Barriers and facilitators of research in Cameroon (Part II) – an e-survey of medical students

Introduction: research fosters critical thinking and prepares students for a career in academic medicine. This study aimed to identify the facilitators and barriers to research among Cameroonian medical students.

Methods: an electronic survey was distributed between May 23, 2020, and June 07, 2020. The survey was made of closed-, opened-, and Likert scale questions. A Preference Score (PS) was used to quantify the medical students’ perception of barriers and facilitators to research. The Kruskal-Wallis H and Fisher’s Exact tests were used to evaluate bivariate relationships

Results: one hundred and eighty-eight (188) students with a mean age of 24.1 ± 2.3 years were enrolled. Most respondents were male (56.9%), francophone (69.1%), and in their final year of medical school (46.8%). Twenty-one students (11.1%) had a peer-reviewed article, and all the published students were in their sixth- or seventh-year of undergraduate medical studies. Barriers to research included lack of funding (PS=203), obsolete patient information management systems (PS=198), and limited understanding of biostatistics (PS=197). Facilitators to research included research focused on the student’s interests (PS=255), the study’s capacity to improve practice (PS=247), and scientific recognition (PS=198).
Conclusion: barriers to research among Cameroonian medical students are mainly institutional. However, facilitators are primarily linked to career goals. To improve research activities among these undergraduates, initiatives must target institutional barriers and incentives that foster career development.

National approaches to trichiasis surgical follow-up, outcome assessment and surgeon audit in trachoma-endemic countries in Africa

Background: Poor outcomes of trichiasis surgery, including postoperative trichiasis, are common in many trachoma-endemic countries in Africa. To improve outcomes, WHO recommends regular follow-up and outcome assessment of surgical cases plus audit of trichiasis surgeons.

Aims: To assess national approaches to trichiasis surgical follow-up, outcome assessment and audit, and identify national targets for good surgical outcome (defined as the percentage of patients undergoing surgery for trichiasis remaining free of post-operative trichiasis for a defined interval after surgery).

Methods: A cross-sectional survey was carried out between May and July 2018, involving all 29 known-trachoma-endemic countries in Africa. An emailed questionnaire was used to collect information on national targets for surgical outcomes, policies, monitoring and strategies to address underperformance by surgeons.

Results: All national programmes provided information; 2 of the 29 had not yet implemented trichiasis surgery as part of their trachoma elimination programme. Findings from 27 countries are therefore reported. Only four countries reported having a national policy for trichiasis surgery follow-up and outcome assessment and only two had a national policy for conducting audits of trichiasis surgeons. Only 9 of the 27 countries had a cut-off point at which poorly performing surgeons would be instructed to discontinue surgery until retraining or other interventions had been undertaken.

Discussion: To address the challenge of post-operative trichiasis and other poor outcomes, national trachoma programmes should create and implement policies and systems to follow up patients, assess surgical outcomes and monitor the performance of individual surgeons through post-surgical audits.

Is AJCC/UICC Staging Still Appropriate for Head and Neck Cancers in Developing Countries?

By 2030, 70% of cancers will occur in developing countries. Head and neck cancers are primarily a developing world disease. While anatomical location and the extent of cancers are central to defining prognosis and staging, the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) have incorporated nonanatomic factors that correlate with prognosis into staging (eg, p16 status of oropharyngeal cancers). However, 16 of 17 head and neck surgeons from 13 African countries cannot routinely test for p16 status and hence can no longer apply AJCC/UICC staging to oropharyngeal cancer. While the AJCC/UICC should continue to refine staging that best reflects treatment outcomes and prognosis by incorporating new nonanatomical factors, they should also retain and refine anatomically based staging to serve the needs of clinicians and their patients in resource-constrained settings. Not to do so would diminish their global relevance and in so doing also disadvantage most of the world’s cancer patients.

Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa—a scoping review

Background
Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries.

Methods
We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks.

Results
Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties.

Conclusion
A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.

Surgical Management of Urolithiasis of the Upper Tract – Current Trend of Endourology in Africa

Urolithiasis is a global pathology with increasing prevalence rate. The lifetime recurrence of urolithiasis ranges from 10– 75% creating a public health crisis in affected regions. The epidemiology of urolithiasis in most parts of Africa and Asia remains poorly documented as incidence and prevalence rates in these settings are extrapolated from hospital admissions. The surgical management of kidney and ureteral stones is based on the stone location, size, the patient’s preference and the institutional capacity. To date, the available modalities in the management of urolithiasis includes external shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy (URS) including flexible and semirigid ureteroscopy. However, regarding the lack of endourological equipment and expertise in most parts of Sub-Saharan Africa (SSA), most urological centers in these regions still consider open surgery for kidney and ureteral stones. This review explores the current trend and surgical management of upper tract urolithiasis in SSA with insight on the available clinical guidelines

Toward a complete estimate of physical and psychosocial morbidity from prolonged obstructed labour: a modelling study based on clinician survey

Introduction: Prolonged obstructed labour often results from lack of access to timely obstetrical care and affects millions of women. Current burden of disease estimates do not include all the physical and psychosocial sequelae from prolonged obstructed labour. This study aimed to estimate the prevalence of the full spectrum of maternal and newborn comorbidities, and create a more comprehensive burden of disease model.

Methods: This is a cross-sectional survey of clinicians and epidemiological modelling of the burden of disease. A survey to estimate prevalence of prolonged obstructed labour comorbidities was developed for prevalence estimates of 27 comorbidities across seven categories associated with prolonged obstructed labour. The survey was electronically distributed to clinicians caring for women who have suffered from prolonged obstructed labour in Asia and Africa. Prevalence estimates of the sequelae were used to calculate years lost to disability for reproductive age women (15 to 49 years) in 54 low- and middle-income countries that report any prevalence of obstetric fistula.

Results: Prevalence estimates were obtained from 132 participants. The median prevalence of reported sequelae within each category were: fistula (6.67% to 23.98%), pelvic floor (6.53% to 8.60%), genitourinary (5.74% to 9.57%), musculoskeletal (6.04% to 11.28%), infectious/inflammatory (5.33% to 9.62%), psychological (7.25% to 24.10%), neonatal (13.63% to 66.41%) and social (38.54% to 59.88%). The expanded methodology calculated a burden of morbidity associated with prolonged obstructed labour among women of reproductive age (15 to 49 years old) in 2017 that is 38% more than the previous estimates.

Conclusions: This analysis provides estimates on the prevalence of physical and psychosocial consequences of prolonged obstructed labour. Our study suggests that the burden of disease resulting from prolonged obstructed labour is currently underestimated. Notably, women who suffer from prolonged obstructed labour have a high prevalence of psychosocial sequelae but these are often not included in burden of disease estimates. In addition to preventative and public health measures, high quality surgical and anaesthesia care are urgently needed to prevent prolonged obstructed labour and its sequelae.

Oxygen availability in sub-Saharan African countries: a call for data to inform service delivery

Oxygen is central to the management of patients admitted to hospital with severe COVID-19. Furthermore, the availability of oxygen therapy is just as important for the management of other patients who are acutely ill. However, despite recognition from most health-care providers that oxygen is a fundamental component of a health-care system, it has not been a focus of health-care delivery in sub-Saharan African countries, as shown by the lack of data collected on oxygen availability.

Investing in Surgery: A Value Proposition for African Leaders

Globally, poor access to high-quality surgical, obstetric, and anaesthesia care remains a main contributor to global disease burden accounting for about a third of deaths worldwide. The need for strengthening surgical care systems is especially urgent in sub-Saharan Africa, where access is strikingly limited, leading to the highest mortality and morbidity from surgically preventable and treatable conditions in the world. Approximately 93% of the population of sub-Saharan Africa lacks access to safe, affordable, and timely surgical care, compared with less than 10% in high-income countries.2 Despite the immense and growing need for surgical services in sub-Saharan Africa, investments by African public sector leaders to improve surgical systems on the subcontinent have been inadequate. The current COVID-19 pandemic has disrupted health care globally, with an estimation by the CovidSurg Collaborative showing that more than 28 million surgeries will be postponed or cancelled worldwide during the 12 weeks of peak disruption. There is a basic ethical responsibility to provide surgical care as a fundamental human right, in keeping with the principles espoused in the Universal Declaration of Human Rights. Additionally, improved access to high-quality surgical care is an essential component of universal health coverage and will contribute to good health and wellbeing, leading to improved human capital—all of which are vital for poverty reduction and economic growth on the continent.

Emergency department management of traumatic brain injuries: A resource tiered review

Introduction
Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma.

Objectives
Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework.

Methods
A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings.

Key recommendations
Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.

The Millennial Generation Plastic Surgery Trainees in sub-Saharan Africa and Social Media: A Review of the Application of Blogs, Podcasts, and Twitter as Web-Based Learning Tools

The delivery of education and training in plastic surgery in Sub-Saharan Africa face increasing challenges. These include endemic shortages of plastic surgeons within postgraduate medical school faculties, the erosion of financial and clinical resources for teaching, and more recently, the millennial generation paradigm shift. It is generally accepted that the millennial generation will be more discerning and comfortable in their requirements for web-based learning content to support their education and training in plastic surgery. We reviewed current literature including original and review articles obtained through a search of PubMed database, Medline, Google Scholar, and hand searching of bibliographies of published articles using the keywords: social media, Blogs, Twitter, plastic surgery, and millennial generation. This article defines and explores Blogs, Podcasts, and Twitter, as web-based learning tools, and discusses how to leverage social media to maximize their educational value and effectiveness.