Academic Advancement in Global Surgery: Appointment, Promotion, and Tenure: Recommendations From the American Surgical Association Working Group on Global Surgery.

: There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).

A Case Report of a Bite From the Nile Crocodile (Crocodylus niloticus) Managed with Regional Anesthesia.

Crocodile attack injuries plague communities near bodies of water and continue to be an infrequent but significant form of trauma encountered in our medical facility. Regional anesthesia techniques are a novel adjunct to treatment and may facilitate simplified definitive management and better utilization of constrained operating room resources. We report a case of an adult male who presented with a large lower extremity wound after a crocodile bite. The patient was managed with initial debridement and irrigation and serial wound care entirely under regional anesthesia at the bedside. The patient did not develop wound infection, eventually receiving a skin graft with good functional outcomes. Regional anesthesia techniques are increasingly being used in the trauma setting, and their versatility allows for their use in multiple settings, by practitioners with limited experience and in resource-limited environments. No specific guidelines exist for performance of neuraxial techniques in the setting of animal bite injuries, but concerns about infectious complications have been raised. Regional anesthesia techniques may be useful in the management of extremity trauma due to crocodile attacks without infectious complications. They may reduce utilization of theatre resources and reduce opioid requirements.

Maffucci's syndrome in association with giant tubular adenoma of the breast: Case report and literature review.

INTRODUCTION: Maffucci's syndrome is a rare congenital, non-hereditary mesodermal dysplasia characterised by multiple enchondromas and vascular lesions. To our knowledge this is the first report of tubular adenoma of the breast in association with Maffucci's syndrome. PRESENTATION OF CASE: We report a 31-year-old female who presented with a large, ulcerated slow-growing painless breast mass. She had also sustained two pathological fractures during childhood as well as progressive deformity and limb shortening on the right side of the body. Skeletal survey revealed enchondromas exclusively on the right side in association with phleboliths. Excision of the breast mass was performed. Histological examination of the breast lesion revealed a diagnosis of tubular adenoma, core biopsy of the bony lesions confirmed enchondromas and a cutaneous haemangioma was excised from the abdominal wall. DISCUSSION: Tubular adenoma of the breast is a rare benign tumour. When large they may cause ulceration leading to diagnostic and management dilemmas. Patients with Maffucci's Syndrome require lifelong surveillance for the development of malignancy. CONCLUSION: Tubular adenomas of the breast carry no risk of malignancy. However, malignancy remains high on the differential list when the skin is ulcerated. Ulceration can also be caused by pressure necrosis in benign tumours. This diagnostic dilemma can lead to unnecessarily radical surgery.

Volvulus of the ascending colon due to failure of zygosis: A case report and review of the literature.

INTRODUCTION: Volvulus of the mobile ascending colon is a serious complication of a subtle embryological abnormality that frequently goes unrecognised. There has been renewed interest in the development of the mesentery because of its relevance to the contemporary management of surgical diseases. This case is presented to illustrate the dire consequences of missing this diagnosis and to review the fascinating embryology of the condition as well as its clinical implications. PRESENTATION OF CASE: We report on a 23-year-old male who presented with signs and symptoms of distal small bowel obstruction after a long prior history of intermittent right lower quadrant pain. At laparotomy, a 360-degree counter-clockwise volvulus of the entire right colon was noted as the result of an excessively long ascending mesocolon and unattached hepatic flexure. All gangrenous bowel was resected with primary ileocolic anastomosis performed thereafter. The patient did well post-operatively and was subsequently discharged. DISCUSSION: Interruption of the in-utero events of fixation known as peritoneal zygosis lead to a persistence of the mesocolon in parts of the bowel that ordinarily are retroperitoneal. The events that lead to this anomaly are poorly understood and have been subject to controversy for centuries. New insights have challenged surgical dogma and informed new surgical techniques. Its true incidence is probably underestimated because of its indolent clinical prodrome, and it requires a high index of suspicion. CONCLUSION: Failure of peritoneal zygosis is implicated in a myriad of clinical conditions. Expeditious recognition and intervention in the prodromal period can avert potentially disastrous complications.

Validation of POSSUM, P-POSSUM and the surgical risk scale in major general surgical operations in Harare: A prospective observational study.

BACKGROUND: Raw mortality and morbidity, though commonly studied in surgical audit can nonetheless be misleading because of differences in preoperative and intraoperative findings of patients. There are some common scoring systems specifically designed to cater for case mix but these have not been tried locally. This study sought to validate these scoring systems and hopefully adopt them for our teaching hospitals. MATERIALS AND METHODS: A prospective observational cohort study was conducted at two central hospitals in Harare Two hundred and two patients undergoing a variety of major general surgical operations were recruited into the study. Results of physiological and intraoperative parameters collected from the patients' records were scored according to POSSUM, P-POSSUM and SRS scores. Predicted mortality and morbidity rates of all these subjects were then compared to the observed rates. RESULTS: One hundred and eighty one patients participated (123 males, 58 females). Using the POSSUM morbidity score, the observed versus expected (O: E) ratio of 0.88 showed no difference (p = 0.970). Using POSSUM, P-POSSUM and SRS mortality scores, O: E ratios of 0.74, 1.06 and 1.0 respectively were obtained, the differences were not significant (p = 0.650, p = 0.987 and 0.730). All three scores were comparable on the Receiver Operating Characteristic curve. The Physiological score independently predicted mortality (p < 0.00001). CONCLUSION: POSSUM, P-POSSUM and SRS scores are comparable and suitable for estimating outcomes after major surgery in Harare. A larger study inclusive of low risk patients is needed to generalise these findings across Zimbabwean patients.

Anal human papillomavirus infection in HIV-positive men and women at two opportunistic infections clinics in Harare, Zimbabwe.

BACKGROUND: HIV-infected individuals are at increased risk of anal cancer; in the majority of cases this is linked to human papillomavirus (HPV) infection. Anal cancer screening is not routinely offered in Zimbabwe. METHODS: A cross-sectional study was performed on 152 patients (88 females; 64 males) attending Opportunistic Infection Clinics at 2 tertiary hospitals between November 2014 and June 2015. Demographic data, immunological parameters and behavioural characteristics were collected. An anal swab was collected from each patient for HPV genotype testing. HPV testing was performed using MY09/MY11 PCR, followed by typing using the dot blot method. RESULTS: The mean age was 39.6 years (range, 18-69 years). Median CD4 count was 375 cells/µL. 96% were on antiretroviral therapy. Only one patient identified as a man who has sex with men. Of 122 samples tested for HPV, 54 were positive (44%). HPV was three times more common in females (60%) than males (20%). Being HPV-positive was associated with history of perianal warts, history of cervical intraepithelial neoplasia and having more than ten lifetime sexual partners. The most commonly detected high-risk HPV genotypes were HPV-58 (13%), HPV-31 (11%) and HPV-16 (9%). Nine patients harboured multiple high-risk HPV types. The two most commonly detected low-risk genotypes were HPV-11 (17%) and HPV-53 (11%). CONCLUSION: Overall anal HPV prevalence was 44% in this mostly heterosexual HIV-positive population. Oncogenic HPV types accounted for almost half of infections, supporting the need for surveillance of anal cancer in this population.

Prevalence of Helicobacter pylori in asymptomatic patients at surgical outpatient department: Harare hospitals.

BACKGROUND: Helicobacter pylori infection is present in more than 50% of the world's population. The estimated life time risk of peptic ulcer disease is 20 percent and of gastric cancer is 1-2 percent. MATERIALS AND METHODS: A cross sectional study was done at two Central hospitals in Harare, Zimbabwe, with the objective being to estimate the prevalence of Helicobacter pylori infection in asymptomatic individuals. Other objectives were to determine the association of the Helicobacter pylori infection with potential risk factors.Four hundred and fifty patients visiting the outpatient surgical clinics for other complaints other than upper gastrointestinal symptoms were recruited in the study. Drops of whole blood were obtained by fingertip puncture from each patient. The Onsite H. pylori Combo Rapid Test was used to confirm the presence or absence of antibodies against Helicobacter pylori. A questionnaire was used to record the sociodemographics of the participants. RESULTS: Three hundred patients, 186 males (62%) and 114 females (38%) participated. The prevalence of Helicobacter pylori infection was 67.7 percent (203/300). The prevalence of H pylori infection was significantly correlated with increasing age (p = 0.012), sharing of a bed with siblings during childhood (p = 0.013) and the mode of sanitation methods (p = 0.023). There was no association found between H pylori infection and other risk factors such as; gender, level of education, employment status or number of rooms in a house. CONCLUSION: H. pylori infection prevalence was significantly associated with increasing age, sharing of a bed with siblings during childhood and the mode of sanitation used. Clinicians and the public have to be aware of the important role of H pylori in upper gastrointestinal disease. Use of better sanitation methods, appropriate hygiene, avoidance of over-crowding amongst other measures should be encouraged as a means to reduce the acquisition and transmission of H pylori.

Prominent ears: Anthropometric study of the external ear of primary school children of Harare, Zimbabwe.

BACKGROUND: Prominent ear is the most common congenital ear deformity affecting 5% of children in the Western world and has profound psychosocial effects on the bearer. It is important to know the prevalence in the local population to have a better appreciation of the local burden of the abnormality as well as to know the parameters of ear morphology locally. These parameters can be useful in the diagnosis and evaluation of ear anomalies and may help reconstructive surgeons in reproducing an anatomically correct ear of an African/Zimbabwean child. OBJECTIVES: To evaluate the frequency of prominent ears in black school going children in Zimbabwe and to establish morphometric properties of the ear. DESIGN: Prospective observational, cross sectional study. SETTING: Three Primary schools in Harare. Two in a high density area and one in a low density area. MATERIALS AND METHODS: Three Primary schools in Harare were selected at random. The following measurements were taken: ear lengths, ear projection and face height using a sliding caliper. Three hundred and five healthy pupils of the age range 9-13 years of both sexes were included in the study, whilst children with congenital anomalies, ear tumours and history of ear trauma were excluded. RESULTS: The mean ear height across the cohort was 56.95 ± 5.00 (right ear) and 56.86 ± 4.92 (left ear). Ear projection was 19.52 ± 2.14 (right ear) and 19.59 ± 2.09 (left ear). Gender related differences were noted. Mean ear height was significantly higher in males (p-value = 0.000). Ear projection was higher in males compared to females. A total of 6.89% had prominent ears. Among males, 7.69% had prominent ears whilst 6.17% of females had prominent ears. CONCLUSION: The prevalence of prominent ear among black African children in the studied population is comparable to that of Caucasians. The study provides a set of biometric data of auricular dimensions for normal black African children aged 9-13 years.