Feasibility of delivering foot and ankle surgical courses in a partnership in Eastern, Central and Sothern Africa

BACKGROUND

Foot and ankle pathology if not treated appropriately and in a timely manner can adversely affect both disability and quality adjusted life years. More so in the low- and middle-income countries where ambulation is the predominant means of getting around for the majority of the population in order to earn a livelihood. This has necessitated the equipping of the new generation of orthopaedic surgeons with the expertise and skills set to manage these conditions. To address this need, surgeons from the British Orthopaedic Foot & Ankle Society (BOFAS) and College of Surgeons of Eastern, Central and Southern Africa (COSECSA) transferred the "Principles of Foot and Ankle Surgery" course to an African regional setting. The course was offered to surgical trainees from 14-member countries of the COSECSA region and previously in the UK. The faculty was drawn from practicing surgeons experienced in both surgical education and foot and ankle surgery. The course comprises didactic lectures, case-based discussions in small groups, patient evaluations and guided surgical dissections on human cadavers. It was offered free to all participants. The feasibility of the course was evaluated using the model defined by Bowen considering the eight facets of acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. At the end of the course participants were expected to give verbal subjective feedback and objective feedback using a cloud based digital feedback questionnaire. The course content was evaluated by the participants as "Poor", "Below average", "Average", "Good" and "Excellent", which was converted into a value from 1-5 for analysis. The non-parametric categorical data was analysed using the Two-sample Wilcoxon rank-sum (Mann-Whitney) test, and significance was considered to be p < 0.05.

RESULTS

Six courses in total were held between 2018 and 2020. Three in the UK and three in the COSECSA region. There were 78 participants in the three UK courses and 96 in the three courses run in the COSECSA region. Hundred percent of the UK participants and 97% of the COSECSA participants completed the feedback. Male to female ratio was 4:1 for the UK courses and 10:1 for the COSECSA Courses. In both regions all the participants responded that they would recommend the course to their colleagues. Among the COSECSA participants 91% reported that the course was pitched at the right level, which is similar to the 89% of the UK participants (p = 0.28).

CONCLUSION

The BOFAS Principles of Foot and Ankle Surgery course design provides core knowledge, with an emphasis on clinical examination techniques of the foot and ankle, while at the same time, caters for the anticipated difference in the local clinical case mix and resources. This study establishes that by attending the course surgical trainees can achieve their learning goals in foot and ankle surgery with the same high quality qualitative and quantitative feedback in both regions. This would improve their clinical practice and confidence. The multifaceted approach adopted in this course blending didactic teaching, small group discussions, interactive sessions, case-based discussions, cadaveric surgical skills training printed educational materials and feedback helped fulfil these educational objectives. Working in partnership with local expert orthopaedic surgeons from a number of Sub-Saharan countries, was key to adapting the course to local pathology and the COSECSA setting.

Barriers to Women Entering Surgical Careers: A Global Study into Medical Student Perceptions

BACKGROUND

Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown.

METHODS

A cross-sectional survey was developed by the International Federation of Medical Students' Associations (IFMSA)'s Global Surgery Working Group assessing medical students' desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students' perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata.

RESULTS

639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students' decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053].

CONCLUSION

Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student's decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.

Barriers to Women Entering Surgical Careers: A Global Study into Medical Student Perceptions

BACKGROUND

Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown.

METHODS

A cross-sectional survey was developed by the International Federation of Medical Students' Associations (IFMSA)'s Global Surgery Working Group assessing medical students' desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students' perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata.

RESULTS

639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students' decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053].

CONCLUSION

Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student's decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.

Delivering a sustainable trauma management training programme tailored for low-resource settings in East, Central and Southern African countries using a cascading course model

BACKGROUND

Injuries cause five million deaths and 279 Disability Adjusted Life Years (DALYS) each year worldwide. The COSECSA Oxford Orthopaedic Link (COOL) is a multi-country partnership programme that has delivered training in trauma management to nine sub-Saharan countries across a wide-cadre of health-workers using a model of "primary" courses delivered by UK instructors, followed by "cascading" courses led by local faculty. This study examines the impact on knowledge and clinical confidence among health-workers, and compares the performance of "cascading" and "primary" courses delivered in low-resource settings.

METHODS

Data was collated from 1030 candidates (119 Clinical Officers, 540 Doctors, 260 Nurses and 111 Medical Students) trained over 28 courses (9 "primary" and 19 "cascading" courses) in nine sub-Saharan countries between 2012 and 2013. Knowledge and clinical confidence of candidates were assessed using pre- and post-course MCQs and confidence matrix rating of clinical scenarios. Changes were measured in relation to co-variants of gender, job roles and primary versus cascading courses. Multivariate regression modelling and cost analysis was performed to examine the impact of primary versus cascading courses on candidates' performance.

FINDINGS

There was a significant improvement in knowledge (58% to 77%, p<0.05) and clinical confidence (68% to 90%, p<0.05) post-course. "Non-doctors" demonstrated a greater improvement in knowledge (22%) and confidence (24%) following the course (p<0.05). The degree of improvement of MCQ scores differed significantly, with the cascading courses (21%) outperforming primary courses (15%) (p<0.002). This is further supported by multivariate regression modelling where cascading courses are a strong predictor for improvement in MCQ scores (Coef=4.83, p<0.05).

INTERPRETATION

Trauma management training of health-workers plays a pivotal role in tackling the ever-growing trauma burden in Africa. Our study suggests cascading PTC courses may be an effective model in delivering trauma training in low-resource settings, however further studies are required to determine its efficacy in improving clinical competence and retention of knowledge and skills in the long term.

The effect of HIV on early wound healing in open fractures treated with internal and external fixation

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union.

This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study.

The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.

New method of Scoliosis Deformity Assessment: ISIS2 System

Scoliosis deformity has been assessed using radiographic angle measurements. Surface topography systems are an alternative and complementary methodology. Working systems include the original ISIS1 system, Quantec and COMOT techniques. Over the last five years the new ISIS2 (Integrated Shape Imaging System) has been developed from basic principles to improve the speed, accuracy, reliability and ease of use of ISIS1. The aim of this study was to confirm that ISIS2 3D back shape measurements are valid for assessment and follow up of patients with scoliosis. Three-dimensional back measurements were performed in Oxford. ISIS2 includes a camera/projector stand, patient stand with a reference plane, and Mac computer. Pixel size is approximately 0.5 mm with fringe frequency of approximately 0.16 fringes/mm ( approximately 6.5 mm/fringe). Clinical reports in pdf format are of coloured images with numerical values. Reports include a height map, contour plot, transverse section plots, coronal plot, sagittal sections and bilateral asymmetry maps. A total of 520 ISIS2 scans on 242 patients were performed from February 2006 to December 2007. There were 58 male patients (median age 16 years, SD 3.71, min 7, max 25) and 184 female patients (median age 14.5 years, SD 3.23, min 5, max 45). Average number of scans per patient was 2.01 with the range of 1-10 scans. Right sided thoracic curves were the most frequent pattern. The median values and 95% CI are reported of back length; pelvic rotation; flexion/extension; imbalance; lateral asymmetry; skin angle; kyphosis angle; lordosis angle; volumetric asymmetry. ISIS2 scoliosis measurements are non-invasive, low-cost, three-dimensional topographic back measurements which can be confidently used in scoliosis assessment and monitoring of curve progression.