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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 2019

See all articles by Jacob Lepard

Jacob Lepard

Harvard University - Department of Neurosurgery; Harvard University - Program in Global Surgery and Social Change; University of Alabama at Birmingham - Department of Neurosurgery

Michael C Dewan

Harvard University - Program in Global Surgery and Social Change

Stephanie H Chen

University of Miami - Department of Neurosurgery

Olufemi B Bankole

University of Lagos - Department of Surgery

John Mugamba

CURE Children’s Hospital of Uganda

Peter Ssenyonga

CURE Children’s Hospital of Uganda

Abhaya V Kulkarni

University of Toronto - Division of Neurosurgery

Benjamin C Warf

Harvard University - Department of Neurosurgery

More...

Abstract

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

Suggested Citation

Lepard, Jacob and Dewan, Michael C and Chen, Stephanie H and Bankole, Olufemi B and Mugamba, John and Ssenyonga, Peter and Kulkarni, Abhaya V and Warf, Benjamin C, The CURE Protocol: Evaluation and External Validation of a New Public Health Strategy for Treatment of Paediatric Hydrocephalus in Low-Resource Countries (July 8, 2019). Available at SSRN: https://ssrn.com/abstract=3436263 or http://dx.doi.org/10.2139/ssrn.3436263

Jacob Lepard (Contact Author)

Harvard University - Department of Neurosurgery ( email )

United States

Harvard University - Program in Global Surgery and Social Change ( email )

Boston, MA
United States

University of Alabama at Birmingham - Department of Neurosurgery ( email )

Birmingham, AL
United States

Michael C Dewan

Harvard University - Program in Global Surgery and Social Change

Boston, MA
United States

Stephanie H Chen

University of Miami - Department of Neurosurgery

1475 N.W. 12th Ave.
Miami, FL 33136
United States

Olufemi B Bankole

University of Lagos - Department of Surgery

Lagos
Nigeria

John Mugamba

CURE Children’s Hospital of Uganda

Mbale
Uganda

Peter Ssenyonga

CURE Children’s Hospital of Uganda

Mbale
Uganda

Abhaya V Kulkarni

University of Toronto - Division of Neurosurgery

555 University Ave
Toronto, Ontario M5G 1X8
Canada

Benjamin C Warf

Harvard University - Department of Neurosurgery

United States

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