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1.
World Neurosurg ; 2020 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-32376375

RESUMO

BACKGROUND: Traumatic brain injury (TBI) prognostic models are potential solutions to severe human and technical shortages. Although numerous TBI prognostic models have been developed, none are widely used in clinical practice, largely due to a lack of feasibility research to inform implementation. We previously developed a prognostic model and web-based application for in-hospital TBI care in low-resource settings. In this study, we tested the feasibility, acceptability, and usability of the application with potential end-users. METHODS: We performed our feasibility assessment with providers involved in TBI care at both a regional and national referral hospital in Uganda. We collected qualitative and quantitative data on decision support needs, application ease of use, and implementation design. RESULTS: We completed 25 questionnaires on potential uses of the app and 11 semi-structured feasibility interviews. Top-cited uses were informing the decision to operate, informing the decision to send the patient to intensive care, and counseling patients and relatives. Participants affirmed the application's potential to support difficult triage situations, particularly in the setting of limited access to diagnostics and interventions, but were hesitant to use this technology with end-of-life decisions. While all participants were satisfied with the application and agreed it is easy to use, several expressed a need for this technology to be accessible by smartphone and offline. CONCLUSIONS: We elucidated several potential uses for our app and important contextual factors that will support future implementation. This investigation helps address an unmet need to determine the feasibility of TBI clinical decision support systems in low-resource settings.

2.
J Neurosurg ; : 1-9, 2020 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-32244205

RESUMO

OBJECTIVE: Traumatic brain injury (TBI), a burgeoning global health concern, is one condition that could benefit from prognostic modeling. Risk stratification of TBI patients on presentation to a health facility can support the prudent use of limited resources. The CRASH (Corticosteroid Randomisation After Significant Head Injury) model is a well-established prognostic model developed to augment complex decision-making. The authors' current study objective was to better understand in-hospital decision-making for TBI patients and determine whether data from the CRASH risk calculator influenced provider assessment of prognosis. METHODS: The authors performed a choice experiment using a simulated TBI case. All participant doctors received the same case, which included a patient history, vitals, and physical examination findings. Half the participants also received the CRASH risk score. Participants were asked to estimate the patient prognosis and decide the best next treatment step. The authors recruited a convenience sample of 28 doctors involved in TBI care at both a regional and a national referral hospital in Uganda. RESULTS: For the simulated case, the CRASH risk scores for 14-day mortality and an unfavorable outcome at 6 months were 51.4% (95% CI 42.8%, 59.8%) and 89.8% (95% CI 86.0%, 92.6%), respectively. Overall, participants were overoptimistic when estimating the patient prognosis. Risk estimates by doctors provided with the CRASH risk score were closer to that score than estimates made by doctors in the control group; this effect was more pronounced for inexperienced doctors. Surgery was selected as the best next step by 86% of respondents. CONCLUSIONS: This study was a novel assessment of a TBI prognostic model's influence on provider estimation of risk in a low-resource setting. Exposure to CRASH risk score data reduced overoptimistic prognostication by doctors, particularly among inexperienced providers.

3.
Int J Inj Contr Saf Promot ; 27(2): 181-187, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32138575

RESUMO

Objective: Road traffic injuries (RTI) cause ∼1.2 million deaths and 50 million injuries annually, disproportionately occurring in low- and middle-income countries. Although policy changes and infrastructural developments have continued to contribute to the decrease in RTI-related deaths, limited studies have investigated the relationship between motorcycle taxi driver behaviors and RTIs in Rwanda. This study aims to describe the safety behaviors of commercial motorcyclists in Kigali, Rwanda.Methods: We surveyed 609 commercial motorcyclists in January 2014 then conducted a cross-sectional analysis of the results, including descriptive and bivariate logistic regression analyses.Results: We found that 38.7% of surveyed motorcycle drivers experienced a crash during their lifetime, of which, more than half (n = 134, 56.8%) suffered injuries. Of all injuries, 38.8% (n = 52) resulted in hospitalization, and 14.2% (n = 19) in disability. Among motorcyclists, 100% reported always wearing a helmet, 99% reported always wearing a chin strap, and 98.8% reported always having a passenger helmet. There was an association between sustaining a crash and believing that helmets (p = 0.08) and chin straps (p = 0.05) reduced crash risk.Conclusions: Rwandan commercial motorcyclists demonstrate generally proper safety behaviors, but remain a high-risk occupational group. Road safety policy initiatives have been effective in changing driver behavior regardless of driver safety beliefs.

4.
BMJ Glob Health ; 4(6): e001827, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31798991

RESUMO

Background: Brazil faces huge health inequality challenges since not all municipalities have access to primary care physicians. The More Doctors Programme (MDP), which started in 2013, was born out of this recognition, providing more than 18 000 doctors in the first few years. However, the programme faced a restructuring at the end of 2018. Methods: We construct a panel municipality-level data between 2008 and 2017 for 5570 municipalities in Brazil. We employ a difference-in-differences empirical approach, combined with propensity score matching, to study the impacts of the programme on hospitalisations for ambulatory care sensitive conditions and its costs. We explore heterogeneous impacts by age of the patients, type of admissions, and municipalities that were given priority. Findings: The MDP reduced ambulatory admissions by 2.9 per cent (p value <0.10) and the costs by 3.7 per cent (p value <0.01) over the mean. The reduction was driven by infectious gastroenteritis, bacterial pneumonias, asthma, kidney and urinary infections, and pelvic inflammatory disease. The results held on the subsample of municipalities targeted by the programme. By comparing the benefits of the programme from the reduction in the costs of ambulatory admissions to the total financial costs of the MDP, the impacts allowed the government to save at least BRL 27.88 (US$ 6.9 million) between 2014 and 2017. Conclusion: Addressing inequalities in the distribution of the medical workforce remains a global challenge. Our results inform the discussion on the current strategy adopted in Brazil to increase access to primary healthcare in underserved areas.

5.
Neurosurg Focus ; 47(5): E6, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31675716

RESUMO

OBJECTIVE: The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury. METHODS: The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania. RESULTS: Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI. CONCLUSIONS: Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

6.
Alcohol ; 83: 9-15, 2019 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-31195127

RESUMO

Alcohol is one of the leading causes of death and disability worldwide. Rates of alcohol abuse in Moshi, Tanzania, are about 2.5 times higher than the Tanzanian average. We sought to qualitatively assess the perceptions of alcohol use among injury patients in Moshi, including availability, consumption patterns, abuse, and treatments. Participants were Emergency Department injury patients, their families, and community advisory board members. Participants were included if they were ≥18 years of age, a patient or patient's family member seeking care at the Kilimanjaro Christian Medical Center Emergency Department, Moshi, Tanzania, for an acute injury, clinically sober at the time of enrollment, medically stable, able to communicate in Swahili and consented to participate. Focus group discussions were audiotaped, transcribed, translated, and analyzed in parallel using an inductive thematic content analysis approach. Resultant themes were then reanalyzed to ensure internal homogeneity and external heterogeneity. Fourteen focus group discussions, with a total of 104 participants (40 patients, 50 family members, 14 community advisory board members), were conducted. Major themes resulting from the analysis included: 1) Early/repeated exposure; 2) Moderate use as a social norm with positive attributes; 3) Complications of abuse are widely stigmatized; and 4) Limited knowledge of availability of treatment. Our findings suggest that, among our unique injury population and their families, despite the normalization of alcohol-related behaviors, there is strong stigma toward complications stemming from excess alcohol use. Overall, resources for alcohol treatment and cessation, although broadly desired, are unknown to the injury population.

7.
J Neurosurg ; : 1-9, 2019 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-31075779

RESUMO

OBJECTIVETraumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionate burden of this injury on low- and middle-income countries (LMICs). Limited access to diagnostic technologies and highly skilled providers combined with high patient volumes contributes to poor outcomes in LMICs. Prognostic modeling as a clinical decision support tool, in theory, could optimize the use of existing resources and support timely treatment decisions in LMICs. The objective of this study was to develop a machine learning-based prognostic model using data from Kilimanjaro Christian Medical Centre in Moshi, Tanzania.METHODSThis study is a secondary analysis of a TBI data registry including 3138 patients. The authors tested nine different machine learning techniques to identify the prognostic model with the greatest area under the receiver operating characteristic curve (AUC). Input data included demographics, vital signs, injury type, and treatment received. The outcome variable was the discharge score on the Glasgow Outcome Scale-Extended.RESULTSThe AUC for the prognostic models varied from 66.2% (k-nearest neighbors) to 86.5% (Bayesian generalized linear model). An increasing Glasgow Coma Scale score, increasing pulse oximetry values, and undergoing TBI surgery were predictive of a good recovery, while injuries suffered from a motor vehicle crash and increasing age were predictive of a poor recovery.CONCLUSIONSThe authors developed a TBI prognostic model with a substantial level of accuracy in a low-resource setting. Further research is needed to externally validate the model and test the algorithm as a clinical decision support tool.

8.
Neurosurgery ; 84(1): 95-103, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29490070

RESUMO

BACKGROUND: 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.


Assuntos
Lesões Encefálicas Traumáticas , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/cirurgia , Humanos , Estudos Prospectivos , Centros de Atenção Terciária , Uganda
9.
Neurosurg Focus ; 45(4): E15, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30269580

RESUMO

OBJECTIVE: In addition to the rising burden of surgical disease globally, infrastructure and human resources for health remain a great challenge for low- and middle-income countries, especially in Uganda. In this study, the authors aim to explore the trends of neurosurgical care at a regional referral hospital in Uganda and assess the long-term impact of the institutional collaboration between Mulago National Referral Hospital and Duke University. METHODS: An interrupted time series is a quasi-experimental design used to evaluate the effects of an intervention on longitudinal data. The authors applied this design to evaluate the trends in monthly mortality rates for neurosurgery patients at Mbarara Regional Referral Hospital (MRRH) from March 2013 to October 2015. They used segmented regression and autoregressive integrated moving average models for the analysis. RESULTS: Over the study timeframe, MRRH experienced significant increases in referrals received (from 117 in 2013 to 211 in 2015), neurosurgery patients treated (from 337 in 2013 to 625 in 2015), and operations performed (from 61 in 2013 to 173 in 2015). Despite increasing patient volumes, the hospital achieved a significant reduction in hospital mortality during 2015 compared to prior years (p value = 0.0039). CONCLUSIONS: This interrupted time series analysis study showed improving trends of neurosurgical care in Western Uganda. There is a steady increase in volume accompanied by a sharp decrease in mortality through the years. Multiple factors are implicated in the significant increase in volume and decrease in mortality, including the addition of a part-time neurosurgeon, improvement in infrastructure, and increased experience. Further in-depth prospective studies exploring seasonality and long-term outcomes are warranted.


Assuntos
Internato e Residência , Procedimentos Neurocirúrgicos/tendências , Encaminhamento e Consulta/tendências , Mortalidade Hospitalar/tendências , Hospitais , Humanos , Intercâmbio Educacional Internacional , Análise de Séries Temporais Interrompida , Neurocirurgia/educação , Procedimentos Neurocirúrgicos/educação , Procedimentos Neurocirúrgicos/mortalidade , North Carolina , Estudos Retrospectivos , Centro Cirúrgico Hospitalar/tendências , Uganda
11.
J Clin Neurosci ; 47: 79-83, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29066002

RESUMO

BACKGROUND: In Uganda, TBI constitute the majority of neurosurgical admissions and deaths specially in the pediatric population. This study aims to determine the factors associated with poor outcome among pediatric TBI cases at a major referral hospital in western Uganda. METHODS: This study was conducted at Mbarara Regional Referral Hospital (MRRH) in western Uganda. All pediatric neurosurgical cases between 2012 and 2015 were reviewed. In-hospital mortality and discharge GCS were the main outcomes of interest. Multivariable logistic regression with backward elimination was used to determine the factors significantly associated with outcome. RESULTS: A total of 381 pediatric TBI patients were admitted to MRRH between 2012 and 2015. The mean age was 8.6 (SD 5.6) with a male predominance (62.0%). The most common mechanism of injury overall was RTI, which was responsible for 71% of all TBI cases. In the multivariable logistic regression model, admission GCS < 13 was a strong predictor of poor outcome and in-hospital mortality compared to admission GCS ≥ 13, with patients demonstrating an odds ratio of 30 (95%CI: 7-132) and OR of 18 (95%CI: 4-79), respectively. CONCLUSION: Given the lack of published literature on pediatric TBI in LMICs, this study was the first to describe and evaluate risk factors associated with TBI severity among pediatric patients at a major referral hospital in western Uganda. Injury severity on admission was the only variable found to be significantly associated with discharge outcome. This study ultimately highlights the need for more effective preventative measures to decrease admission severity.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/epidemiologia , Escala de Coma de Glasgow/estatística & dados numéricos , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Adolescente , Lesões Encefálicas Traumáticas/mortalidade , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Uganda/epidemiologia
12.
World Neurosurg ; 108: 844-849.e4, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28826868

RESUMO

INTRODUCTION: There is a significant burden of unmet surgical need in many low- and middle-income countries (>80% in parts of Africa). This need is even larger for specialties such as neurosurgery. Surgical capacity tools have been developed and used to assess needs and plan for resource allocation. This study piloted a new tool to assess neurosurgical capacity and describes its use. METHODS: A surgical capacity tool was adapted to assess neurosurgical capacity. An expert panel of neurosurgeons and researchers reviewed the Surgeons OverSeas PIPES (personnel, infrastructure, procedures, equipment, and supplies) assessment and added additional items essential to perform common neurosurgery procedures. This tool was then piloted at 3 public hospitals in Uganda and each hospital was given a score of neurosurgical capacity. At 1 hospital, 3 respondents were asked to answer the survey to assess reliability. RESULTS: The hospital with the largest neurosurgery caseload and 5 neurosurgeons scored the highest on our survey, followed by a regional hospital with 1 practicing neurosurgeon. The third hospital, without a neurosurgeon, scored the lowest on the scale. At the hospital that completed the reliability assessment, scores were varied between respondents. CONCLUSIONS: NeuroPIPES survey scores were in keeping with the number of neurosurgeons and respective caseloads of each hospital. However, the variation in scores between respondents at the same hospital suggests that adaptations could be made to the tool that may improve reliability and validity. The methodology used to create NeuroPIPES may be successfully applied to a variety of other surgical subspecialties for similar assessments.


Assuntos
Países em Desenvolvimento , Necessidades e Demandas de Serviços de Saúde , Mão de Obra em Saúde , Hospitais Públicos , Neurocirurgia , Salas Cirúrgicas/provisão & distribução , Equipamentos Cirúrgicos/provisão & distribução , Humanos , Procedimentos Neurocirúrgicos , Salas Cirúrgicas/normas , Projetos Piloto , Reprodutibilidade dos Testes , Equipamentos Cirúrgicos/normas , Uganda
14.
World Neurosurg ; 102: 571-582, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28336445

RESUMO

OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with TBI in low and middle-income countries have worse outcomes than patients in high-income countries. We evaluated important clinical indicators associated with mortality for patients with TBI at University Teaching Hospital of Kigali, Kigali, Rwanda. METHODS: A prospective consecutive sampling of patients with TBI presenting to University Teaching Hospital of Kigali Accident and Emergency Department was screened for inclusion criteria: reported head trauma, alteration in consciousness, headache, and visible head trauma. Exclusion criteria were age <10 years, >48 hours after injury, and repeat visit. Data were assessed for association with death using logistic regression. Significant variables were included in a multivariate logistic regression model and refined via backward elimination. RESULTS: Between October 7, 2013, and April 6, 2014, 684 patients were enrolled; 14 (2%) were excluded because of incomplete data. Of patients, 81% were male with mean age of 31 years (range, 10-89 years; SD 11.8). Most patients (80%) had mild TBI (Glasgow Coma Scale [GCS] score 13-15); 10% had moderate (GCS score 9-12) and 10% had severe (GCS score 3-8) TBI. Multivariate logistic regression determined that GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were significantly associated with death. CONCLUSIONS: GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were associated with mortality. These findings inform future research that may guide clinicians in prioritizing care for patients at highest risk of mortality.


Assuntos
Lesões Encefálicas Traumáticas/mortalidade , Acidentes de Trânsito , Adolescente , Adulto , Idoso , Bradicardia/mortalidade , Criança , Mortalidade Hospitalar , Hospitais de Ensino/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Humanos , Hipóxia/mortalidade , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Ruanda , Taquicardia/mortalidade , Adulto Jovem
15.
Rev. psicol. deport ; 25(2): 261-269, 2016. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-154862

RESUMO

Este estudio investigó las relaciones existentes entre las estrategias de afrontamiento (coping) y la motivación de futbolistas profesionalizados y no profesionalizados de un equipo de la primera división de la liga brasileña. Se empleó una muestra de 182 individuos, evaluados con la Escala de Motivación Deportiva y el Inventario de Estrategias de Afrontamiento. En el análisis de los datos, se utilizaron el test de Mann-Whitney, la correlación de Spearman y regresión múltiple. Los resultados señalaron que los jugadores de perfil profesionalizado presentan un grado más alto en la motivación autónoma, mientras que los jugadores de perfil no profesionalizado tienden a la desmotivación. Los jugadores profesionalizados utilizan más estrategias de Confidence and Achievement Motivation (confianza y motivación), Peaking under Pressure (rendimiento máximo bajo presión) y Goal Setting (formulación de objetivos) si se los compara a los no profesionalizados. La motivación autónoma tuvo impacto sobre las estrategias de Coping with Adversity (afrontamiento de las adversidades), Goal Setting (establecimiento de objetivos) y Confidence and Achievement Motivation (confianza y motivación) de los jugadores profesionalizados. Se concluye que, para los jugadores profesionalizados, la motivación autónoma es un elemento clave para impulsar el uso de las estrategias de afrontamiento, mientras que la misma relación no tiene resultados expresivos en los jugadores no profesionalizados (AU)


This study investigated the relationship between coping and motivation in professional and amateur footballers in a first division team in the Brazilian football league. A total of 182 footballers at two different stages of their careers took part. Data collection was conducted using the Sport Motivation Scale and the Athletic Coping Skills Inventory. the Mann-Whitney test, the Spearman Correlation and Multiple Regression were used for data analysis. The results showed that players with a professional profile showed higher levels of self-determined motivation in comparison to players with a non-professional profile, who also had a tendency towards demotivation. Professional players used more strategies for Confidence and Achievement Motivation, Peaking under Pressure and Goal Setting than non-professional players. Autonomous motivation had an impact on Coping with Adversity, Goal Setting and Confidence and Achievement Motivation strategies in professional players. It was concluded that, for professional players, autonomous motivation is a key factor in boosting coping, while the same relationship was not to be found in non-professional players (AU)


Assuntos
Humanos , Masculino , Motivação/fisiologia , Adaptação Psicológica/fisiologia , Escalas de Graduação Psiquiátrica Breve/normas , Esportes/psicologia , Autonomia Pessoal , Estatísticas não Paramétricas , Autoimagem
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