The Basic Surgical Skills course in sub-Saharan Africa: an observational study of effectiveness

Background: The Basic Surgical Skills (BSS) course is a common component of postgraduate surgical training programmes in sub-Saharan Africa, but was originally designed in a UK context, and its efficacy and relevance have not been formally assessed in Africa. Methods: An observational study was carried out during a BSS course delivered to early-stage surgical trainees from Rwanda and the Democratic Republic of the Congo. Technical skill in a basic wound closure task was assessed in a formal Objective Structured Assessment of Technical Skills (OSAT) before and after course completion. Participants completed a pre-course questionnaire documenting existing surgical experience and self-perceived confidence levels in surgical skills which were to be taught during the course. Participants repeated confidence ratings and completed course evaluation following course delivery. Results: A cohort of 17 participants had completed a pre-course median of 150 Caesarean sections as primary operator. Performance on the OSAT improved from a mean of 10.5/17 pre-course to 14.2/17 post-course (mean of paired differences 3.7, p < 0.001). Improvements were seen in 15/17 components of wound closure. Pre-course, only 47% of candidates were forming hand-tied knots correctly and 38% were appropriately crossing hands with each throw, improving to 88 and 76%, respectively, following the course (p = 0.01 for both components). Confidence levels improved significantly in all technical skills taught, and the course was assessed as highly relevant by trainees. Conclusion: The Basic Surgical Skills course is effective in improving the basic surgical technique of surgical trainees from sub-Saharan Africa and their confidence in key technical skills

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

Improving starting time in operating rooms of a tertiary hospital in Rwanda: a quality improvement project

Background: Delay in the first surgery start time at operating room (OR) could inevitably decrease utilization, lose very expensive OR resources, reduce satisfaction of patients and staff and potentially affect quality of patient care.Objectives: This study utilized the Strategic Problem Solving (SPS) quality improvement approach to increase the percentage of first surgeries started on time at a tertiary hospital in Rwanda.Methods: A pre- and post-intervention study was conducted between March 2016 and March 2017. The intervention included developing a policy on staff arrival time, training sessions on the policy and regular supervision of OR managers to ensure staff were arriving on time.Results: Chi square tests were performed to analyze the pre- and post-intervention results. The percentage of first surgeries started on time significantly increased from 3% pre-intervention to 25% postintervention (P<0.001), average duration of delay decreased by 55 minutes (P<0.001) and the percentages of nurses, anesthetists and surgeon arrived on time also significantly increased (P<0.001).Conclusion: The SPS approach can be useful in addressing the starting time of first surgery at OR. Support from the senior management team and buy-in from staff are essential. This project cannot eliminate confounding factors and the results cannot be generalizable to other settings. Longer term evaluation on sustainability is needed.Keywords: Delay first surgery, operating room efficiency, quality improvement, strategic problem solvin

Exploring the Significance of Bidirectional Learning for Global Health Education

The value of bidirectional learning is emphasized both in global health and local community engagement. Conceptualizations of bidirectional learning for global health education are discussed, including implications when it is defined as mutual learning, codevelopment, or academic partnerships. Additionally, we review the relationship of bidirectional learning to different learning theories. Case studies from the field offer examples of how bidirectional learning can occur in the classroom, through academic partnerships, or both. Finally, recommendations are offered to facilitate bidirectional learning in global health education, including in identifying challenges faced by educators in lower-resourced settings who wish to offer bidirectional learning to their students through partnership with higher-resourced academic institutions

Impact of COVID-19 on global burn care.

Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care. The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher's exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic. The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p = 0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p = 0.04). Use of telemedicine was implemented (p < 0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors. During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care. [Abstract copyright: Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London