A thematic review of the use of electronic logbooks for surgical assessment in sub-Saharan Africa.

INTRODUCTION: Ensuring that surgical training programmes in low- and middle-income countries (LMICs) provide high quality training, including adequate operative experience, is of crucial importance in meeting the goals set out in the Lancet Global Surgery 2030. Electronic logbooks (eLogbooks) have been adopted to monitor both individual trainee progression and the performance of surgical training programmes. METHODS: We performed a thematic review of the current evidence base surrounding the use of eLogbooks for the assessment of surgeons in training in sub-Saharan Africa, with a view to identifying the learning to date and areas for future research. RESULTS: Whilst there are multiple papers highlighting the use of surgical eLogbooks in high-income countries, we identified only three papers which discussed their use in sub-Saharan Africa. Four common themes emerged which related to the use of surgical eLogbooks throughout sub-Saharan Africa: ease of analysis, centralised databases, discrepancies in reporting and technology limitations. CONCLUSIONS: Robust data to demonstrate trainee progression and the quality of surgical training programmes are of crucial importance in ensuring that surgical training programmes can rapidly scale up to deliver large numbers of well-trained surgical providers to address the unmet patient need in LMICs in the next decade. The limited data on the use of well designed, centralised electronic surgical logbooks indicate that this tool may play an important role in providing key data to underpin these training programmes.

Analysing the Operative Experience of Paediatric Surgical Trainees in Sub-Saharan Africa Using a Web-Based Logbook.

BACKGROUND: The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines. METHODS: Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines. RESULTS: A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56-1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (n = 1051, 13.8%). Trainees performed the majority (n = 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities. CONCLUSIONS: Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.

An Exploratory Study of the Impact of the Medico-Legal Environment on Surgical Practice in Ireland.

Defensive medicine describes behaviours engaged in by physicians, for the purposes of averting the threat of medical negligence litigation and/or complaints. Defensive practice typically encompasses 'assurance' or 'avoidance' behaviours, or 'positive' or 'negative' defensive medicine. Assurance behaviours include, for example, meticulous notetaking and ordering further clinically unnecessary tests, whereas avoidance behaviours encompass actions such as refusing to engage with a patient perceived to be high-risk. Whilst such practices may be understandable, defensive medicine is problematic for a number of reasons: it may result in a lower standard of patient care, where for example, a patient is exposed to unnecessary risk(s); and it can increase healthcare costs, which in turn limits resources. Drawing on the findings of a survey of surgeons in Ireland, this study investigates the existence of defensive practices, and explores the impact of the civil and regulatory responses to patient safety incidents on surgical practice. Given the increasing emphasis on patient safety and cultivating a "no-blame" culture both nationally and internationally, the findings of this research illustrate the tension between the current medico-legal and regulatory environment and medical practice, with implications for quality and safety.

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.

The Specialist Surgeon Workforce in East, Central and Southern Africa: A Situation Analysis.

BACKGROUND: In East, Central and Southern Africa accurate data on the current surgeon workforce have previously been limited. In order to ensure that the workforce required for sustainable delivery of surgical care is put in place, accurate data on the number, specialty and distribution of specialist-trained surgeons are crucial for all stakeholders in surgery and surgical training in the region. METHODS: The surgical workforce in each of the ten member countries of the College of Surgeons of East, Central and Southern Africa (COSECSA) was determined by gathering and crosschecking data from multiple sources including COSECSA records, medical council registers, local surgical societies records, event attendance lists and interviews of Members and Fellows of COSECSA, and validating this by direct contact with the surgeons identified. This data was recorded and analysed in a cloud-based computerised database, developed as part of a collaboration programme with the Royal College of Surgeons in Ireland. RESULTS: A total of 1690 practising surgeons have been identified yielding a regional ratio of 0.53 surgeons per 100,000 population. A majority of surgeons (64 %) practise in the main commercial city of their country of residence and just 9 % of surgeons are female. More than half (53 %) of surgeons in the region are general surgeons. CONCLUSIONS: While there is considerable geographic variation between countries, the regional surgical workforce represents less than 4 % of the equivalent number in developed countries indicating the magnitude of the human resource challenge to be addressed.

Experience with botulinum toxin therapy for axillary hyperhidrosis and comparison to modelled data for endoscopic thoracic sympathectomy - A quality of life and cost effectiveness analysis.

AIM: To estimate cost-effectiveness of botulinum toxin therapy for axillary hyperhidrosis compared to the standard surgical intervention of endoscopic thoracic sympathectomy (ETS). METHODS: The validated dermatology life quality index questionnaire was given to patients attending for treatment over a 4 month period, to assess their quality of life (QoL) over the preceding week (n = 44). Follow-up was performed 4-6 weeks later by telephone using the same questionnaire to validate the effectiveness of the treatment. The duration of effect of the botulinum toxin treatment was also recorded and this data was used as the basis for cost effectiveness analysis. Using HIPE data, the baseline cost for single intervention using botulinum toxin and ETS was retrieved. Using figures provided by HIPE and expert opinion of the costs of complications, a stochastic model for 10,000 patients was used to evaluate the total costs for ETS including the complications. RESULTS: The results from the QoL analysis show that botulinum toxin therapy is a successful therapy for improvement of symptoms. It was revealed that the mean interval before recurrence of original symptoms after botulinum toxin therapy was 5.6 months. The baseline cost for both treatments are €389 for botulinum toxin and €9389 for uncomplicated ETS. The stochastic model yields a mean cost of €11,390 for ETS including complications. CONCLUSIONS: Treatments reached cost equivalence after 13.3 years. However, given the efficacy of the botulinum toxin therapy and the low risk we propose that botulinum toxin therapy for hyperhidrosis should be considered the gold standard.

An assessment of the readability and quality of elective orthopaedic information on the Internet.

This study assessed the readability and quality of websites related to; total hip replacement, total knee replacement and anterior cruciate ligament reconstruction using validated instruments. 225 websites were analyzed from Google, Yahoo and Bing. Readability was assessed using the Flesch Reading Ease Score and Flesch-Kincaid grade level. Quality was assessed using the LIDA tool, HON-code status and an original assessment tool. Only 13.7% were set at or below the recommended 6th grade readability level. 27.35% were HON-code certified. There was a wide variation in quality scores between websites and the information relating to the three procedures was inconsistent and generally of poor quality. Given the deficit in information it is important Orthopaedic surgeons provide patients with high quality, readable information or direct them to an appropriate source.

Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting.

BACKGROUND/AIMS: Data are limited on the frequency of 'consensus decisions' between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM 'adherence' to such advice. METHODS: This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom 'consensus management decisions' were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), 'indeterminate symptomatic status stenosis' (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / - intervention. RESULTS: One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50-99% SCS patients was 12.5 days (IQR: 9-18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1-7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up. CONCLUSIONS: The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.

Prevalence of lymphoedema and quality of life among patients attending a hospital-based wound management and vascular clinic.

Lymphoedema is a chronic, incurable, debilitating condition, usually affecting a limb and causes discomfort, pain, heaviness, limited motion, unsatisfactory appearance and impacts on quality of life. However, there is a paucity of prevalence data on this condition. This study aimed to determine the prevalence of lymphoedema among persons attending wound management and vascular clinics in an acute tertiary referral hospital. Four hundred and eighteen patients meeting the inclusion criteria were assessed. A prevalence rate of 2.63% (n = 11) was recorded. Thirty-six percent (n = 4) had history of cellulitis and broken skin, 64% (n = 7) had history of broken skin and 36% (n = 4) had undergone treatment for venous leg ulcers. The most common co-morbidities were hypertension 55% (n = 6), deep vein thrombosis (DVT) 27% (n = 3), hypercholesterolemia 36% (n = 4) and type 2 diabetes 27% (n = 3). Quality of life scores identified that physical functioning was the domain most affected among this group. This study has identified the need to raise awareness of this condition among clinicians working in the area of wound management.

Lower extremity amputations in Ireland: a registry-based study.

OBJECTIVE: To analyse the current provision of lower extremity amputations (LEA) in Irish public hospitals by patient characteristics and assess the potential savings for reducing numbers if a national multi-disciplinary foot protection clinic (MDFPC) was established nation-wide. DESIGN AND DATA SOURCES: Patient characteristics of LEA conducted during 2016-2019 were analysed based on discharge data from the national hospital inpatient enquiry system. Reported consequences from existing literature were used to extrapolate national consequences. RESULTS: Public hospitals registered 3104 hospital admissions with LEA during 2016-2019. 68% (n = 2099) of these were minor amputations. About 76% (n = 1592) of minor amputations and 52% (n = 525) of major amputations were performed on patients with a diagnosis of diabetes. If the implementation of a national MDFPC programmed could reduce the number of diabetic amputations by 20%, 80 minor and 26 major amputations could be avoided annually. This would avoid nearly 3000 hospital bed days and correspond to a potential annual saving of €3 M. CONCLUSION: LEA has severe impact on patients' lives and hospital resources. Potential savings from effective prevention strategies may offer both health improvements and cost-savings.

Re-amputation and survival following toe amputation: outcome data from a tertiary referral centre.

PURPOSE: Toe amputation is a commonly performed procedure for irreversible foot sepsis. However, outcome and predictors of outcome are poorly understood. Our aim was to determine survival and rate of progression to further amputation following index toe amputation. METHODS: Consecutive patients between 2010 and 2015 were included. Progression to further minor amputation, major amputation or death was recorded. Multivariable Cox regression analyses were undertaken to determine independent predictors of outcome and survival. RESULTS: One hundred forty-six patients were included, with mean age of 65 years. Fifty-five (37.7%) patients underwent hallux amputation, while 91 (62.3%) underwent amputation of non-hallux digit(s). Following index toe amputation, 63 (43.2%) patients progressed to further minor or major ipsilateral amputation, median time to which was 36 months. Twenty-one patients (14.4%) progressed to major ipsilateral amputation. Patients undergoing index non-hallux amputation were significantly more likely to require further minor amputation (P = 0.050); however, the rate of major amputation between hallux (14.5%) and non-hallux (14.3%) groups was similar. Overall, 5-year ipsilateral amputation-free (iAFS) was 39.6 ± 4.1%, ipsilateral major amputation-free (iMAFS) was 55.9 ± 4.1% and overall survival (OS) was 64.3 ± 4.0% and did not differ between index amputation sites. CONCLUSION: Almost half of patients undergoing toe amputation required further digital amputation. However, limb preservation rates are high, and a majority of patients are alive at 5-year follow-up. There was no significant difference in outcome between patients undergoing hallux and non-hallux primary procedures. Overall, increasing age remains the only independent predictor of iMAFS and OS.

Enhanced ex vivo inhibition of platelet function following addition of dipyridamole to aspirin after transient ischaemic attack or ischaemic stroke: first results from the TRinity AntiPlatelet responsiveness (TrAP) study.

Ex vivo dipyridamole 'non-responsiveness' has not been extensively studied in ischaemic cerebrovascular disease. Platelet surface marker expression, leucocyte-platelet complex formation and inhibition of platelet function at high shear stress as detected by the PFA-100® Collagen-Adenosine-diphosphate (C-ADP) and Collagen-Epinephrine cartridges was assessed in 52 patients within 4 weeks of transient ischaemic attack (TIA) or ischaemic stroke on aspirin, and then 14 d (14 d) and >90 d (90 d) after adding dipyridamole. A novel definition of 'Dipyridamole non-responsiveness' was used. The median C-ADP closure time increased following addition of dipyridamole, remained elevated at 90 d (P ≤ 0·03), and was unaffected by aspirin dose. 59% at 14 d and 56% at 90 d were 'dipyridamole non-responders' on the PFA-100. The proportion of non-responders at 14 and 90 d was similar (P= 0·9). Compared with baseline (4·6%), median monocyte-platelet complexes increased at 14 d (5·0%, P= 0·03) and 90 d (4·9%, P= 0·04). Low C-ADP closure times were associated with increased monocyte-platelet complexes at 14 d (r= -0·32, P= 0·02) and 90 d (r= -0·33, P = 0·02). Monocyte-platelet complexes increased in the subgroup of dipyridamole non-responders on the PFA-100 (P≤ 0·045), but not in responders (P ≥ 0·5), at 14 and 90 d versus baseline. Additional inhibition of platelet function has been detected with the PFA-100 when dipyridamole is added to aspirin. Elevated monocyte-platelet complexes may contribute to ex vivo dipyridamole non-responsiveness.

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook.

BACKGROUND: There is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets. METHODS: Retrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009. RESULTS: 104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee. CONCLUSIONS: A centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.

von Willebrand Factor Antigen, von Willebrand Factor Propeptide, and ADAMTS13 in Carotid Stenosis and Their Relationship with Cerebral Microemboli.

BACKGROUND: The relationship between von Willebrand factor antigen (VWF:Ag), VWF propeptide (VWFpp), VWFpp/VWF:Ag ratio, ADAMTS13 activity, and microembolic signal (MES) status in carotid stenosis is unknown. METHODS: This prospective, multicenter study simultaneously assessed plasma VWF:Ag levels, VWFpp levels and ADAMTS13 activity, and their relationship with MES in asymptomatic versus symptomatic moderate-to-severe (≥50-99%) carotid stenosis patients. One-hour transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES+ve or MES-ve. RESULTS: Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the "early phase" (≤4 weeks) and 37 patients in the "late phase" (≥3 months) after transient ischemic attack (TIA)/ischemic stroke. VWF:Ag levels were higher (p = 0.049) and VWFpp/VWF:Ag ratios lower (p = 0.006) in early symptomatic than in asymptomatic patients overall, and in early symptomatic versus asymptomatic MES-ve subgroups (p ≤0.02). There were no intergroup differences in VWFpp expression or ADAMTS13 activity (p ≥0.05). VWF:Ag levels and ADAMTS13 activity decreased (p ≤ 0.048) and VWFpp/VWF:Ag ratios increased (p = 0.03) in symptomatic patients followed up from the early to late phases after TIA/stroke. Although there were no differences in the proportions of symptomatic and asymptomatic patients with blood group O, a combined analysis of early symptomatic and asymptomatic patients revealed lower median VWF:Ag levels in patients with blood group O versus those without blood group O (9.59 vs. 12.32 µg/mL, p = 0.035). DISCUSSION: VWF:Ag expression, a marker of endothelial ± platelet activation, is enhanced in recently symptomatic versus asymptomatic carotid stenosis patients, including in MES-ve patients, and decreases with ADAMTS13 activity over time following atherosclerotic TIA/ischemic stroke.

Simultaneous assessment of plaque morphology, cerebral micro-embolic signal status and platelet biomarkers in patients with recently symptomatic and asymptomatic carotid stenosis.

The relationship between plaque morphology, cerebral micro-embolic signals (MES) and platelet biomarkers in carotid stenosis patients warrants investigation.We combined data from two prospective, observational studies to assess carotid plaque morphology and relationship with cerebral MES and platelet biomarkers in patients with recently symptomatic (≤4 weeks of transient ischaemic attack (TIA)/ischaemic stroke) versus asymptomatic carotid stenosis. Plaque morphology on ultrasound was graded with Grey-Scale Median (GSM) and Gray-Weale (GW) scoring. Bilateral transcranial Doppler ultrasound classified patients as 'MES+ve' or 'MES-ve'. Full blood counts were analysed and flow cytometry quantified CD62P and CD63 expression, leucocyte-platelet complexes and reticulated platelets.Data from 42 recently symptomatic carotid stenosis patients were compared with those from 36 asymptomatic patients. There were no differences in median GSM scores between symptomatic and asymptomatic patients (25 vs. 30; P = 0.31) or between MES+ve vs. MES-ve symptomatic patients (36 vs. 25; P = 0.09). Symptomatic patients with GSM-echodense plaques (GSM ≥25) had higher platelet counts (228 vs. 191 × 109/L), neutrophil-platelet (3.3 vs. 2.7%), monocyte-platelet (6.3 vs. 4.55%) and lymphocyte-platelet complexes (2.91 vs. 2.53%) than 'asymptomatic patients with GSM-echodense plaques' (P ≤ 0.03).Recently, symptomatic carotid stenosis patients with 'GSM-echodense plaques' have enhanced platelet production/secretion/activation compared with their asymptomatic counterparts. Simultaneous assessment with neurovascular imaging and platelet biomarkers may aid risk-stratification in carotid stenosis.

Defining useful surrogates for user participation in online medical learning.

"School for Surgeons" is a web-based distance learning program which provides online clinical-based tutorials to surgical trainees. Our aim was to determine surrogates of active participation and to assess the efficacy of methods to improve usage. Server logs of the 82 participants in the "School for Surgeons" were assessed for the two terms of the first year of the program. Data collected included total time online, mean session time, page requests, numbers of sessions online and the total number of assignments. An intervention regarding comparative peer usage patterns was delivered to the cohort between terms one and two. Of the 82 trainees enrolled, 83% (85% second term) logged into the program. Of all participants 88% (97% second term) submitted at least one assignment. Median submissions were four (eight second term) per trainee. Assignment submission closely correlated with number of sessions, total time online, downloads and page requests. Peer-based comparative feedback resulted in a significant increase in the number of assignments submitted (p < 0.01). Despite its recent introduction, "School for Surgeons" has a good participation rate. Assignment submission is a valid surrogate for usage. Students can be encouraged to move from passive observation to active participation in a virtual learning environment by providing structured comparative feedback ranking their performance.