Comparing the drivers of medical student emigration intention across two African nations.

BACKGROUND: Sub-Saharan Africa faces the highest relative need for health care workers in the world and the emigration of physicians significantly contributes to this deficit. Few studies have explored development of these patterns during medical education. This study investigates career aspirations of medical students in two African nations with similar Human Development Indices, but distinct differences in training structure to better inform retention strategies. METHODS: A cross-sectional survey was administered in 2018 to medical students in Madagascar (University of Antananarivo, University of Mahajanga) and Tanzania (Kilimanjaro Christian Medical College, KCMC). Outcomes included emigration/career intentions, and factors influencing these decisions. Analysis utilised chi-square and Fisher's exact tests (α < 0.05, two-tailed) for statistical differences, logistic regression and qualitative content analysis of free text data. RESULTS: A total of 439 students responded to the survey with a response rate of 12.9% from Antananarivo (n = 142/1097), 11.6% from Mahajanga (n = 43/370), and 60.0% from KCMC (n = 254/423). Significantly more Malagasy (49.7%, n = 90/181) than Tanzanian (25.2%, n = 54/214) students expressed emigration intent (P < .001). Malagasy students indicating research, possibility of working abroad, or work intensity as influencing career choice more frequently expressed a desire to emigrate. Satisfaction with computer/internet access was inversely correlated with a desire to work abroad. In comparison, Tanzanian students reporting income potential as influential in their career choice or attending a private high school were more likely to express a desire to work abroad. Qualitative content analysis of free text data demonstrated deficits in faculty availability, diversity of training locations and a particular emphasis on infrastructure challenges within Madagascar. INTERPRETATION: A significant number of students desire to work abroad. Emigration interests are influenced by access to postgraduate training, infrastructure and opportunities in academia, which differ across countries. Efforts to retain physicians should consider these country and institution-specific factors that influence medical student desire to emigrate.

Developing Sustainable Orthopaedic Care in Northern Tanzania: An International Collaboration.

There is a devastating lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries. Similar to other low- and middle-income countries, Tanzania has a severe shortage of trained orthopaedic surgeons. The surgeons available are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise annually. Over the past several years, our interdisciplinary team of both American and Tanzanian members has worked to understand the current local cultural and economic barriers to increasing surgical capacity, ensuring surgical safety, delivering affordable care, providing adequate patient follow-up, and improving surgical education. We propose a new paradigm for the delivery of musculoskeletal care and creation of sustained surgical capacity in this setting by building an Orthopaedic Center of Excellence in Moshi, Tanzania, augmented by international partner institutions year-round. This initiative is a public-private partnership led by the University of Pennsylvania in conjunction with Kilimanjaro Christian Medical Center. A growing number of contributors, including the Tanzanian Health Ministry, several universities, and industry partners, including general electric (GE) Health Care Africa, are currently helping to advance this concept into reality. Through our model, we aim to increase surgical capacity and quality, as well as enhance local surgical education, with the ultimate objective of training the next generation of African surgeons in the latest surgical techniques and equipment.

Advances in Computer-Aided Technology for Total Knee Arthroplasty.

Technology such as computer-assisted navigation systems, robotic-assisted systems, and patient-specific instrumentation has been increasingly explored during the past decade in an effort to optimize component alignment and improve clinical outcomes. Computer-assisted navigation accurately restores mechanical-axis alignment, but clinical outcome data are inconsistent. Computer-assisted navigation gap balancing has shown early promise in establishing mechanical-axis alignment with improved functional outcomes. Robotic-assisted systems more accurately restore component alignment when compared with computer-assisted navigation, but clinical outcomes have yet to be determined. Patient-specific instrumentation does not consistently improve alignment, accuracy, or patient outcomes. Studies demonstrating implant survivorship, cost-efficiency, and improved clinical outcomes and patient satisfaction are needed. [Orthopedics. 2017; 40(6):338-352.].

Describing the medial longitudinal arch using footprint indices and a clinical grading system.

BACKGROUND: The current literature is not clear regarding the best method of determining medial longitudinal arch (MLA) height. Differences in MLA height can significantly alter lower extremity biomechanics; therefore, an accurate and reproducible assessment of arch height is essential for clinical evaluation and future research. The goal of this project was to determine the reliability of common arch height measurement techniques. METHODS: Foot length, truncated foot length, navicular height, dorsal height, and footprint indices were obtained from healthy volunteers using a mirrored foot photograph box (MFPB). Between-rater and between-day reliability was determined using the interclass correlation coefficient, and the Pearson correlation coefficient was used to determine if any of the footprint parameters correlated with navicular height or normalized navicular height. RESULTS: The most reliable footprint measurement was the footprint index, followed by the Staheli index, Chippaux-Smirak Index, arch index, truncated arch index, and arch length index. The correlation of footprint measurements to normalized navicular height ranged from 0.585 to 0.648. CONCLUSIONS: Historically, the height of the navicular is considered to be the best approximation of MLA height. The results of this study indicate that the footprint indices are highly correlated with navicular height, indicating that both navicular height measurements and footprint measurements are valid measures of MLA height. Multiple methods exist for measuring the height of the MLA; therefore, it is important to develop a standard set of measurements to be used when foot type is used as a variable in research studies or when making a clinical diagnosis.

Effects of wearing foot orthosis with medial arch support on the fifth metatarsal loading and ankle inversion angle in selected basketball tasks.

STUDY DESIGN: Preintervention and post-intervention, repeated-measures experimental design. OBJECTIVES: The objective was to investigate the effects of foot orthoses with medial arch support on ankle inversion angle and plantar forces and pressures on the fifth metatarsal during landing for a basketball lay-up and during the stance phase of a shuttle run. BACKGROUND: Proximal fractures of the fifth metatarsal, specifically the Jones fracture, are common in sports. Wearing foot orthoses with medial arch support could increase the ankle inversion angle and the plantar forces and pressure on the fifth metatarsal that may increase the risk for fifth metatarsal fracture, METHODS AND MEASURES: Three-dimensional (3-D) videographic, force plate, and in-shoe plantar force and pressure data were collected during landing after a basketball lay-up and during the stance phase of a shuttle run with and without foot orthoses with medial arch support for 14 male subjects. Two-way ANOVAs with repeated measures were performed to compare ankle inversion angle, maximum forces, and pressure on the fifth metatarsal head and base between conditions and between tasks. RESULTS: The maximum ankle inversion angle and maximum plantar force and pressure on the base of the fifth metatarsal during both tasks as well as the maximum plantar force and pressure on the head of the fifth metatarsal during the stance of the shuttle run were significantly increased (P< or =026) when wearing foot orthoses. No significant differences were found in the maximum vertical ground reaction forces between foot orthotic conditions. CONCLUSION: Generic use of off-the-shelf foot orthoses with medial arch support causes increased plantar forces and pressures on the fifth metatarsal and may increase the risk for proximal fracture of the fifth metatarsal. Future studies are needed to investigate this risk, acknowledging that the differences noted in our study were small in magnitude and the foot type was not measured.

Forefoot loading during 3 athletic tasks.

BACKGROUND: Due to the popularity of soccer and the high incidence of injury among soccer players, it is valuable to know the effects of tasks like side cuts, crossover cuts, and forward acceleration on the foot. PURPOSE: To determine the differences in forefoot loading during three different athletic tasks. STUDY DESIGN: Descriptive laboratory study. METHODS: Thirty-six subjects (17 women and 19 men) were tested. Subjects ran a slalom-style agility course 5 times while plantar pressure data was collected at 100 Hz. Plantar pressure was recorded under both feet; however, a right-foot contact was used in the analysis of the side-cut task, a left-foot plant was used in the analysis of the crossover cut, and an average of the 3 steps of acceleration were used in the analysis. The peak pressure, contact area, and contact time for the entire foot were compared between the 3 tasks. The force and the force-time integral were obtained during 5 trials for each of the 3 tasks. The foot was divided into 8 masked regions, which were used to determine the loading patterns specifically in the forefoot. Each variable was analyzed using a 1 x 3 analysis of variance to determine differences between the three movement tasks in the forefoot region (a = .05). RESULTS: Significant differences in peak pressure, contact area, and contact time existed between the movement tasks when examining the entire foot. In addition, significant differences in the force-time integral and peak pressure in the forefoot existed between the movement tasks. The force-time integral was highest during the side cut in the medial forefoot, hallux, and the lesser toes, while the force-time integral was highest during the crossover cut in the middle forefoot and the lateral forefoot. Similarly, the peak pressure was highest during the side cut in the medial forefoot, hallux, and the lesser toes, while peak pressure was highest in the middle forefoot during the acceleration task and highest in the lateral forefoot during the crossover-cutting task. CONCLUSIONS: The results of this study demonstrated that the crossover cut places an increased load on the lateral portion of the forefoot, while the side-cut task places an increased load on the medial portion of the forefoot and the acceleration task places increased load on the middle forefoot. CLINICAL RELEVANCE: The differences in loading patterns based on athletic task are important for understanding potential injury mechanisms. In addition, this information could be important for defining a return to play protocol for athletes who have had specific injuries.

The reliability and reproducibility of foot type measurements using a mirrored foot photo box and digital photography compared to caliper measurements.

UNLABELLED: The height of the medial longitudinal arch (MLA) is thought to be a predisposing factor to various lower extremity injuries. Discrepancy exists as to whether MLA height plays a role in injury prevention. The purpose of this study was to determine the intertester and intratester reliability, and the validity of the mirrored foot photo box (MFPB) and caliper measurements to radiographic measurements. METHODS: Thirty subjects with equal numbers of men and women were recruited. Both feet were tested (n=60) in a 90% weight bearing stance. A set of anatomic landmarks were palpated, marked, and measured using a caliper, MFPB, and radiographs. The protocol was completed by two testers on 2 days approximately 1 week apart. Intertester and intratester reliability were determined using the intraclass correlation coefficient (ICC)(2,k) and the ICC(2,1), respectively. Validity of both measurement techniques to radiographic measurements was determined using the ICC(2,k). RESULTS: The intertester reliability ranged from 0.991 to 0.577, while the intratester reliability ranged from 0.994 to 0.527, with first metatarsal angle being the only variable with poor reliability. Most variables demonstrated acceptable validity between the MFPB and the caliper measurements, and acceptable validity between the MFPB and calipers compared to radiographic measurements. The MFPB took 51.3+/-19.6s per foot while the caliper measurements averaged 227.4+/-68.9s to complete the measurements. DISCUSSION: The MFPB is as reliable as the caliper measurements, and offers better intertester reliability. Both the caliper and MFPB measurements demonstrated acceptable validity to radiographic measurements and testing time was reduced when using the MFPB compared to calipers.