Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania

BACKGROUND

Providing basic surgical and emergency care in rural settings is essential, particularly in Tanzania, where the mortality burden addressable by emergency and surgical interventions has been estimated at 40%. However, the shortages of teaching faculty and insufficient learning resources have hampered the traditionally intensive surgical training apprenticeships. The Muhimbili University of Health and Allied Sciences consequently has experienced suboptimal preparation for graduates practising surgery in the field and a drop in medical graduates willing to become surgeons. To address the decline in circumstances, the first step was to enhance technical skills in general surgery and emergency procedures for senior medical students by designing and implementing a surgical skills practicum using locally developed simulation models.

METHODS

A two-day training course in nine different emergency procedures and surgical skills based on the Canadian Network for International Surgery curriculum was developed. Simulation models for the surgical skills were created with locally available materials. The curriculum was pilot-tested with a cohort of 60 senior medical students who had completed their surgery rotation at Muhimbili University. Two measures were used to evaluate surgical skill performance: Objective Structured Clinical Examinations and surveys of self-perceived performance administered pre- and post-training.

RESULTS

Thirty-six students participated in the study. Prior to the training, no student was able to correctly perform a surgical hand tie, only one student was able to correctly perform adult intubation and three students were able to correctly scrub, gown and glove. Performance improved after training, demonstrated by Objective Structured Clinical Examination scores that rose from 6/30 to 15/30. Students perceived great benefit from practical skills training. The cost of the training using low-tech simulation was four United States dollars per student.

CONCLUSION

Simulation is valued to gain experience in practising surgical skills prior to working with patients. In the context of resource-limited settings, an additional benefit is that of learning skills not otherwise obtainable. Further testing of this approach will determine its applicability to other resource-limited settings seeking to develop skill-based surgical and emergency procedure apprenticeships. Additionally, skill sustainability and readiness for actual surgical and emergency experiences need to be assessed.

Manual laparoscopic skills development using a low-cost trainer box in Tanzania

OBJECTIVES

To explore the feasibility and effectiveness of guided practice using a low-cost laparoscopic trainer on the development of laparoscopic skills by surgeons in a resource-poor setting.

DESIGN

This was a prospective trial involving a pretest/posttest single-sample design. Study participants completed a background survey and pretest on the 5 McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks using a simulator developed and validated by researchers from the University of California, San Francisco. On completion of a 3-month guided practice course, participants were again tested on the MISTELS tasks and completed an exit survey.

SETTING

The Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania.

PARTICIPANTS

Fourteen Tanzanian surgery residents and specialists completed the study.

RESULTS

Most of the subjects were surgical residents (64.3%). Only 2 participants (14.2%) had previous laparoscopic training, and baseline laparoscopic surgical experience was limited to intraoperative observation only. Study subjects practiced the MISTELS tasks for an average of 8.67 hours (range: 4.75-15.25) over the 3-month course. On the posttest, participants improved significantly in performance of each of the MISTELS tasks (p < 0.001). Total scores on the tasks increased from 24 ± 44 on the pretest to 384 ± 49 on the posttest (p < 0.001). All study participants were satisfied with the course, found the training personally valuable, and felt that their laparoscopic skills had improved on completion of the training.

CONCLUSIONS

We have demonstrated the feasibility and effectiveness of training with a low-cost laparoscopic trainer box in Tanzania. Study participants achieved impressive posttest scores on the 5 MISTELS tasks with minimal baseline laparoscopic exposure. We feel that guided training by an expert was key in ensuring correct technique during practice sessions.

Identity formation and motivation of new faculty developers: A replication study in a resource constrained university

INTRODUCTION

Previous studies on the identity development and motivation of faculty developers have occurred with seasoned developers in a research-rich environment. We sought to determine if the findings of those studies could be replicated with novice faculty developers in a resource-constrained environment.

METHODS

We interviewed 15 novice faculty developers from Muhimbili University of Health and Allied Sciences (MUHAS) who, at the time, had led faculty development activities for no more than two years. We conducted a qualitative analysis sensitized by the previous findings.

RESULTS

Results were very similar to the previous work. The developers described compartmentalized, hierarchical, and merged identities. The impact was on their teaching as well as on others at MUHAS and on the institution itself. The motivations related to mastery, purpose, duty, satisfaction, and relatedness.

CONCLUSION

This replication led us to conclude that identity development as a faculty developer occurs even in novice developers who do faculty development as only part of their work and despite constrained resources and a different culture. These developers find the work richly rewarding and their motivations benefit the institution. This body of research highlights how faculty development provides benefits to the institution as well as engaging career opportunities.

Prevalence and clinical presentation of HIV infection among newly hospitalised surgical patients at Muhimbili National Hospital, Dar es Salaam, Tanzania

BACKGROUND

In Tanzania information is lacking on the prevalence of HIV infection in surgical patients in tertiary care facilities, in whom there are many points of special interest.

OBJECTIVE

To determine the prevalence of HIV infection and associated clinical and demographic features among hospitalised surgical patients at Muhimbili National Hospital (MNH).

SETTING

Muhimbili National Hospital.

MATERIALS AND METHODS

Consecutive newly admitted patients were tested for HIV antibodies after pre-test counselling. Sera were tested using a dual ELISA algorithm. The data were analysed to determine the prevalence of HIV infection and relationships of serostatus with clinical and socio-demographic characteristics.

RESULTS

Of 1,534 patients admitted during the study, 1,031(67.2%) consented to HIV testing following pre-test counselling. The prevalence of AIDS-related clinical features in patients who declined to be HIV tested was similar to that of seronegative patients, but significantly lower than that of seropositive patients. The overall age-adjusted HIV prevalence was 10.5% (95% CI = 9.9-14.0). The highest age-specific HIV prevalence was in the age group 35-44 years at 27.9%. No one was infected in the age group 0-4 years (n = 111). Differences in prevalence between age groups were statistically significant (p < 0.0001). Patients with granulomatous and suppurative infections had HIV prevalence of 28.3%. Twenty of 124 seropositive patients (16.1%) died in hospital compared to 58 of 907(6.4%) of seronegative patients (p = 0.0001).

CONCLUSION

At Muhumbili National Hospital overall HIV prevalence in hospitalised surgical patients were 10.5%, compared to an overall national prevalence of 6.7%. Patients in the age groups 25 to 34 and 35 to 44 years had HIV seroprevalence of 26.8% and 27.9% respectively. Patients with infective conditions had the highest HIV prevalence. HIV seropositive patients were associated with higher hospital mortality than seronegative patients.

Fishing Line Suture: Cost-saving Alternative for Atraumatic Intracutaneous Skin Closure?Randomized Clinical Trial in Rwanda

Experience with the use of nylon fishing line for surgical sutures has been reported from several African countries. A recent publication suggested that fishing line and an injection needle may provide an atraumatic suture that is especially suitable for intracutaneous skin closures. This article provides further empirical support for such alternative technology. We describe a randomized, blinded clinical trial conducted in Butare (Rwanda) with 220 cutaneous wounds closed by intracutaneous sutures, with either the homemade suture or a commercial nylon thread (Ethilon). We compared the clinical outcomes as well as the costs of those two materials. There are no significant differences between the two sutures in terms of clinical findings or in the reported ease of use by the surgeons. The cost of a homemade atraumatic suture is US $0.07, which is less than one-thirtieth the cost of the commercial thread. The advantage of the commercial thread is the assurance of quality. We consider whether this quality assurance justifies the large price difference, and if the homemade suture should be recommended to surgeons in countries where the costs of surgical material often remain an obstacle for life-saving operations.

Small volume resuscitation with 7.5% hypertonic saline solution--treatment of haemorrhagic shock in the tropics

Rapid intravenous injection of 4 mL/kg body weight of a 7.5% hypertonic sodium chloride solution immediately increases intravascular osmotic pressure and intravascular volume after haemorrhage. This 'small volume resuscitation' rapidly improves blood pressure and microcirculatory perfusion in patients with hypovolaemic shock after large blood losses. Pathophysiological findings as well as practical application approaches are described. Small volume resuscitation is an effective and economic method in the first-line treatment of acute haemorrhagic shock.

Atraumatic intracutaneous skin closure with self-made fishing line suture compared to commercial thread

OBJECTIVE

The aim of this study was to prove, whether the intracutaneous skin closure with self made fishing line suture is equivalent to commercial sutures.

DESIGN

It was a randomised blinded animal study.

SETTING

The study was performed in December 2002 at the Muhimbili University College of Health Sciences in Dar-es-salaam.

SUBJECTS

Both German surgeons from Mannheim, and Tanzanian surgeons from Dar es salaam operated on nine one year old Tanzanian domestic sheep.

INTERVENTIONS

108 standardised cutaneous wounds on the backs of the animals were closed by intracutaneous sutures either with self produced fishing line suture or a commercial nylon suture (Ethilon).

MAIN OUTCOME MEASURES

The clinical and histological outcomes, as well as the costs of this self-made fishing line suture, with a commercial nylon thread were evaluated and compared.

RESULTS

There are no significant differences between the two sutures in histological or clinical findings, or in the reported ease of use by the surgeons. The cost of a self-produced atraumatic thread is US$ 0.12, less than one-twentieth of the cost of the commercial thread.

CONCLUSION

Self-made fishing nylon suture has characteristics and properties in sheep skin wounds comparable to commercial nylon suture. The advantage of the commercial thread is the guaranteed quality assurance. It is discussed whether this quality assurance justifies the large price difference, and whether the self-produced thread should be recommended to surgeons in countries where the costs of surgical material often remains an obstacle for life saving operations.

Applying innovative educational principles when classes grow and resources are limited: Biochemistry experiences at Muhimbili University of Allied Health Sciences

Teaching to large classes is often challenging particularly when the faculty and teaching resources are limited. Innovative, less staff intensive ways need to be explored to enhance teaching and to engage students. We describe our experience teaching biochemistry to 350 students at Muhimbili University of Health and Allied Sciences (MUHAS) under severe resource limitations and highlight our efforts to enhance the teaching effectiveness. We focus on peer assisted learning and present three pilot initiatives that we developed to supplement teaching and facilitate student interaction within the classroom. These included; instructor-facilitated small group activities within large group settings, peer-led tutorials to provide supplemental teaching and peer-assisted instruction in IT skills to enable access to online biochemistry learning resources. All our efforts were practical, low cost and well received by our learners. They may be applied in many different settings where faculties face similar challenges.

Successful surgical excision of the accessory urethra in a 13-year-old boy with Effmann Type IIA-2 urethral duplication. Case report and literature review

INTRODUCTION AND CLINICAL IMPORTANCE

Urethral duplication is a congenital anomaly characterized by the partial or full development of an auxiliary urethra as a second urethral channel varying in extent and location. The course of treatment for urethral duplication should be individualized for each patient based on the type of anomaly and the existence of symptoms. In most cases, if the ventral orthotopic urethra is normal, excision of the dorsal auxiliary urethra is almost always curative.

CASE PRESENTATION

We report a case of a 13-year-old boy who presented with recurrent urinary tract infection, occasionally having drops of urine at an external pin hole meatal opening on the dorsum of the penile shaft. Several investigations were performed to confirm the presence of the dorsal accessory urethra. The patient underwent complete excision of the accessory urethra, and 12 weeks post-surgery the patient was completely asymptomatic.

DISCUSSION

Urethral duplications are rare anomalies. These anomalies have been classified in various ways in the literature, including sagittal and lateral duplications, dorsal and ventral duplications. The sagittal plane is where the majority of urethral duplications occur. Based on the anatomic variation, clinical presentation and severity of the anomaly, urethral duplication treatment should be customized for each patient. An asymptomatic child may require no specific treatment. Total surgical excision of the dorsal accessory urethra appears to offer the best curative solution.

CONCLUSION

Excision of the dorsal accessory urethra is usually curative when the ventral orthotopic urethra is normal. Thorough investigation before surgery is mandatory to determine the type of urethral duplication. The most common diagnostic procedures for urethral duplications include cystoscopy, KUB ultrasonography, and micturating cystourethrography. These procedures can help plan surgery, prevent complications such as neurovascular bundle injuries and urine incontinence, and improve patient self-esteem and quality of life.

Favorable outcome of open partial cystectomy for muscle-invasive squamous cell carcinoma of the bladder: A case report and literature review

Key Clinical Message

The "gold standard" treatment for Squamous cell carcinoma (SCC) is radical cystectomy and different management approaches that combine chemotherapy and radiation in a neoadjuvant or adjuvant setting have been attempted with varying degrees of effectiveness. For certain individuals, partial cystectomy offers sufficient local control for muscle-invasive bladder cancer. Lifelong follow-up with cystoscopy is advised due to the possibility of potentially fatal late recurrence.

Abstract

Squamous cell carcinoma (SCC) of the bladder is a rare urologic malignancy that is estimated to affect 3%-5% of the bladder cases. SCC of the bladder remains the most common subtype throughout Africa. Most of the literatures focused on the management of Urothelial carcinoma (UC), with fewer discussions on SCC management. UC typically presents with painless hematuria, whereas SCC presents with painful hematuria, bladder mass, and necroturia. SCC is mostly radioresistant and does not respond to chemotherapy. The mainstay treatment is partial cystectomy or radical cystectomy, which can be performed through open surgery or laparoscopic or robot-assisted approaches, all of which have acceptable results. We report a patient with a favorable outcome following partial cystectomy who was managed by open surgery. At the 12-month follow-up, the patient remained asymptomatic with good surgical outcomes.

Career intentions of medical students trained in six sub-Saharan African countries

INTRODUCTION

Sub-Saharan Africa(SSA) is the world region worst affected by physician migration. Identifying reasons why medical students wish to stay or leave Africa could assist in developing strategies which favour retention of these graduates. This study investigated the career intentions of graduating students attending medical schools in SSA to identify interventions which may improve retention of African physicians in their country of training or origin.

METHODS

Final year medical students attending nine medical schools in SSA were surveyed--students from four schools in South Africa and one school each in the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda. The response rate was 78.5% (990 of 1260 students); data from the 984 students who indicated they were remaining in medicine were entered into a database, and descriptive statistics were obtained.

RESULTS

Most (97.4%) of the 984 responding students were African by birth. The majority (91.2%) intended to undertake postgraduate training; the top three specialty choices were surgery (20%), internal medicine (16.7%), and paediatrics (9%). Few were interested in family medicine (4.5%) or public health (2.6%) or intended to practice in rural areas (4.8%). Many students (40%) planned to train abroad. About one fifth (21%) intended to relocate outside sub-Saharan Africa. These were about equally divided between South Africans (48%) and those from the other five countries (52%). The top perceived career-related factors favouring retention in Africa were career options and quality and availability of training opportunities. Several factors were reported significantly more by South African than the other students. The top personal factors for staying in Africa were a desire to improve medicine in Africa, personal safety, social conditions and family issues. The top career-related factors favouring relocation outside Africa were remuneration, access to equipment and advanced technology, career and training opportunities, regulated work environment and politics of health care in Africa. Several of these were reported significantly more by students from the other countries as compared with South Africans. The top personal factors favouring relocation outside Africa were personal safety, opportunity for experience in a different environment, social conditions and greater personal freedom.

DISCUSSION

The career intentions of African medical students are not aligned with the continent's health workforce needs. A number of interventions that warrant further attention were identified in this study.

Research on medical migration from sub-Saharan medical schools: usefulness of a feasibility process to define barriers to data collection and develop a practical study

CONTEXT

The maldistribution of physicians in sub-Saharan Africa is having serious impacts on population health. Understanding the effect requires investigation from both donor and recipient countries. However, investigation from the perspective of donor countries has been lacking.

METHODS

This brief communication describes a model process for the design of a research project that addresses medical migration issues from the perspective of eight African medical schools. During an international meeting, the participants designed an initial "ideal" study, and then rapidly tested its feasibility through a brief survey, and group discussion through a listserv, teleconferences and one face-to-face meeting.

FINDINGS AND PRACTICAL IMPLICATIONS

Innovative research ideas can be followed-up with surveys to test the feasibility of an "ideal" research design, modifying the design accordingly. This is currently occurring with our medical migration survey study.

"A successful reconstruction of remnants of corporal bodies and penile urethra after Total Glans Penis amputation following surgical circumcision in a 5-year-old boy". A case report and literature review

INTRODUCTION AND IMPORTANCE

Circumcision is the most common surgical procedure done in boys. Its complication varies from minor to severe. In most of African countries circumcision is often performed by traditional circumcisers. The management of penile glans amputation depends on the duration before presentation with auto-transplantation being the favorable management in acute phase of presentation. The amputation of the glans is a serious complication of circumcision because it can derange the urinary and sexual functions of a patient and may lead into psychological instability and low self-esteem.

CASE PRESENTATION

We report a case of total glansectomy in a 5-year old boy who presented 12 months after surgical circumcision which was done by inexperienced medical personnel at his house. Patient presented with a pinhole urethra opening, missing glans, buried phallus with remnants of corporal bodies. Penile exploration was done, with successful significant phallus stump of about 5 cm, phallus reconstruction and meatoplasty was achieved. Partial Skin thickness grafting of the phallus stump was performed. At six- month follow up, the patient had both satisfactory cosmetic and functional outcomes.

CLINICAL DISCUSSION

Total glansectomy is a rare surgical emergency with auto transplantation being the best option in acute management however successful outcome for a delayed glansectomy depends on proficient surgical penile exploration and comprehensive post operative care. Based on the clinical presentation, the goals of management for our patient were to achieve a largely patent urethral opening in the long term and to prevent further urethral meatal stenosis as well as achieving adequate phallus stump for sexual function.

CONCLUSION

The amputation of the glans is a serious complication of circumcision because it can derange the urinary and sexual functions of a patient if neglected. Findings on this case report highlight the importance of raising awareness among traditional health care workers to prevent urinary and sexual function disabilities. Prevention of penile amputation can be prevented by providing proper training for circumcisers and providing public education for hospital circumcision.

A rare case report of ectopic-adrenal paraganglioma with inferior vena cava infiltration. Case report and literature review

INTRODUCTION AND IMPORTANCE

Phaeochromocytomas are neuroendocrine neoplasms arising from chromaffin cells of the adrenal medulla and are known as intra-adrenal paragangliomas. On the contrary, paragangliomas are non-epithelial neuroendocrine neoplasms that produce other peptide hormones such as norepinephrine, epinephrine, and dopamine. In a setting with limited resources, such a condition may result in inaccurate diagnosis and treatment, which may lose a patient life if left untreated. In addition, PPGLs present a surgical challenge to many surgeons who are not thoroughly prepared.

CASE PRESENTATION

We describe a case of extra-adrenal paraganglioma in a 27-year-old female who presented with symptoms of heartbeat awareness for almost a year and abdominal swelling for three months. Physical examination revealed a palpable mass around the umbilicus. Abdominal pelvic CT scan revealed a well-circumscribed mass in the central retroperitoneum displacing the IVC laterally and abdominal aorta medially with no invasion of surrounding structures. Results for pheochromocytoma workup showed elevated levels of 24-h urine Vanillylmandelic acid (VMA), and 24-h metanephrine excretion. Laparotomy through extended midline incision was done with successful excision of the tumor. The blood pressure, which was initially high normalized after surgery.

DISCUSSION

The diagnosis of a malignant EAP is commonly made based on recurrence and the development of metastasis to lymph nodes or to other organs. Our patient presented with similar symptoms as pheochromocytoma. Compared to the commonly stated 10 % risk for pheochromocytomas, people with EAPs have been observed to have a 20 % to 50 % incidence of malignancy. EAPs account for at least 15 % of adult and 30 % of pediatric pheochromocytomas and are frequently found in the Zuckerkandl organ. Pheochromocytoma symptoms may manifest asymptomatically in patients with EAPs, or they may occur because of compression of nearby tissues. Surgical excision of the tumor is always the best option in managing EAP.

CONCLUSION

Extra-adrenal paragangliomas can be successfully managed surgically, provided there is a multidisciplinary team, and the tumor location is well recognized and can reduce the chance of tumor metastasis.

Advanced prostate cancer with brain metastasis presenting with isolated severe headache without urinary symptoms.: Case report and literature review

INTRODUCTION AND CLINICAL IMPORTANCE

Brain metastases from prostate cancer are uncommon, occurring in fewer than 1 % of cases of metastatic prostate cancer. Brain metastasis can cause cerebral edema, neurologic symptoms, and may be misdiagnosed as primary brain tumors on imaging if thorough investigations are not done. It is difficult to identify and diagnose brain metastasis from prostate cancer since the intracranial metastatic process and presentation are poorly understood and limited to case studies. Most patients with brain metastases from prostate cancer exhibit a variety of metastatic symptoms; however, this patient's presentation was defined by only isolated intense headache. Our goal is to draw attention to the uncommon instance of brain metastases from prostate cancer in addition to reviewing the literature on the advances in treatment for prostatic cancer with metastasis to the brain.

CASE PRESENTATION

We report the case of a 67-year-old male with metastatic prostate adenocarcinoma into the brain, presenting with isolated severe headache with no prostate cancer symptoms. Following extensive radiologic examination, metastatic deposits were detected in the left side of the brain with multiple intracerebral and cerebellar vermis lesions. Multiplanar T2 weighted abdominal pelvic MRI visualized the primary lesion in the prostate which was confirmed by histology. After a month following surgical castration, the patient reported resolved headache and resumed his daily activities. The patient's serum PSA decreased from 7.8 ng/ml to 0.3 ng/ml during a 12-months follow-up with no neurological symptoms.

CLINICAL DISCUSSION

Prostate cancer rarely causes brain metastases, and the percentage of all brain metastases that originate from prostate cancer is seldom updated. It can be difficult to distinguish between primary brain lesions and metastatic brain prostate cancer, particularly when there is just one lesion present. Despite the recently developed diagnostic approaches, symptomatic patients exhibit a variety of clinical manifestations that vary depending on the location of the metastatic focus. These manifestations include headache, seizures, and focal neurological deficits, in addition to some common non-focal manifestations like confusion and memory deficits. Our patient had a PSA of 7.8 ng/ml at the beginning and the DRE results were normal, clinically prostate cancer was not thought to be the main cause of brain metastasis. Abdominal pelvic MRI was performed to investigate the primary lesion and confirmed the presence of prostate cancer with extra prostatic extensions. Adenocarcinoma prostate cancer was found to be the main cause when histopathology was done.

CONCLUSION

This report reviews the literature on brain metastases from prostate cancer and points out that while very rare, brain metastases from prostatic cancer do occur and should not be overlooked, particularly in light of the recent advancements in prostatic cancer therapies that may extend the patient's survival. Gadolinium-enhanced MRI is necessary to confirm or rule out brain metastases if it is suspected, as well as to monitor prostate cancer patients.