Training facilitated by inter-institutional collaboration and telemedicine: An alternative for improving results in the placenta accreta spectrum

Background
Placenta accreta spectrum (PAS) is a severe condition that requires trained interdisciplinary group participation. However, achieving that specific training is difficult without academic programs or hospitals dedicated to teaching PAS skills.

Objectives
We describe an interinstitutional collaboration process focused on improving PAS treatment and facilitated by telemedicine. Finally, we propose a replicable model for other centres

Study Design
This was a retrospective, descriptive study including PAS patients treated over 10-years in a low-middle income country (LMIC) hospital (local hospital [LH]). We evaluated the clinical results and impact of interinstitutional collaboration with a PAS expert group (EG) at another LMIC. Virtual strategies of continuous communication between the LH and EG were used, such as telemedicine, teleradiology and telepresence during surgeries.

Results
Eighty-nine PAS patients were included. We observed a progressive improvement in clinical results (intraoperative bleeding, transfusion frequency, postoperative length of stay and frequency of complications) as the LH fixed interdisciplinary group gained experience by treating more cases.

Conclusions
Interinstitutional collaboration (through telemedicine and remote supervision) and PAS team formation, were related to the best results in the most recent years of observation. Thus, ongoing PAS team training, facilitated by inter-institutional collaboration and telemedicine, is a valid strategy for improving clinical outcomes in PAS.

The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review

The COVID-19 pandemic has disrupted neurosurgical training worldwide, with the shutdown of academic institutions and the reduction of elective surgical procedures. This impact has disproportionately affected LMICs (lower- and/or middle-income countries), already burdened by a lack of neurosurgical resources. Thus, a systematic review was conducted to examine these challenges and innovations developed to adapt effective teaching and learning for medical students and neurosurgical trainees. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and The Cochrane Handbook of Systematic Reviews of Interventions. MEDLINE, PubMed, Embase and Cochrane databases were accessed, searching and screening literature from December 2019 to 5th December 2020 with set inclusion and exclusion criteria. Screening identified 1254 articles of which 26 were included, providing data from 96 countries. Twenty-three studies reported transition to online learning, with 8 studies also mentioned redeployment into COVID wards with 2 studies mentioning missed surgical exposure as a consequence. Of 7 studies conducted in LMICs, 3 reported residents suffering financial insecurities from reduced surgical caseload and recession. Significant global disruption in neurosurgical teaching and training has arisen from the COVID-19 pandemic. Decreased surgical exposure has negatively impacted educational provision. However, advancements in virtual technology have allowed for more affordable, accessible training especially in LMICs. Using this, initiatives to reduce physical and mental stress experienced by trainees should be paramount.

A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education

Background
In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research.

Objectives
We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS.

Program design and implementation
In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics.

Main achievements
In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program’s success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors.

Policy implications
The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.

Improving knowledge about breast cancer and breast self examination in female Nigerian adolescents using peer education: a pre-post interventional study

Background
Prevention of BC of which the cornerstone is creating awareness and early detection is important in adolescents and young women because of their worse outcomes. Early detection strategies such as mammography are currently beyond the reach of most women in sub-Saharan Africa.. Lack of awareness and late presentation contribute to the poor outcomes. Awareness creation among adolescents may result in modification of some risk factors for BC with adoption of healthy life styles including accessing early detection activities. This study determined the effect of peer education as a strategy to create awareness on BC and breast self examination (BSE) among in-school female adolescents in Benin City.

Methods
This was a pre-post interventional study carried out in October –December 2016 on female students of four secondary schools in Benin City. Pre-peer training, using a pre-tested self-administered questionnaire, knowledge about BC and BSE was assessed in about 30% of each school population. This was followed by training of 124 students selected from the schools (one student per class) as peer trainers. The peer trainers provided training on BC and BSE (the intervention) for their classmates. Within two weeks of peer training knowledge about BC and BSE was reassessed in 30% of each school population. Selection of students for assessment pre and post intervention was by systematic sampling. Correct knowledge was scored and presented as percentages. Chi square test, student t test and ANOVA were used to assess associations and test differences with level of significance set at p < 0.05.

Results
There were 1337 and 1201 students who responded to the pre and post-training questionnaires respectively. The mean BC knowledge score (20.61 ± 13.4) prior to training was low and it statistically significantly improved to 55.93 ± 10.86 following training p < 0.0001 Following peer training, statistically significant improvement (p 0.037- < 0.001) occurred in most knowledge domains apart from symptomatology. Pre-peer training 906(67.8%) students knew about BSE but only 67(4.8%). Significantly more students 1134(94.7%) knew about BSE following peer training.

Conclusions
Peer education strategy can be used to improve BC and BSE knowledge in adolescents. This strategy is low cost and could be very useful in low resource settings.

Mixed Methods Evaluation of Simulation-Based Training for Postpartum Hemorrhage Management in Guatemala

Background
To assess if simulation-based training (SBT) of B-lynch suture and uterine balloon tamponade (UBT) for the management of postpartum hemorrhage (PPH) impacted provider attitudes, practice patterns, and patient management in Guatemala, using a mixed-methods approach.

Methods
We conducted an in-country SBT course on the management of PPH in a governmental teaching hospital in Guatemala City, Guatemala. Participants were OB/GYN providers (n = 39) who had or had not received SBT before. Surveys and qualitative interviews evaluated provider knowledge and experiences with B-lynch and UBT to treat PPH. In addition, a retrospective chart review was performed to evaluate management of PPH over a 2-year period before and after the introduction of SBT.

Results
Multiple-choice surveys indicated that providers who received SBT were more comfortable performing and teaching B-lynch compared to those who did not (p = 0.003 and 0.005). Qualitative interviews revealed increased provider comfort with B-lynch compared to UBT and identified multiple barriers to uterine balloon tamponade implementation. Chart review demonstrated an increased use of UBT after the introduction of simulation-based training, though not statistically significant (p = 0.06) in contrast to no change in B-lynch use.

Conclusions
Simulation-based training had a stronger impact on provider comfort with B-lynch compared to uterine balloon tamponade. Qualitative interviews provided insight into the challenges that hinder uptake of uterine balloon tamponade, namely resource limitations and decision-making hierarchies. Capturing data through a mixed-methods approach allowed for more comprehensive program evaluation in low and middle income countries (LMICs).

Global Surgery Education and Training Programmes—a Scoping Review and Taxonomy

Global surgery is an emerging field of study and practice, aiming to respond to the worldwide unmet need for surgical care. As a relatively new concept, it is not clear that there is a common understanding of what constitutes “global surgery education and training”. This study examines the forms that global surgery education and training programmes and interventions take in practice, and proposes a classification scheme for such activities. A scoping review of published journal articles and internet websites was performed according to the PRISMA Extension for Scoping Review guidelines. PubMed MEDLINE, EMBASE and Google were searched for sources that described global surgery education and training programme. Only sources that explicitly referenced a named education programme, were surgical in nature, were international in nature, were self-described as “global surgery” and presented new information were included. Three hundred twenty-seven records were identified and 67 were ultimately included in the review. “Global surgery education and training” interventions described in the literature most commonly involved both a High-Income Country (HIC) institution and a Low- and Middle-Income Country (LMIC) institution. The literature suggests that significant current effort is directed towards academic global surgery programmes in HIC institutions and HIC surgical trainee placements in LMICs. Four categories and ten subcategories of global surgery education and training were identified. This paper provides a framework from which to study global surgery education and training. A clearer understanding of the forms that such interventions take may allow for more strategic decision making by actors in this field

Nursing students’ experiences with simulation-based education as a pedagogic method in low-resource settings: A mixed-method study

Aims and Objectives
This study introduced simulation-based education in nurse education programs in Tanzania and Madagascar and explored nursing students’ experiences with this pedagogic method as a mode of learning.

Background
Simulation-based education has barely been introduced to education programs in resource-constrained settings. The study was conducted in two nurse education programs: one in rural Tanzania and the other in the mid-land of Madagascar. Both institutions offer diploma programs in nursing. Simulation-based education has not been included in the teaching methods used in these nursing programs.

Design
A descriptive and convergent mixed method design was employed.

Methods
Ninety-nine nursing students were included in the study. Simulation sessions followed by data collection took place once in 2017 and twice in 2018. Data were collected by means of several questionnaires and six focus groups. The data were analyzed using descriptive statistics and qualitative content analysis. The Standards for Reporting Qualitative Research (SRQR) was used to report the results.

Results
The quantitative data revealed that the students rated all the questions related to the simulation design elements, educational practices, and students’ satisfaction and self-confidence in learning with scores of above four on a 5-point Likert scale. The qualitative data from the first theme, building competence and confidence, further emphasized and outlined the quantitative results. Additionally, the qualitative data revealed a second theme, improving through encouragement and corrections. The students clearly expressed that they wanted to be aware of their weaknesses to be able to improve; however, the provision of feedback should be carried out in an encouraging way.

Conclusion
The findings indicated that the nursing students were satisfied with simulation as a pedagogic method, as it improved their competence and prepared them for professional practice. Further research is necessary to explore whether the students are able to transfer their knowledge into clinical practice.

Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) – Observational feasibility study

Background
Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India.

Methods
A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated.

Results
Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers.

Conclusion
Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.

Evaluation and usability study of low-cost laparoscopic box trainer “Lap-Pack”: a 2-stage multicenter cohort study

Introduction:
Laparoscopic training is restricted in low resource settings due to limited access to specialist training equipment and financial constraints. This study aimed to evaluate simulation skills and usability of an original low-cost laparoscopic trainer, the “Lap-Pack,” developed at the University of Leeds, UK.

Methods:
Stage I evaluation was conducted in Kolkata (India) between March, 12 and 14, 2019. Laparoscopic simulation training was based on the 5 domains of fundamentals of laparoscopic surgery (FLS), which assessed skill acquisition across 7 rural surgeons from North-East India. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) criteria was used to statistically analyze trainee performance between pretraining and posttraining sessions. Also, Lap-Pack was qualitatively compared with a commercial box trainer, Inovus Pyxus HD (IPHD). Stage II involved a multi-center usability study in 2 centers of India and the United Kingdom (2019). Seventy-eight participants performed 2 FLS tasks using Lap-Pack and provided scores on a 25-point questionnaire, including a preestablished Face-Validity Criteria and 4 evaluation categories—Usability, Camera, View, and, Material.

Results:
In stage I, the total posttraining MISTELS score for Lap-Pack was higher, that is 773.37 (SD: 183.67) than pretraining score, that is 351.2 (SD: 471.5). The posttraining scores showed laparoscopic skill acquisition with statistically significant (P<0.05) difference for precision cutting, intracorporeal and extracorporeal knot. In stage II, Lap-Pack scored highly in Face-Validity with a combined mean score of 4.81 [95% confidence interval (CI): 4.52–5.09, P<0.05] out of a possible 6. It scored highest (scale: 1=low to 7=high) in Usability 6.14 (95% CI: 6.05–6.22, P<0.05) and Camera 6.14 (95% CI: 6.01–6.27, P<0.05). The “Lightweight” (6.46, 95% CI: 6.32–6.60, P<0.05) and “Portability” (6.35, 95% CI: 6.18–6.51, P<0.05) features of Lap-Pack were appreciated.

Conclusion:
The Lap-Pack is a suitable low fidelity simulator for laparoscopic training in a low-resource setting.

Evaluating the effect of interventions for strengthening non-physician anesthetists’ education in Ethiopia: a pre- and post-evaluation study

Background
Access to safe surgery has been recognized as an indispensable component of universal health coverage. A competent anesthesia workforce is a prerequisite for safe surgical care. In Ethiopia, non-physician anesthetists are the main anesthesia service providers. The Government of Ethiopia implemented a program intervention to improve the quality of non-physician anesthetists’ education, which included faculty development, curricula strengthening, student support, educational resources, improved infrastructure and upgraded regulations. This study aimed to assess changes following the implementation of this program.

Methods
A pre-and post-evaluation design was employed to evaluate improvement in the quality of non-physician anesthetists’ education. A 10-station objective structured clinical examination (OSCE) was administered to graduating class anesthetists of 2016 (n = 104) to assess changes in competence from a baseline study performed in 2013 (n = 122). Moreover, a self-administered questionnaire was used to collect data on students’ perceptions of the learning environment.

Results
The overall competence score of 2016 graduates was significantly higher than the 2013 class (65.7% vs. 61.5%, mean score difference = 4.2, 95% CI = 1.24–7.22, p < 0.05). Although we found increases in competence scores for 6 out of 10 stations, the improvement was statistically significant for three tasks only (pre-operative assessment, postoperative complication, and anesthesia machine check). Moreover, the competence score in neonatal resuscitation declined significantly from baseline (from 74.4 to 68.9%, mean score difference = − 5.5, 95% CI = -10.5 to − 0.5, p  0.05 in favor of females), and female students scored better in some stations. Student perceptions of the learning environment improved significantly for almost all items, with the largest percentage point increase in the availability of instructors from 38.5 to 70.2% (OR = 3.76, 95% CI = 2.15–6.55, p < 0.05).

Conclusion
The results suggest that the quality of non-physician anesthetists’ education has improved. Stagnation in competence scores of some stations and student perceptions of the simulated learning environment require specific attention.