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OBJECTIVE In sub-Saharan Africa, neural tube defects (NTDs) are the second most common birth defect, occurring eight times more frequently than in the US. The objective of this study was to assess baseline Zambian caregiver understanding of folate and NTDs and the effectiveness of an NTD prevention educational program. METHODS This prospective survey-based study included Zambian caregivers of children born with NTDs who completed pre- and post-educational program surveys between January 2020 and January 2021. The verbal survey was administered in English or local Zambian dialects. The 1-hour educational program administered by local Zambian research nurses sought to facilitate understanding of the direct relationship between prenatal folate supplementation and NTDs. RESULTS Sixty-one eligible caregivers with a median age of 20 (IQR 24–29) years completed the survey. Participants were predominantly from regions outside of Lusaka Province (68%, 41/60) rather than the capital city, Lusaka (32%, 19/60). Most had received prenatal care (91%, 57/61), and 80% (47/59) reported folate use in pregnancy. Of the mothers who took folate during pregnancy, 24% (11/45) reported use within the first 4 weeks after conception, while 76% (34/45) started thereafter. Myelomeningocele was the most common NTD (74%, 32/43), followed by meningocele (14%, 6/43). Prior to the educational program, 52% (29/56) of caregivers reported that NTDs were caused by a vitamin deficiency, which improved to 98% (55/56) after the program (p < 0.001). Furthermore, only 54% (33/61) of caregivers believed that folate should be taken before conception on the baseline survey evaluation, which improved to 95% (58/61, p < 0.001) after the program. All survey participants (58/58) found the educational session helpful. CONCLUSIONS This study found that a high proportion of Zambian caregivers had received prenatal care and even had taken folate during pregnancy, but none had taken it prior to pregnancy. An educational program effectively improved understanding about the role and timing of perinatal folate administration in NTD prevention. This result also emphasizes the need for folate fortification and folate education for not only mothers but also primary care providers.

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. Methods: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)—a composite of life expectancy, education, and income measures—into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Findings: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24–51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34–69) and the youngest in the low HDI tier (median 28 years, IQR 20–38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6–32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55–5·2) and high HDI tier (2·26, 1·23–4·15), but not the low HDI tier (1·66, 0·61–4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17–2·49). Interpretation: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. Funding: National Institute for Health Research Global Health Research Group.

Pediatric postoperative neurosurgical care is an essential component of a child's treatment pathway. It is important to better understand how neurosurgeons in lower middle-income countries (LMICs) have been able to address socioeconomic and systemic factors to improve their patients' access to quality pediatric postoperative neurosurgical care. We aim to characterize the pediatric neurosurgical postoperative system in place in Zambia and to discuss how these efforts have been implemented to improve outcomes and address socioeconomic barriers to accessing health care.We acquired a patient list of 90 tenants of House of Hope (HOH)-an out-of-hospital center caring for children awaiting surgery, as well as those recovering from surgery. Of the patient list, 44 patients qualified for our study. Survey responses and occurrence of demographic and clinical characteristics were calculated. Non-normally distributed variables (age) were reported by median and interquartile range (IQR). Dichotomous variables were presented as percentages. Fisher's Exact test was applied to compare categorical data and hospital re-admission. A P-value of0.05 was considered significant.Our study demonstrates two key findings: (1) low 30-day hospital re-admission rate of 9% and (2) favorable postoperative experience by patient families. Of the 44 patients, a majority were 1-year-old children (n = 31, 70%) and female (n = 24, 55%) (IQR 1-2 years). Presenting conditions included: hydrocephalus only (n = 35, 80%), hydrocephalus and myelomeningocele (n = 5, 11%), myelomeningocele only (n = 2, 5%), cerebral palsy (n = 1, 2%), and encephalocele (n = 1, 2%). Half (n = 22, 50%) of the patients lived in east Zambia, 8 (18%) lived in central, 8 (18%) in north, 5 (11%) in south, and 1 (2%) in west Zambia.We report the first qualitative and quantitative analysis of postoperative care for LMIC pediatric neurosurgical patients in the academic literature. Quality, patient-centered postoperative pediatric neurosurgical care that is rooted in addressing socioeconomic determinants of health produces good outcomes in LMICs.

OBJECTIVE: Spina bifida disproportionally impacts low-and-middle-income countries. The authors describe myelomeningocele surgical outcomes in Zambia and predictors of postoperative complications and mortality. METHODS: This two-center retrospective cohort study includes children who underwent surgical treatment for myelomeningocele in Lusaka, Zambia from 2017 to 2019. Primary outcomes included mortality and 30-day postoperative complications. RESULTS: Seventy-five patients were identified. Median age at first neurosurgical evaluation was 9 days [IQR 6, 21] and at surgery was 21 days [IQR 15, 36]. Lumbosacral myelomeningocele was most common (73%, n=54). At first preoperative evaluation, 28% of the neural tube defects were deemed infected (n=21), and 30% were leaking CSF (n=21). Postoperatively, 7% of patients died (n=5) while 31% experienced a complication (n=23). Most common complications included wound dehiscence (n=10, 42%) and wound purulence (n=6, 25%). Median follow-up duration was 41 days [IQR 6, 128]. On univariable analysis, mortality was significantly associated with shorter follow-up duration (5 days [IQR 2, 7] versus 46 days [IQR 12, 132]; p = 0.02) and any complication (p

Highlights • An estimated 27 million traumatic brain injuries (TBIs) occur worldwide every year. • In certain cases, neurosurgical intervention for TBI is necessary and life-saving. • The timing and quality of surgery for TBI has long been known to dramatically affect outcome. • There is a paucity of data on outcomes following neurosurgery globally. • GNOS will compare outcomes following emergency surgery for TBI worldwide., Introduction Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. Methods and analysis The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. Ethics and dissemination This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.

OBJECTIVEHydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia.METHODSThis retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications.RESULTSA total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26–4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3–149.1], p < 0.001).CONCLUSIONSPediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.

To review management and outcome of patients with brain abscess treated at Groote Schuur Hospital (GSH) between 1993 and 2003.Case notes, radiological results and laboratory records were reviewed retrospectively for 121 patients at GSH who underwent a neurosurgical procedure for treatment of a brain abscess between 1993 and 2003. Patients not treated surgically were excluded. Follow-up with serial computed tomography (CT) scans, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels and the temperature chart were used to determine the duration of parenteral antibiotic treatment and the need for repeat surgical evacuation of pus by either aspiration or excision of the capsule.The mean patient age was 33 years, with a male-to-female ratio of 5:1. Headache, depressed level of consciousness and pyrexia were the commonest presenting symptoms. Other symptoms included seizures and hemiparesis. The frontal lobe was the commonest site (44%); the majority of abscesses occurred as a result of infection following trauma. Mastoiditis (21%) and sinusitis (8%) were the second and third most common causes. Organisms were identified in 81% of cases; polymicrobial infections occurred in half of these. Thirty-three different organisms were identified, the majority of which were Gram-positive bacteria. Anaerobes were present in 23%, while methicillin-resistant Staphylococcus aureus was identified in 1 patient. Nocardia was seen in 3 patients, 2 of whom were diabetic. The average duration of parenteral antibiotic therapy was 15 and 19 days for excision and aspiration respectively. Accurate ESR records were available in 75% of cases, with a positive predictive value in 81%, while CRP (in use since 1999) was helpful in 92% of cases.Sixteen patients (13%) died, 12 of whom had been admitted with a Glasgow Coma Score (GCS) of less than 4T/15. Thirteen patients developed epilepsy. On discharge, patients continued to take oral antibiotics for another 4 weeks, at the end of which they were reviewed at the neurosurgery outpatient department.Compared with previous studies from this hospital, mortality and morbidity have been diminishing progressively. GCS at the time of admission remains the most important prognostic factor.