The effects of selected neglected tropical diseases on economic performance at the macrolevel in Africa.

BACKGROUND: Neglected tropical diseases (NTDs) such as leprosy, lymphatic filariasis (LF), schistosomiasis and onchocerciasis are endemic in several African countries. These diseases can lead to severe pain and permanent disability, which can negatively affect the economic productivity of the affected person(s), and hence resulting into low economic performance at the macrolevel. Nonetheless, empirical evidence of the effects of these NTDs on economic performance at the macrolevel is sparse. This study therefore investigates the effects of the above-mentioned NTDs on economic performance at the macrolevel in Africa. METHODS: The study employs a panel design with data comprising 24 to 45 African countries depending on the NTD in question, over the period, 2002 to 2019. Gross domestic product (GDP) is used as the proxy for economic performance (Dependent variable) and the prevalence of the above-mentioned NTDs are used as the main independent variables. The random effects (RE), fixed effects (FE) and the instrumental variable fixed effects (IVFE) panel data regressions are used as estimation techniques. RESULTS: We find that, an increase in the prevalence of the selected NTDs is associated with a fall in economic performance in the selected African countries, irrespective of the estimation technique used. Specifically, using the IVFE regression estimates, we find that a percentage increase in the prevalence of leprosy, LF, schistosomiasis and onchocerciasis is associated with a reduction in economic performance by 0.43%, 0.24%, 0.28% and 0.36% respectively, at either 1% or 5% level of significance. CONCLUSION: The findings highlight the need to increase attention and bolster integrated efforts or measures towards tackling these diseases in order to curb their deleterious effects on economic performance. Such measures can include effective mass drug administration (MDA), enhancing access to basic drinking water and sanitation among others.

Financial inclusion and improved water usage among households in Ghana.

BACKGROUND: In Ghana, about 76% of households are at risk of drinking water polluted with faecal matter, hence, poor sanitation and unsafe water are responsible for 80% of all diseases in the country. Given this, some studies have been carried out concerning the factors that determine access and use of improved water among households in Ghana. However, although financial inclusion can make it easy for households to afford and hence, use improved water, it has received very little attention. This study, thus, examines the effect of financial inclusion on the use of improved water among households in Ghana. METHODS: The Ghana Living Standards Survey round 7 (GLSS7) is used as the data source while the binary logit regression is employed as the main empirical estimation technique. RESULTS: The results show that households with financial inclusion (employing an indicator which has not been disaggregated into formal and informal financial inclusion) have a higher likelihood of using improved water sources relative to those without financial inclusion. The results are robust using formal financial inclusion as well as a combined index of financial inclusion. CONCLUSION: Enhancing financial inclusion, especially formal financial inclusion can be utilised as a major policy instrument towards increasing access and use of improved water sources among households in Ghana.

Symmetry of computerised tomography of the brain in traumatic brain injury: a quality improvement audit.

BACKGROUND: Non-contrast Computerised Tomography (NCCT) of brain is the gold standard investigation for diagnosis and management of Traumatic brain injury (TBI). Asymmetrical CT brain images as a result of improper head positioning in the CT gantry will compromise the diagnostic value. Therefore, this audit aimed to assess the degree of asymmetry in CT brain studies carried out in TBI patients. METHODS: This audit was carried out at a level one trauma centre and included CT scans of TBI patients with a Glasgow come scale (GCS) score ≤ 13, admitted to the Neurological intensive care unit (NICU). The first cycle involved a period of three months. The data collected included demographic data and variables such as GCS at the time of the scan and whether the patient was intubated or not. The visualisation of bilateral internal auditory meatuses was used as landmark to determine scan symmetry. If the internal auditory meatus on both sides were visible on the same slice of CT scan, it was considered symmetric. The degree of asymmetry was gauged based on the axial slice difference between bilateral meatuses. The data collected was tabulated and presented to Neurosurgery residents and a checklist was formulated which had to be followed while positioning the patient on CT table prior to imaging. RESULTS: The first cycle of the audit showed that 83.8% of scans were asymmetric and among them 44.1% revealed gross asymmetry affecting interpretation of the scan. Following, implementation of the checklist the percentage of gross asymmetry dropped to 21.86% in the second and to 22.22% in the third audit. CONCLUSION: The use of checklist prior to CT brain studies showed sustainable improvement in reducing gross asymmetry and in acquisition of symmetrical CT brain images.

An E-cadherin-actin clutch translates the mechanical force of cortical flow for cell-cell contact to inhibit epithelial cell locomotion.

Adherens junctions (AJs) allow cell contact to inhibit epithelial migration yet also permit epithelia to move as coherent sheets. How, then, do cells identify which contacts will inhibit locomotion? Here, we show that in human epithelial cells this arises from the orientation of cortical flows at AJs. When the leader cells from different migrating sheets make head-on contact with one another, they assemble AJs that couple together oppositely directed cortical flows. This applies a tensile signal to the actin-binding domain (ABD) of α-catenin, which provides a clutch to promote lateral adhesion growth and inhibit the lamellipodial activity necessary for migration. In contrast, AJs found between leader cells in the same migrating sheet have cortical flows aligned in the same direction, and no such mechanical inhibition takes place. Therefore, α-catenin mechanosensitivity in the clutch between E-cadherin and cortical F-actin allows cells to interpret the direction of motion via cortical flows and signal for contact to inhibit locomotion.

Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations.

BACKGROUND: Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE: To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS: We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS: Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION: Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.

Evaluation of a photodynamic therapy agent using a canine prostate cancer model.

BACKGROUND: Male dogs can develop spontaneous prostate cancer, which is similar physiologically to human disease. Recently, Tweedle and coworkers have developed an orthotopic canine prostate model allowing implanted tumors and therapeutic agents to be tested in a more translational large animal model. We used the canine model to evaluate prostate-specific membrane antigen (PSMA)-targeted gold nanoparticles as a theranostic approach for fluorescence (FL) imaging and photodynamic therapy (PDT) of early stage prostate cancer. METHODS: Dogs (four in total) were immunosuppressed with a cyclosporine-based immunosuppressant regimen and their prostate glands were injected with Ace-1-hPSMA cells using transabdominal ultrasound (US) guidance. Intraprostatic tumors grew in 4-5 weeks and were monitored by ultrasound (US). When tumors reached an appropriate size, dogs were injected intravenously (iv) with PSMA-targeted nano agents (AuNPs-Pc158) and underwent surgery 24 h later to expose the prostate tumors for FL imaging and PDT. Ex vivo FL imaging and histopathological studies were performed to confirm PDT efficacy. RESULTS: All dogs had tumor growth in the prostate gland as revealed by US. Twenty-four hours after injection of PSMA-targeted nano agents (AuNPs-Pc158), the tumors were imaged using a Curadel FL imaging device. While normal prostate tissue had minimal fluorescent signal, the prostate tumors had significantly increased FL. PDT was activated by irradiating specific fluorescent tumor areas with laser light (672 nm). PDT bleached the FL signal, while fluorescent signals from the other unexposed tumor tissues were unaffected. Histological analysis of tumors and adjacent prostate revealed that PDT damaged the irradiated areas to a depth of 1-2 mms with the presence of necrosis, hemorrhage, secondary inflammation, and occasional focal thrombosis. The nonirradiated areas showed no visible damages by PDT. CONCLUSION: We have successfully established a PSMA-expressing canine orthotopic prostate tumor model and used the model to evaluate the PSMA-targeted nano agents (AuNPs-Pc158) in the application of FL imaging and PDT. It was demonstrated that the nano agents allowed visualization of the cancer cells and enabled their destruction when they were irradiated with a specific wavelength of light.

Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group.

Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

The Choice of Healthy Source of Energy for Cooking Among Households in Ghana: Does Financial Inclusion Matter?

Air pollution resulting from the use of unhealthy/unclean energy sources for cooking causes illnesses such as lung cancer, stroke, chronic obstructive pulmonary disease and ischaemic heart disease. In Ghana, each year, about 18 000 deaths are recorded due to the use of unhealthy energy sources for cooking. While financial inclusion can influence the adoption of healthy energy sources for cooking, less attention has been paid to it. This study, therefore, investigates the effect of financial inclusion on the choice of healthy source of energy for cooking among households in Ghana. Doing so reveals whether financial inclusion can be employed as a tool to decrease the use of unhealthy sources of energy for cooking in Ghana. We employ the Ghana Living Standards Survey round 7 (GLSS7) as the data source for the study whiles the binary logistic regression is used as the estimation technique. The findings show that, households with financial inclusion (using a single indicator) are more likely to choose healthy sources of energy for cooking relative to those without financial inclusion (OR = 2.52, P < .01). Moreover, the effect of financial inclusion (using a single indicator) on choosing a healthy source of energy for cooking is greater among rural households (OR = 3.18, P < .01) relative to their urban counterparts (OR = 2.27, P < .01). The findings are robust even after using a different estimation technique and a combined index of financial inclusion. Thus, in the quest to improve the use of healthy sources of energy for cooking, enhancing financial inclusion among households, could be a useful strategy.

Cutaneous Intestinal Metaplasia With Adenocarcinoma Treated With Intralesional Fluorouracil.

This case report describes a patient with cutaneous intestinal metaplasia with invasive adenocarcinoma treated successfully with intralesional fluorouracil.

Head Injury and Pregnancy-Does the Outcome Differ? A Descriptive Analysis of 15 Years from a Single Tertiary Care Center.

BACKGROUND: There are conflicting data about the outcome of head injury in pregnant patients. Since they comprise a small proportion of the traumatic brain-injured (TBI) patients, the literature is sparse on true evidence on this issue. METHODS: A 15-year observational study to analyze the outcome of TBI in pregnant women admitted to a level 1 trauma center from 2005-2020 was carried out with the approval of institutional review board. Female patients aged 18-50 years admitted with TBI were included. Patients with polytrauma or dead-on arrival to the emergency department were excluded from the study. The vital parameters, Glasgow Coma Scale (GCS) score at admission, Rotterdam computed tomography (CT) scan, severity score, and Glasgow Outcome Score (GOS) at 3 months were collected from the trauma database, discharge summaries, and patient records. RESULTS: During the study period, 5071 patients with head injury were admitted. Among the 228 patients who met inclusion criteria, 31 (13.6%) were pregnant with a mean age of 24.2 ± 3.8 years. The Rotterdam CT severity score, which moderately correlated with outcome in the control group, was found to be a poor predictor in the pregnant group. The outcome measures were compared using GCS score at discharge for immediate and GOS at 3 months for long-term periods. A better functional outcome was observed at 3 months among pregnant patients (P = 0.02). CONCLUSIONS: Pregnant TBI patients have better long-term outcomes than their similar-aged counterparts. However, radiologic severity of injury does not seem to predict outcome in this cohort.

Biogeographical and diversification analyses of Indian pseudoscorpions reveal the Western Ghats as museums of ancient biodiversity.

The tropical forests of the Western Ghats (WG) of India are considered 'refugia' harbouring highly diverse and endemic taxa but these refugia are under immense anthropogenic pressure. Most phylogenetic studies have explained diversity patterns across the WG using vertebrates, however, the processes impacting the highly endemic invertebrate fauna are still poorly understood. Here we investigate the evolutionary history of an ancient and widespread arachnid lineage (Pseudoscorpiones: Chthoniidae: Tyrannochthoniini) in the WG through a variety of biogeographical and diversification analyses, including sequence data from three markers for 45 terminals from the WG and 22 from Africa, East and Southeast Asia, Australasia and the Neotropics. Our results show that WG Tyrannochthoniini are rendered paraphyletic by African taxa, a result consistent with continental drift. WG Tyrannochthoniini are further split into two major clades, a southern WG clade and an African-central WG clade, due to vicariance along a major biogeographical barrier, the Palghat Gap. Central WG pseudoscorpions diverged from their African relatives at the Jurassic-Cretaceous boundary, coinciding with the separation of India from Africa. Despite ancient vicariance, six dispersal events occurred across the Palghat Gap, beginning in the Early Cretaceous as India was rafting towards Southeast Asia and ending by the early Miocene, implying that the Palghat Gap became impermeable to dispersal for these humid-adapted organisms during Miocene aridification. Although the ancestor of WG Tyrannochthoniini originated in lowland WG forests, three dispersal events into high montane Shola forests occurred most likely as a result of Late Cretaceous orogenesis and Neogene uplift, allowing lineages to occupy niches at higher elevations. An exponentially declining diversification rate, typical of older lineages, supports the 'museum' model of diversification for WG Tyrannochthoniini. Our study sheds light on the historical biogeography of relictual soil-arthropods in the WG and emphasises the role of WG forest refugia in preserving ancient invertebrate biodiversity.

Long-Term Follow-up of Patients Managed Conservatively for Acute Traumatic CSF Rhinorrhea.

OBJECTIVE: Conservative management of acute traumatic cerebrospinal fluid rhinorrhea (TCR) results in cessation of the leak in most patients. The objective of this study was to estimate the incidence of recurrent cerebrospinal fluid (CSF) rhinorrhea and meningitis in these patients on long-term follow-up and to determine the risk factors associated with them. METHODS: Data on 50 patients with acute TCR who were successfully treated with conservative management between 2013 and 2015 and had long-term follow-up was retrieved from our head injury database. Patient variables were analyzed to determine the risk factors associated with recurrence of CSF rhinorrhea and meningitis. RESULTS: All patients in our series developed CSF rhinorrhea within 48 hours of trauma. The mean duration of follow-up was 6.3 ± 1.3 years. CSF rhinorrhea recurred in 16 (32%) patients, 15 (93.8%) of whom developed it within 3 years of trauma. Meningitis occurred in 5 (10%) patients and 1 died. Sphenoid sinus fractures and features of raised intracranial pressure on computerized tomography of the brain at admission were significantly associated with the development of meningitis. There were no risk factors identified for the recurrence of CSF rhinorrhea. CONCLUSIONS: Patients with acute TCR in whom rhinorrhea subsides with conservative therapy have the highest risk for recurrence of leak or meningitis within 3 years of the trauma. Therefore, we recommend that these patients be counselled about the need for periodic follow-up for several years.

Customized cost-effective polymethylmethacrylate cranioplasty: a cosmetic comparison with other low-cost methods of cranioplasty.

BACKGROUND: Intraoperative hand-moulded cranioplasty and polymethylmethacrylate (PMMA) prostheses made from bone impressions are economical but the cosmetic results are less than satisfactory. Commercially available customized prostheses perform better but are prohibitively expensive. We evaluate the performance of a locally developed, low-cost customized PMMA cranioplasty prosthesis. OBJECTIVE: To compare the cosmetic outcome of 3 types of PMMA cranioplasty as well as with objective measurements on postoperative CT scans METHODS: This study includes 70 patients who underwent cranioplasty between March 2016 and June 2020. In this period, patients had their cranioplasty prostheses made by intra-operative hand moulding (HM), by using the removed bone as a template and making a bone impression (BI) or by 3D printing the prosthesis based on a CT scan. Cosmetic outcomes were assessed by the patient and the operating surgeon on an 8-point scale. The degree of measured anthropometric asymmetry was measured on a postoperative CT scan and correlated with the cosmetic outcome. RESULTS: Our locally produced 3D-printed cranioplasty prostheses showed a statistically better performance in cosmetic scores when compared to the HM and BI (p value < 0.001). CT anthropometric measurements significantly correlated with cosmetic outcome (p value 0.01) CONCLUSION: Our 3D cranioplasty prostheses had better cosmetic outcomes than HM and BI prostheses, and our technique is able to produce them at 10% of the cost of the currently available commercial customized prostheses.

A Novel Evidence-Based Predictor Tool for Hospitalization and Length of Stay: Insights from COVID19 Patients in New York City

BackgroundCoronavirus disease 2019 (COVID-19) has evolved into a true global pandemic infecting more than 30 million people worldwide. Predictive models for key outcomes have the potential to optimize resource utilization and patient outcome as outbreaks continue to occur worldwide. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19 positive patients presenting to the Emergency Department (ED) in a New York City health system. MethodsThe study cohort consisted of consecutive adult (>18 years) patients presenting to the ED of one of the Mount Sinai Health System hospitals between March, 2020 and April, 2020 who were diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged (>3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented. ResultsThe cohort consisted of 5859 patients with a hospitalization rate of 65% and a prolonged LOS rate of 75% among hospitalized patients. Independent predictors of hospitalization included older age (OR=6.29; 95% CI [1.83-2.63], >65 vs. 18-44), male sex (OR=1.35 [1.17-1.55]), chronic obstructive pulmonary disease (OR=1.74; [1.00-3.03]), hypertension (OR=1.39; [1.13-1.70]), diabetes (OR=1.45; [1.16-1.81]), chronic kidney disease (OR=1.69; [1.23-2.32]), elevated maximum temperature (OR=4.98; [4.28-5.79]), and low minimum oxygen saturation (OR=13.40; [10.59-16.96]). Predictors of extended LOS included older age (OR=1.03 [1.02-1.04], per year), chronic kidney disease (OR=1.91 [1.35-2.71]), elevated maximum temperature (OR=2.91 [2.40- 3.53]), and low minimum percent oxygen saturation (OR=3.89 [3.16-4.79]). AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ ConclusionThe prediction tool derived from this study can be used to optimize resource allocation, guide quality of care, and assist in designing future studies on the triage and management of patients with COVID-19.

Post Traumatic Hydrocephalus: Incidence, Pathophysiology and Outcomes.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is a sequel of traumatic brain injury (TBI) that is seen more often in patients undergoing decompressive craniectomy (DC). It is associated with prolonged hospital stay and unfavorable outcomes. OBJECTIVE: To study the incidence and risk factors for development of PTH in patients undergoing DC in our institution and to review the literature on PTH with respect to incidence, risk factors, pathophysiology, and outcomes of management. METHODS: Data from 95 patients (among 220 patients who underwent DC for TBI and fulfilled the inclusion criteria) over a 5-year period at Christian Medical College, Vellore were collected and analyzed to study the incidence and possible risk factors for development of PTH. A review of the literature on PTH was performed by searching PUBMED resources. RESULTS: Thirty (31.6%) out of 95 patients developed post-traumatic ventriculomegaly, of whom seven (7.3%) developed symptomatic PTH, necessitating placement of ventriculoperitoneal shunt (VPS). No risk factor for development of PTH could be identified. The reported incidence of PTH in the literature is from 0.07% to 29%, with patients undergoing DC having a higher incidence. Younger age, subarachnoid hemorrhage, severity of TBI, presence of subdural hygroma, and delayed cranioplasty after DC are the main risk factors reported in the literature. CONCLUSIONS: PTH occurs in a significant proportion of patients with TBI and can lead to unfavorable outcomes. PTH has to be distinguished from asymptomatic ventriculomegaly as early as possible so that a CSF diversion procedure can be planned early during development of PTH.

On a new synonymy in the spider genus Nephila Leach, 1815 (Araneidae, Nephilinae) from India with supplementary notes on colour polymorphism in the genus.

The golden orb-weaving spider genus Nephila Leach, 1815 currently has four representatives in India: Nephila dirangensis Biswas Biswas, 2006, Nephila kuhlii (Doleschall, 1859), Nephila pilipes (Fabricius, 1793) and Nephila robusta Tikader, 1962 (World Spider Catalog 2020). While N. kuhlii has its type locality in Java (Doleschall 1859) and that of N. pilipes in Australasia (Fabricius 1781), N. dirangensis and N. robusta are both confined to India (World Spider Catalog 2020). Tikader (1962) described the species N. robusta based on a single female specimen collected in West Bengal. The original genitalic illustrations of this species, however, show close resemblance to that of N. pilipes, indicating its possible synonymy with the latter. To confirm the novelty of N. robusta, we examined its type specimen and the result is presented below. Additionally, we discuss the occurrence of colour morphs in the Indian populations of N. pilipes.

Toward a new picture of the living plasma membrane.

Our understanding of the plasma membrane structure has undergone a major change since the proposal of the fluid mosaic model of Singer and Nicholson in the 1970s. In this model, the membrane, composed of over thousand lipid and protein species, is organized as a well-equilibrated two-dimensional fluid. Here, the distribution of lipids is largely expected to reflect a multicomponent system, and proteins are expected to be surrounded by an annulus of specialized lipid species. With the recognition that a multicomponent lipid membrane is capable of phase segregation, the membrane is expected to appear as patchwork quilt pattern of membrane domains. However, the constituents of a living membrane are far from being well equilibrated. The living cell membrane actively maintains a trans-bilayer asymmetry of composition, and its constituents are subject to a number of dynamic processes due to synthesis, lipid transfer as well as membrane traffic and turnover. Moreover, membrane constituents engage with the dynamic cytoskeleton of a living cell, and are both passively as well as actively manipulated by this engagement. The extracellular matrix and associated elements also interact with membrane proteins contributing to another layer of interaction. At the nano- and mesoscale, the organization of lipids and proteins emerge from these encounters, as well as from protein-protein, protein-lipid, and lipid-lipid interactions in the membrane. New methods to study the organization of membrane components at these scales have also been developed, and provide an opportunity to synthesize a new picture of the living cell surface as an active membrane composite.

Management and outcomes following emergency surgery for traumatic brain injury - A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

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.