Neurosurgery in Sub-Saharan Africa – Historical Background and Development of Training Programs in East Africa.

1 INTRODUCTION
Modern Neurosurgery in Sub-Saharan Africa (SSA) has its roots in the 1960s when Neurosurgeons from Europe set up Units in West Africa and East Africa. While it would be unfair to give credit to some individuals, and inadvertently not naming others, Prof Abdeslam El Khamlichi (1) in his book, “Emerging Neurosurgery in Africa,” quoting Professor Adelola Adeloye (2), provided a valuable account: A French Neurosurgeon, Dr. Courson, set up the first neurosurgical unit in West Africa in Senegal in 1967. He was joined by two other French neurosurgeons, Dr. Claude Cournil and Dr. Alliez, in 1972 and 1975. They trained the first Senegalese Neurosurgeon, Dr. Mamadou Gueye, who joined as a trainee in 1977. Dr. Gueye was to become the first Senegalese Professor and Chairman of the Neurosurgery Department.

2 | REGIONS BEGINS

In Ivory Coast, the first unit was set up by Dr. Claude Cournil in Abidjan in 1976, having left Dakar. He joined the first Ivorian Neurosurgeon, Dr. Kanga, who set up practice in 1974 in Abidjan. In Ghana, the first Neurosurgical Unit was set up by Ghanaian Neurosurgeon Dr. Osman Mustaffah in 1969. In Nigeria, the first units were set up by Nigerian Neurosurgeon Dr. Latunde Odeku started the service in Ibadan in 1962. He was joined by two other pioneer neurosurgeons, Dr. Adelola Adeloye in 1967 and Dr. Adebayo Ajayi Olumide in 1974. A second department was set up in Lagos by Dr. de Silva and Dr. Nosiru Ojikutu; in 1968, Dr. Samuel C. Ohaegbulam started the third service in Enugu in 1974 (2). In East Africa, Neurosurgical procedures had been carried out by Dr. Peter Clifford, an ENT surgeon, in 1955 (3).
In Kenya, modern Neurosurgery was introduced by Dr. Renato Ruberti, an Italian Neurosurgeon from Napoli, who set up Private practice in the European hospital in Nairobi in 1967 part-time at the King George V Hospital, which served as the National Hospital. He was joined in 1972 by Dr. Jawahar Dar, from New Delhi. The Indian Dr. Jawahar Dar set up the First Neurosurgery Unit at the King George V hospital, renamed Kenyatta National Hospital while teaching at the University of Nairobi. They were joined by Dr. Gerishom Sande, the first Kenyan Neurosurgeon following his training in Belfast, in 1979 (3).
In Uganda, on advice and recommendation of the renowned British Neurosurgeon, Professor Valentine Logue of the Hospital for Nervous Diseases, Queen Square, London, was invited by the government in 1968 to advise the establishment of neurosurgery at Mulago Hospital, Dr. Ian Bailey moved to Uganda. He was instrumental in establishing the first neurosurgical unit in Uganda at Mulago Hospital in 1969, equipped with 54 beds for the department of neurosurgery and cardiothoracic surgery (4). He was joined by the first Ugandan Neurosurgeon, Dr. Jovan Kiryabirwe, in 1971, who became the first indigenous Ugandan Neurosurgeon and the first African Neurosurgeon in East and Central Africa. He attended medical school at Makerere University School of Medicine in Kampala and subsequently completed postgraduate training at the Royal College of Surgeons in Ireland and Scotland; he also trained at Queens Square with Professor Logue (5).
In Tanzania, the first step towards modern neurosurgery was the establishment of orthopedic and trauma services in 1971 at the
Muhimbili Medical Center (MMC) by Professor Philemon Sarangi (6). At the time, orthopedic surgeons treated most of the cranial and spinal trauma. Over the next few years, several foreign neurosurgeons from Cuba, China, and the Soviet Union spent short stints practicing neurosurgery at MMC. Dr. Reulen, Professor and Chairman of Neurosurgery at University Hospital in Inselspital, Bern, Switzerland, and later in Munich, Germany, provided the impetus for the establishment of a neurosurgery program at MMC teaching in hospital of the University of Dar-es-Salaam and creating a “sandwich” program with training split between national and international centers. He trained Dr. Simpert Kinunda, a plastic surgeon who later became the first Tanzanian with any neurosurgical training.
Peter Kadyanji was the first fully trained Tanzanian neurosurgeon, and he joined MMC in 1985 after completing his training in the Soviet Union. Yadon M. Kohi followed in Kadyanji’s footsteps, graduating from Makerere University and the Faculty of Medicine at the University of Dar-es-Salaam. He obtained his FRCS in Ireland and Glasgow and later was appointed as the General Director of the National Commission for Science and Technology. Dr. Mlay was the third neurosurgeon to join MMC in 1989, with a specialty in pediatric neurosurgery. Professor Sarungi was essential to establish the Muhimbili Orthopedic Institute (MOI), which was opened in 1993 and later combined with MMC to become Muhimbili National Hospital, the national institute of neurosurgery, orthopedics, and traumatology.
Several neurosurgeons have practiced at MOI since its founding, including Dr. Abednego Kinasha and Dr. Joseph Kahamba. They, along with Professor Laurence Museru, the Medical Director of MOI, played a pivotal role in laying the foundation for training the current generation of neurosurgeons in Tanzania (6). Contemporary, locally trained neurosurgeons form the core of the specialized expertise in the country. They provide neurosurgical training and care at MOI at several healthcare institutions around the country. There are currently 20 neurosurgeons in the country, 18 of whom are in public service, one at a Mission hospital in Moshi, one in a private hospital (the Aga Khan University Hospital) Dar-es-salaam, and one at the Mnazi Mmoja/NED Institute in Zanzibar. No dedicated neuroscience nurses or beds are available in the country; however, currently, there are eight neurosurgical intensive care unit beds at MOI. An additional 14 at the new hospital within the Muhimbili hospital complex in Dar-es-Salaam opened in 2018. There are 5 CT scanners and 3 MRI scanners available across the country, mainly in Dar-es-Salaam, the largest city in Tanzania.
In Zimbabwe, Dr. Lawrence Frazer Levy, a British neurosurgeon, started in 1956 (Zimbabwe was called Rhodesia). He set up the Neurosurgery Department at the Central Hospital in Harare (Salisbury), becoming its first Professor and Chairman in 1971. He was joined by a young Scottish neurosurgeon, Dr. Carol Auchtertonie, responsible for starting the second unit at the European Hospital in Harare. The two served patients from Zimbabwe and neighboring Zambia, Malawi, and others for quite a long time (2). From these early beginnings, progress in neurosurgery remained slow, with only a handful of neurosurgeons available in SSA. In 1959, Professor Adelola Adeloye noted that there were only 20 neurosurgeons all across Africa, the majority practicing in South Africa (2). It is against this backdrop that the need to develop neurosurgical care in Sub-Saharan Africa came into focus.

Cervical cancer in Sub‐Saharan Africa: a multinational population‐based cohort study on patterns and guideline adherence of care

Abstract
Background
Cervical cancer (CC) is the most common female cancer in many countries of sub‐Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS).

Methods
Our observational study covered nine population‐based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44‐125 patients diagnosed 2010‐2016 were selected in each. Cancer‐directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (USA) Guidelines.

Results
Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline‐adherent, 2.4% with minor and 8.2% major deviations. CDT was not documented or without curative potential in 22%; 15.7% were diagnosed FIGO IV disease. Adherence was not assessed in 46.9% (no stage or follow‐up documented 11.9%) or records not traced (35.1%). The largest share of guideline‐adherent CDT was observed in Nairobi (49%), the smallest in Maputo (4%). In FIGO I‐III patients (n=190), minor and major guideline deviations were associated with impaired OS: hazard rate ratio (HRR) 1.73, 95% confidence interval (CI) 0.36‐8.37; and HRR 1.97, CI 0.59‐6.56 respectively. CDT without curative potential (HRR 3.88, CI 1.19‐12.71) and no CDT (HRR 9.43, CI 3.03‐29.33) showed substantially worse survival.

Conclusion
We found only one in six cervical cancer patients in SSA received CDT with curative potential. At least one‐fifth and possibly up to two thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of man

Working title: high dose rate intra-cavitary brachytherapy with cobalt 60 source for locally advanced cervical cancer: the Zimbabwean experience

Background and purpose
Cervical cancer is the fourth commonest cancer in women in the world with the highest regional incidence and mortality seen in Southern, Eastern and Western Africa. It is the commonest cause of cancer morbidity and mortality among Zimbabwean women. Most patients present with locally advanced disease that is no longer amenable to surgery. Definitive concurrent chemoradiation (CCRT), which is the use of external beam radiotherapy (EBRT) and weekly cisplatin, includes use of intracavitary brachytherapy, as the standard treatment. In the setting of this study, cobalt-60 (Co60)-based high dose rate brachytherapy (HDR-BT) has been in use since 2013. This study sought to review practices pertaining to use of brachytherapy in Zimbabwe, including timing with external beam radiotherapy, adverse effects and patient outcomes.

Methods
A retrospective analysis of data from records of patients with histologically confirmed cervical cancer treated with HDR-BT at the main radiotherapy centre in Zimbabwe from January 2013 to December 2014 was done. Outcome measures were local control, overall survival as well as gastro-intestinal and genito-urinary toxicity.

Results
A total of 226 patients were treated with HDR-BT during the study period, with a 97% treatment completion rate. All patients received between 45-50Gy of pelvic EBRT. Seventy-four percent received concurrent platinum-based chemotherapy. In 52% of the patients, HDR-BT was started when they were still receiving EBRT. The commonest fractionation schedule used was the 7Gy × 3 fractions, once a week (87%). Clinical complete tumour response was achieved in 75% at 6 weeks post treatment, 23% had partial response. Follow-up rates at 1 year and 2 years were 40 and 19% respectively. Disease free survival at 1 year and 2 years was 94 and 95% respectively. Vaginal stenosis was the commonest toxicity recorded, high incidence noted with increasing age. Four patients developed vesico-vaginal fistulae and two patients had rectovaginal fistulae.

Conclusion
One hundred and seventeen patients patients started HDR-BT during EBRT course, with a treatment completion rate of 97%. The overall treatment duration was within 56 days in the majority of patients. Early local tumour control was similar for all the HDR-BT fractionation regimes used in the study, with a high rate (75%) of complete clinical response at 6 weeks post-treatment. Prospective studies to evaluate early and long-term outcomes of HDR-BT in our setting are recommended.

Implementation Science Protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

Background ASSET (Health System Strengthening in Sub-Saharan Africa) is a health system strengthening (HSS) programme that aims to develop and evaluate effective and sustainable solutions that support high-quality care that involve eight work packages across four sub-Saharan African countries. Here we present the protocol for the implementation science (IS) theme within ASSET that aims to (1) understand what HSS interventions work, for whom and how; and (2) how implementation science methodologies can be adapted to improve the design and evaluation of HSS interventions within resource-poor contexts.

Pre-implementation phase The IS theme, jointly with ASSET work-packages, applies IS determinant frameworks to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work packages also theorise selective mechanisms to achieve the expected outcomes.

Piloting phase and rolling implementation phase Work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, refection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers and enablers to implementation in a series of workshops, surveys and interviews. Selective mechanisms of action are also investigated. In a final workshop, ASSET teams come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.

Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data is analysed using means and proportions.

Conclusions We use a novel combination of implementation science methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study will also contribute conceptual development and clarification at the underdeveloped interface of implementation science, HSS and global health.

Clubfoot patients’ demographic profile and outcomes of using the ponseti method at three selected hospitals in Zimbabwe

Background: Clubfoot is the most common musculoskeletal congenital abnormality and the Ponseti method is regarded as the gold standard of treatment. It has proven to be affordable, simple, and effective in correcting this deformity, particularly in low resource settings similar to Zimbabwe. Aim: The aim of this study was to establish the demographic profile and outcomes of patients with clubfoot treated using the Ponseti method at 3 hospitals in Zimbabwe, as well as determine whether results obtained were similar to those from regional and international research. Methodology: A descriptive retrospective records review of patients with clubfoot treated between January 2013 and December 2015 at Parirenyatwa, Harare Central and Mutare Provincial Hospitals was conducted. The main outcome was the final Pirani score at the end of the corrective phase. Data was analysed using STATISTICA Version 13.5. Results: There were 310 participants, mostly male (64.2%), with the majority (79.7%) in the maintenance phase of treatment. A total of 88.3% of the were participants between zero and two years of age at initial presentation, and the median (IQR) age was 3months (0.15-11months). Clubfoot was mostly of idiopathic (90.5%) and bilateral (55.2%) presentation, with positive family history of the deformity reported in 14.5% of participants. Mean (SD)Pirani scores at initial assessment for the right and left feet were 3.92 (1.33) and 3.99 (1.25) respectively. The Mean (SD) number of casts applied before tenotomy was 7.14 (4.48) ranging from 0-26 casts, and 72.5% of the participants had a tenotomy done. The proportion of left and right feet that attained a Pirani score of one or less at the end of the corrective phase was 79.2% and 82.5% respectively. Relapse was reported for 42.6% of participants in braces. At time of data collection, as many as 73.6% of the participants had stopped attending the clinics. Conclusion: Clubfoot treated using the Ponseti method had a good outcome at the end of the corrective phase. The demographic profile of patients managed at the three clinics and their treatment outcomes were in line with literature findings. There is, however, evidence of poor compliance and a high loss to follow up during the bracing phase and these need to be addressed to improve long term results.

Increases in cholecystectomy for gallstone related disease in South Africa

tudies suggest that the rate gallstone disease in Africa is low. Previous studies suggested an increase in gallstone rates and cholecystectomies related to urbanization and the adoption of Western lifestyle habits. This study examined cholecystectomy rates for gallstone disease in South Africa (SA). An audit of cholecystectomies in SA was done by reviewing gallbladder specimens processed by the SA National Health Laboratory Service (NHLS) from 2004 and 2014. Urbanization rates were obtained from Statistics South Africa and BMI data from previously published studies. Fisher’s exact test, t test’s and Pearson’s R were used for comparisons; cholecystectomy rates were calculated per 100,000 population. 33,467 cholecystectomy specimens were analysed. There was a 92% absolute increase in cholecystectomies during the study period (Pearson r 0.94; p < 0.01) with the overall cholecystectomy rate increasing by 65% from 8.36 to 13.81 per 100,000 population. The data was divided into two equal periods and compared. During the second period there was a 28.8% increase in the number cholecystectomies and patients were significantly younger (46.9 vs 48.2 years; p ≤ 0.0001). The Northern Cape was the only province to show a decline in the cholecystectomy rate in this period and was also the only province to record a decline in urbanization. Population based studies in SA demonstrate increases in BMI and an association with increased urbanization. This nationwide African study demonstrates a sustained increase in cholecystectomies for gallstone disease. Increases in BMI and urbanization may be responsible for this trend.

Remote Monitoring of Clubfoot Treatment With Digital Photographs in Low Resource Settings: Is It Accurate?

Background: Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment.

Methods: In this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as ‘success’, ‘borderline’ or ‘failure’. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score.

Results: There was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%-88.3% and specificity ranged from 57.9%-73.3%.

Conclusion: Digital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings.

Availability, procurement, training, usage, maintenance and complications of electrosurgical units and laparoscopic equipment in 12 African countries

Background: Strategies are needed to increase the availability of surgical equipment in low- and middle-income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment.

Methods: A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018.

Results: Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty-six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three-quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre.

Conclusion: Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.

A comparison of outcome measures used to report clubfoot treatment with the Ponseti method: results from a cohort in Harare, Zimbabwe.

BACKGROUND:
There are various established scoring systems to assess the outcome of clubfoot treatment after correction with the Ponseti method. We used five measures to compare the results in a cohort of children followed up for between 3.5 to 5 years.

METHODS:
In January 2017 two experienced physiotherapists assessed children who had started treatment between 2011 and 2013 in one clinic in Harare, Zimbabwe. The length of time in treatment was documented. The Roye score, Bangla clubfoot assessment tool, the Assessing Clubfoot Treatment (ACT) tool, proportion of relapsed and of plantigrade feet were used to assess the outcome of treatment in the cohort. Inter-observer variation was calculated for the two physiotherapists. A comparative analysis of the entire cohort, the children who had completed casting and the children who completed more than two years of bracing was undertaken. Diagnostic accuracy was calculated for the five measures and compared to full clinical assessment (gold standard) and whether referral for further intervention was required for re-casting or surgical review.

RESULTS:
31% (68/218) of the cohort attended for examination and were assessed. Of the children who were assessed, 24 (35%) had attended clinic reviews for 4-5 years, and 30 (44%) for less than 2 years. There was good inter-observer agreement between the two expert physiotherapists on all assessment tools. Overall success of treatment varied between 56 and 93% using the different outcome measures. The relapse assessment had the highest unnecessary referrals (19.1%), and the Roye score the highest proportion of missed referrals (22.7%). The ACT and Bangla score missed the fewest number of referrals (7.4%). The Bangla score demonstrated 79.2% (95%CI: 57.8-92.9%) sensitivity and 79.5% (95%CI: 64.7-90.2%) specificity and the ACT score had 79.2% (95%CI: 57.8-92.9%) sensitivity and 100% (95%CI: 92-100%) specificity in predicting the need for referral.

CONCLUSION:
At three to five years of follow up, the Ponseti method has a good success rate that improves if the child has completed casting and at least two years of bracing. The ACT score demonstrates good diagnostic accuracy for the need for referral for further intervention (specialist opinion or further casting). All tools demonstrated good reliability.

An approach to identify a minimum and rational proportion of caesarean sections in resource-poor settings: a global network study.

Caesarean section prevalence is increasing in Asia and Latin America while remaining low in most African regions. Caesarean section delivery is effective for saving maternal and infant lives when they are provided for medically-indicated reasons. On the basis of ecological studies, caesarean delivery prevalence between 9% and 19% has been associated with better maternal and perinatal outcomes, such as reduced maternal land fetal mortality. However, the specific prevalence of obstetric and medical complications that require caesarean section have not been established, especially in low-income and middle-income countries (LMICs). We sought to provide information to inform the approach to the provision of caesarean section in low-resource settings.We did a literature review to establish the prevalence of obstetric and medical conditions for six potentially life-saving indications for which caesarean section could reduce mortality in LMICs. We then analysed a large, prospective population-based dataset from six LMICs (Argentina, Guatemala, Kenya, India, Pakistan, and Zambia) to determine the prevalence of caesarean section by indication for each site. We considered that an acceptable number of events would be between the 25th and 75th percentile of those found in the literature.Between Jan 1, 2010, and Dec 31, 2013, we enrolled a total of 271 855 deliveries in six LMICs (seven research sites). Caesarean section prevalence ranged from 35% (3467 of 9813 deliveries in Argentina) to 1% (303 of 16 764 deliveries in Zambia). Argentina’s and Guatemala’s sites all met the minimum 25th percentile for five of six indications, whereas sites in Zambia and Kenya did not reach the minimum prevalence for caesarean section for any of the indications. Across all sites, a minimum overall caesarean section of 9% was needed to meet the prevalence of the six indications in the population studied.In the site with high caesarean section prevalence, more than half of the procedures were not done for life-saving conditions, whereas the sites with low proportions of caesarean section (below 9%) had an insufficient number of caesarean procedures to cover those life-threatening causes. Attempts to establish a minimum caesarean prevalence should go together with focusing on the life-threatening causes for the mother and child. Simple methods should be developed to allow timely detection of life-threatening conditions, to explore actions that can remedy those conditions, and the timely transfer of women with those conditions to health centres that could provide adequate care for those conditions.Eunice Kennedy Shriver National Institute of Child Health and Human Development.