In memoriam: Mr Jimmy James (1940–2019). His contribution to the training of surgeons in Malawi and the College of Surgeons of East Central and Southern Africa (COSECSA) region

John “Jimmy” James MB ChB FRCS Ed passed on the 4th December 2019, the day we had our COSECSA annual general meeting in Kampala, Uganda. He died after a short battle with metastatic prostate cancer

The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

BackgroundOperative note writing is one of the fundamental parts in surgical practice. Accurate documentation is critical, to be of value when used for postoperative care, research, academic purposes and medical legal clarity. Although guidelines guiding surgeons on how to write operative notes exist, deficiencies are noted worldwide.PurposeTo assess quality of hand-written operative notes in surgical unit at Queen Elizabeth Central Hospital (QECH) using the RCSEng guidelines as a standard.MethodsTo identify key areas of weaknesses, a sole observer in this study assessed prospectively the quality of operative notes in our setting. The audit loop was completed after adoption of new interventions.Results Sixty-seven percent of the notes were written by trainees in both audits. Key areas of missing data were on time of performing the operation, urgency, estimated blood loss, complications and extra procedure in the first audit, with a frequency of 0%, 2%, 14%, 38% and 11% respectively. The results improved significantly to 62%, 84%, 62%, 70%and 32% respectively [p<0.05] in the second audit. Half of the postoperative care instructions were inadequate with 29% of the notes partially illegible or completely illegible.ConclusionThe study identifies significant deficiencies in our operative note writing. Surgeon’s education, use of detailed pro formas with heading prompts and aide memoirs for vital information play a major role in better note completion. The role of electronic health records is highlighted

Integration of ear and hearing care into primary health care in Malawi with special reference to task-sharing.

Introduction: The prevalence of hearing impairment has increased rapidly over the last two decades. The burden is higher in Africa and South East Asia than in richer parts of the world. The majority of this hearing impairment is preventable and can be managed at primary care level. However, the primary care level is generally weak in the provision of ear and hearing services. In recognition of this gap, the overall aim of the present thesis is to investigate the need for and feasibility of integrating ear and hearing care into primary health care in Malawi, specifically through task-sharing. Methods: The thesis is composed of five sub-studies. Apart from the first two studies which were trans-national, all the other studies took place in Malawi. The first study aimed to synthesise the available data on the prevalence and causes of hearing impairment in Africa through a systematic review of literature. The second study aimed at assessing availability and progress of ENT, Audiology and Speech Therapy services in Africa. It was a cross sectional study and a questionnaire was distributed by email to an ad hoc group of ENT Surgeons and Audiologists across Africa. The third study aimed at assessing the outcome of children with ear and hearing disorders, three years after diagnosis, in terms of uptake of referral to hospital, treatment given and satisfaction, and their participation in different aspects of life (school enrolment, ability to make friends, and ability to communicate needs). This was a longitudinal analysis of a population-based sample of children with hearing disorders, screened clinically and through questionnaires at baseline (2013) and follow-up (2016). The fourth study aimed to assess the uptake of and barriers to referrals to ear and hearing services for children in Thyolo District, Malawi. This was a mixed methods study, using both quantitative and qualitative methods. The fifth study was a cluster randomised control trial and was aimed at assessing the feasibility and accessibility of training community health workers (CHWs) in ear and hearing care and their ability to identify participants with ear and hearing disorders. . CHWswere given a pre-test and post-test to assess the effect of training on their knowledge of ear and hearing care. Results: The thesis showed that sub-Saharan Africa bears a high burden of ear and hearing disorders and that there are gaps in resources available to address these ear and hearing disorders. In Africa, the estimated prevalence for hearing impairment in children was 7.7% (2.4%–21.3%) using a cut-off of 25 dB HL and 17% for the general population of all ages. Our study II indicated that there are between 0.1 and 4.6 ENT surgeons per million persons across the region. Apart from South Africa, there is less than one audiologist for every million persons in sub-Saharan African countries. The impact of ear and hearing disorders often goes unnoticed and has not been explored adequately in low and middle income countries (LMICs). Study III showed that school enrolment among children with hearing loss was associated with ability to communicate and ability to make friends. Among children with hearing loss, those with speech impairment were more likely to report difficulties in making friends and in communicating needs. Among children with hearing loss, older children, girls and those with an illiterate caregiver were less likely to be enrolled in school. Training of CHWs in ear and hearing disorders proved feasible and acceptable and that CHWs were able to identify patients with ear and hearing disorders, and make referrals to a tertiary hospital as appropriate. A follow-up study on the uptake of referrals showed that there was a low uptake and the thesis has highlighted that while caregivers appeared to be motivated to seek care for their child, several often-interacting factors prevented them from doing so. These included location of/distance to the hospital, indirect costs, lack of transportation, procedural challenges in camps, awareness and understanding of ear and hearing issues, fear and uncertainty about the referral hospital, and lack of availability/visibility of hearing health services. Conclusion: There is high prevalence of ear and hearing disorders in Africa. The majority of the causes are avoidable and these conditions have significant impact on the people affected. There are low levels of services available for people with ear and hearing disorders and low uptake due to difficulties with accessing services. Task-sharing at primary level is feasible and acceptable and could help to fill gaps in service provision

Feasibility and acceptability of training community health workers in ear and hearing care in Malawi: a cluster randomised controlled trial.

OBJECTIVE: To assess the feasibility and acceptability of training community health workers (CHWs) in ear and hearing care, and their ability to identify patients with ear and hearing disorders. DESIGN: Cluster randomised controlled trial (RCT). SETTING: Health centres in Thyolo district, Malawi. PARTICIPANTS: Ten health centres participated, 5 intervention (29 CHWs) and 5 control (28 CHWs). INTERVENTION: Intervention CHWs received 3 days of training in primary ear and hearing care, while among control CHWs, training was delayed for 6 months. Both groups were given a pretest that assessed knowledge about ear and hearing care, only the intervention group was given the posttest on the third day of training. The intervention group was given 1 month to identify patients with ear and hearing disorders in their communities, and these people were screened for hearing disorders by ear, nose and throat clinical specialists. OUTCOME MEASURES: Primary outcome measure was improvement in knowledge of ear and hearing care among CHWs after the training. Secondary outcome measures were number of patients with ear or hearing disorders identified by CHWs and number recorded at health centres during routine activities, and the perceived feasibility and acceptability of the intervention. RESULTS: The average overall correct answers increased from 55% to 68% (95% CI 65 to 71) in the intervention group (p<0.001). A total of 1739 patients with potential ear and hearing disorders were identified by CHWs and 860 patients attended the screening camps, of whom 400 had hearing loss (73 patients determined through bilateral fail on otoacoustic emissions, 327 patients through audiometry). Where cause could be determined, the most common cause of ear and hearing disorders was chronic suppurative otitis media followed by impacted wax. The intervention was perceived as feasible and acceptable to implement. CONCLUSIONS: Training was effective in improving the knowledge of CHW in ear and hearing care in Malawi and allowing them to identify patients with ear and hearing disorders. This intervention could be scaled up to other CHWs in low-income and middle-income countries. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry (201705002285194); Results

Survey of ENT services in sub-Saharan Africa: little progress between 2009 and 2015.

BACKGROUND: A 2009 survey of ENT, audiology, and speech therapy services and training opportunities in 18 Sub-Saharan African countries reported that the availability of services was extremely poor, the distribution of services was very inequitable, and training opportunities were limited. ​​Objective: We conducted a new survey to determine the current status of ear, nose, and throat (ENT), audiology, and speech therapy services in sub-Saharan Africa. METHOD: This study is a cross-sectional study. A questionnaire was distributed by email to an ad hoc group of ENT surgeons and audiologists in 30 sub-Saharan African countries. Data from the current survey were compared to those of a 2009 survey. The numbers of ENT surgeons, audiologists, and speech therapists/100,000 people were compared to the ratios in the United Kingdom. RESULTS: A total of 22 countries responded to the questionnaire. When data of the 15 countries that responded in both 2009 and 2015 are compared, the number of ENT surgeons had increased by 43%, audiologists had increased by 2.5%, and speech therapists by 30%. When the 23% population growth is taken into account, the numbers of ENT surgeons, audiologists, and speech therapists per 100,000 people had declined in four countries, and there remains a severe shortfall of ENT surgeons, audiologists, and speech therapists when compared to the UK Respondents cited lack of availability of basic equipment as the most frequent limitation in providing ENT services. Other important factors causing limitations in daily practice were: lack of ENT training facilities and audiological rehabilitation, low awareness of the burden of ENT pathology, as well as poor human resources management. CONCLUSIONS: There has been a lack of progress in ENT, audiology, and speech therapy services and training opportunities in sub-Saharan Africa between 2009 and 2015. There is a need to look at increased collaboration with developed countries and non-governmental organisations, establishing new and improving existing training centres in Africa, and task-shifting of some ENT services to primary health workers

Reasons for low uptake of referrals to ear and hearing services for children in Malawi.

BACKGROUND: Early detection and appropriate intervention for children with hearing impairment is important for maximizing functioning and quality of life. The lack of ear and hearing services in low income countries is a significant challenge, however, evidence suggests that even where such services are available, and children are referred to them, uptake is low. The aim of this study was to assess uptake of and barriers to referrals to ear and hearing services for children in Thyolo District, Malawi. METHODS: This was a mixed methods study. A survey was conducted with 170 caregivers of children who were referred for ear and hearing services during community-based screening camps to assess whether they had attended their referral and reasons for non-attendance. Semi-structured interviews were conducted with 23 caregivers of children who did not take up their referral to explore in-depth the reasons for non-uptake. In addition, 15 stakeholders were interviewed. Thematic analysis of the interview data was conducted and emerging trends were analysed. RESULTS: Referral uptake was very low with only 5 out of 150 (3%) children attending. Seven main interacting themes for non-uptake of referral were identified in the semi-structured interviews: location of the hospital, lack of transport, other indirect costs of seeking care, fear and uncertainty about the referral hospital, procedural problems within the camps, awareness and understanding of hearing loss, and lack of visibility and availability of services. CONCLUSION: This study has highlighted a range of interacting challenges faced by families in accessing ear and hearing services in this setting. Understanding these context specific barriers to non-uptake of ear and hearing services is important for designing appropriate interventions to increase uptake

Squamous cell carcinoma in black patients with discoid lupus erythematosus

Squamous cell carcinoma has rarely been reported in black african people, with only 11 cases reported in the world literature to date. We report on 2 further cases, the first to be reported in southern Africa, of squamous cell carcinoma in lesions of discoid lupus erythematosu

Adult tonsillectomy - are long waiting lists putting patients at risk?

There is a paucity of data on morbidity associated with long waiting lists for adult tonsillectomy. The aim of this study was to assess the morbidity associated with long waiting lists for adult tonsillectomy in a developing world setting. Of 350 patients on the waiting list at Groote Schuur Hospital for 18 months or more, only 55 were contactable. This low yield (15.7%) from the telephonic survey highlighted the difficulty of managing long waiting lists efficiently in a developing world setting. As only 1/55 patients on the waiting list had a complication (quinsy), it appears to be safe to delay tonsillectomy in adult patients. Only half of patients ultimately required tonsillectomy because of a natural reduction in the number of episodes of tonsillitis with time. In order to avoid unnecessary tonsillectomy we need to find better prognosticators to identify the subgroup of adult patients likely to have continued recurrent tonsilliti

Reflections on the first twenty-five years of the University of Malawi College of Medicine

September 2016 marks 25 years since the College of Medicine of the University of Malawi was established. In this article we reflect on its conception, birth, adolescence, and youth. The contributions of multiple stakeholders are celebrated while being mindful of the ongoing efforts to consolidate past and current gains. For instance, the College of Medicine was, until recently, the only medical school in the country, but a new private medical school has just been opened in Lilongwe. International partnerships and wide-ranging resource mobilisation from both internal and international funders has been the hallmark of the growth and expansion of the Malawi College of Medicine. Further, the expanding needs for specialists in several clinical and non-clinical areas among the health professions calls for responsive strategies to address this and other human resources needs

Shared Decision-making Among Clinicians and Patients With Low-risk Differentiated Thyroid Cancer

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