Teaching surgical skills in a resource-limited setting: Comparing massed versus distributed practice in an ultrasound-guided breast biopsy simulator

Background: Teaching surgical skills in the simulation lab has increased markedly compared to teaching only in the operating room. Although many studies have been performed investigating the optimal teaching methodology for skills acquisition, there is no consensus on the best method. Massed and distributed practices are important methods in teaching procedural skills. Considering the limited human and logistical resources in low and middle-income settings, it is valuable to understand the optimal methodology for learning and acquiring surgical skills. Methods: Thirty-two core needle biopsy-naïve first-year residents and final year medical students rotating in general surgery were enrolled in and completed the study at University Teaching Hospital of Kigali, a tertiary, teaching and referral hospital in Kigali, Rwanda. They were assigned to a “massed” group (i.e., one time, 3-hour practice) or “distributed” group (i.e., 1-hour practice per week for 3 weeks). Trainees were taught ultrasound-guided core needle biopsy on a high-fidelity breast simulator. All participants completed pre- and post-tests and an evaluation of skill retention was performed one month after completion of the training. Analysis of performance was completed, and p-value ≤ 0.05 was considered statistically significant. Results: There was no difference between performance on the pretest (p=0.985) and the posttest (p=0.680). Both groups demonstrated improvement after implementation of the simulation training when comparing pretest and posttest results (p<0.001); there were no differences in the evaluation of skills retention after one month after the training between the two groups (p=0.273). Conclusions: The results of this study demonstrate that both groups have improved significantly their knowledge and skills. Trainees have similar retention of skills in ultrasound guided core needle biopsy on a breast simulator whether trained under a massed or distributed practice schedule. Both methods may be considered in our setting for teaching surgical skills. Keywords: surgical simulation; resource-limited setting; global surgery

Role of Collaborative Academic Partnerships in Surgical Training, Education, and Provision

The global disparities in both surgical disease burden and access to delivery of surgical care are gaining prominence in the medical literature and media. Concurrently, there is an unprecedented groundswell in idealism and interest in global health among North American medical students and trainees in anesthesia and surgical disciplines. Many academic medical centers (AMCs) are seeking to respond by creating partnerships with teaching hospitals overseas. In this article we describe six such partnerships, as follows: (1) University of California San Francisco (UCSF) with the Bellagio Essential Surgery Group; (2) USCF with Makerere University, Uganda; (3) Vanderbilt with Baptist Medical Center, Ogbomoso, Nigeria; (4) Vanderbilt with Kijabe Hospital, Kenya; (5) University of Toronto, Hospital for Sick Children with the Ministry of Health in Botswana; and (6) Harvard (Brigham and Women’s Hospital and Children’s Hospital Boston) with Partners in Health in Haiti and Rwanda. Reflection on these experiences offers valuable lessons, and we make recommendations of critical components leading to success. These include the importance of relationships, emphasis on mutual learning, the need for “champions,” affirming that local training needs to supersede expatriate training needs, the value of collaboration in research, adapting the mission to locally expressed needs, the need for a multidisciplinary approach, and the need to measure outcomes. We conclude that this is an era of cautious optimism and that AMCs have a critical opportunity to both shape future leaders in global surgery and address the current global disparities

Simplified Negative Pressure Wound Therapy Device for Application in Low-Resource Settings

Negative pressure wound therapy (NPWT) provides proven wound healing benefits and is often a desirable wound treatment. Unfortunately, NPWT devices are not widely available in low-resource settings (LRSs). In order to overcome identified NPWT barriers, a simplified NPWT (sNPWT) system was designed and iteratively improved during field-based testing. The sNPWT technology, our device design iterations, and the design-based results of our field tests are described. The sNPWT system includes a bellows hand pump, an occlusive drape, and a tube with tube connectors, connecting the drape to the pump. The most critical property of a sNPWT system is that it must be airtight. The details of the design iterations needed to achieve an occlusive system are explained. During the design process, the sNPWT system was tested during the earthquake relief in Haiti. This testing found that a liquid sealant was necessary to seal the drape to the peri-wound skin. A study conducted in Rwanda verified that a liquid latex sealant was safe to use and that the tube connector must be connected to the drape with an airtight method during the manufacturing process. This work has shown that sNPWT is feasible in LRSs. Since the completion of the clinical testing, the design has been further evolved and the developers are working with contract manufactures to produce the final design and preparing for regulatory approval applications

Strategies for improving quality and safety in global health:Lessons from nontechnical skills for surgery implementation in rwanda

The Non-Technical Skills for Surgeons (NOTSS) framework is a taxonomy of cognitive and social skills that foster expertise and medical knowledge in the operating room. This framework can be used as a method to improve the quality of surgical care in global efforts to improve access to affordable surgery

Synthesizing postpartum care pathways, facilitators, and barriers for women after cesarean section: a qualitative analysis from rural Rwanda

# Background In low- and middle-income countries (LMICs), c-section is the most commonly performed operation, and surgical site infection (SSI) is the most common post-operative complication following all surgical procedures performed. Whilst multiple interventions have been rolled out to address high SSI rates, strategies for optimal care of patients at risk of developing SSIs need to include an understanding of the general care seeking behaviors, facilitators, and barriers among high-risk groups, including mothers delivering via c-section. This study explores the healthcare experiences of women who delivered by c-section section, from giving birth through recovery, and their associated decision-making, perceptions of care, and social and financial supports. # Methods We conducted protocol-guided interviews in rural Kirehe District, Rwanda with twenty-five mothers who delivered by c-section at Kirehe District Hospital between February-April 2018, exploring their experience with delivery, hospitalization, recovery, and complications. Coded interviews were analyzed using the Grounded Theory approach to identify emergent themes. Thematic saturation was achieved. # Results Overall, women largely followed the tiered referral system, as it was designed. A majority faced financial barriers to returning to care, and a majority were not able to describe the reason for their c-section, the complications experienced, or the treatment prescribed. We constructed a process map to summarize key steps where interventions should be designed to promote facilitators, to reduce barriers, and to identify and target the women being diverted from this designated path. # Conclusions Understanding the existing healthcare pathway and the associated facilitators and barriers among postpartum women is critical to designing appropriate interventions that properly serve their needs. Our findings strongly suggest that moving or complimenting post-operative wound assessments from the health center into home-based care, and ensuring unified messaging around c-section indications, care, and complications at the community-level are two of the areas that may improve utilization of existing healthcare infrastructure for women who deliver by c-section in rural districts in Rwanda

The “Other” Neglected Diseases in Global Public Health: Surgical Conditions in Sub-Saharan Africa

Doruk Ozgediz and Robert Riviello discuss the burden of premature death and disability and the economic burden of surgical conditions in Africa

Using mobile health technology and community health workers to identify and refer caesarean-related surgical site infections in rural Rwanda: a randomised controlled trial protocol

Introduction: Surgical site infections (SSIs) are a significant cause of morbidity and mortality in low-income and middle-income countries, where rates of SSIs can reach 30%. Due to limited access, there is minimal follow-up postoperatively. Community health workers (CHWs) have not yet been used for surgical patients in most settings. Advancements in telecommunication create an opportunity for mobile health (mHealth) tools to support CHWs. We aim to evaluate the use of mHealth technology to aid CHWs in identification of SSIs and promote referral of patients back to healthcare facilities. Methods and analysis Prospective randomised controlled trial conducted at Kirehe District Hospital, Rwanda, from November 2017 to November 2018. Patients ≥18 years who undergo caesarean section are eligible. Non-residents of Kirehe District or patients who remain in hospital >10 days postoperatively will be excluded. Patients will be randomised to one of three arms. For arm 1, a CHW will visit the patient’s home on postoperative day 10 (±3 days) to administer an SSI screening protocol (fever, pain or purulent drainage) using an electronic tablet. For arm 2, the CHW will administer the screening protocol over the phone. For both arms 1 and 2, the CHW will refer patients who respond ‘yes’ to any of the questions to a health facility. For arm 3, patients will not receive follow-up care. Our primary outcome will be the impact of the mHealth-CHW intervention on the rate of return to care for patients with an SSI. Ethics and dissemination The study has received ethical approval from the Rwandan National Ethics Committee and Partners Healthcare. Results will be disseminated to Kirehe District Hospital, Rwanda Ministry of Health, Rwanda Surgical Society, Partners In Health, through conferences and peer-reviewed publications. Trial registration number NCT03311399

Gaps and opportunities in refractory status epilepticus research in children: A multi-center approach by the Pediatric Status Epilepticus Research Group (pSERG)

PURPOSE: Status epilepticus (SE) is a life-threatening condition that can be refractory to initial treatment. Randomized controlled studies to guide treatment choices, especially beyond first-line drugs, are not available. This report summarizes the evidence that guides the management of refractory convulsive SE (RCSE) in children, defines gaps in our clinical knowledge and describes the development and works of the \u27pediatric Status Epilepticus Research Group\u27 (pSERG). METHODS: A literature review was performed to evaluate current gaps in the pediatric SE and RCSE literature. In person and online meetings helped to develop and expand the pSERG network. RESULTS: The care of pediatric RCSE is largely based on extrapolations of limited evidence derived from adult literature and supplemented with case reports and case series in children. No comparative effectiveness trials have been performed in the pediatric population. Gaps in knowledge include risk factors for SE, biomarkers of SE and RCSE, second- and third-line treatment options, and long-term outcome. CONCLUSION: The care of children with RCSE is based on limited evidence. In order to address these knowledge gaps, the multicenter pSERG was established to facilitate prospective collection, analysis, and sharing of de-identified data and biological specimens from children with RCSE. These data will allow identification of treatment strategies associated with better outcomes and delineate evidence-based interventions to improve the care of children with SE

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

Abstract Background: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. Methods: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. Results: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. Conclusion: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals