Surgery in the Time of Covid-19: Reflections on a Pandemic

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Reflections on clinical mentorship in surgical practice, training, and research

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Schistosoma mansoni proctocolitis with polyposis

Schistosoma proctocolitis is a rare disease entity, with limited literature on its occurrence. We report the case of a 17 year old male from an endemic area around Lake Victoria, Western Kenya, where detailed disease mapping of Schistosomiasis has been carried out. The patient presented with a seven year history of a protruding rectal mass and occasional hematochezia. Colonoscopy revealed multiple polyps involving the entire colon to the anus, and pathology showed inflammatory polyps secondary to Schistosoma  mansoni. He was successfully managed with medical therapy.Keywords: Schistosomiasis, Helminthiasis, Neglected Diseases, Colonoscopy, Colonic Polyp

Do the feeding practices and nutrition status among HIV-exposed infants less than 6 months of age follow the recommended guidelines in Bomet County, Kenya?

BACKGROUND: Globally, about 1.5 million pregnancies are among women living with the Human Immuno-deficiency Virus (HIV). In 2013, an estimated overall HIV prevalence of 0.34 % was reported in antenatal women in Kenya, with 13,000 new HIV infections among children. Appropriate feeding practices and good nutrition status are important for the survival, growth, development and health of HIV-exposed infants, as well as the wellbeing of their mothers. The purpose of this study was to determine the feeding practices and nutrition status of HIV-exposed infants 0–5 months of age, attending the paediatric clinic in a mission hospital in Bomet County, Kenya. METHODS: This was a cross-sectional study with quantitative and qualitative techniques in data collection and analysis. A comprehensive sample of 118 mothers/caregivers with HIV-exposed infants 0–5 months of age participated in the study. The data was analysed using SPSS software. Statistical significance was set at p values less than 0.05. RESULTS: Exclusive breastfeeding was practiced by the majority of the participants (73.7 %), 14.4 % practiced exclusive replacement feeding and 11.9 % mixed fed their infants. More than half the infants had normal length for age (57.7 %), weight for age (60.2 %) and weight for length (76.3 %). About a third (38.1 %) of the infants were stunted, 39 % were underweight and 19.5 % were wasted. Infants on mixed feeding were more likely to be stunted (OR = 2.401; 95 % CI: 0.906–5.806; p = 0.001) or underweight (OR = 2.001; 95 % CI: 0.328–6.124; p = 0.001) compared to those on exclusive breastfeeding. There was however, no significant difference in the likelihood for wasting among infants on exclusive breastfeeding, compared to those on exclusive replacement feeding (OR = 0.186; 95 % CI: 0.011–3.130; p = 0.996) or mixed feeding (OR = 1.528; 95 % CI: 0.294–7.954; p = 0.614). No significant differences were observed in the likelihood for malnutrition among infants on exclusive breastfeeding, compared to those on exclusive replacement feeding. CONCLUSION: Most mothers/caregivers fed their infants as recommended. The 11.9 % who did not observe the recommendations were however, at risk for contracting HIV. We recommend that the Ministry of Health and National AIDS and STI Control Programme develop a policy to support infants who qualify for exclusive replacement feeding but whose mothers/caregivers face constraints in compliance

Pediatric Trauma Care in Low- and Middle-Income Countries: A Brief Review of the Current State and Recommendations for Management and a Way Forward

Traumatic injuries are a significant cause of death and disability worldwide. The vast majority of these injuries occur in low- and middle-income countries (LMICs). Attention to protocolized care and adaptations to treatments based on availability of resources, regionalization of care, and the development of centers of excellence within each LMIC are crucial to improving outcomes and lowering trauma-related morbidity and mortality worldwide. Given limitations in the availability of the resources necessary to provide the levels of care found in high-income countries, strategies to prevent trauma and make the best use of available resources when prevention fails, and thus achieve the best possible outcomes for injured and critically ill children, are vital. Overall, a commitment on the part of governments in LMICs to the provision of adequate health care services to their populations will improve the outcomes of injured children. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs

An Online, Modular Curriculum Enhances Surgical Education and Improves Learning Outcomes in East, Central, and Southern Africa: A Mixed-Methods Study

Objective: We aimed to determine the impact of a standardized curriculum on learning outcomes for surgical trainees in East, Central, and Southern Africa (ECSA). Background: As surgical education expands throughout ECSA, there is a recognized need for a standardized curriculum. We previously described the design of a novel, large-scale, flipped-classroom, surgical curriculum for trainees in ECSA. Methods: In January 2020, the first year of curricular content for trainees of the College of Surgeons of ECSA was released, containing 11 monthly thematic topics, each with 2 to 5 weekly modular subtopics. We aimed to evaluate 3 outcomes utilizing data sources incorporated into the curriculum structure. Learner engagement was assessed by the number of trainees completing curriculum topics. User experience was evaluated using quantitative and qualitative feedback responses to embedded surveys for each content week. Curriculum impact on trainee examination performance was assessed by comparing certification examination scores stratified by the number of curricular topics each trainee completed. Results: Two hundred seventy-one trainees (96%) in 17 countries accessed at least 1 weekly module. Trainees completed a median of 9 topics (interquartile range: 6-10). The feedback survey response rate was 92% (5742/6233). Quantitative and qualitative responses were positive in overall module value (93.7% + 2.6%), amount of learning experienced (97.9% + 1.4%), confidence in achieving learning objectives (97.1% + 2.4%), and ease of use of the module (77.6% + 5.98%). Topic-related certification examination performance improved significantly with increased completion of thematic topics. Conclusions: A standardized surgical curriculum in ECSA demonstrated excellent trainee usage, positive feedback, and improved examination scores

Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions

Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3–6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs

Operative case volumes and variation for general surgery training in East, Central, and Southern Africa

Background: Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries. Methods: Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored. Results: One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level. Conclusions: Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.</p