Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury

Abstract

OBJECTIVETraumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI.METHODSA prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery.RESULTSA total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128–0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53–0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05–16.7) and older age (continuous HR 1.03, 95% CI 1.009–1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress.CONCLUSIONSInpatient and postdischarge mortality remain high following admission to Uganda’s main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

Effects of timing to surgery on outcomes among adult patients with traumatic expansive intracranial hematomas in a sub-Saharan tertiary hospital: A prospective cohort study

“…In addition, LMIC can be challenging due to a lack of pre-hospital system, few intensive care unit beds and standardised guidelines in management of TBI patients with intracranial hematoma (25). These ndings concur with a study that reported that surival of TBI patients was low (12).…”

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Trauma Causes, Injury Types, and Clinical Presentation

“…[21][22][23]24,25 The high proportion of assaults is distinctive from many studies from both developed and developing countries, 26,27 but reflects a selection of less injured patients for surgery. Non-RTA associated TBI, such as assault, was also found significantly associated with receiving surgery in recent studies from referral hospitals in Uganda 28 and Tanzania. 29 Most of the registered assaults in our study took place in rural areas outside of Addis Ababa; interestingly, this has also been noted in other reports comparing rural and urban areas.…”

“…In a recent study from the main tertiary hospital in Uganda looking at all admitted TBI patients in the period 2014-2015, only 242 (19%) of 1247 patients were operated. 28 In a similar study from a referral hospital in Tanzania of 2502 TBI patients admitted in the period 2013-2017, only 609 (24%) received surgery. 29 Taken together, although relatively few patients undergo surgery, the latter study showed a variable but clear benefit of surgery for all TBI severities, providing a clear rationale for further development of neurosurgical services in Sub-Saharan Africa.…”

The Importance of Collaboration in Global Neurosurgery

“…One of our first research projects involved digitizing ten years' worth of neurosurgery patient data in Uganda and developing a prospective neurosurgical patient database; this has allowed our group to examine patient outcomes (6), explore delays to car e (7) and understand patient outcomes post-hospitalization (8). There are now over 3,000 patients in our prospective database, which has allowed us to perform complex analyses for traumatic brain injury (TBI) patients and utilize recent advancements in predictiv e modeling and machine learning (9).…”