COVID-19 Preparedness Within the Surgical, Obstetric and Anesthetic Ecosystem in Sub Saharan Africa

Community transmission of COVID-19 is already being reported in Africa. Most countries on the continent will have +10,000 confirmed cases within the month. The population, while generally younger than in Europe and North America, has much higher rates of poverty, malnutrition, HIV, and TB, which could shift the demographics of lethality. For surgeons, obstetricians, and anesthesiologists, the major challenge will be maintaining provision of emergency and essential surgery and obstetric care while preserving precious resources, minimizing exposure of health care workers, and preventing onward transmission (Table ​(Table11). The human skill sets, resources, and supply chains supporting surgical services are also those needed for responding to the crisis.

A woman’s worth: an access framework for integrating emergency medicine with maternal health to reduce the burden of maternal mortality in sub-Saharan Africa

Background
Within each of the Sustainable Development Goals (SDGs), the World Health Organization (WHO) has identified key emergency care (EC) interventions that, if implemented effectively, could ensure that the SDG targets are met. The proposed EC intervention for reaching the maternal mortality benchmark calls for “timely access to emergency obstetric care.” This intervention, the WHO estimates, can avert up to 98% of maternal deaths across the African region.

Access, however, is a complicated notion and is part of a larger framework of care delivery that constitutes the approachability of the proposed service, its acceptability by the target user, the perceived availability and accommodating nature of the service, its affordability, and its overall appropriateness.

Without contextualizing each of these aspects of access to healthcare services within communities, utilization and sustainability of any EC intervention-be it ambulances or simple toll-free numbers to dial and activate EMS-will be futile.

Main text
In this article, we propose an access framework that integrates the Three Delays Model in maternal health, with emergency care interventions. Within each of the three critical time points, we provide reasons why intended interventions should be contextualized to the needs of the community. We also propose measurable benchmarks in each of the phases, to evaluate the successes and failures of the proposed EC interventions within the framework. At the center of the framework is the pregnant woman, whose life hangs in a delicate balance in the hands of personal and health system factors that may or may not be within her control.

Conclusions
The targeted SDGs for reducing maternal mortality in sub-Saharan Africa are unlikely to be met without a tailored integration of maternal health service delivery with emergency medicine. Our proposed framework integrates the fields of maternal health with emergency medicine by juxtaposing the three critical phases of emergency obstetric care with various aspects of healthcare access. The framework should be adopted in its entirety, with measureable benchmarks set to track the successes and failures of the various EC intervention programs being developed across the African continent.

Non-endoscopic management of a giant ureterocele: a case report in resource poor African hospital

Ureterocele is a cystic dilatation of the distal sub mucosal part of the ureter. It is a congenital anomaly that may co-exist with other anomalies. It has an incidence 1 in 4000 live births. Patients present with symptoms at paediatric age or may remain asymptomatic till adulthood. Our 30 year old female patient was assessed for a giant orthotropic right ureterocele with obstructive uropathy, in a hospital that has no modern facilities for endoscopic treatment. She then had successful open surgical repair of the ureterocele with satisfactory outcome. Minimally invasive endoscopic treatment options remains the gold standard. Patients from poor resource regions can as well be treated successfully by open surgical repair like our index case presented.

Popliteal fossa reconstruction with medial genicular artery flap in a low resource setting: A report of two cases

Background: Popliteal fossa defects are common arising from several causes. Options of reconstruction around the knee could be limited by the cause of defect or interventions. Medial genicular artery flap is known in the books but not in popular use despite its obvious advantages of superior vascularity, adequate size, suppleness, and hidden donor site.

Aim: To promote the use of this flap due to its advantages and ease of use especially in resource poor settings.

Patients and methods: We report two patients from a low resource setting aged 23 and 20 years respectively. The first case was managed for avulsion wound of the popliteal fossa while the second had post burn knee contracture release. The resultant large popliteal fossa defects on both patients were seen on clinical examination. Both patients were offered popliteal fossa reconstruction for the popliteal fossa defects using medial genicular artery flap with good outcome.

Conclusion: The medial genicular artery flap is a veritable option of popliteal fossa reconstruction especially for defects that are located contiguous to the flap and when other regional flap options are not available. Flap survival is excellent and donor site is hidden

Burden of Neonatal Surgical Conditions in Northern Ghana

Background: Congenital anomalies have risen to become the fifth leading cause of under-five mortality globally. The majority of deaths and disability occur in low- and middle-income countries including Ghana. This 3-year retrospective review aimed to define, for the first time, the characteristics and outcomes of neonatal surgical conditions in northern Ghana.

Methods: A retrospective study was conducted to include all admissions to the Tamale Teaching Hospital (TTH) neonatal intensive care unit (NICU) with surgical conditions between January 2014 and January 2017. Data were collected on demographics, diagnosis and outcomes. Descriptive analysis was performed on all data, and logistic regression was used to predict determinants of neonatal mortality. p < 0.05 was deemed significant.

Results: Three hundred and forty-seven neonates were included. Two hundred and sixty-one (75.2%) were aged 7 days or less at presentation, with males (n = 177, 52%) slightly higher than females (n = 165, 48%). The majority were delivered by spontaneous vaginal delivery (n = 247, 88%); 191 (58%) were born in hospital. Congenital anomalies accounted for 302 (87%) of the neonatal surgical cases and 45 (96%) deaths. The most common anomalies were omphalocele (n = 48, 13.8%), imperforate anus (n = 34, 9.8%), intestinal obstruction (n = 29, 8.4%), spina bifida (n = 26, 7.5%) and hydrocephalus (n = 19, 5.5%). The overall mortality rate was 13.5%. Two-thirds of the deaths (n = 30) from congenital anomalies were conditions involving the digestive system with gastroschisis having the highest mortality of 88%. Omphalocele (n = 11, 23.4%), gastroschisis (n = 7, 14.9%) and imperforate anus (n = 6, 12.8%) contributed to the most deaths. On multivariate analysis, low birthweight was significantly associated with mortality (OR 3.59, CI 1.4-9.5, p = 0.009).

Conclusion: Congenital anomalies are a major global health problem associated with high neonatal mortality in Ghana. The highest burden in terms of both caseload and mortality is attributed to congenital anomalies involving the digestive system, which should be targeted to improve outcomes.

Management guidelines of penile cancer- a contemporary review of sub-Saharan Africa

Background
Penile cancer is a rare malignancy with prevalence higher in areas of high Human Papilloma Virus (HPV) such as Africa, Asia and South America. In middle- and low-income countries where circumcision is not routinely practiced, the rate of penile cancer could be ten times higher.

Main body of the abstract
A literature review was conducted from 1992 to 2019 using PubMed, Google Scholar, African Journal Online and Google with inclusion of 27 publications with emphasis on the Sub-Saharan literature. Findings revealed that most men with penile cancer in Sub-Saharan Africa (SSA) present with locally advanced to advanced disease with devastating consequences. The option of penile sparing procedure is reduced with most treatment option directed to mutilating surgeries. The lack of appropriate chemotherapy and radiotherapy worsens the prognosis in the region.

Short conclusion
Human Papilloma Virus (HPV) vaccination may not be cost-effective for most regions in SSA. Therefore, early childhood circumcision might be the best advocated alternative for prevention.

Lagos state ambulance service: a performance evaluation

Objectives: The mortality rate from road traffic accidents (RTAs) in Nigeria is almost double that of the USA. In Nigeria, the first emergency medical services (EMS) system was established in March 2001, The Lagos State Ambulance Service (LASAMBUS). The objectives of this study are to (1) determine the burden of RTAs in Lagos, (2) assess RTA call outcomes, and (3) analyze LASAMBUS’s response time and causes for delay.

Methodology: We reviewed completed LASAMBUS intervention forms spanning December 2017 to May 2018. We categorized the call outcomes into five groups: I. Addressed Crash, II. No Crash (False Call), III. Crash Already Addressed, IV. Did Not Respond, and V. Other. We further explored associations between the (1) causes for delay and outcomes and (2) response times and the outcomes.

Results: Overall, we analyzed 1352 intervention forms. We found that LASAMBUS did not address 53% of the RTA calls that they received. Of this, Outcome II. No Crash (False Call) accounted for 26% and Outcome III. Crash Already Addressed accounted for 22%. Self-reported causes for delay were recorded in 180 forms, representing 13.7% of the RTA burden. Traffic congestion accounted for 60% of this distribution.

Conclusion: LASAMBUS response rates are significantly lower than response rates in high-income countries such as the USA and lead to increased RTA mortality rates. Eliminating causes for delay will improve both LASAMBUS effectiveness and RTA victims’ health outcomes. Changing the public perception of LASAMBUS and standardizing LASAMBUS’ contact information will aid this as well.

Challenges and Outcome of Management of Gastroschisis at a Tertiary Institution in North-Eastern Nigeria

Introduction: Gastroschisis is a congenital anterior abdominal wall defect characterized by herniation of abdominal contents through a defect usually located to the right side of the umbilical cord. It occurs in about 1 in 2,000–4,000 live births and is slightly commoner in males. Management has remained challenging in the low and middle-income countries, with high mortality rates. This study highlights the clinical presentation, treatment, outcomes, and challenges in the management of gastroschisis at a tertiary healthcare center in a resource-limited setting.

Methods: This was a retrospective review of the records of all patients with gastroschisis managed over a period of 30 months (January 2016–June 2018). Data on patients’ demographics, age, birth weight, clinical presentation, method of gastroschisis reduction and closure, complications, and outcomes were collated. Statistical analysis was performed using SPSS version 20. A p < 0.05 was considered significant.

Results: Twenty-four patients with gastroschisis were managed. Of these, 18 patients had data available for analysis. There were 14 males, with a male-female ratio of 3.5:1. The median age at presentation was 11.0 h (range 1–36 h). Ten patients (55.6%) were delivered in a medical facility. One patient had type II jejunal atresia and transverse colonic atresia as associated anomalies. Improvised silos were applied by the bedside in 15 (83.3%) patients, while two patients (11.1%) had primary closure under general anesthesia. One patient died before definitive treatment could be done. Sterile urobags and female condoms were used for constructing improvised silos in 9 (60%) and 6 (40%) patients, respectively. Eight patients who had initial silo application had complete bowel reduction over a median time of 8.0 days (mean 10.0 ± 6.5days, range 2–23 days). Total parenteral nutrition was not available. The average time to commencement of feeding was 8.0 days ± 6.6 (median 6.0 days, range 2–22 days). Full feeding was achieved in five patients (two patients in the primary closure group and three from the silo group) over a mean time of 16.8 days ± 10.4 (median 14.0 days). Sepsis was the commonest complication. Four patients (22.2%) survived.

Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters

Background
Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system.

Methods
Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method.

Results
Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them.

Conclusion
This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

The Impact of African-trained Neurosurgeons on sub-Saharan Africa

Objective: Sub-Saharan Africa (SSA) represents 17% of the world’s land, 14% of the population, and 1% of the gross domestic product. Previous reports have indicated that 81/500 African neurosurgeons (16.2%) worked in SSA-i.e., 1 neurosurgeon per 6 million inhabitants. Over the past decades, efforts have been made to improve neurosurgery availability in SSA. In this study, the authors provide an update by means of the polling of neurosurgeons who trained in North Africa and went back to practice in SSA.

Methods: Neurosurgeons who had full training at the World Federation of Neurosurgical Societies (WFNS) Rabat Training Center (RTC) over the past 16 years were polled with an 18-question survey focused on demographics, practice/case types, and operating room equipment availability.

Results: Data collected from all 21 (100%) WFNS RTC graduates showed that all neurosurgeons returned to work to SSA in 12 different countries, 90% working in low-income and 10% in lower-middle-income countries, defined by the World Bank as a Gross National Income per capita of ≤ US$995 and US$996-$3895, respectively. The cumulative population in the geographical areas in which they practice is 267 million, with a total of 102 neurosurgeons reported, resulting in 1 neurosurgeon per 2.62 million inhabitants. Upon return to SSA, WFNS RTC graduates were employed in public/private hospitals (62%), military hospitals (14.3%), academic centers (14.3%), and private practice (9.5%). The majority reported an even split between spine and cranial and between trauma and elective; 71% performed between 50 and more than 100 neurosurgical procedures/year. Equipment available varied across the cohort. A CT scanner was available to 86%, MRI to 38%, surgical microscope to 33%, endoscope to 19.1%, and neuronavigation to 0%. Three (14.3%) neurosurgeons had access to none of the above.

Conclusions: Neurosurgery availability in SSA has significantly improved over the past decade thanks to the dedication of senior African neurosurgeons, organizations, and volunteers who believed in forming the new neurosurgery generation in the same continent where they practice. Challenges include limited resources and the need to continue expanding efforts in local neurosurgery training and continuing medical education. Focus on affordable and low-maintenance technology is needed.