostly infants) in whom shunts were placed were studied prospectively. In Group 1, 90 patients randomly received either the Chhabra or Codman shunt as primary treatment for hydrocephalus. In Group 2, 105 patients received the Chhabra shunt when endoscopic third ventriculostomy could not be performed or had failed. The end points of the study were shunt malfunction, shunt migration, wound complication, death, or no problem at 1 year. Of all patients, 9.7% were lost to follow up and 15.9% died before 1 year. The occurrence of complications in all patients were infection (9.7%), migration/disconnection (6.3%), wound complication (5.7%), valve malfunction (3.4%), ventricular catheter obstruction (2.8%), and peritoneal catheter obstruction (1.1%). There was no statistically significant difference in any outcome category for patients receiving the Codman or Chhabra shunt (p = 0.2463–1.0000).ConclusionsVentriculoperitoneal shunt insertion for treatment of hydrocephalus can be performed in a developing country with results similar to those reported in developed countries. No difference in outcome was noted between the two shunt types. No advantage was found in using a shunt system that, in this setting, is prohibitively expensive. |
Warf, B. C., |
| 2005 | Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy | Uganda | Warf, B. C. | Journal of Neurosurgery | AbstractObject:The aim of this prospective study was to investigate the causes of hydrocephalus in Uganda, the efficacy of endoscopic third ventriculostomy (ETV) in this environment, and whether existing parameters could be used to guide patient selection.Methods:Three hundred consecutive children, 81.3% of whom were younger than 1 year of age, underwent ventriculoscopy preceding ETV as an initial treatment for hydrocephalus. In 179 patients (60%) the hydrocephalus was caused by a cerebrospinal fluid infection; in 76% of patients the infection had occurred in the 1st month of life. In 229 patients (76.3%) ETV was performed; 2% of patients were lost to follow up after less than 1 month and the surgical mortality rate was 1.8%. The first ETV was successful in 115 patients (52%); the mean follow-up period was 15.2 months. The mean time to repeated operation following a failed ETV was 1.5 months. Sixty-five patients underwent a second endoscopy; 37 underwent a second ETV, of which 14 procedures (38%) were successful (mean follow-up period 12.25 months). The overall success rate for ETV was 59%. Among patients older than 1 year of age, the procedure was successful in 22 (81%) of 27 with postinfectious hydrocephalus (PIHC) and 18 (90%) of 20 with nonpostinfectious hydrocephalus (NPIHC). The success rate of ETV among those patients younger than 1 year of age was 59% (60 of 101) for patients suffering from PIHC and 40% (21 of 52) for those suffering from NPIHC. Age correlated with success for NPIHC (p = 0.0002) and PIHC (p = 0.0421). The success rate of the surgery for patients with myelomeningocele and hydrocephalus who were younger than 1 year of age was 40% (eight of 20). The success rate of the surgery for PIHC in infants younger than 1 year of age was 70% (44 of 63) among patients with aqueductal obstruction but 45% (14 of 31) among patients with aqueductal patency (p = 0.0254). Fourth ventricular size as demonstrated on cranial ultrasonography or computerized tomography scanning predicted whether the aqueduct was patent (p = 0.0001).Conclusions:Infection is the most common cause of hydrocephalus in Uganda. In all children older than 1 year of age and in those younger than 1 year of age with PICH and aqueductal obstruction, which was reliably predicted by cranial ultrasonography, ETV was effective. |
Warf, B. C., |
| 2005 | Orthopaedic training in developing countries | Malawi | Lavy, C. B. D. | The Journal of Joint and Bone Surgery | AbstractMore than 80% of the population of the world and a vast reservoir of orthopaedic pathology is located in developing countries. Our experience is mainly in central and sub-Saharan Africa, yet our conclusions hold for poor countries of all continents. The need for both elective and emergency orthopaedic services in developing countries is great. Most of the degenerative musculoskeletal diseases seen in the West are prevalent, as well as conditions such as untreated club foot, gross genu varum and valgus, tuberculosis of the spine and severe chronic osteomyelitis. Road traffic accidents are becoming an epidemic. More than 80% of deaths in road traffic accidents and more than 90% of those involving children occur in developing countries.1 In Malawi there are only four orthopaedic surgeons to care for a population of 12 million people. The need for postgraduate training in orthopaedic surgery in a developing country is undeniable, but whether this should be the only level of training depends on the general level of health services in the country. In Malawi, most of the 25 district hospitals have only one doctor of Senior House Officer level and no specialists. The majority of patients are managed by paramedical personnel known as clinical officers. Our main emphasis in training is to instruct these clinical officers in practical orthopaedics and the treatment of fractures. Each district hospital has one or more orthopaedic clinical officers (OCOs), who are able to treat most trauma safely and relatively conservatively. We have a visiting consultant support service which is patchy at present, but will improve as the number of trained specialists increases. Thus, in Malawi a two-tiered orthopaedic training programme has evolved, where we can train OCOs and postgraduate orthopaedic surgeons side-by-side. The majority of the OCOs work at the district level, while the orthopaedic surgeons are in central or teaching hospitals providing service for clinical referral and increasing the scope of training programmes. We believe this is to be a realistic, cost-effective, and achievable strategy. Other developing countries, where there are more doctors, may aim to have a postgraduate level surgeon at every district hospital (either an orthopaedic surgeon, or a generalist with orthopaedic experience). |
Lavy, C. B. D., Mkandawire, N., Harrison W. J., |
| 2004 | One-year follow-up of orthopedic implants in HIV-positive patients | Malawi | Harrison, W. J. | International Orthopaedics | Abstract
We followed prospectively 38 orthopaedic implants in 36 HIV-positive patients. X-rays and clinical examination were used to assess union, and observation was made for early and late wound sepsis for 12 months from the time of surgery. Two patients died of causes unrelated to the implantation, two patients had implants removed for reasons other than infection and eight cases were lost to follow-up. Of the 26 cases that were reviewed at 1 year, no late sepsis was identified. All of the fractures, non-unions, osteotomies and arthrodeses united. The literature indicates that late sepsis following arthroplasty occurs more frequently in haemophiliacs who are HIV positive than their HIV-negative counterparts. It is still not certain whether or not such a risk also applies to HIV-positive patients who are not haemophiliacs and have undergone internal fixation of fractures or non-unions. This study increases the confidence that fixation in immune-compromised patients with intact skin is safe, at least for the time period that the implant is required. Further studies are required to know whether or not fixation implants should be removed.
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Harrison, W. J., Lavy, C. B. D., Lewis, C. P., |
