Browsing by Author "Fuller, Anthony"

Introduction: Traumatic brain injury (TBI) accounts for the majority of Uganda’s neurosurgical disease burden, but invasive intracranial pressure (ICP) monitoring is infrequently used. Noninvasive monitoring through tools like pupillometry could change the care of TBI patients in such a setting. Given the novelty of noninvasive monitoring in Uganda, this study sought to assess the feasibility of pupillometry for noninvasive ICP monitoring for TBI patients. Methods: Healthcare workers in Kampala, Uganda received education on pupillometry, practiced using the device on healthy volunteers, and completed interviews focused on pupillometry and its potential implementation. Qualitative analysis of the interviews assessed pupillometry acceptability and feasibility. Quantitative analysis assessed learning time, time to obtain a measurement, and accuracy of measurements during training. Results: Twenty-two providers completed the study. Participants described how pupillometry would add value to the care of patients with TBI during examination, delivering interventions, and monitoring. Reported concerns included the cost, understanding, and maintenance needs of the pupillometer. Participants also discussed potential challenges with using pupillometry, including limited accessibility and availability as well as challenges with documentation. They suggested offering continued education and providing technical support as strategies to support successful implementation. During training, average time to learn was 13.6 minutes (IQR 3.8) and average time to obtain a measurement was 51.1 seconds (IQR 14.2). Paired t tests to evaluate accuracy after training showed no statistically significant difference in the comparison measurements. Conclusion: Pupillometry would be feasible to use for noninvasive ICP monitoring for TBI patients in Uganda, as long as concerns about the device could be addressed and implementation barriers overcome.

Neurosurgical and neurological conditions account for a significant disease burden worldwide, with low- and middle-income countries bearing more than 90% of the burden. Uganda is a low-income nation with a high demand for neuro care services but limited access, especially in rural and remote areas. Mobile health clinics, which have proven to be effective in other specialties, could be adapted to provide neurological care in such regions. The objective of this research was to establish the feasibility, appropriateness, and usability of mobile neuro clinics for providing neurological care to people in Uganda's rural and remote communities. Participants who met the inclusion criteria were invited to participate in an education session. Following the education session, the participants participated in an interview session to evaluate the feasibility, appropriateness, and usability of mobile neuro clinics. The education and interview tools were developed using the Consolidated Framework for Implementation Research (CFIR). To weight provider views, a sentiment weighted scale was used, with total aggregate sentiment scores greater than 42 in each CFIR domain indicating high feasibility, acceptability, and usability. All the assessed CFIR domains scored above sentiment score of 49. The implementation process domain (167) received the best overall sentiment score, followed by the implementation climate structure (141), inner setting domain (102), innovation domain (59), and outer setting domain (55). According to the findings of the research, mobile neuro clinics are feasible, appropriate, and usable in Uganda. To achieve the best results, however, careful planning and integration involving stakeholders from conceptualization to execution are required.

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Globally, disparities in the availability of surgical care are prevalent, and for specialty care such as neurosurgery, services are typically scarce to non-existent. In low-and-middle-income countries, most medical centers have limited resources and are not equipped to handle neurosurgical emergencies. Within the field of global neurosurgery, there has been a push to incorporate advanced technologies such as predictive modeling to facilitate triage and neurosurgical care decision-making. However, to successfully implement such technologies, it is vital to consider the ethical framework within which neurosurgical care decisions are made and how ethical challenges inform decision-making. The objective of this study is to determine whether the potential ethical challenges that neurosurgical care providers encounter are differentially important to decision-making. This study utilizes a rank-order survey to evaluate surgical risk tolerance, the relative importance of several patient-level and system-level factors to the decision to offer surgery, and perceptions of the fairness of several resource-allocation principles when surgery cannot be offered to all patients in need. Further, we assessed whether geographic, demographic, cultural, and institutional characteristics and utilitarian ethical orientation differentially impact these aspects of decision-making. Based on the results, it does seem as though there is a differential impact of ethical challenges on decision-making. In conclusion, this data will allow identification of key commonalities and differences in approaches to neurosurgical decision-making across practice settings, which will potentially facilitate ethically responsible, cross-cultural collaborations and implementations of neurosurgical decision support tools.

Duke University Medical Center neurosurgeon, Dr. Micheal Haglund, established a twinning program between Duke and Mulago Hospital in Kampala, Uganda back in 2008. While a study was performed in 2011 that showed that the program had increased neurosurgical capacity, there was no study looking at patient outcomes. This study was thus undertaken to explore patient outcomes in an effort to provide information the program could use for evaluating its impact.

This study was carried out in a retrospective fashion including all patients who underwent a neurosurgical procedure at Mulago Hospital from fiscal year 2005 to 2013. Data for this study was extracted from three sources: surgical log books, patient charts, and Mulago Hospital death registry. Information from these sources were collected using electronic data collection tools to determine morality rate (30-day and overall), infection rate (pre-op and post-op), and length of stay (total, pre-op, and post-op). These three outcome measures were then compared pre-program versus post-program.

Peri-operative mortality rate (POMR), or 30-day mortality, was significantly increased from 7.41% pre-program to 13.62% post-program. Overall mortality was also significantly increased from 12.96% pre-program to 19.89% post-program. Relative risk for POMR was 1.85 (1.13, 3.03) and overall mortality was 1.53 (1.06, 2.22). Pre-op infection was significantly decreased from 29.74% pre-program to 22.1% post-program with a relative risk of 0.75 (0.56, 1.00). Mean total length of stay and pre-operative length of stay were both significantly decreased.

The results show that the program has had a generally positive impact, but the mortality increase is an important question to explore. This result may be attributed to complexity and triaging issues, but a prospective analysis would be the only way to make that determination. Additionally, further qualitative and deeper quantitative investigations can provide a fuller evaluation of the program's impact. Overall it is clear that this program is allowing greater access to neurosurgical care to a population that would have otherwise went without care.