The impact of COSECSA in developing the surgical workforce in East Central and Southern Africa.

BACKGROUND: The Association of Surgeons of East Africa (ASEA) was formed in 1952. In 1996 a Steering Committee was formed to transform ASEA into a surgical college. The College of Surgeons of East Central and Southern Africa was officially launched in December 1999 in Nairobi, Kenya. Today the College consists of 14 constituent member countries but trains in 20 countries in Sub-Saharan Africa. PROGRAMMES: COSECSA runs a 5 year training programme in all the surgical specialties. In the first 2 years trainees do the Membership (MCS) programme. This is followed by 3 years of the Fellowship (FCS) programme. More recently the College has started a 2 year sub-specialty Fellowship in paediatric orthopaedics. GRADUATES: The main aim of the College was to expand and improve surgical training in the COSECSA region. This goal was partially realised in December 2020 when the total number of surgeons produced by the College from inception reached 557. RETENTION: Another key success story of COSECSA is that the majority of graduates have remained in the region leading to a high retention rate of 88.3%. WOMEN IN SURGERY AFRICA (WISA): Since the formation of WISA in 2015 the College has witnessed an increase in the number of female trainees. Currently only 9% of surgeons in the region are women. CONCLUSION: In its current Strategic Plan (2021-2025) COSECSA aims not only to increase the surgical workforce in the region but also to modernise its training programmes and strengthen its governance structures.

Health facilities' readiness for safe surgical care provision in Uganda and the Eastern Democratic Republic of Congo during Ebola and COVID-19 era.

OBJECTIVE: This study aimed to assess health facilities' readiness to provide safe surgical care during Ebola and COVID-19 era in Uganda and in the Eastern DR Congo. METHODS: A cross-sectional study was conducted in selected national, regional referral and general hospital facilities in Uganda and in the eastern part of DR Congo from 1st August 2020 to 30th October 2020. Data was analysed using Stata version 15. RESULTS: The participation rate was of 37.5 % (72/192) for both countries. None of the hospitals fulfilled the readiness criteria for safe surgical care provision in both countries. The mean bed capacity of participating health facilities (HF) was 184 in Eastern DR Congo and 274 in Uganda with an average surgical ward bed capacity of 22.3 % (41/184) and 20.4 % (56/274) respectively. The mean number of operating rooms was 2 and 3 in Eastern DR Congo and Uganda respectively. Nine hospitals (12.5 %) reported being able to test for Ebola and 25 (34.7 %) being able to test for COVID-19. Postponing of elective surgeries was reported by 10 (13.9) participating hospitals. Only 7 (9.7 %) hospitals reported having a specific operating room for suspect or confirmed cases of Ebola or COVID-19. Appropriate Personal Protection Equipment (PPE) was reported to be available in 60 (83.3 %) hospitals. Most of the staff had appropriate training on donning and doffing of PPE 40 (55.6 %). Specific teams and protocols for safe surgical care provision were reported to be present in 61 (84.7 %) and 56 (77.8 %) respectively in Uganda and Eastern DR Congo participating hospitals. CONCLUSIONS: The lack of readiness to provide safe surgical care during Ebola and COVID-19 era across the participating hospitals in both countries indicate a need for strategies to enhance health facility supplies and readiness for safe surgical provision in resource-limited settings.

The Brain Drain Myth: Retention of Specialist Surgical Graduates in East, Central and Southern Africa, 1974-2013.

BACKGROUND: This study assesses the retention of specialist surgical graduates from training programmes across eight countries in East, Central and Southern Africa from 1974 to 2013. It addresses the gap in existing data by analysing retention rates of surgical graduates by comparing graduating institution to current location. Data were assessed by country, region, specialty and gender with a view to informing national and regional healthcare and education strategies. METHODS: Twenty-five institutions train surgeons in the ten countries covered by the College of Surgeons of East, Central and Southern Africa (COSECSA)-24 Universities and the College itself. These institutions were requested in November 2014 to supply details of graduates from their postgraduate surgical training programmes. Complete graduate lists were returned by the College and 14 universities by March 2016. These surgical graduates were compared against the database of current practising surgeons in the region held by COSECSA. Data were cross-checked against medical council registers, surgical society records, and with members and fellows of COSECSA. RESULTS: Data were incomplete for 126 surgical graduates. Of the remaining 1038 surgical graduates, 85.1% were retained in the country they trained in, while 88.3% were retained within the COSECSA region. Ninety-three per cent (93.4%) were retained within Africa. Of the eight countries, Malawi had the highest retention rate with 100% of surgical graduates remaining in country, while Zimbabwe had the lowest rate with 65.5% remaining. CONCLUSION: High surgical graduate retention rates across the region indicate that the expansion of national surgical training initiatives is an effective solution to addressing the surgical workforce shortage in East, Central and Southern Africa and counters long-held arguments regarding brain drain in this region.

Access, availability, and infrastructure deficiency: The current management of thyroid disease in the developing world.

Thyroid disease, a neglected tropical disease and the most common noncommunicable disease in the developing world, is overlooked, under-diagnosed, and inadequately managed. The spectrum of thyroid disorders in the developing world is qualitatively different from that found in industrialized countries. This qualitative difference has resulted in limited access to clinical, laboratory, and imaging resources that are necessary for the care of patients with thyroid disease. The management of thyroid disease in the developing world is comparable to the care provided for disorders of the thyroid in North America fifty years ago.This article reviews public health and clinical aspects of developing world medical and surgical thyroid disease. Topics covered include iodine deficiency disorders, congenital hypothyroidism, goiter, thyroid cancer, and hyper- and hypothyroidism. The review concludes with a description of programs based on smartphone technology to improve the availability, affordability, and quality of thyroid disease care.

A prospective analysis of thyroidectomy outcomes in a resource-limited setting.

BACKGROUND: This study aimed to document thyroidectomy outcomes in the surgical endocrine unit, Mulago Hospital, Kampala, Uganda. The burden of global surgical disease is currently receiving much attention, especially in countries experiencing epidemiological transition. There is a paucity of publications on surgical outcomes from Sub-Saharan Africa. International thyroid guidelines from high-income countries do not factor in the logistical challenges or the advanced pathology faced by the surgeon in resource-limited settings. METHODS: This was a prospective cohort study in 2013. Eight peri-operative variables of poor outcome were analysed statistically against six outcomes variables. Data was collected from 0 to 6 months post-operatively. RESULTS: Forty-two thyroidectomies were performed over a 3-month period (female = 38). Intraoperative events recorded included rebleeding = 10 %, infection = 0 %, transient voice symptoms = 30 %, transient hypocalcaemia = 12.5 %, recurrent laryngeal nerve (RLN) paralysis = 7.5 % and permanent hypocalcaemia = 15 %. There was a weak powered association between RLN paralysis and total thyroidectomy and smaller thyroid size. There were associations between large thyroid size and both permanent hypocalcaemia and rebleeding. Younger patients showed statistically more transient voice changes compared to older patients. Older patients were statistically more likely to develop rebleeding. Shorter operative duration was associated with transient voice change, permanent hypocalcaemia and rebleeding. Airway difficulties and transient hypocalcaemia were statistically significant in prolonged procedures. CONCLUSIONS: Whilst the thyroidectomy outcomes are not equal to international standards, an acceptable standard is achievable in this resource-limited setting. Poor outcomes are multifactorial but extremes of thyroid size, extremes of operation duration and total thyroidectomies all have statistically poorer outcomes in this setting.

Red blood cell folate as a risk factor for breast cancer among patients at a tertiary hospital in Uganda: a case control study.

BACKGROUND: Folate has been shown to play a complex but unclear role in carcinogenesis, with some studies showing that low folate intake protects against early carcinogenesis while high folate intake promotes advanced carcinogenesis. Other studies have shown that high folate is associated with decreased breast cancer risk and overall survival, yet others found no such association.This study therefore sought to determine the association between red blood folate levels and breast cancer among women seen at a tertiary Ugandan hospital. METHODS: A case control study was conducted where female patients with a histological diagnosis of breast cancer were recruited as cases, and females without cancer attending other surgical clinics as controls. Demographics and social behavior data were collected and 5 mls of blood drawn for laboratory testing of red blood cell (RBC) folate, serum vitamin B12 and RBC count. Ethical approval was obtained. RESULTS: In this study, a total of 145 women were recruited as 72 cases and 73 controls. The odds of having breast cancer among women with normal folate levels compared to those with low folate levels were 1.4 (95% CI 0.7 to 2.9) P = 0.290. Ninety participants (63%) had low RBC folate and 53 participants (37%) had normal RBC folate. Thirty five (45%) of the women from a rural setting had normal folate levels compared to 18(28%) women from an urban setting. CONCLUSIONS: There was no significant association found between RBC folate and breast cancer among this group of women in Uganda.

Euthyroidectomy under local versus general anesthesia in health camp settings in Uganda: a protocol for randomized prospective equivalence single-blind controlled trial.

BACKGROUND: Endemic goiter is highly prevalent in Uganda at 60.2%, contributing to the high surgical burden. While compelling evidence suggest that in selected cases, thyroidectomy under local anesthesia (LA) is associated with fewer post-operative complications, low costs, and short hospital stays, local anesthesia is not considered a priority technique for thyroidectomy in resource-constrained settings such as Uganda, despite having fewer general anesthesia (GA) and critical care providers. The objective of this trial is to compare euthyroidectomy under local versus general anesthesia among patients with grade 1-2 uncomplicated euthyroid goiter in Uganda. METHODS: This prospective equivalence randomized, single-blind controlled trial protocol will be conducted among eligible participants with grade 1-2 uncomplicated euthyroid goiters. The recruitment processes will start in October 2022 and end in April 2023. Consenting participants with an indication for thyroidectomy will be randomized into two arms of 29 participants in each arm during the Bulamu Health Care Organization surgical camps in Uganda. DISCUSSION: The primary outcome of this trial protocol is to compare the early post-operative complications of euthyroidectomy done under LA versus GA. The outcome variables include post-operative pain based on visual analogue scale, nausea, vomiting, hematoma formation, and transient voice changes determined at an interval of 6, 12, and 24 h and at 30 days. In addition, we shall compare the surgical site infection rates, procedure costs, hospital stay, and patients' level of satisfaction based on a 5-point Likert scale and their willingness to undergo a similar surgery using the same anesthetic technique between the two groups. We hypothesize that euthyroidectomy under LA could potentially offer similar benefits as GA, reduce costs related to procedure, complications, and hospital stay while at the same time mitigating the unmet need for surgery attributable to shortage of general anesthesia providers and critical care facilities in low-income settings. TRIAL REGISTRATION: Pan African Clinical Trial Registry PACTR202208635457430. Registered on 11th August 2022. All items from the WHO trial registration data set are within the protocol. Version number and date: version 3, 15/03/2023.

Correlation of the ultrasound thyroid imaging reporting and data system with cytology findings among patients in Uganda.

BACKGROUND: Ultrasonography is a noninvasive modality for the initial assessment of thyroid nodules. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) has demonstrated good performance in differentiating malignant thyroid nodules. However, the combination of ACR TI-RADS categories and cytology has not been studied extensively, in Uganda. The study aims to correlate ACR TI-RADS with cytology among patients referred for US-guided fine-needle aspiration at Mulago National Referral Hospital. METHODS: This was a hospital-based cross-sectional study that recruited 132 patients with thyroid nodules. Spearman's correlation was used to establish a relationship between TI-RADS and cytology findings. The diagnostic accuracy of TI-RADS was assessed using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. RESULTS: Of 132 study participants, 90% (n = 117) were females, and the mean age was 41 ± 13 years. One hundred sixty-one thyroid nodules were analyzed. More than half of the thyroid nodules (54.7%, n = 87) were solid or almost solid, 96.9% (n = 154) were shaped wider than tall, 57.2% (n = 91) had smooth margins, 83.7% (n = 133) were hyperechoic or isoechoic, and 88.7% (n = 141) had no echogenic foci. TI-RADS 3 was the most common at 42.9% (n = 69). The proportions of malignancy for TI-RADS 4 and TI-RADS 5 were 73.3% and 85.7%, respectively. The correlation between ACR TI-RADS and the Bethesda system of thyroid classification scores was r = 0.577. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of ACR TI-RADS were 90.9%, 98.5%, 90%, 99.3%, 62.3, and 0.1, respectively. CONCLUSION: We found that ACR TI-RADS classification is an appropriate and noninvasive method for assessing thyroid nodules in routine practice. It can safely reduce the number of unnecessary fine-needle aspiration in a significant proportion of benign thyroid lesions. Thyroid nodules classified as TI-RADS 3 should be followed routinely. ACR TI-RADS should be standardized as the screening tool in resource-limited areas.

Diagnostic accuracy of fine needle aspiration cytology in patients undergoing thyroidectomy in Uganda: tertiary hospital experience.

BACKGROUND: Thyroid disease affects about 5% of the World's population. Fine Needle Aspiration Cytology (FNAC) helps in planning extent of surgery. In some studies, FNAC has been found to have a low accuracy for malignancy. OBJECTIVES: To estimate the sensitivity and specificity of FNAC in detecting malignancy for thyroid disease using histopathology as the gold standard. METHODS: Patients who underwent clinical and laboratory evaluation and thyroidectomy at Mulago National Referral hospital and the Pathology department of Makerere University College of Health Sciences were consecutively recruited over a four months period. Analysis using STATA version 10 focused on sensitivity, specificity and accuracy of FNAC in detecting malignancy. RESULTS: In total, 99 patients were recruited, the F:M ratio was 15.5:1 and median age was 42 years (IQR 34-50). The median duration of symptoms was 364 weeks (IQR 104-986). The proportion of patients with malignancy was 13.3% with papillary thyroid carcinoma being the most predominant type and colloid goiter was the most predominant benign thyroid disease. The sensitivity was 61.5% and specificity 89.5%. CONCLUSION: This study revealed high specificity and low sensitivity of Fine Needle Aspiration Cytology (FNAC) at detecting malignancy in thyroid nodules.

Iodine deficiency among goiter patients in rural South Sudan.

BACKGROUND: It is estimated that 2.2 billion or approximately 30% of the world's population live in iodine-deficient areas. In a 2005 study households consuming iodized salt in South Sudan increased from 40% to 73%. Despite this achievement, there are still many goiter cases in rural South Sudan and iodine deficiency remains as a major public health problem in this part of sub Saharan Africa.The purpose of this study therefore was to determine the prevalence of iodine deficiency among rural Southern Sudan goiter patients. METHODS: A cross-sectional study was carried out in three South Sudan counties, adults with goiter were from three centers following a mobilization campaign that lasted 4 weeks for free medical care. They were clinically evaluated and completed interviewer administered questionnaires to determine their age, gender, diet, family history, drug history, and medical history. Urine samples were then taken for urinary iodine levels. The outcome was iodine deficiency measured as urinary iodine less than 100 µg per/ L. Multiple logistic regression was used to establish the factors associated with iodine deficiency in South Sudan. Ethical approval was obtained. RESULTS: A total of 286 goitre patients were recruited. The mean age was 38 years (SD 9), 262(92%) were females (F: M ratio 11:1), and 257(90%) were rural- peasants, 25% (20/286) had moderate to severe iodine deficiency. 174(62%) consumed non-iodized salts. CONCLUSION: Iodine deficiency is highly prevalent among rural South Sudan communities and a likely cause for goiters. Rural poor women are highly vulnerable.

High serum estradiol confers no risk for breast cancer: another disparity for sub Saharan Africa women.

INTRODUCTION: There are breast cancer epidemiological and tumor behaviour disparities between black women in sub Saharan Africa and their counter parts in western high resource countries. In Uganda, the incidence of breast cancer has nearly tripled in over a four decades for uncertain reasons. High serum estradiol is a known risk factor for breast cancer among women in high resourced nations. The objective of this study was to establish whether high serum estradiol is an associated risk for breast cancer amongst a group of black Ugandan women. METHODS: A case control study, conducted over eight month period with incident breast cancer as cases and the controls were without breast cancer but at risk and representative of the population from which the cases were chosen. Questionnaires were administered, clinical examination was done, serum estradiol level estimation was done using cobase immunoassay analyzer using Electro chemiluminescence Immuno assay (ECLIA). Data was analyzed using logistic regression model, and a p - value of less than 0.05 was considered significant. IRB approval was secured. RESULTS: A total of 140 women participated, 70 cases and 70 controls. The median estrogen levels was 43.2 pg/ml with IQR of 18.48 to 75.8 pg/ml, the value was higher among premenopausal women than those without cancer but with no statistical significance. No association was found between level of estradiol and breast cancer (p 0.647). The median oestrogen levels were significantly higher than normal levels in Caucasian women. CONCLUSION: There was no association between level of estradiol and breast cancer. This is yet another disparity between women of African origin and the non Africans in high resourced countries. There is need to explore more to explain this disparity.

Neonatal age and point of careTSH testing in the monitoring of iodine deficiency disorders: findings from western Uganda.

BACKGROUND: Iodine deficiency is a major public health problem throughout Africa. Although salt for human consumption is said to contain adequate amounts of iodine in Uganda, iodine intake may not be optimal. We undertook a field study to assess the adequacy of iodine nutrition in western Uganda using on-site measurement methods of neonatal thyroid stimulating hormone (TSH) levels as recommended by the World Health Organization (WHO) for monitoring the degree of iodine deficiency during pregnancy. METHODS: The study design consisted of a prevalence study using the percentage of newborns between the ages of 3 and 7 days with TSH >5 mIU/L, measured with a point-of-care immunochromatographic TSH assay, as a surrogate marker of iodine deficiency. Five districts in western Uganda were selected for study on the basis of a past history of iodine deficiency. One thousand seventy-eight newborns from the five districts were sequentially enrolled in each separate district and tested between July 2007 and January 2008. RESULTS: The prevalence of TSH levels >5 mlU/L ranged from 20% to 32%. Neonates tested on or before the age of 3 days were more likely to have a TSH level >5 mlU/L than those tested beyond the age of three days (28.2% vs. 18.7%, p < 0.001). CONCLUSIONS: Assessing neonatal TSH levels in developing countries with a TSH assay method suitable for field use can be successfully used to screen for congenital hypothyroidism and to indirectly assess a population's iodine status. Based on the percentage of neonates with TSH values >5 mIU/L, presumptive iodine deficiency persists in western Uganda. This finding suggests that continued monitoring of iodine nutrition in the area surrounding the Rwenzori Mountains in Uganda and Congo is needed. Due to the progressive fall in the percent of TSH values >5 mIU/L from day three to day five of life, we conclude that TSH measurement earlier than day five of life in newborns at risk for iodine deficiency may be misleading. Guidelines for the use of neonatal TSH to monitor iodine nutrition should specify that TSH measurement take place no earlier than day five of life.