The CURE Protocol: Evaluation and External Validation of a New Public Health Strategy for Treatment of Paediatric Hydrocephalus in Low-Resource Countries
33 Pages Posted: 22 Aug 2019More...
Background: Managing paediatric hydrocephalus with shunt placement is especially risky in resource-limited settings due to risks of infection and delayed life-threatening shunt obstruction. This study evaluated a new evidence-based treatment algorithm to reduce shunt-dependence in this context.
Methods: The CURE Protocol employs pre- and intra-operative data to choose between endoscopic treatment and shunt placement. Data were prospectively collected for 730 children in Uganda (managed by local neurosurgeons highly-experienced in the protocol) and, for external validation, 96 children in Nigeria (managed by a local neurosurgeon trained in the protocol).
Findings: The age distribution was similar between Uganda and Nigeria, but there were more cases of post-infectious hydrocephalus in Uganda (64·2% vs 26·0%, p<0 ·001). Initial treatment of hydrocephalus was similar at both centers and included either a shunt at first operation or endoscopic management without a shunt. The Nigerian cohort had a higher failure rate for endoscopic cases (adjusted hazard ratio 2·5 [1·6-4.0], p<0·001), but not for shunt cases (adjusted hazard ratio 1·3 [0·5-3·0], p=0·6). Despite the difference in endoscopic failure rates, a similar proportion of the entire cohort was successfully treated without need for shunt at 6 months (55·2% in Nigeria versus 53·4% in Uganda, p=0·74).
Interpretation: Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar final results, with over half of all children remaining shunt-free. Where feasible, this could represent a better public health strategy in low-resource settings than primary shunt placement.
Funding Statement: CURE International, Harvard Program in Global Surgery and Social Change, MacArthur Foundation.
Declaration of Interests: The authors declare there are no conflicts of interest.
Ethics Approval Statement: The use of patient information in this study was reviewed and approved by the Institutional Review Board of the Cure Children's Hospital of Uganda (Mbale, Uganda) with joint approval for participation by the Lagos University Teaching Hospital.
Keywords: hydrocephalus; endoscopic third ventriculostomy; sub-saharan africa; post-infectious hydrocephalus; neurosurgery; surgical education
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