title: Surgery for hydrocephalus in sub-Saharan Africa versus developed nations: a risk-adjusted comparison of outcome.
abstract: OBJECTIVE
  Surgery for children in developing nations is challenging. Endoscopic third ventriculostomy (ETV) is an important surgical treatment for childhood hydrocephalus and has been performed in developing nations, but with lower success rates than in developed nations. It is not known if the lower success rate is due to inherent differences in prognostic factors.
  
  
  METHODS
  We analyzed a large cohort of children (≤20 years old) treated with ETV in developed nations (618 patients from Canada, Israel, United Kingdom) and developing nations of sub-Saharan Africa (979 patients treated in Uganda). Risk-adjusted survival analysis was performed.
  
  
  RESULTS
  The risk of an intra-operative ETV failure (an aborted procedure) was significantly higher in Uganda regardless of risk adjustment (hazard ratio (HR), 95% confidence interval (CI), 11.00 (6.01 to 19.84) P<0.001). After adjustment for patient prognostic factors and technical variation in the procedure (the use of choroid plexus cauterization), there was no difference in the risk of failure for completed ETVs (HR, 95% CI, 1.04 (0.83 to 1.29), P=0.74).
  
  
  CONCLUSIONS
  Three factors account for all significant differences in ETV failure between Uganda and developed nations: patient prognostic factors, technical variation in the procedure, and intra-operatively aborted cases. Once adjusted for these, the response to completed ETVs of children in Uganda is no different than that of children in developed nations.
authors.affiliation: Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Room 1503, 555 University Avenue, Toronto, Ontario, Canada. abhaya.kulkarni@sickkids.ca
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Warf
authors.forename: James M
authors.initials: JM
authors.lastname: Drake
authors.forename: Conor L
authors.initials: CL
authors.lastname: Mallucci
authors.forename: Spyros
authors.initials: S
authors.lastname: Sgouros
authors.forename: Shlomi
authors.initials: S
authors.lastname: Constantini
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D002170:Canada / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D019049:Developed Countries / Q000706:statistics & numerical data; D003906:Developing Countries / Q000706:statistics & numerical data; D006801:Humans; D006849:Hydrocephalus / Q000401:mortality* / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D007557:Israel / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D044583:Neuroendoscopy / Q000379:methods / Q000401:mortality*; D012306:Risk; D020542:Third Ventricle / Q000601:surgery; D017211:Treatment Failure; D014454:Uganda / Q000453:epidemiology; D006113:United Kingdom / Q000453:epidemiology; D014696:Ventriculostomy / Q000379:methods / Q000401:mortality*