Challenges Facing Surgical Training in the Great Lakes Region in Sub-Saharan Africa: a Review Article

Background: There is a severe shortage of health workers in sub-Saharan Africa yet this subcontinent experiences a significant proportion of the world’s disease burden. This shortage is further reflected in the lack of personnel for surgical sub specialities such as orthopaedics, paediatrics, neurology and urology to mention but a few.Objective: This review therefore sought to summarize the current literature on the state of surgical training in sub Saharan Africa, discuss the  challenges faced and the possible ways to overcome these challengesMethods: We performed online searches of electronic databases i.e. PUBMED, MEDLINE and African Journals online that feature many African Journals not index by the ‘regular’ databases.Results: The searches returned 88 articles and 24 of which were included in the review, we present results focused on; training capacity and methods, scope of practice, technology and surgery, and low research capacity and output.Conclusion: The future of surgical training in Africa will depend on the ability of the leadership to create or and adopt innovative educational technologies, recruit and retain trainers and attract trainees on one hand and on the other, the growth of demand for quality surgical care in the great lakes regions. For those that have excelled in training need to build on those successes and share their stories.Keywords: Surgical Training, challenges, sub- Saharan Afric

Breast transillumination a viable option for breast cancer screening in limited resource settings?

Background: Mammography is an established screening tool for breastcancer in high-income countries but may not be feasible for most resourcepoor nations. Alternative modalities are needed to mitigate the impact of the increasing incidence and mortality due to breast cancer. This may require the development of new technologies or reevaluation of old technologies applicable to resource limited settings.Objective: To determine the sensitivity and specificity of breast transillumination as compared to mammography and to describe featuresof benign and malignant breast lesions as seen with breast transillumination.Methods: A single group descriptive analytical study was conductedover a six month period (2011) in the breast unit of Mulago Nationalhospital. Eligible participants were consecutively sampled. Participantsunderwent Clinical Breast Examination (CBE), breast transillumination(BT), mammography (MG) and histopathological analysis of identifiedbreast lumps. Sensitivity, specificity and predictive values werecalculated. Features of the masses detected by transillumination werethen described.Results: The number of participants recruited was 201 (mean age 42years, range 30-80 years). The average palpable lump size was 3.8cm (range 0.5 to 10 cm). BT had a sensitivity of 63.2% (PPV 86.8%) anda specificity of 89.5% (NPV 61.2%) with mammography as the referencestandard. Also, 73.3% of breast lumps with irregular margins and 88.5%with dense opacity at transillumination turn out to be malignant athistopathology examination.Conclusion: The Breast transillumination technique had a moderatesensitivity of 63.2%. This warrants a large scale population-basedevaluation of BT as a screening tool. This technique may not substitutemammography but to be considered an option where mammographyaccess is limited

Diagnostic accuracy of the Tzanakis score for acute appendicitis in a resource-limited setting: A tertiary hospital-based survey

Background: The management of acute appendicitis remains challenging with high peri-operative morbidity and mortality due diagnostic delay or high negative appendicetomy rates due to aggressive surgical approaches. CT scan is accurate for pre-operative diagnosis but not available or affordable in all settings. There remains a need for an affordable yet accurate tool for diagnosing acute appendicitis in the resource limited setting. Methods: To determine the diagnostic accuracy of Tzanakis score in the preoperative evaluation of patients with acute appendicitis, we conducted a descriptive cross-sectional study at Mulago Hospital in Kampala, Uganda. Eligible consenting patients diagnosed with acute appendicitis consecutively underwent Tzanakis scoring and appendicectomy. Appencieal samples were sent for histological examination. Sensitivity, specificity, positive predictive value, negative predictive values, and diagnostic accuracy of the Tzanakis scoring system were calculated, relative to histological examination. Results: We enrolled 160 participants of mean age 30.4 years with male:female ratio of 2:1. The Tzanakis score had sensitivity of100% (95% CI 98-100), positive predictive value 97 % (95% CI 95-99), specificity of 64% (95% CI 31-89), negative predictive value of 100%, and overall diagnostic accuracy of 98% with 3% negative appendectomy rate. Conclusions: The Tzanakis score is found to be a sensitive and specific tool that should be considered for preoperative diagnosis of acute appendicitis in resource limited settings. Keywords: appendicitis; appendicectomy; acute abdomen; diagnosis; Tzanakis score; Uganda

The scourge of head injury among commercial motorcycle riders in Kampala; a preventable clinical and public health menace

Background: Trauma is an increasingly important cause of disease globally. Half of this trauma is from road traffic injuries with motorcycles contributing 21-58%. Low protective gear use, lack of regulation and weak traffic law enforcement contribute to unsafe nature of commercial motorcycles also known as “boda boda” in Uganda.Objectives: To determine the prevalence of protective gear use, the occurrence of head injury and the relationship between the two among commercial motorcycle riders in Kampala.Methods: Following ethical approval we recruited consecutive consenting participants to this analytical cross-sectional study. Data was collected using pretested interviewer administered questionnaires, double entered in Epidata and analyzed with STATA. Proportions and means were used to summarize data. Odds ratios were calculated for association between wearing helmets and occurrence and severity of head injury.Results: All 328 participants recruited were male. Of these, 18.6% used Protective gear and 71.1 % sustained head injury. Helmets protected users from head injury (OR 0.43, 95% CI, 0.23-0.8) and significantly reduced its severity when it occurred.Conclusion: Protective gear use was low, with high occurrence of head injury among commercial motorcycle riders in Uganda. More effective strategies are needed to promote protective gear use among Uganda’s commercial motorcycle riders.Keywords: Boda-boda, okada, commercial motorcycle, head injury, protective gear, helmet, Mulago hospital

Post-operative complications of stapled versus Ferguson hemorrhoidectomy at Mulago Hospital. A randomized comparative study

Background: Hemorrhoids are a common anorectal condition. New surgical treatments have led to a reappraisal of hemorrhoid disease over the last few decades and despite a range of treatment modalities, the options are limited in their effectiveness and can lead to a number of complications. This study set out to compare post operative complications between stapled haemorrhoidopexy (SH) and Ferguson haemorrhoidectomy (FH) for patients with Grade III and IV in Mulago National Referral and teaching Hospital.Methods: Following ethical approval 48 consenting participants with Grade III/IV hemorrhoids were randomized to either FH or SH under regional anesthesia on 1:1 allocation. Early and short term post-operative complications were analyzed. .Results: We enrolled 24 participants in each arm with equal sex allocation and mean age of 39 years with 100% follow up. There was largely no difference in early and short term complications between FH and SH save for bleeding in the short term follow up which occurred more frequently in the FH group (p-value 0.045). The bleeding was mild and did not require transfusion.Conclusion: There was no major difference in short term complication rates between SH and FH. SH is a safe alternative to FH in Mulago Hospital.Keywords: Ferguson hemorrhoidectomy. Stapled hemorrhoidopexy. Hemorrhoids.PPH, Mulago Hospital, colorectal surger

Clinico-pathological pattern and early post-operative complications of gastro-duodenal perforations at Mulago Hospital Kampala- a prospective cohort study

Background: Gastro-Duodenal Perforations are one of the commonest causes of mortality and morbidity in conditions that require emergency surgery. The main objective of this study was to determine the clinico-pathological pattern and evaluate factors for early post operative complications of Gastro-duodenal perforations in Mulago. Methods: This was a prospective cohort study of patients with gastro-duodenal perforations managed by simple repair between September 2014 and April 2015 in Mulago was studied. Primary/ secondary outcomes were mortality and complications respectively. Data was managed using stata-12 and multivariate analysis using log-binomial regression model. Results: A total of 65 patients were operated for Gastro-duodenal perforations in the study period. 86.2% were male (M: F 6.2:1). Median age was 35 years (range 16- 80 years). 93.9% had gastric perforations. Clinical diagnosis was predicted in 89.3%. H. pyloriwas present in 7.9%. Mortality was 18.5% and complications developed in 58.5%. Age above 35 and presence of   co morbidity predicted mortality (CI 1.22- 21.12, p= 0.009) (CI 1.26- 8.82, p= 0.024) and early post-operative complications (CI 1.03- 2.44, p= 0.031) (CI 1.23- 2.44, p= 0.011) respectively. Conclusion: Gastroduodenal perforations remain a common surgical emergency in Mulago hospital affecting mainly young men below 35 years. Majority are gastric perforations. Mortality and early post-operative complications are high, and increase with age and presence of co morbidity. Keywords: gastro-duodenal perforations, perforated peptic ulcer disease, gastric perforation

The scourge of head injury among commercial motorcycle riders in Kampala; a preventable clinical and public health menace

Background: Trauma is an increasingly important cause of disease globally. Half of this trauma is from road traffic injuries with motorcycles contributing 21-58%. Low protective gear use, lack of regulation and weak traffic law enforcement contribute to unsafe nature of commercial motorcycles also known as \u201cboda boda\u201d in Uganda. Objectives: To determine the prevalence of protective gear use, the occurrence of head injury and the relationship between the two among commercial motorcycle riders in Kampala. Methods: Following ethical approval we recruited consecutive consenting participants to this analytical cross-sectional study. Data was collected using pretested interviewer administered questionnaires, double entered in Epidata and analyzed with STATA. Proportions and means were used to summarize data. Odds ratios were calculated for association between wearing helmets and occurrence and severity of head injury. Results: All 328 participants recruited were male. Of these, 18.6% used Protective gear and 71.1 % sustained head injury. Helmets protected users from head injury (OR 0.43, 95% CI, 0.23-0.8) and significantly reduced its severity when it occurred. Conclusion: Protective gear use was low, with high occurrence of head injury among commercial motorcycle riders in Uganda. More effective strategies are needed to promote protective gear use among Uganda\u2019s commercial motorcycle riders

Anaesthetic research in low- and middle-income countries.

In this issue of Anaesthesia, Kwikiriza et al. [1] report a randomised controlled trial comparing the analgesic effects of intrathecal morphine with ultrasound-guided transversus abdominis plane block after caesarean section at a Ugandan Regional Referral Hospital. The publication of this study, authored by an international team, represents an important example of the role of academic anaesthesia in global health.NIHR Global Health Research Group on Neurotraum

Carbapenem resistance expressed by Gram-negative bacilli isolated from a cohort of Libyan patients

Background and objectives: Carbapenem-resistant Enterobacteriaceae (CRE) and other Gram-negative bacteria are among the most common pathogens responsible for both community and hospital acquired infection. The global spread of cephalosporinases in Enterobacteriaceae has led to the increased use of carbapenems resulting in the emergence and rapid spread of CRE. This has become an alarming public health concern, yet the condition in Libya remains unclear. The aim of this study was to obtain a better understanding of CRE strains prevalent in Libyan patients by investigating their phenotypic characteristics and antibiograms. Methods: Gram-negative bacterial species were collected from Misrata Central Hospital, Misrata Cancer Centre and Privet Pathology Laboratories. Clinical samples and swabs were obtained from hospitalised and non-hospitalised patients and from mechanical ventilation and suction machines. Patients who had received antibiotic therapy for at least three days prior to the study were excluded. The identification and characterization of the isolated species were achieved using the growth characteristics on MacConkey and blood agar, spot tests and API 20E or API 20NE biochemical testing systems. Screening for carbapenem resistance was performed using the disk diffusion method with carbapenem 10 μg and cephalosporin 30 μg disks and minimum inhibitory concentrations (MIC) determined using the Sensititre Gram-negative Xtra plate format (GNX2F). All strains demonstrating resistance or reduced susceptibility to one of the four carbapenems were subjected to carbapenememase activity detection using the RAPIDEC CARBA NP test, Modified Hodge test and carbapenem inactivation methods. Results: A total of one hundred and forty isolates representing fourteen bacterial species were isolated from 140 non-duplicated specimens. Clinical specimens included urine samples (96/140, 68.57%), sputum (15/140, 10.71%), surgical wound swabs (18/140, 12.85%), foot swabs from diabetes mellitus (DM) patients (6/140, 4.29%), ear swabs (3/140, 2.14%) and wound swabs (2/140, 1.43%). Thirty-four (24.29%) isolates demonstrated resistance to at least one of the four carbapenems with Klebsiella pneumoniae representing 73.53% (25 isolates) of all carbapenem resistant species, followed by 8.82% for Pseudomonas aeruginosa (3 isolates), 5.88% for both Proteus mirabilis (2 isolates) and Escherichia coli (2 isolates) and 2.94% for both Citrobacter koseri (1 isolate) and Rahnella aquatilis (1 isolate). The other isolates were either susceptible or cephalosporinase producers. Conclusion: This study has revealed the high rate of carbapenem resistance amongst Libyan patients and emphasizes the crucial need for accurate screening, identification and susceptibility testing to prevent further spread of nosocomial and community acquired resistance. This may be achieved through the establishment of antibiotic stewardship programmes along with firm infection control practices.National Research Foundation of South Africa; Libyan GovernmentWeb of Scienc

Prevalence of Finger Millet Diseases in Kaberamaido Subcounty, Soroti District, Uganda

A survey of finger millet (Eleusine coracana) diseases was conducted in Kaberamaido subcounty, Soroti district, Uganda, in 1984. Three diseases, namely finger  millet blast (Pyricularia grisea), tar spot . (Phyllachora eleusines) and sclerotium wilt (Sclerodum rolsfii) were prevalent on all the cultlvars grown in the area. Tar spot and sclerotium wilt were of little economic significance but neck and head blast infections caused up to 10.8 % loss in seed yield. Of the four common culti -vars of finger millet grown in the area - Emiroit, Ebaati (late maturity, with large leaves and open fingers), Okwete and Ekama (early maturity, with small leaves and closed fingers) - Ebaati was the most susceptible and Ekama the least susceptible to blast.Key words: Finger millet, Eleusine, Pyricularia, Sclerotium, Phyllachora, diseases