The ward round: friend or foe in postgraduate training? A grounded theory study of residents’ perspectives

The ward round has traditionally been a learning activity in medical education. Apart from education, ward rounds have multiple roles including patient care and communication. Some studies have described the ward round as an ideal place to learn patient management while others reported that little learning happens on rounds due to lack of time and patient volume. This study aimed to develop a deeper understanding of ward round learning from the perspec-tive of postgraduate trainees. A constructivist grounded theory approach was used and data was collected during focus group discussions. Data were analyzed by initial coding, then grouped into focused codes and development of a theoretical framework by the process of constant compar-ison. Six categories evolved which contributed to the framework. Postgraduate trainees perceive the ward round as an important space where they use different learning activities to acquire knowledge, attitude and skills required of a specialist doctor. They progress from novices to experts under supervision of faculty who lead ward rounds. The round can achieve its full learning potential if planned and organized well but can become a missed opportunity if the learning environment is unfriendly. Patient- and learner-related barriers exist that hinder ward round learning. The framework explains how ward round learning occurs in postgraduate medical education from a trainee perspective. The findings can guide interventions to improve the learning experience. Studies comparing perspectives of teachers to those of learners are needed to further understand the complex learning milieu of the ward round

Kawasaki disease: two case reports from the Aga Khan Hospital, Dar es Salaam-Tanzania

Background Kawasaki disease is a common childhood vasculitis which may result in cardiovascular morbidity if not adequately treated. Its epidemiology in the African region is not well described. Its features may mimic other childhood infections and hemoglobinopathies and it is rarely diagnosed in the East African region. These are the first reports of this disease from Tanzania. Case presentation We present two cases of complete Kawasaki disease seen over a 2 year period and diagnosed as per the criteria defined by the American Heart Association. One child was and infant and the other a 3 year old. Both of them presented with a prolonged fever and mucocutaneous findings. None of the children developed coronary artery aneurysms. One was treated with aspirin alone and the other with both aspirin and intravenous immunoglobulin. Both children had complete recovery and did not have any cardiovascular sequelae. Conclusion Kawasaki disease may be more common in the East African region than previously thought. It should be considered as a differential diagnosis in children who present with a prolonged fever of greater than 5 days and mucocutaneous findings. More awareness about this condition, its epidemiology, diagnosis and management are required in order to prevent the cardiovascular morbidity associated with it

Magnitude of screening for gestational diabetes mellitus in an urban setting in Tanzania; a cross-sectional analytic study

Background: Medical screening detects risk factors for disease or presence of disease in otherwise well persons in order to intervene early and reduce morbidity and mortality. During antenatal care (ANC) it is important to detect conditions that complicate pregnancy, like gestational diabetes mellitus (GDM). Despite international and local guidelines recommending screening for GDM during ANC, there is evidence to suggest that the practice was not being carried out adequately. A major challenge may be lack of consensus on uniform GDM screening and diagnostic guidelines internationally and locally. The primary objective was to determine the magnitude of screening for GDM among women receiving ANC at the Aga Khan Hospital, Dar es Salaam and Muhimbili National Hospital, Dar es Salaam. Secondary objectives were: to determine the methods used by health practitioners to screen for GDM, to determine the magnitude of undiagnosed gestational diabetes mellitus among women attending ANC and factors associated with screening for GDM among these women. Methods: A cross-sectional analytical study was done. Data collection was done using pre-tested questionnaires and reviewing antenatal care records. The proportion of women attending ANC who were screened for GDM was determined. The 75 g Oral Glucose Tolerance Test (OGTT) was offered to women who had not been screened after education and consent. Results: Only 107 out of 358 (29.9%) had been offered some form of GDM screening. Tests used for GDM screening were random blood sugar (56.8%), fasting blood sugar (32.8%), HbA1C (6%) and 75 g OGTT (3.4%). The uptake of the OGTT was 27%. Of these women the prevalence of GDM was 27.9%. Factors associated with screening for GDM were history of big baby, history of pregnancy induced hypertension and participant awareness of GDM (all p: \u3c 0.05). Conclusions: Screening for GDM among women attending ANC was lower than the World Health Organization target. Efforts should be directed towards promoting GDM screening, increasing awareness about GDM and developing more effective screening methods

Tuberculous Meningitis Presenting with Stroke in an Immunocompetent Adolescent: A Case Report

Background: Tuberculous meningitis (TBM) is a severe infection of the central nervous system that has high mortality. The disease predominantly affects young children and those who are immuncompromised. Strokes have been reported in about one-third of children with tuberculous meningitis and are associated with poor clinical outcomes.Case report: A previously healthy 14-year-old girl living in Dar es Salam, Tanzania presented with one month history of weight loss associated with weakness, loss of appetite, apathy; without respiratory symptoms. Anti-TB therapy was started, based on radiological findings of the chest which showed multiple patchy centrilobular nodules with linear branching pattern bilaterally, mediastinum lymph node enlargement with punctate calcification. She then became aphasic and developed right-sided hemiparesis. Brain imaging showed infarction, hydrocephalus and meningeal enhancement. Diagnosis of tuberculous meningitis (TBM) with left sided ischaemic stroke was made and dexamethasone was added to her regimen. Treatment and rehabilitation was continued for 12 months with minimal improvement.Conclusion: Tuberculous meningitis can present with non-specific features and has grave outcomes. Stroke is an uncommon complication in older immunocompetent children and results in severe morbidity. A high index of suspicion is required in adolescents with neurological symptoms that can be confused with behavioural symptoms

Tuberculous Meningitis Presenting with Stroke in an Immunocompetent Adolescent: A Case Report

Background: Tuberculous meningitis (TBM) is a severe infection of the central nervous system that has high mortality. The disease predominantly affects young children and those who are immuncompromised. Strokes have been reported in about one-third of children with tuberculous meningitis and are associated with poor clinical outcomes. Case report: A previously healthy 14-year-old girl living in Dar es Salam, Tanzania presented with one month history of weight loss associated with weakness, loss of appetite, apathy; without respiratory symptoms. Anti-TB therapy was started, based on radiological findings of the chest which showed multiple patchy centrilobular nodules with linear branching pattern bilaterally, mediastinum lymph node enlargement with punctate calcification. She then became aphasic and developed right-sided hemiparesis. Brain imaging showed infarction, hydrocephalus and meningeal enhancement. Diagnosis of tuberculous meningitis (TBM) with left sided ischaemic stroke was made and dexamethasone was added to her regimen. Treatment and rehabilitation was continued for 12 months with minimal improvement. Conclusion: Tuberculous meningitis can present with non-specific features and has grave outcomes. Stroke is an uncommon complication in older immunocompetent children and results in severe morbidity. A high index of suspicion is required in adolescents with neurological symptoms that can be confused with behavioural symptoms

Residency training on the frontlines of the COVID-19 pandemic - a qualitative study from Tanzania

Introduction: the Coronavirus Disease 2019 pandemic has affected residency training globally. The aim of this study was to understand how the pandemic affected teaching and learning in residency programs in low resource settings where residents and faculty were working on the front line treating patients with the disease. Methods: this qualitative study enrolled residents and faculty from the Aga Khan University in Tanzania who were providing front line care during the pandemic. Purposeful sampling was used and data was collected using focus group discussions and in-depth interviews between August and September 2020. Analysis was done using qualitative content analysis. Results: twelve residents and six faculty members participated in this study. Two main themes emerged. The first was: “New and unfamiliar teaching and learning experiences.” Residents and faculty had to adapt to changes in the learning environment and the academic program. Residents had increased responsibilities, including providing front line care and working with reduced supervision. The second theme was: “Learning opportunities amidst crisis.” There were opportunities to improve critical care and procedural skills. They also had opportunities to improve non-technical skills like teamwork and communication. Conclusion: residents and faculty had to adapt to changes in teaching and learning. Residents also had to take up additional responsibilities. Support systems are required to help them adapt to the changes and settle in their new roles. There were opportunities to learn new skills, and training should be restructured to maximize the use of these opportunities

Residency training on the frontlines of the COVID-19 pandemic - a qualitative study from Tanzania

Introduction: the Coronavirus Disease 2019 pandemic has affected residency training globally. The aim of this study was to understand how the pandemic affected teaching and learning in residency programs in low resource settings where residents and faculty were working on the front line treating patients with the disease. Methods: this qualitative study enrolled residents and faculty from the Aga Khan University in Tanzania who were providing front line care during the pandemic. Purposeful sampling was used and data was collected using focus group discussions and in-depth interviews between August and September 2020. Analysis was done using qualitative content analysis. Results: twelve residents and six faculty members participated in this study. Two main themes emerged. The first was: New and unfamiliar teaching and learning experiences. Residents and faculty had to adapt to changes in the learning environment and the academic program. Residents had increased responsibilities, including providing front line care and working with reduced supervision. The second theme was: Learning opportunities amidst crisis. There were opportunities to improve critical care and procedural skills. They also had opportunities to improve non-technical skills like teamwork and communication. Conclusion: residents and faculty had to adapt to changes in teaching and learning. Residents also had to take up additional responsibilities. Support systems are required to help them adapt to the changes and settle in their new roles. There were opportunities to learn new skills, and training should be restructured to maximize the use of these opportunities

The ward round: friend or foe in postgraduate training? A grounded theory study of residents’ perspectives

The ward round has traditionally been a learning activity in medical education. Apart from education, ward rounds have multiple roles including patient care and communication. Some studies have described the ward round as an ideal place to learn patient management while others reported that little learning happens on rounds due to lack of time and patient volume. This study aimed to develop a deeper understanding of ward round learning from the perspective of postgraduate trainees. A constructivist grounded theory approach was used and data was collected during focus group discussions. Data were analyzed by initial coding, then grouped into focused codes and development of a theoretical framework by the process of constant comparison. Six categories evolved which contributed to the framework. Postgraduate trainees perceive the ward round as an important space where they use different learning activities to acquire knowledge, attitude and skills required of a specialist doctor. They progress from novices to experts under supervision of faculty who lead ward rounds. The round can achieve its full learning potential if planned and organized well but can become a missed opportunity if the learning environment is unfriendly. Patient- and learner-related barriers exist that hinder ward round learning. The framework explains how ward round learning occurs in postgraduate medical education from a trainee perspective. The findings can guide interventions to improve the learning experience. Studies comparing perspectives of teachers to those of learners are needed to further understand the complex learning milieu of the ward round

Factors Associated With Glycaemic Control in Children and Adolescents With Type 1 Diabetes Mellitus at Muhimbili National Hospital, Dar Es Salaam

Type 1 Diabetes Mellitus (T1DM) is a rapidly growing problem in Tanzania and Africa as a whole. Its long term complications are devastating for individuals and families and impose a considerable burden to health care systems. Maintaining strict glycaemic control in type 1 diabetics has been shown to greatly reduce the incidence and progression of long term complications. Various risk factors have been found to be associated with poor glycaemic control. Children and adolescents with T1DM in Dar es Salaam have previously been found to have very poor glycaemic control and a high prevalence of chronic complications. Identification of factors associated with poor control in our setting is critical in order to institute appropriate interventions that will result in improved metabolic control and prevent chronic complications. To determine the mean glycaemic control and identify factors associated with poor control in children and adolescents with T1DM. A cross sectional study was carried out at the diabetes clinic for children and adolescents at Muhimbili National Hospital. Children and adolescents attending the clinic were enrolled into the study after obtaining informed consent from the parent/guardian or assent from the adolescents themselves. A structured questionnaire was used to collect data from participants and parents/guardians. Glycaemic control was assessed by measurement of glycosylated haemoglobin (HbA1c). Data entry and analysis was done using Epi Info software version 3.5.1 and SPSS version 16. 75 participants were recruited into the study (51% males). The mean HbA1c was 11.1 ± 2.1%. Children aged < 10 years were found to have a significantly better glycaemic control (9.83%) as compared to 10 – 14 year olds (11.46%) and > 14 year olds (11.39%) (P value = 0.022). Sixty eight percent (68%) of patients had good adherence to insulin while good adherence to blood glucose monitoring regimen (BGM) and diet was 48% and 28% respectively. Younger children had better adherence to all treatment modalities and had optimal caregiver involvement in diabetes related tasks. Adherence to insulin injections was better in children who had optimal caregiver involvement in the task of injecting insulin. Younger age, having the mother as the primary caregiver, better caregiver knowledge of T1DM, better adherence to blood glucose monitoring (BGM) regimen and diabetes duration of less than 1 year were associated with better glycaemic control. In multivariate analysis, age of the child, adherence to BGM regimen and the mother as the primary caregiver were found to independently predict glycaemic control.(R2 = 0.332, p value = 0.00). Sixty percent (60%) of children and adolescents reported a negative impact of T1DM on their daily lives. This was not related to glycaemic control. Children and adolescents with T1DM in Dar es Salaam have very poor glycaemic control and poor adherence to treatment. Factors associated with poor control include older age, a caregiver other than the mother and poor adherence to BGM. There is also a high frequency of negative impact of the disease on daily life. In order to improve metabolic control, more frequent BGM should be encouraged. Emphasis needs to be put on adherence counseling and active participation of caregivers in diabetes related tasks of their children. Close follow up of the adolescents is necessary as this group is the most vulnerable to poor control.\u