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The CURE Protocol: evaluation and external validation of a new public health strategy for treating paediatric
Jacob R Lepard1,2, Michael C Dewan2,3, Stephanie H Chen4
1Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Insights
A new CURE Protocol algorithm successfully reduced shunt dependence in paediatric hydrocephalus patients in low-resource settings. Over half of children remained shunt-free at six months, offering a promising public health strategy.
Area of Science:
- Neurosurgery
- Paediatric Medicine
- Global Health
Background:
- Paediatric hydrocephalus management with shunts is challenging in low-resource settings due to infection and obstruction risks.
- The CURE Protocol was developed as an evidence-based treatment algorithm to minimize shunt dependence.
Purpose of the Study:
- To evaluate the effectiveness of the CURE Protocol in reducing shunt dependence for paediatric hydrocephalus in resource-limited environments.
- To compare outcomes between two distinct African centres with varying patient populations and surgeon experience.
Main Methods:
- A prospective cohort study involving 730 children in Uganda and 96 in Nigeria.
- The CURE Protocol guided treatment decisions between endoscopic procedures and shunt placement based on pre- and intraoperative data.
- Local neurosurgeons managed patients, with Ugandan surgeons highly experienced and Nigerian surgeons trained in the protocol.
Main Results:
- While Nigerian patients had a higher endoscopic failure rate (adjusted HR 2.5), overall successful treatment without a shunt at 6 months was similar between Uganda (53.4%) and Nigeria (55.2%).
- Shunt placement success rates were comparable between the two centres.
- Postinfectious hydrocephalus was significantly more prevalent in the Ugandan cohort (64.2% vs 26.0%).
Conclusions:
- The CURE Protocol demonstrated consistent 6-month outcomes across two diverse centres, with over half of children avoiding shunts.
- Implementing this protocol could offer a superior public health strategy compared to primary shunt placement in low-resource settings.
Introduction:
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:
A prospective cohort design was used. The CURE Protocol employs preoperative and intraoperative 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).
Results:
The age distribution was similar between Uganda and Nigeria, but there were more cases of postinfectious hydrocephalus in Uganda (64.2% vs 26.0%, p<0.001). Initial treatment of hydrocephalus was similar at both centres 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 HR 2.5 (95% CI 1.6 to 4.0), p<0.001), but not for shunt cases (adjusted HR 1.3 (0.5 to 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 vs 53.4% in Uganda, p=0.74).
Conclusion:
Use of the CURE Protocol in two centres with different populations and surgeon experience yielded similar 6-month 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.
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