Browsing by Author "Haglund, Michael M"
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Item Embargo A Mixed-Method Approach to Assessing the Need and Capacity for Epilepsy Surgery in a National Referral Hospital in Uganda(2024) Antwi, PrinceAbstract
Background: An estimated 80% of patients with epilepsy reside in LMICs, where surgical options for treating medication refractory epilepsy (MRE) may not be readily available. This study assesses the need for an epilepsy surgery program in Uganda and evaluates the current capacity for implementing such a program at the nation’s largest hospital, the Mulago National Referral Hospital (MNRH).
Methods: Medical records of 183 adult patients receiving care for epilepsy at the Bosa Psychiatric Clinic between January and April 2021 were retrospectively reviewed to determine patterns of medical management of epilepsy. 13 clinicians across Psychiatry, Neurology, and Neurosurgery were interviewed; these interviews were analyzed thematically to address the subjects of need and capacity for epilepsy surgery at MNRH. 41 patients and 63 caregivers were surveyed on their perceptions and attitudes toward surgery as a potential treatment for epilepsy.
Results: Nearly half (49%) of patients receiving care at the Bosa Clinic had been treated on two or more anti-epileptic drugs (AEDs) over the course of their disease, with Carbamazepine, Sodium Valproate, and Phenytoin being the most commonly prescribed medications. Only few patients had records of prior brain imaging (8.2%) and EEG (21%) in their medical charts, and no patient had prior referral for surgical evaluation. The interviewed clinicians noted that there is a need for an epilepsy surgery program to augment the current medical practice. They identified infrastructure, cost, further specialized training, and public perception as factors to address in implementing a sustainable epilepsy surgery program locally. 53.3% of patients and 58.5% of caregivers would consider epilepsy surgery only after they had tried 5 or more AEDs without resolution of seizures, citing complications and cost as deterrents.
Conclusions: Both clinical records and clinician interviews demonstrated a need for a surgical option for treating idiopathic epilepsy among Ugandans with medication refractory epilepsy. Investigative modalities such as EEG, CT, and MRI are locally accessible for preliminary evaluation of surgical candidacy. A future pilot program could serve as a platform for training personnel to sustain an epilepsy surgery program at MNRH, and patients and caregivers would subscribe to surgical treatment if a local program is affordable and has a low complication rate.
Item Open Access A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda.(PloS one, 2017-01) Kuo, Benjamin J; Vaca, Silvia D; Vissoci, Joao Ricardo Nickenig; Staton, Catherine A; Xu, Linda; Muhumuza, Michael; Ssenyonjo, Hussein; Mukasa, John; Kiryabwire, Joel; Nanjula, Lydia; Muhumuza, Christine; Rice, Henry E; Grant, Gerald A; Haglund, Michael MBackground
Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.Methods
We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.Results
563 TBI patients were enrolled from 1 June- 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.Conclusions
The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.Item Open Access Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda.(BMC health services research, 2018-09-20) Smith, Emily R; van de Water, Brittney J; Martin, Anna; Barton, Sarah Jean; Seider, Jasmine; Fitzgibbon, Christopher; Bility, Mathama Malakha; Ekeji, Nelia; Vissoci, Joao Ricardo Nickenig; Haglund, Michael M; Bettger, Janet PrvuBACKGROUND:Community services and supports are essential for children transitioning home to recover from the hospital after surgery. This study assessed the availability and geographic capacity of rehabilitation, assistive devices, familial support, and school reintegration programs for school-aged children in Uganda with identified surgical need. METHODS:This study assessed the geographic epidemiology and spatial analysis of resource availability in communities in Uganda. Participants were children with identified surgical need using the Surgeons OverSeas Assessment of Surgical need (SOSAS). Community-based resources available to children and adolescents after surgery in Uganda were identified using publicly available data sources and searching for resources through consultation with in-country collaborators We sought resources available in all geographic regions for a variety of services. RESULTS:Of 1082 individuals surveyed aged 5 to 14 yearsr, 6.2% had identified surgical needs. Pediatric surgical conditions were most prevalent in the Northern and Central regions of Uganda. Of the 151 community-based services identified, availability was greatest in the Central region and least in the Northern region, regardless of type. Assuming 30% of children with surgical needs will need services, a maximum of 50.1% of these children would have access to the needed services in the extensive capacity estimates, while only 10.0% would have access in the minimal capacity estimates. The capacity varied dramatically by region with the Northern region having much lower capacity in all scenarios as compared to the Central, Eastern, or Western regions. CONCLUSIONS:Our study found that beyond the city of Kampala in the Central region, community-based services were severely lacking for school-aged children in Uganda. Increased pediatric surgical capacity to additional hospitals in Uganda will need to be met with increased availability and access to community-based services to support recovery and community re-integration.Item Open Access Boda Bodas and Road Traffic Injuries in Uganda: An Overview of Traffic Safety Trends from 2009 to 2017.(International journal of environmental research and public health, 2020-03) Vaca, Silvia D; Feng, Austin Y; Ku, Seul; Jin, Michael C; Kakusa, Bina W; Ho, Allen L; Zhang, Michael; Fuller, Anthony; Haglund, Michael M; Grant, GeraldRoad traffic injuries (RTIs) are an important contributor to the morbidity and mortality of developing countries. In Uganda, motorcycle taxis, known as boda bodas, are responsible for a growing proportion of RTIs. This study seeks to evaluate and comment on traffic safety trends from the past decade. Traffic reports from the Ugandan police force (2009 to 2017) were analyzed for RTI characteristics. Furthermore, one month of casualty ward data in 2015 and 2018 was collected from the Mulago National Referral Hospital and reviewed for casualty demographics and trauma type. RTI motorcycle contribution rose steadily from 2009 to 2017 (24.5% to 33.9%). While the total number of crashes dropped from 22,461 to 13,244 between 2010 and 2017, the proportion of fatal RTIs increased from 14.7% to 22.2%. In the casualty ward, RTIs accounted for a greater proportion of patients and traumas in 2018 compared to 2015 (10%/41% and 36%/64%, respectively). Although RTIs have seen a gross reduction in Uganda, they have become more deadly, with greater motorcycle involvement. Hospital data demonstrate a rising need for trauma and neurosurgical care to manage greater RTI patient burden. Combining RTI prevention and care pathway improvements may mitigate current RTI trends.Item Open Access Clinical and Radiographic Outcomes for Patients with Cervical Adjacent Segment Disease Treated with Anterior Cervical Discectomy and Fusion with Integrated Interbody Spacers.(World neurosurgery, 2023-12) Zaidi, Saif E; Venkatraman, Vishal; Sykes, David AW; Albanese, Jessica; Erickson, Melissa M; Crutcher, Clifford L; Goodwin, C Rory; Groff, Michael W; Grossi, Peter; Than, Khoi D; Haglund, Michael M; Abd-El-Barr, Muhammad MIntroduction
Anterior cervical discectomy and fusion (ACDF) is among the most common spine procedures. Adjacent segment disease (ASD), characterized by degenerative disease at an adjacent spinal level to a prior fusion, is a well-recognized and significant sequela following ACDF. Adjacent segment ACDF may be considered after the failure of non-surgical options for patients with symptomatic ASD. This study aimed to assess the incidence of dysphagia and other complications as well as radiographic outcomes in adult patients who have undergone ACDF with an integrated interbody spacer device for symptomatic ASD.Methods
This was a retrospective review of patients who underwent ACDF for symptomatic ASD with commercially available integrated interbody spacers by three spine surgeons at an academic institution from March 2018 to April 2022. Demographic, radiographic, and postoperative data were collected, including dysphagia, device-related complications, and the need for revision surgery.Results
There were 48 patients (26 male, 22 female) who met inclusion criteria (mean age 59.7 years, mean body mass index 19.5 kg/m2) who underwent ACDF for symptomatic ASD (1one-level, n = 44; 2-level, n = 4). Overall, 12 patients (25%) experienced dysphagia postoperatively before the first follow-up appointment. Nine of 44 (20.4%) of 1-level ACDF patients experienced dysphagia, and 3 of 4 (75%) of 2-level ACDF patients experienced dysphagia. Three patients had severe dysphagia which prompted an otolaryngology referral. Two of those patients remained symptomatic at 6 weeks postoperatively. Of 43 patients with prior plate cage systems, none required hardware removal at the time of surgery. Preoperative global and segmental lordosis were 9.07° ± 8.36° (P = 0.22) and 3.58° ± 4.57° (P = 0.14), respectively. At 6 weeks postoperatively, global and segmental lordosis were 11.44° ± 9.06° (P = 0.54) and 5.11° ± 4.44° (P = 0.44), respectively. This constitutes a change of +2.37° and +1.53° in global and segmental lordosis, respectively. The mean anterior disc height change between preoperative and immediate postoperative time points was 6.3 ± 3.1 mm. Between the immediate postoperative and 6-week postoperative time points, the mean anterior disc height change was -1.5 ± 2.7 mm. Between the immediate postoperative and 3-month postoperative time points, the mean anterior disc height change was -3.7 ± 5.0 mm. The posterior disc height changes at the same time points were 2.5 ± 1.7 mm, -0.4 ± 1.8. and -0.5 ± 1.4 mm, respectively. This fusion rate was 50% and 70% at 6 months and 1 year post-surgery, respectively.Conclusions
ACDF with integrated spacer is a viable alternative to traditional plate-cage systems for symptomatic ASD. An advantage over traditional plate-cage systems is that the removal of prior instrumentation is not needed in order to place implants. Based on a review of the literature, these standalone systems allowed for a shorter operative time and had less incidence of dysphagia than plate-cage systems for ASD after ACDF. The different standalone and plate-cage systems used in treating ASD after ACDF surgeries should be compared in prospective studies.Item Open Access Intraoperative microseizure detection using a high-density micro-electrocorticography electrode array.(Brain communications, 2022-01) Sun, James; Barth, Katrina; Qiao, Shaoyu; Chiang, Chia-Han; Wang, Charles; Rahimpour, Shervin; Trumpis, Michael; Duraivel, Suseendrakumar; Dubey, Agrita; Wingel, Katie E; Rachinskiy, Iakov; Voinas, Alex E; Ferrentino, Breonna; Southwell, Derek G; Haglund, Michael M; Friedman, Allan H; Lad, Shivanand P; Doyle, Werner K; Solzbacher, Florian; Cogan, Gregory; Sinha, Saurabh R; Devore, Sasha; Devinsky, Orrin; Friedman, Daniel; Pesaran, Bijan; Viventi, JonathanOne-third of epilepsy patients suffer from medication-resistant seizures. While surgery to remove epileptogenic tissue helps some patients, 30-70% of patients continue to experience seizures following resection. Surgical outcomes may be improved with more accurate localization of epileptogenic tissue. We have previously developed novel thin-film, subdural electrode arrays with hundreds of microelectrodes over a 100-1000 mm2 area to enable high-resolution mapping of neural activity. Here, we used these high-density arrays to study microscale properties of human epileptiform activity. We performed intraoperative micro-electrocorticographic recordings in nine patients with epilepsy. In addition, we recorded from four patients with movement disorders undergoing deep brain stimulator implantation as non-epileptic controls. A board-certified epileptologist identified microseizures, which resembled electrographic seizures normally observed with clinical macroelectrodes. Recordings in epileptic patients had a significantly higher microseizure rate (2.01 events/min) than recordings in non-epileptic subjects (0.01 events/min; permutation test, P = 0.0068). Using spatial averaging to simulate recordings from larger electrode contacts, we found that the number of detected microseizures decreased rapidly with increasing contact diameter and decreasing contact density. In cases in which microseizures were spatially distributed across multiple channels, the approximate onset region was identified. Our results suggest that micro-electrocorticographic electrode arrays with a high density of contacts and large coverage are essential for capturing microseizures in epilepsy patients and may be beneficial for localizing epileptogenic tissue to plan surgery or target brain stimulation.Item Open Access Osteoimmunology: Interactions With the Immune System in Spinal Fusion.(International journal of spine surgery, 2023-12) Bergin, Stephen M; Crutcher, Clifford L; Keeler, Carolyn; Rocos, Brett; Haglund, Michael M; Michael Guo, H; Gottfried, Oren N; Richardson, William J; Than, Khoi DSpinal fusion is important for the clinical success of patients undergoing surgery, and the immune system plays an increasingly recognized role. Osteoimmunology is the study of the interactions between the immune system and bone. Inflammation impacts the osteogenic, osteoconductive, and osteoinductive properties of bone grafts and substitutes and ultimately influences the success of spinal fusion. Macrophages have emerged as important cells for coordinating the immune response following spinal fusion surgery, and macrophage-derived cytokines impact each phase of bone graft healing. This review explores the cellular and molecular immune processes that regulate bone homeostasis and healing during spinal fusion.Item Open Access Reorganization and stability for motor and language areas using cortical stimulation: case example and review of the literature.(Brain sciences, 2013-11) Serafini, Sandra; Komisarow, Jordan M; Gallentine, William; Mikati, Mohamad A; Bonner, Melanie J; Kranz, Peter G; Haglund, Michael M; Grant, GeraldThe cerebral organization of language in epilepsy patients has been studied with invasive procedures such as Wada testing and electrical cortical stimulation mapping and more recently with noninvasive neuroimaging techniques, such as functional MRI. In the setting of a chronic seizure disorder, clinical variables have been shown to contribute to cerebral language reorganization underscoring the need for language lateralization and localization procedures. We present a 14-year-old pediatric patient with a refractory epilepsy disorder who underwent two neurosurgical resections of a left frontal epileptic focus separated by a year. He was mapped extraoperatively through a subdural grid using cortical stimulation to preserve motor and language functions. The clinical history and extensive workup prior to surgery is discussed as well as the opportunity to compare the cortical maps for language, motor, and sensory function before each resection. Reorganization in cortical tongue sensory areas was seen concomitant with a new zone of ictal and interictal activity in the previous tongue sensory area. Detailed neuropsychological data is presented before and after any surgical intervention to hypothesize about the extent of reorganization between epochs. We conclude that intrahemispheric cortical plasticity does occur following frontal lobe resective surgery in a teenager with medically refractory seizures.Item Open Access Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda.(Neurosurgery, 2019-01) Vaca, Silvia D; Kuo, Benjamin J; Nickenig Vissoci, Joao Ricardo; Staton, Catherine A; Xu, Linda W; Muhumuza, Michael; Ssenyonjo, Hussein; Mukasa, John; Kiryabwire, Joel; Rice, Henry E; Grant, Gerald A; Haglund, Michael MBACKGROUND:Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed. OBJECTIVE:To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda. METHODS:Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed. RESULTS:Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04). CONCLUSION:Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.